Dietary Management of Diverticular Disease

Chapter 1: Diverticular disease, Diverticulosis and Diverticulitis- What is the difference?

Diverticular disease is a disorder of the gastro-intestinal tract that particularly affects the colon (however studies have shown that it can affect any part of the gastrointestinal tract). This disorder is characterised by the development of pockets or diverticula within the colon wall. These diverticula tend to develop in the weak areas of the bowel, in particular, sites where a large number of bloods vessels penetrate the walls of the bowel and in areas that are generally narrower than most others- such as the sigmoid colon. It is believed that the development of diverticula is a result of the adoption of western diets, which tend to be low in fibre.

This is evident in developed or industrialised countries. Due to the large amounts of refining processes implemented within the food system, the amount of fibre contained in many foods is severely diminished. A diet low in fibre results in the production of stools of a different consistency to normal. This consistency requires a higher pressure to be present in order to move the stools through the bowel. It is the presence of these high pressures that result in the bowel expanding or pocketing outwards through the surrounding muscle, consequently forming the pocket like structures known as diverticula. Diets high in beef and animal products as opposed to plants foods are also shown to result in diverticular disease. This is due to similar reasons as mentioned above. Animal products contain little amounts of fibre, whereas plant products are the main supply for fibre in the diet. Should an individual limit the amount of plant foods they consume, whether intentionally or unintentionally, they limit the amount of fibre in the diet, resulting in an increase in pressure in the bowel and consequent development of diverticula. Studies have shown that diets high in vegetable foods, such as those in developing countries, decrease the chances of developing diverticular disease, as these foods are high in fibre and thus decrease the amount of pressure required to move

stools through the bowel. It has also been identified that there may be a genetic component affecting the development of diverticular disease. This suggests that raised pressure in the bowel may be hereditary. Another factor associated with diverticular disease is age. Diverticular disease is commonly found in individuals over the age of forty. It is estimated that one third of the population at forty years of age and two thirds of the population at eighty years of age have diverticular disease. Individuals already suffering form colonic mobility problems or from defects in the strength of the colon wall are also at risk of developing diverticular disease. This is due to the presence of sections of the colon that do not work effectively, resulting in isolated segments with high levels of pressure which consequently lead to the development of diverticula within these segments. Diverticular disease does not affect people based on gender. Studies have shown the male to female ratio of the incidence of diverticular disease to be equal. Generally, the condition does not discriminate race-wise if the individuals have adopted the same culture and consequent diet (i.e. a western diet), however will affect according to race if different

cultural diets have been adopted. The term diverticula disease is an overall description of the condition, and encompasses the two phases of the disease, diverticulosis and diverticulitis. Diverticulosis: This term refers to the presence of diverticula (pockets) within the colon. A person with diverticulosis may have no symptoms and it is possible that they may never develop the active phase of the condition. Diverticulitis: This term describes the active phase of the disease, in which the diverticula become inflamed. Current belief is that diverticulitis occurs when bodily fluids or faecal matter becomes trapped in the diverticula. This creates a perfect environment in which bacteria can manifest and consequently cause infection. The infection may proceed in one of four ways. 4 The infection may spontaneously resolve itself without medical intervention. 5 The infection may progress, leading to more serious complications (mentioned in chapters 2 and 3). 6 The infection may cause partial or complete obstruction of the bowel. This generally must be

addressed via surgery. 7 The infection may fistulize. If the infection is not treated the site of infection will spread and consequently break through to another organ or cavity of the body, creating a tunnel or fistula (explained in chapter 3). Diverticulitis does not occur in every individual with diverticulosis. In reality only a small proportion of those with diverticulosis will develop diverticulitis. From the above information, it can be concluded that diverticular disease is the encompassing term for diverticulosis (the inactive phase of the disease in which the diverticula exist, but are not infected or inflamed) and diverticulitis (the active phase of the disease in which the diverticula are inflamed and infected due to the presence of bodily fluid or faecal matter trapped inside). Diverticular disease can be diagnosed via one of three procedures: 1) Colonoscopy: This procedure involves a thin, lighted tube being passed through the rectum in order for a doctors to obtain a thorough look at the bowel wall. This also enables the removal of small pieces of the bowel wall for further investigation via biopsy.

