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Diverticular Disease: A Common Intestinal Disorder You May Not Know About

Diverticular Disease: A Common Intestinal Disorder You May Not Know About

Diverticular disease, ranging from mild to painful disorders, more than a third of all Australians over 45 years of age may be affected by this group of diseases.

 

Diverticular disease: the basics

 

Diverticulosis is a condition where random parts of the muscles of the large intestine or colon form small pouches, called diverticula. Diverticulosis is very common, affecting about a third of all Australians over 45 years of age, and significantly increasing in prevalence with age: more than 65% of older adults (over 85 years old) develop diverticulosis1.

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 can include abdominal pain and bloat, constipation or diarrhoea, flatulence, and bloody stools.

In some people, diverticulosis can develop into a more serious condition, called diverticulitis, which occurs when the intestinal diverticula become infected and inflamed. This can cause symptoms like a sharp, localised pain in the abdominal area, fever, nausea, and vomiting. Diverticulitis is considered a medical emergency, requiring immediate hospitalisation.

Both conditions, collectively known as diverticular disease represent an important health burden, costing healthcare systems billions and causing as many as 23,000 deaths per year in Europe2-3.

 

Factors influencing Diverticular disease

 

      • Underlying factors

        While there is no clear understanding of the causes behind diverticulosis, genetics has been established as an important underlying factor4-5. Other important underlying factors that have been identified include inflammation, gut microbial dysbiosis, and abnormal colon motility.

 

      • Inflammation

        Chronic inflammation occurring in and around diverticula has been strongly associated with diverticular diseases like Symptomatic Uncomplicated Diverticular Disease and acute diverticulitis6.

 

      • Colon Motility

        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 contractions7. Also, anatomical issues, like the reduced density of certain cells have been identified in patients with diverticular disease8.

 

      • Gut Microbiota

        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 function9-10.

        • For example, the SCFA butyrate, commonly produced by certain strains of gut bacteria has been shown to decrease the risk of recurrent diverticulitis11.

 

        • 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 levelsaDecrease in bacterial levelsaStudies
Acute diverticulitis vs healthy controlsMarvinbryantia and SubdoligranulumClostridium12, 13
Acute diverticulitis vs diverticulosisProteobacteria diversity 14
Symptomatic uncomplicated diverticular disease (SUDD) vs diverticulosis Clostridium Fusobacterium and Lactobacillaceae15
Diverticulitis vs controlsPseudobutyrivibrio,

Bifidobacterium and Christensenellaceae

 16
aIncrease in bacterial levels occur on the underlined condition.

 

 

      • Associated factors that increase risk

        In Australia and other developed regions such as Europe, the United States and Canada, research has identified multiple factors that increase the risk of hospitalization for diverticular disease. These factors include obesity, high intake of 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 (like aspirin or ibuprofen) have been shown to increase this risk17.

        Below are further details about the key factors associated with the development of diverticulitis or diverticular disease:

 

          • Diet

            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 diseases18. 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 diverticulitis19.

 

            • 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 studies20-21.

 

          • Stress

            It is important to reduce your stress levels, as studies show that stress activates inflammatory pathways in the intestine22.

 

          • Smoking

            Smoking is the world’s leading preventable cause of death, and it also associated with worst outcomes in diverticular disease23-24.

 

          • Physical activity and obesity

            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 risk25-26.

 

          • Drug use

            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 diverticulitis27-29.

 

Treatment and prevention of Diverticulitis

 

Treatment of diverticular disease 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:

      • SUDD

        Patients with this condition can be treated with a high-fibre diet30, antibiotics31, anti-inflammatory drugs such as mesalazine or balsalazide32 and probiotics33.

 

      • Acute diverticulitis

        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 surgery12-145.

 

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

 

What You Can Do

 

      • Reduce levels of stress, change your lifestyle

 

      • Follow an optimal diet, design by a dietician

 

      • Take prebiotics, minerals supplements and probiotics, consult your functional medicine practitioner for a personalised plan

 

      • Evaluate the health of your gut microbiota, consult with our expert team at AUSCFM

 

Functional Medicine and Diverticular Disease

 

The Australian Centre for Functional Medicine in Perth takes a comprehensive approach in the treatment of diverticulitis and other diverticular diseases.

Our approach is backed by systematic and state-of-the-art testing of all possible factors that influence this disease and employs a combination of evidence-based therapies. 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

 

 

References

 

