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Diverticulosis and diverticulitis: treatment and prevention

Ranging from mild to painful disorders, more than a third of all Australians over 45 years of age may be affected by diverticulosis or diverticulitis.

Diverticulosis vs diverticulitis: learn the differences

Diverticulosis occurs when random parts of the muscles lining the large intestine or colon form small pouches, called diverticula.

Diverticulitis occurs when the intestinal diverticula become infected and inflamed.

Together, diverticulosis and diverticulitis are commonly known as diverticular disease, and they are common conditions among certain age groups.

How common is diverticulosis and diverticulitis?

Diverticular disease, including either diverticulosis or diverticulitis, is very common: about a third of all Australians over 45 years of age are affected by some degree of diverticular disease.
  • As you age, your chances of developing diverticulosis or diverticulitis increase: more than 65% of older adults (over 85 years of age) develop some form of diverticular disease1.
  • Diverticulosis and diverticulitis represent an important health burden, costing healthcare systems billions and causing as many as 23,000 deaths per year in Europe2-3.

What are some typical symptoms of diverticulosis and diverticulitis?

  • For most people, diverticulosis is a condition with no evident symptoms.
  • However, when the number of intestinal pouches (diverticula) increases, the condition can affect the normal functioning of the intestine.
  • Symptoms associated with diverticulosis include:
    • abdominal pain and bloating,
    • constipation or diarrhoea,
    • flatulence, and
    • bloody stools.
  • In some people, diverticulosis can develop into diverticulitis, where the intestinal diverticula become infected and inflamed.
  • Diverticulitis can cause symptoms like:
    • A sharp, localised pain in the abdominal area.
    • Fever
    • Nausea, and vomiting.

Important: Diverticulitis is considered a medical emergency and requires immediate hospitalisation.

Are you likely to get diverticulosis or diverticulitis?

As you age, and especially if you are over 40 years of age, you are at an increased risk of developing diverticulosis or diverticulitis, but there are other factors involved. You might be at an increased risk if you:
  • Are male – a study found that, on average, males develop complications related to diverticulosis or diverticulitis five years earlier than women4.
  • Are overweight or obese – a study found that obese people were 1.4 more likely to develop diverticulosis5.
  • Follow a low-fibre diet, high in fat and poor-quality red meat.
  • Don’t exercise.
  • Take nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin or ibuprofen.

What causes diverticulosis and diverticulitis?

Underlying factors of diverticulosis and diverticulitis

While there is no clear understanding of the causes behind diverticulosis and diverticulitis, genetics has been established as an important underlying factor6-7. Other important underlying factors that have been identified include:

Chronic inflammation occurring in and around diverticula has been strongly associated with diverticular diseases like Symptomatic Uncomplicated Diverticular Disease and acute diverticulitis8.

Abnormal colon motility is another problem tightly associated with diverticular disease. People with diverticular disease have been shown to have physiological problems like “spastic colon”, where there is an excess of contractions9. Also, anatomical issues, like reduced density of certain cells has been identified in patients with diverticular disease10.

Following a low fibre diet is a known factor affecting the composition of the gut microbiota, potentially causing gut dysbiosis. This has an important factor for people suffering from diverticular disease, as gut dysbiosis as well as Small intestinal bacterial overgrowth (SIBO) can lead to a decrease in the abundance of certain beneficial gut bacteria. Various species of gut bacteria produce short-chain fatty acids (SCFA) that are important for the optimal functioning of the intestine, especially for mucosal barrier and immune function11-12.
  • For example, the SCFA butyrate, commonly produced by certain strains of gut bacteria has been shown to decrease the risk of recurrent diverticulitis13.
  • Studies have shown that people with a history of acute diverticulitis have a gut microbiota composition that is different from that of people with diverticulosis or with other intestinal conditions (Table 1).


Conditions comparedIncrease in bacterial levels( a)Decrease in bacterial levels (a)Studies
Acute diverticulitis vs healthy controlsMarvinbryantia and SubdoligranulumClostridium14, 15
Acute diverticulitis vs diverticulosisProteobacteria diversity16
Symptomatic uncomplicated diverticular disease (SUDD) vs diverticulosisClostridium Fusobacterium and Lactobacillaceae17
Diverticulitis vs controlsPseudobutyrivibrio,

Bifidobacterium and Christensenellaceae
18


aIncrease in bacterial levels occur on the underlined condition.

What factors increase the risk of diverticulosis and diverticulitis?