2) Single Contrast Barium Enema: A thin tube is passed through the rectum in order to feed a white liquid known as barium into the bowel. The presence of the barium allows for the outline of the walls of the bowel to show in an x-ray. If over activity due to presence of the disease is prevalent, the bowel wall will appear thickened. 3) Double Contrast Barium Enema: If it is believed that an individual may have diverticular an enema (thin tube passed through the rectum) may be implemented to view the wall of the colon. The double contrast enema is more accurate than a single contrast enema. An enema is not used if there is any possibility of diverticulitis (inflamed diverticula) as this may increase the risk of perforation of the diverticula. 4) Computerised Tomography (CT) Scan: This procedure is less invasive than the aforementioned as it does not required a tube to be passed through the rectum. Instead a scan is used to produce a 3D image on a computer screen in which the bowel can be viewed. If possible, Ct scans are used where possible due to the high degree of accuracy in diagnosing diverticula disease and identifying the development of abscesses. 5) Water-soluble contrast enema: Another form of enema- this enables imaging of

the intraluminal space and consequent diagnosis of diverticular disease. 6) Ultrasonography: This test is equally as accurate and non-invasive as a CT scan in diagnosing acute colonic diverticulitis if the operator of the machinery is well trained and reliable. Ultrasonography involves the use of a skin probe that emits sound waves. Like an ultrasounds, these sound waves produce echoes which form a picture of organs and tissues inside the body on an ultrasound machine. For those diagnosed with diagnosed with diverticular disease, many will find that their diverticula will cause them no problems and that they never develop the active phase of the disorder (diverticulitis). Some may develop this phase once or very rarely and will recover very quickly form the event via treatment through optimal diet and antibiotics. There are however the rare cases in which the diverticular disease and consequent diverticulitis are more severe. Approximately ten to twenty percent of those with diverticulosis will develop the active phase of the disease (diverticulitis). Doctors are unsure as to the exact cause of diverticulitis, which can occur suddenly and without warning. As mentioned above current belief is that inflammation occurs when stools or bacteria become caught in the diverticula, which consequently becomes infected.

Chapter 2: The symptoms of diverticular disease.

Many individuals who develop diverticular disease will no display symptoms. In a small percentage of individuals diverticulitis (the active phase of the disease) might occur and the following symptoms may present themselves: 1) Diarrhoea: Diarrhoea is characterised by large, frequent, watery bowel movements. Constant loss of fluid via diarrhoea may lead to dehydration. If this symptom is severe replenishing of fluids is necessary. If this cannot be done in the home an individual my require hospitalisation. OR Increased constipation: Constipation is characterised by failure of the body to eliminate faecal matter, despite the individual feeling the urge to do so.

Constipation can result in feeling bloated and lethargic and in extreme cases (if left untreated) may even results in toxicity in the body. If constipation remains untreated if may also worsen or cause diverticulitis in an individual. 2) Abdominal Pain or cramps: This is commonly the feeling of pain or tenderness around the abdominal area (the stomach region or belly). Abdominal pain is the most common symptom of diverticulitis and tends to present as tenderness around the lower left side of the abdomen- this is typically indicative of inflammation of the diverticula due to infection. The severity of the pain is not always indicative of seriousness of the condition as a mild condition may result in extreme pain, whereas a serious condition may result in mild pain. Rather the suddenness of the onset should be used to judge severity of the condition. Abdominal pain caused by diverticulitis tends to be steady, sever and deep. 3) Abdominal Bloating: This symptom is characterised by feelings of tightness and fullness within the abdominal area and is usually due to a build up in pressure or gas. 4) Steatorrhoea: This term refers to the

