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Diverticular Disease

Introduction

What should I know about Diverticular Disease?

Diverticula are herniations in the wall of either the esophagus or intestines. The most common type of diverticula are found in either the large or small intestine and may be the result of a congenital deformity or they may be acquired. Congenital diverticula are herniations of the entire thickness of the intestinal wall, while the more common acquired diverticula consist of herniations of the thinner mucosa generally at the site of an artery which provides nutrients to the area. (1)

The most common location for diverticula in the small intestine, is either in the middle part of the small intestine called the jejunum or in the first part of the small intestine called the duodenum. Most of the time, diverticula do not produce any symptoms that are noticeable and are usually discovered almost accidentally when the individual has reason to have an upper GI x-ray. When symptoms do occur, it is because the diverticula are close to other structures or because they have become inflamed.

A patient with multiple jejunal diverticula may have not been able to absorb nutrients properly from the food that they eat. This occurs as a result of bacterial overgrowth within the diverticula. Such bacterial overgrowth results in mucosal damage and primarily affects the absorption of vitamin B12. Another type of diverticular disease is called Meckel’s diverticulum. This is a congenital abnormality of the digestive tract. This condition is usually found in children and teenagers, however they are rarely symptomatic after age five.

Diverticula of the large intestine occur most frequently in the lower part of the large intestine called the sigmoid colon. Sometimes they occur in the first part of the large intestine called the proximal colon, but this does not happen quite as often. In western populations such as in the US, the occurrence increases with age. While the exact mechanism is unknown, it is thought to involve increased pressure from the inside of the intestine.

Since colonic diverticula are rare in underdeveloped nations, it has been postulated that the formation may be due at least in part to highly refined western diets, which generally lack in dietary fiber or roughage. In such diets, the feces contain less bulk, which causes the colon to narrow and requires an increased pressure to move the smaller fecal mass. As with small intestinal diverticula, they usually do not have any symptoms and are often found incidentally during colonoscopy or barium enema.

Diverticulitis can be defined as inflammation that occurs in or around the diverticular sac. The cause of diverticulitis is probably mechanical, related to the retention of undigested food residues and bacteria, which may form a hard mass called a fecalith. (2) This compromises blood supply to the thin-walled sac and makes it more susceptible to invasion by unwanted bacteria. Diverticulitis occurs more often in men than women, and occurs most often in the left side of the colon as opposed to the right side. This seems to indicate that diverticulitis is related to the increased pressure involved in pushing more solid fecal material found in the sigmoid and descending colon. Some attacks are accompanied by minimal pain and seem to heal spontaneously, while others can be severe.

Statistic

Everhart, J. E. (Ed.). (1994). Digestive diseases in the United States: Epidemiology and impact. (NIH Publication No. 94-1447).

    Incidence: 300,000 new cases (1987). Prevalence: 2 million people (1983-87). Mortality: 3,000 deaths (1985). Hospitalizations: 440,000 (1987). Physician office visits: 2 million (1987). Disability: 112,000 people (1983-87).

National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health, 1996.

    About half of all Americans age 60 to 80, and almost everyone over age 80, have diverticulosis. 10 to 25 percent of people with diverticulosis get Diverticular Disease.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

Often diverticular disease has no symptoms and is frequently discovered only when a patient has an upper GI test (barium swallow) or a barium enema for other reasons. When inflammation occurs in or around the pouches created by the disease, symptoms are noticed. Diverticulitis is most likely to happen in the colon (large intestine), and is most likely caused by undigested food particles and bacteria that have become trapped. The signs and symptoms include fever and pain in the lower left portion of the abdomen (like cramping), which may increase over several days. Nausea may be present and sometimes constipation may be seen. When the abdominal cavity is irritated several signs may be present including; muscle spasms, pain that occurs when fingers are pressed on the abdomen, and that hurts even worse when pressure is released (rebound tenderness) and protecting the area that hurts, making sure nothing bumps, or makes the abdomen hurt worse (guarding).