In Australia and other developed regions, such as Europe and the United States, studies have identified multiple factors that increase the risk of hospitalization for diverticulosis and diverticulitis. These factors include obesity, high intake of poor-quality red meat, smoking, hypertension, hyperlipidaemia. Also, the use of some drugs, like oral contraceptives, hormone replacement therapy, or over the counter medications like corticosteroids and nonsteroidal anti-inflammatory drugs (e.g. aspirin or ibuprofen) have been shown to increase this risk19.

Below are further details about the key factors associated with the development of diverticulosis and diverticulitis:
This is the most important factor that can influence different aspect of diverticular diseases.
  • Fibre – a high fibre diet has been associated with decreased risk of hospitalisation by diverticular diseases20. However, more research in this area is needed to fully understand the role of fibre in this condition.

  • Vitamin D – this is an important micronutrient involved in the maintenance of homeostasis in the colon through the regulation of inflammation. Supplementation of Vitamin D has been shown to a reduction in the risk of developing diverticulitis21.

  • Red Meat – high consumption of red meat is a high-risk factor in colon cancer obesity. Now, red meat has also been linked to higher risk of diverticular disease by some studies22-23.

It is important to reduce your stress levels, as studies show that stress activates inflammatory pathways in the intestine24.

It is important to reduce your stress levels, as studies show that stress activates inflammatory pathways in the intestine24.

A recent review that evaluated multiple research reports concluded that even small increased in your ideal Body Mass Index (BMI) may increase your risk of developing diverticular disease. Likewise, this review found that regular exercise reduces this risk27-28.

Use of over-the-counter and prescription drugs, like opiate analgesics, corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to increase the severity of diverticular diseases. Among these NSAIDs, such as aspirin and ibuprofen have shown strong evidence for their role worsening diverticular diseases, leading to conditions like diverticular perforation, diverticular bleeding or diverticulitis29-31.

How are they diagnosed?

Diverticulosis – There is no specific test that is routinely given to diagnose diverticulosis. Diverticulosis is usually diagnosed following the onset of symptoms, or based on results from tests for an unrelated condition.

Diverticulitis – If you are suffering from diverticulitis, you will experience symptoms typical of this condition and it is important that you visit a health care provider immediately. Typical assessment of diverticulitis include:
  • Evaluation of medical history
  • Laboratory testing, including blood, stools
  • Visual inspection of the colon, which may include different tests, including CT scans, X-ray scan, colonoscopy, and sigmoidoscopy.
  • Initially, your doctor may also perform a manual inspection of the rectum area.
  • If you are experiencing rectal bleeding, you may receive an angiography, where a dye is injected to the arteries associated with the colon, to identify where the bleeding is occurring.

Treatment of diverticulosis and diverticulitis

Treatment of diverticulosis and diverticulitis depends on the severity of the condition. For example, most patients who are only experiencing the development of diverticula will not progress to a more serious condition. Hence, these patients do not receive any pharmacological treatment. Below are some examples of standard treatments for different diverticular diseases:

Patients with this condition can be treated with a high-fibre diet32-33, antibiotics34, anti-inflammatory drugs such as mesalazine or balsalazide35 and probiotics36.

Treatment for this condition depends on the severity of the disease, as patients can exhibit uncomplicated diverticulitis, diverticulitis complicated with abscess, perforation or peritonitis. The standard treatment involves anti-microbial treatment, but some patients may require surgery12, 37.

An extensive review of standard treatments of diverticular diseases can be found here.

Prevention of diverticulosis and diverticulitis

There are several factors that influence your chances of developing diverticulosis and diverticulitis, including chronic inflammation, altered intestinal microbiota, and altered colon motility. There is also a genetic component, which may pre-dispose some persons to develop diverticulosis and diverticulitis.

Detecting and treating modifiable risk factors associated with diverticulosis and diverticulitis will result in significant benefits to your health and will help prevent the development of diverticulosis and diverticulitis. Some of the key factors involved with diverticulosis and diverticulitis include:
Diverticulosis and diverticulitis are basically inflammatory diseases, and addressing the causes of inflammation is a guaranteed way of reducing the chances of developing diverticulosis and diverticulitis. The strongest evidence to date, linking chronic inflammation with diverticulosis and diverticulitis comes from the multiple risk factors identified for diverticulosis and diverticulitis.

For example, obesity, physical inactivity, and a Western diet are all factors associated with diverticulosis and diverticulitis and they are also risk factors for conditions like cardiovascular disease, diabetes or IBD – all diseases with established links to chronic inflammation37-38.