presence of excess amounts of fat in the stool due to malabsorption in the gastrointestinal tract. Stools appear to be bulky, light in colour and tend to float in surrounding water. Diarrhoea is a common symptom accompanying steatorrhoea.
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Nausea: An uneasy sensation in the abdomen that occurs as a result of the inflammation of the diverticula and the presence of infection within them. Vomiting: The expulsion of food stuffs or bile via the oesophagus and through the mouth. Vomiting generally follows nausea. Fever: A condition marked by elevated temperatures, sweating, cold clammy hands and in extreme circumstances the individual may become delirious. Excessive flatulence and Distension: Excess passing of gas and accompanied by bloating around the abdominal area may indicative of diverticulitis.

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12Polyuria, Dysuria and Pyuria: a. Polyuria: An increase in frequency of urination i.e. a person finds themselves needing to go to the toilet more often.

b.

Dysuria: Pain upon urination.

c. Pyuiria: The presence of pus or white blood cells in the urine, urine often presents as cloudy if pus is present. These symptoms occurs if the bladder or ureters have been irritated in someway due to the presence of inflamed diverticula. The severity of any of these symptoms is dependent on the degree of inflammation and extent of infection of the diverticula. If a person is experiencing any of the aforementioned symptoms, a visit to the doctor would be recommended. Self-diagnosing is not wise as these symptoms are similar to those of other gastro-intestinal disorders. Most doctors will treat these acute symptoms with a course of antibiotics and a liquid diet until the diverticula cease to be inflamed.

Chapter 3: Complications of diverticular disease.

Without the correct treatment (if any is required), serious cases of diverticular disease can lead to: 1) Infection: Infection occurs when bodily fluids or faeces becomes trapped in the diverticula and begin to stagnate. This provides an optimal environment for the growth of bacteria and consequently the development of infection.
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Rectal Bleeding: Bleeding from the rectum can occur if diverticula present in the colon begin to bleed due to the bursting of a blood vessel.

Rectal bleeding will present in one of two ways: a) Small amounts of blood will be present in the stool over a few days. This generally rectifies itself. b) A large of blood is produced over a small amount of time due to the bursting of a blood vessel. The onset of this type of bleeding is generally painless, immediate and accompanied by the urge to defecate. This symptom is usually only present in those with extreme cases of diverticulitis and requires hospitalisation and possible surgery or the implementation of a

device up through the rectum to burn the bleeding wound shut. In some cases the bleeding may stop spontaneously without the requirement of medical intervention.
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Haemorrhage: The presence of rectal bleeding or bloody stools is generally indicative of internal bleeding or haemorrhage. Internal haemorrhage will present as red or burgundy coloured stools.

4) Fistulas: A fistula is an abnormal tunnel or connection between two organs that develops as a result of infection (in the case of diverticulitis this infection is present with the inflamed diverticula). There are many areas in which fistulas can occur. The main areas affected by diverticular disease are the areas surrounding the bowel (the genitals and the anus). Fistulas may link and of the surrounding organs or cavities with the bowel. The most common occurrences in individuals with a gastrointestinal are as follows:
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Enterocutaneous: Pathway leading form the gut, to the area of infection and finally to the skin. Enteroenteric: Any fistula involving the intestines.

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Enterovaginal: A fistula creating a pathway to the vagina. Symptoms of this fistula include vagina discharge containing faecal matter. Feculent vaginal discharge can also be a results of a fistula developing between the sight of infection and the uterus. Enterovesicular: A fistula creating a pathway form the site of infection to the bladder. Symptoms of the development of this type of fistula include frequent urinary tract infections, pneumaturia and the passing of gas from the urethra during urination.