Further complications can develop from diverticular disease. These complications include a rupture or breaking of the wall of the intestines, spilling intestinal contents into the abdominal cavity (perforation). This may possibly lead to bleeding at the site of perforation and sepsis, an infection in the whole abdominal cavity and blood stream. Perforation is likely very serious, requiring hospitalization and possibly immediate surgery.

General

  • Fever
  • Cramping pain in the lower left portion of the abdomen worsening over several days
  • Possible nausea
  • Possible Constipation
  • Signs of irritation in the abdominal cavity:
    • Muscle spasms
    • Rebound tenderness (pain occurs when fingers are pressed on the abdomen, and hurts even worse when pressure is released)
    • Guarding (taking great care to protect the area that hurts, making sure nothing bumps, or makes the abdomen hurt worse)

Treatment Options

Conventional

If inflammation is mild and a diverticulum has not ruptured, the only treatment required may be bed rest, stool softeners, a liquid diet, and antibiotics. In there is an acute attack, generally bowel rest is recommended, with administration of intravenous fluids and broad-spectrum antibiotics. Repeated attacks in the same area will most likely require surgery. Severe attacks with signs of peritoneal involvement, abscess, or perforation require intravenous antibiotics, followed by surgery. In severe cases, a temporary diverting colostomy may be performed.

Nutritional Suplementation


Lactobacillus acidophilus

Bacterial overgrowth is commonly reported in patients who have diverticulitis. (3) , (4) , (5) One important aspect of correcting abnormalities in the G.I. tract is to normalize the intestinal bacterial microflora. A common recommendation is to take 10 to 15 billion cfu (colony forming units) of a probiotic product containing L. acidophilus alone or in combination with other beneficial bacteria.


Fiber

Colonic diverticulosis is a common problem in the United States and the development of this condition may be associated with low dietary intake of fiber although there is still controversy over this suggestion. Some clinicians suspect that increasing the intake of dietary fiber is an important aspect in the prevention of diverticular disease. (6) In addition to recognizing that a decrease in dietary fiber increases the likelihood of developing diverticular disease, it has been reported that consumption of higher-fiber diets might be useful in treating individuals with diverticular disease who do not have acute inflammation. (7) There is also evidence suggesting that switching to a high-fiber diet enables individuals with diverticular disease to reduce the likelihood that they will need surgery. (8)

Herbal Suplementation


Olive Leaf

Olive leaf extract has been reported to be an effective antimicrobial agent against a wide variety of pathogens, including Salmonella typhi, Vibrio parahaemolyticus and Staphylococcus aureus (including penicillin-resistant strains), Klebsiella pneumonia and Eschericha coli, causal agents of intestinal or respiratory tract infections in man. (9) The component usually associated with olive leaf’s antimicrobial properties is oleuropein. (10) , (11)

As an antifungal and antiviral agent, olive leaf extract is currently used as a supportive agent in maintaining bowel flora.


Cat's Claw

Colon toxicity has been somewhat ignored in Western medicine. It is now becoming apparent that bowel hygiene and proper flora are essential to good health. If the colon flora is disturbed or if food is not being properly digested and assimilated, metabolites and endotoxins may be produced. Cat’s claw is reported to have the ability to soothe irritated and inflamed tissues and help eliminate pathogens from the GI tract. (12)


Grapefruit Seed

Grapefruit seed extract has been reported to be a broad-spectrum antimicrobial both in vitro and in vivo. Studies indicate that the antimicrobial activity of grapefruit seed extract exists in the way that it affects the membranes of the invading bacteria. (13)

Grapefruit seed extract also inhibits the growth of H. pylori and C. jejuni, both causative agents in gastrointestinal ulcers. (14) By inhibiting causative agents of bowel dysbiosis (the imbalance of normal bacterial flora in the GIT) including Candida sp, grapefruit seed extract is a useful agent in maintaining bowel integrity. (15)


Peppermint

Peppermint is a widely used herb for both medicinal and culinary purposes. Peppermint tea has long been used in treating children’s digestive problems such as colic, flatulence, and upset stomach. The oil of peppermint is used routinely in Europe as a spasmolytic, carminative, and cholagogue, with its most prevalent use in Irritable Bowel Syndrome (IBS).