All of these factors, obesity, physical inactivity, and a Western die, are modifiable, meaning that a patient can make changes to their lifestyle to improve them39-40. Changing to a healthier diet (rich in fibre and low in fats and sugar) and increasing levels of exercise will result in multiple benefits, reducing systemic and chronic inflammation and improving you’re the overall function of your body41.
Improving your diet, to include a higher intake of fibre is likely to result in systemic benefits to your body, including improving the composition of the intestinal microbiota. Some key aspects to consider:
  • A recent study showed that following a diet low in carbohydrates and high in healthy fats (keto diets) can influence the composition of the gut microbiota and reduce levels of inflammation. Read about this study in our Journal article: “Keto Diet, Gut Microbiota and Inflammation: new link identified”.
  • Increasing consumption of certain types of fibre, like resistant starch can promote the formation of a healthy gut microbiota. Another benefit of consuming optimal levels of resistant starch is that it promotes the production of short chain fatty acids chemicals produced by gut bacteria. These chemicals are the main source of energy for colonocytes, cells that make up the colon wall, promoting their growth, differentiation and optimal function. Read our Journal article: “Short Chain Fatty Acids: the chemical language of the gut microbiota.
  • Small intestinal bacterial overgrowth (SIBO) commonly affects patients with diverticulosis and diverticulitis. Treatment of SIBO has been shown to result in improved outcomes for patients with diverticulosis and diverticulitis. Learn more about SIBO with our Journal article: “Understanding SIBO (Small Intestinal Bacterial Overgrowth): a hard to treat condition”.
  • Intake of prebiotics and probiotics can help supplement a health diet and improve the growth and function of intestinal bacteria associated with positive health outcomes. Learn more about prebiotics and probiotics with our Journal Article: “Prebiotics vs probiotics, which one is right for your gut?”.
Altered colonic motility is a condition commonly associated with diverticulosis and diverticulitis. Treating conditions like SIBO or gut dysbiosis, as well as improving dietary intake, including intake of prebiotics / probiotics and increasing fibre, can result in positive health outcomes for patients with diverticulosis and diverticulitis42. Increasing levels of serotonin and carbohydrates may also help alleviate some of the symptoms of altered colonic motility, such as constipation.
  • A recent study showed that following a diet low in carbohydrates and high in healthy fats (keto diets) can influence the composition of the gut microbiota and reduce levels of inflammation. Read about this study in our Journal article: “Keto Diet, Gut Microbiota and Inflammation: new link identified”.
  • Increasing consumption of certain types of fibre, like resistant starch can promote the formation of a healthy gut microbiota. Another benefit of consuming optimal levels of resistant starch is that it promotes the production of short chain fatty acids chemicals produced by gut bacteria. These chemicals are the main source of energy for colonocytes, cells that make up the colon wall, promoting their growth, differentiation and optimal function. Read our Journal article: “Short Chain Fatty Acids: the chemical language of the gut microbiota.
  • Small intestinal bacterial overgrowth (SIBO) commonly affects patients with diverticulosis and diverticulitis. Treatment of SIBO has been shown to result in improved outcomes for patients with diverticulosis and diverticulitis. Learn more about SIBO with our Journal article: “Understanding SIBO (Small Intestinal Bacterial Overgrowth): a hard to treat condition”.
  • Intake of prebiotics and probiotics can help supplement a health diet and improve the growth and function of intestinal bacteria associated with positive health outcomes. Learn more about prebiotics and probiotics with our Journal Article: “Prebiotics vs probiotics, which one is right for your gut?”.
In summary, the key steps to prevent diverticulosis and diverticulitis include:
  • Reducing levels of stress, which contributes to reducing levels of chronic inflammation.
  • Following an optimal diet, designed by a dietician. This may include increasing consumption of nuts, fibre, and reducing intake of poor-quality red meats and fats as well as avoiding all refined foods.
  • Improve your lifestyle – this includes increasing your levels of physical activity, reducing your BMI, reducing your waist-to-hip ratio, not smoking.
  • Avoid certain medications – non- aspirin NSAIDs, aspirin, all NSAIDs, corticosteroids, and opiate analgesics should be avoided whenever possible.
  • Taking prebiotics, minerals supplements and probiotics, consulting with your AUSCFM practitioner for a personalised plan.
  • Evaluating the health of your gut microbiota, consult with our expert team at AUSCFM.

a Functional Medicine approach

The Australian Centre for Functional Medicine in Perth, takes a comprehensive approach in the treatment of diverticulosis and diverticulitis.

Our approach is evidence-based and is backed by comprehensive state-of-the-art testing of all relevant factors that influence diverticulosis and diverticulitis. Our therapies are evidence-based, and rely on a combination of standard medical approaches and modern functional medicine, which combines medications, with natural supplements and lifestyle changes.

We consider the symptoms and problems you report but we also investigate potential problems you may not be aware of, hence building a complete picture of your pathology. Become a patient today!

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