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In diverticular disease, the resultant fistulas are generally faecal or anal fistulas, meaning the fistula may cause faeces to pass through openings other than the anus. Fistulas are formed from abscesses (in this case the diverticula) which do not have a chance of healing due to being constantly filled with bodily fluids or stools. If these abscesses remain untreated they will consequently break through to the skin or another organ, creating a tunnel or connection between the two structures. The types of fistulas that may develop include: 19 Blind fistulas- only one end of the

fistula has an opening b) Complete fistula- Both ends of the fistula are open
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Horseshoe fistula- the anus is connected to the surface of the skin via a tunnel around the rectum.

d) Incomplete fistula- is only attached to one organ, generally the skin. Symptoms of a fistula include pain, feeling ill, fever, tenderness or itching and severity will range depending on the location of the fistula itself. 5) Large Bowel Obstruction: This complication only occurs in a small amount of individuals suffering from diverticulitis as a result of the swelling due to inflammation on consequent development of scar tissue. Blockage due to inflammation will settle as the inflammation is treated, however blocking due to scar tissue remains. These blockages can occur as partial or total blockages. Partial blockages are not urgent, and therefore corrective surgery can be planned. Total blockages are urgent and must be addressed via surgery immediately. 6) Development of an Abscess: These are pus filled areas of infection and may form if

initial infection remains untreated. Due to the destruction of tissue by an abscess, small holes often develop, these are known as perforations, and allow the leakage of pus out of the colon into the abdominal area. Perforations may cause the individual to develop pain in the back or lower extremeties. Whilst small abscesses may rectify themselves without the administration of antibiotics, large abscesses may have to be drained in order to allow for sufficient time and conditions to heal appropriately. Abscesses are drained via the insertion of a catheter. If drainage is not successful surgery may be required to clean the abscess. If excessive amounts of infection leak out of the contaminated area into the abdominal cavity, peritonitis may occur in which case the individual will begin experiencing severe, generalised abdominal pain. Peritonitis refers to the infection of the walls of the abdominal and requires immediate surgery to clean the abdomen. Peritonitis can be fatal without treatment. Treatment involves an operation by which the abdomen is cleaned and infected parts of the colon are removed.

Chapter 4: Treatment

of Diverticular disease.
In many cases, diverticular disease presents with no symptoms and thus no treatment is required, however it is ideal that the individual adopt an optimal diet to ensure no symptoms do occur. In the event that symptoms appear, the main form of treatment of diverticulosis is through the adoption of an optimal diet (addressed in chapters 5 and six). In some cases medications are required. For an individual who develops diverticulitis (the active phase of the disease) treatment is more intense. Should symptoms or complications of diverticulitis become severe enough, an individual may often require hospitalisation. In hospital they are treated with changes to diet and appropriate antibiotics. Surgery is the final option, and is only implemented for individuals who suffer from recurring diverticulitis. Surgery generally involves the removal of certain sections of the bowel and consequent resection and is generally suggested if a patient has two or more occurrences of diverticulitis or if a large perforation or peritonitis is present.

Surgery is generally performed via two operations. The first operation aims to remove the diseased section of the colon and clean the abdominal cavity. During this operation, it is not appropriate to rejoin the colon due to the high risk of the patient developing infection or a bowel obstruction. Instead surgeons divert the path of the faecal matter via a colostomy. A colostomy involves the attachment of the colon to the skin in which faeces are passed through a hole into a bag stored externally. After a period of time has elapsed and the infection in the colon has been successfully treated and subsided, the bowel is reattached, thus enabling normal bowel functions and the patient to cease the use of the colostomy bag. The hole that was previously made in the skin is surgically closed..

Chapter 5: Dietary Management of Diverticular disease.

All current literature recommends that the

most effective way to prevent or manage diverticulosis is through the adoption of a diet high in fibre. Fibre is the indigestible portion of plant foods which aids in bulking up the stool (by forming the bulk or the roughage) to assist it in passing through the body to assure regular bowel movements. There are two type of fibre in the diet, soluble and insoluble fibre, both of which aid in the creation of a stool and prevent constipation. 1) Soluble fibre: dissolves easily in water and takes on a soft texture in the intestines. This fibre is the bodies main means of bulking the stool.