Oregano

Oregano has been used as a cooking spice and also as a medicinal agent for centuries. Oregano volatile oil has been used traditionally for respiratory disorders such as coughs, bronchial catarrh, and as an expectorant, and also for dyspepsia, rheumatoid arthritis, and urinary tract disorders. (16) Oregano oil is now used as an antifungal and antibacterial agent in various conditions. (17) Oregano also has been reported as an effective agent in vitro against Aspergillus spp. (18)

References

  1. Isselbacher KJ, Epstein A. Diverticular, Vascular, and Other Disorders of the Intestine and Peritoneum. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:1648-1649.
  2. Isselbacher KJ, Epstein A. Diverticular, Vascular, and Other Disorders of the Intestine and Peritoneum. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:1648-1649.
  3. View Abstract: Kongara KR, Soffer EE. Intestinal motility in small bowel diverticulosis: a case report and review of the literature. J Clin Gastroenterol. Jan2000;30(1):84-6.
  4. View Abstract: Chaussade S, et al. Intestinal motility in patients with small bowel diverticulosis. Gastroenterol Clin Biol. 1991;15(1):16-21.
  5. View Abstract: Montalvo II, et al. Bacterial overgrowth secondary to intestinal diverticulosis. Rev Esp Enferm Dig. Jul1995;87(7):535-7.
  6. View Abstract: Johnson HC Jr, Block MA. Diverticular disease. Current trends in therapy. Postgrad Med. Sep1985;78(3):75-9, 82.
  7. View Abstract: Ozick LA, et al. Pathogenesis, diagnosis, and treatment of diverticular disease of the colon. Gastroenterologist. Dec1994;2(4):299-310.
  8. View Abstract: Leahy AL. High fibre diet in symptomatic diverticular disease of the colon. Ann R Coll Surg Engl. May1985;67(3):173-4.
  9. View Abstract: Bisignano G, et al. On the in-vitro antimicrobial activity of oleuropein and hydroxytyrosol. J Pharm Pharmacol. Aug1999;51(8):971-4.
  10. View Abstract: Visioli F. Antiatherogenic components of olive oil. Curr Atheroscler Rep. Jan2001;3(1):64-7.
  11. Juven B, et al. Studies on the mechanism of the antimicrobial action of oleuropein. J Appl Bact. 1972;35:559.
  12. View Abstract: Sandoval CM, et al. Antiinflammatory actions of cat's claw: the role of NF-kappaB. Aliment Pharmacol Ther. Dec1998;12(12):1279-89.
  13. Ionescu G, et al. Oral Citrus seed extract. J Orthomolecula Med. 1990;5(3):72-74.
  14. View Abstract: Arimi SM. Campylobacter infection in humans. East Afr Med J. Dec1989;66(12):851-5.
  15. Ionescu G, et al. Oral Citrus seed extract. J Orthomolecula Med. 1990;5(3):72-74.
  16. Leung, et al. Encylopedia of Common Natural Ingredients Used in Foods, Drugs, and Cosmetics. New York: Wiley-Interscience Publication; 1996:398-400.
  17. View Abstract: Dorman HJ, et al. Antimicrobial agents from plants: antibacterial activity of plant volatile oils. J Appl Microbiol. Feb2000;88(2):308-16.
  18. View Abstract: Basilico MZ, et al. Inhibitory effects of some spice essential oils on Aspergillus ochraceus NRRL 3174 growth and ochratoxin A production. Lett Appl Microbiol. Oct1999;29(4):238-41.