dietary management of diverticular disease and diverticulitis

7/31/2019 Dietary Management of Diverticular Disease and Diverticulitis

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Dietary

Management of

Diverticular

Disease


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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 thesigmoid 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.


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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 severelydiminished. 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 surroundingmuscle, 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 mainsupply 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 invegetable 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


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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 inisolated 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


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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 inone of four ways.

4 The infection may spontaneously

resolve itself without medical

intervention.

5 The infection may progress,

leading to more serious

complications (mentioned inchapters 2 and 3).

6 The infection may cause partial

or complete obstruction of the

bowel. This generally must be


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addressed via surgery.

7 The infection may fistulize. If

the infection is not treated the

site of infection will spread andconsequently 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 withdiverticulosis 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 thediverticula 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 throughthe 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.


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2) Single ContrastBarium 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 ofthe 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 toview 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


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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.


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Chapter 2: Thesymptoms of

diverticular disease.

Many individuals who develop diverticulardisease 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 bylarge, 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.


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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 mayalso 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 astenderness 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 seriouscondition 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 tightnessand fullness within the abdominal area

and is usually due to a build up in

pressure or gas.

4) Steatorrhoea: This term refers to the


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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 isa common symptom accompanying

steatorrhoea.

8Nausea: An uneasy sensation in the

abdomen that occurs as a result of the

inflammation of the diverticula and the

presence of infection within them.

9Vomiting: The expulsion of food stuffs

or bile via the oesophagus and through

the mouth. Vomiting generally follows

nausea.

10 Fever: A condition marked by elevated

temperatures, sweating, cold clammy

hands and in extreme circumstances the

individual may become delirious.

11 Excessive flatulence and Distension:

Excess passing of gas and accompanied by

bloating around the abdominal area may

indicative of diverticulitis.

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.


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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 andextent 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 symptomswith a course of antibiotics and a liquid

diet until the diverticula cease to be

inflamed.

Chapter 3:

Complications of

diverticular disease.


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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.

13 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 bepresent 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 accompaniedby 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


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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.

14 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 andthe 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:

15 Enterocutaneous: Pathway leading form

the gut, to the area of infection andfinally to the skin.

16 Enteroenteric: Any fistula involving

the intestines.


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17 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 aresults of a fistula developing

between the sight of infection and

the uterus.

18 Enterovesicular: A fistula creating a

pathway form the site of infection to

the bladder. Symptoms of the

development of this type of fistulainclude frequent urinary tract

infections, pneumaturia and the

passing of gas from the urethra

during urination.

In diverticular disease, the resultant

fistulas are generally faecal or anal

fistulas, meaning the fistula may cause

faeces to pass through openings otherthan 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 connectionbetween the two structures.

The types of fistulas that may develop

include:

19 Blind fistulas- only one end of the


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fistula has an opening

b) Complete fistula- Both ends of the

fistula are open

20 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 onconsequent 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 blockagesare urgent and must be addressed via

surgery immediately.

6) Development of an Abscess: These are pus

filled areas of infection and may form if


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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 theabdominal 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 healappropriately. 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 beginexperiencing 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 areremoved.

Chapter 4: Treatment


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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 thedisease) 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.


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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 rejointhe 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 theinfection 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


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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


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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 theabdominal 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, whichis 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.


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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. Thesecretion 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 provehandy 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


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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 pain-so 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 theday.

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 selectcereals 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.

25 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.


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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. Manyitems 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 beendiscontinued as there is no scientific

evidence that these foods may have this

effect.

Foods high in fibre to include in the diet:


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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


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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 manycases 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


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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 isunable 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


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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.

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


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fibre and are the optimal choice for

someone suffering from diverticulitis.

51Limit (but do not completely eliminate)

the amount of plant foods consumed: Asfibre 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 foodsis 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


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fortified with calcium)

55Most cheeses

56Lactose free milk

57Lactose free yoghurt

Chapter 8: Summing

it all upFrom 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 theway 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


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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.

dietary management of diverticular disease and diverticulitis

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