2) Insoluble fibre: passes through the gastro-intestinal tract virtually unchanged. As plant materials are passed through the body, the removal of water, protein, fats, carbohydrates and essential nutrients occurs. Upon entering the colon, all that remains to be digested is water. The colon should remove this remaining water, thus forming the stool. If an individual is not eating sufficient amounts of fibre containing foods, a very dry, hard stool is produced. Stools of this consistency have difficulty moving through

the bowel and require higher amounts of pressure to be passed through. Gradually the body becomes incapable of creating these high amounts of pressure, and begins to rely on the force of the movement of the abdominal walls to transport stools through the bowel. This is known as straining, and puts an excessive amount of pressure on the abdominal wall, resulting in the formation or aggravation of diverticula. On the other hand, diets containing sufficient amount of fibre end in the production of a softer, bulkier stool, which is easily moved through the bowel without requiring high pressures to do so. By ensuring an adequate amount of fibre in the diet it is possible to prevent the occurrence diverticular disease or to manage existing diverticular disease by reducing the required pressure for stools to pass through the bowel. Current recommendations for fibre intake per day are: 21At least 25 grams of fibre per day for adult women. 22At least 30 grams of fibre per day for adult men. 2328 grams of fibre per day for pregnant women over the age of eighteen. 2427-30 grams of fibre per day for women who are breastfeeding.

Another requirement for the formation of a soft, bulky stool is an adequate fluid intake. This will ensure that the stool retains sufficient water to be soft and that the bowel is able to produce mucous. The secretion of mucous allows the stool to pass easily through the bowel rather than sticking to the wall of the colon.

Chapter 6a: Tips on Optimising your diet to prevent or manage diverticulosis.

Diets are very individualised factors of life and will vary from person to person. A decision about diet should be made by the individual depending on what works for them in regards to amounts and types of food they will consume. In general, the following tips may prove handy in order to optimise diet and achieve adequate fluid and fibre intake: 1) Increase the fibre of your content gradually, especially if you are prone to

constipation. This will avoid further gastrointestinal upset and will allow your body to gradually adjust to any changes. A sudden change in fibre can result in flatulence and abdominal painso take it slowly. 2) Consume plenty of plant foods as opposed to meat or dairy. These include: a) Wholegrain breads and cereals: Breads and cereals are the main source of fibre in the diet. Choose from this food group regularly throughout the day. During the processes of refining foods, much of the fibre in a food product will become depleted. When selecting breads and cereals opt for the wholegrain versions, as these are less refined and thus contain higher amount of fibre. Try to select cereals that contain barley, wheat or oats. If wholegrain breads are not to your liking it is possible to purchase high fibre white breads and cereals.
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Fruit and vegetables: These food groups also provide fibre in the diet, particularly those in which the skin of the fruit or vegetable is consumed.

3) Drink plenty of fluids each day. Aim for two litres (eight standard drinking glasses) to ensure sufficient fluid in the body for bulky, soft stools. Be aware that he term fluid does not just apply to water. Many items constitute a fluid. These include: Water Milk Juice Sports drinks Tea Coffee Soft drink Ice cream Custard Soup Previously, many doctors recommended the avoidance of nuts, popcorn, pumpkin, caraway seeds and sunflower seeds as they believed they may become stuck in the diverticula and cause infection and inflammation. These recommendations have since been discontinued as there is no scientific evidence that these foods may have this effect. Foods high in fibre to include in the diet:

26Pears 27Apples 28Bananas 29Dried fruit 30Peas 31Potato with the skin 32Broccoli 33Cabbage 34Spinach 35Asparagus 36Squash 37Carrots 38Baked Beans 39Lentils 40Chick peas 41Kidney Beans 42Lima Beans 43Wholegrain or wholemeal bread (Or alternatively high fibre white bread) 44Whole-wheat pasta 45Breakfast cereals containing barley, wheat or oats 46Dried Beans 47Soy milk

48Psyllium 49Brown Rice Whilst it may be tempting to include a fibre supplement in the diet, try to avoid this where possible as this may exacerbate or cause diarrhoea in the event that an individual is not drinking sufficient fluids. Aim to obtain all fibre requirements by eating a healthy diet.