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  2. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, Gangarosa LM, Thiny MT, Stizenberg K, Morgan DR, Ringel Y. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012 Nov 1;143(5):1179-87. Read it!
  3. Delvaux M. Diverticular disease of the colon in Europe: epidemiology, impact on citizen health and prevention. Alimentary pharmacology & therapeutics. 2003 Nov;18:71-4. Read it!
  4. Reichert MC, Lammert F. The genetic epidemiology of diverticulosis and diverticular disease: Emerging evidence. United European gastroenterology journal. 2015 Oct;3(5):409-18. Read it!
  5. Maguire LH, Handelman SK, Du X, Chen Y, Pers TH, Speliotes EK. Genome-wide association analyses identify 39 new susceptibility loci for diverticular disease. Nature genetics. 2018 Oct;50(10):1359-65. Read it!
  6. Tursi A, Elisei W. Role of inflammation in the pathogenesis of diverticular disease. Mediators of inflammation. 2019 Mar 14;2019. Read it!
  7. Bassotti G, Sietchiping-Nzepa F, de Roberto G, Chistolini F, Morelli A. Colonic regular contractile frequency patterns in irritable bowel syndrome: the ‘spastic colon’revisited. European journal of gastroenterology & hepatology. 2004 Jun 1;16(6):613-7. Read it!
  8. Bassotti G, Battaglia E, Bellone G, Dughera L, Fisogni S, Zambelli C, Morelli A, Mioli P, Emanuelli G, Villanacci V. Interstitial cells of Cajal, enteric nerves, and glial cells in colonic diverticular disease. Journal of clinical pathology. 2005 Sep 1;58(9):973-7. Read it!
  9. Koh A, De Vadder F, Kovatcheva-Datchary P, Bäckhed F. From dietary fiber to host physiology: short-chain fatty acids as key bacterial metabolites. Cell. 2016 Jun 2;165(6):1332-45. Read it!
  10. Krokowicz L, Stojcev Z, Kaczmarek BF, Kociemba W, Kaczmarek E, Walkowiak J, Krokowicz P, Drews M, Banasiewicz T. Microencapsulated sodium butyrate administered to patients with diverticulosis decreases incidence of diverticulitis—a prospective randomized study. International Journal of Colorectal Disease. 2014 Mar 1;29(3):387-93. Read it!
  11. Hullar MA, Sandstrom R, Lampe JW, Strate LL. The fecal microbiome differentiates patients with a history of diverticulitis vs those with uncomplicated diverticulosis. Gastroenterology. 2017 Apr 1;152(5):S624. Read it!
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  13. Barbara G, Scaioli E, Barbaro MR, Biagi E, Laghi L, Cremon C, Marasco G, Colecchia A, Picone G, Salfi N, Capozzi F. Gut microbiota, metabolome and immune signatures in patients with uncomplicated diverticular disease. Gut. 2017 Jul 1;66(7):1252-61. Read it!
  14. Kvasnovsky CL, Leong LE, Choo JM, Abell GC, Papagrigoriadis S, Bruce KD, Rogers GB. Clinical and symptom scores are significantly correlated with fecal microbiota features in patients with symptomatic uncomplicated diverticular disease: a pilot study. European journal of gastroenterology & hepatology. 2018 Jan 1;30(1):107-12. Read it!
  15. Tursi A, Mastromarino P, Capobianco D, Elisei W, Miccheli A, Capuani G, Tomassini A, Campagna G, Picchio M, Giorgetti G, Fabiocchi F. Assessment of fecal microbiota and fecal metabolome in symptomatic uncomplicated diverticular disease of the colon. Journal of clinical gastroenterology. 2016 Oct 1;50:S9-12. Read it!
  16. Crowe FL, Appleby PN, Allen NE, Key TJ. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. Bmj. 2011 Jul 19;343:d4131. Read it!
  17. Tursi A, Scarpignato C, Strate LL, Lanas A, Kruis W, Lahat A, Danese S. Colonic diverticular disease. Nature Reviews Disease Primers. 2020 Mar 26;6(1):1-23. Read it!
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  19. Maguire LH, Song M, Strate LE, Giovannucci EL, Chan AT. Higher serum levels of vitamin D are associated with a reduced risk of diverticulitis. Clinical Gastroenterology and Hepatology. 2013 Dec 1;11(12):1631-5. Read it!
  20. Cao Y, Strate LL, Keeley BR, Tam I, Wu K, Giovannucci EL, Chan AT. Meat intake and risk of diverticulitis among men. Gut. 2018 Mar 1;67(3):466-72. Read it!
  21. Strate LL, Keeley BR, Cao Y, Wu K, Giovannucci EL, Chan AT. Western dietary pattern increases, and prudent dietary pattern decreases, risk of incident diverticulitis in a prospective cohort study. Gastroenterology. 2017 Apr 1;152(5):1023-30. Read it!
  22. Collins SM. IV. Modulation of intestinal inflammation by stress: basic mechanisms and clinical relevance. American Journal of Physiology-Gastrointestinal and Liver Physiology. 2001 Mar 1;280(3):G315-8. Read it!
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  25. Aune D, Sen A, Leitzmann MF, Norat T, Tonstad S, Vatten LJ. Body mass index and physical activity and the risk of diverticular disease: a systematic review and meta-analysis of prospective studies. European journal of nutrition. 2017 Dec 1;56(8):2423-38. Read it!
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  29. Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology. 2011 May 1;140(5):1427-33. Read it!
  30. Carabotti M, Annibale B, Severi C, Lahner E. Role of fiber in symptomatic uncomplicated diverticular disease: a systematic review. Nutrients. 2017 Feb;9(2):161. Read it!
  31. Papi C, Ciaco A, Koch M, Capurso L. Efficacy of rifaximin in the treatment of symptomatic diverticular disease of the colon. A multicentre double‐blind placebo‐controlled trial. Alimentary pharmacology & therapeutics. 1995 Feb;9(1):33-9. Read it!
  32. Scarpignato C, Barbara G, Lanas A, Strate LL. Management of colonic diverticular disease in the third millennium: Highlights from a symposium held during the United European Gastroenterology Week 2017. Therapeutic advances in gastroenterology. 2018 May 18;11:1756284818771305. Read it!
  33. Ojetti V, Petruzziello C, Cardone S, Saviano L, Migneco A, Santarelli L, Gabrielli M, Zaccaria R, Lopetuso L, Covino M, Candelli M. The use of probiotics in different phases of diverticular disease. Reviews on Recent Clinical Trials. 2018 Jun 1;13(2):89-96. Read it!