Chapter 6b: Dietary Management of Diverticulitis.

The treatment of diverticulitis is the opposite to that of diverticulosis. During the inflamed stage of the disease care should be taken to limit fibre in the diet to avoid further upset or inflammation and to allow the bowel time to rest. In many cases a fluid diet may be prescribed to ease the burden on the bowel during times of inflammation. Decreasing fibre in the diet during this stage of the disorder aid in limiting the

substances passing through the inflamed section. The individual is required to continue on a low fibre diet over a month long period, after which symptoms should have subsided. At this point in time a high fibre diet may be resumed. Previous studies have revealed that in some cases, those suffering from a colonic disease such as diverticulitis may consequently suffer from lactose malabsorption. This means that the body is unable to absorb lactose from foods or fluids. Lactose is a form of sugar present in milk and other dairy products. In the event that the body is unable to absorb lactose the individual may suffer from diarrhoea, abdominal pain and abdominal bloating after eating dairy products. For this reason it may be necessary for an individual to select lactose free dairy products whilst diverticulitis persists. Once the condition has been appropriately treated and subsided, the individual should be able to resume dairy products, as studies have shown that lactose malabsorption subsides once diverticulitis has been treated. Very few studies have been done in the area of lactose malabsorption resulting from colonic disease, therefore current evidence

is still slightly controversial. If you find you are suffering from any of the aforementioned symptoms of lactose malabsorption it would be wise to inform your doctor.

Chapter 7: Tips on Optimising your diet to manage diver ticulitis and relieve symptoms
As mentioned in the previous chapter, adopting a diet low in fibre during the onset and duration of diverticulitis will aid in managing and alleviating any symptoms that may occur. The following tips may be useful in decreasing fibre in the diet: 50Consume white breads and cereals: During the process of refinement, foods tend to lose much of their fibre content. Breads and cereals based on white flour are particularly low in

fibre and are the optimal choice for someone suffering from diverticulitis. 51Limit (but do not completely eliminate) the amount of plant foods consumed: As fibre is mainly obtained from these types of foods it makes sense to limit these in the diet for the duration of diverticulitis. 52Remove the skin from fruits and vegetables before consumption. Most of the fibre contained within these foods is held within the skin. 53Avoid seeds, nuts, popcorn, and legumes as these may further exacerbate the condition. Foods that are low in fibre include: White breads and cereals Skinless fruits and vegetables Fruit Juice Vegetable Juice Meat and dairy products 5) In some individuals it may be necessary to select lactose free dairy products, if lactose malabsorption is present. Appropriate dairy foods that are low in lactose include: 54Soy milk (ensure you select a soy milk

fortified with calcium) 55Most cheeses 56Lactose free milk 57Lactose free yoghurt

Chapter 8: Summing it all up

From all the information provided we can see that the management of diverticulosis (the inactive phase of the condition) can be managed through the adoption of a diet high in fibre. It is worth noticing that this is also the way in which the development of diverticular disease is prevented. With the complications that may result from having diverticular disease it would be optimal to start on a high fibre diet before the disease can develop, rather than allow it to form and treat it later, when risks of further complications evolve. Those with diverticular disease who successfully adopt a high fibre diet as recommended severely decrease any chances of developing further complications of the

disease and are able to live a normal life. For the small proportion of people who do develop diverticulitis, treatment is generally as simple as altering the diet to limit fibre for a one month period after which the normal high fibre diet is resumed. Individuals who disregard the advice offered by professionals are at risk of developing severe complications and symptoms.