Diverticulitis is a serious infection of the bowel wall caused by rupture of a small pocket leading to inflammation, tenderness, pain, and often fever and difficulty with passage of the bowel. It is an acute illness, occurring suddenly but takes a long time to resolve. On the other hand the condition of having the pockets is called diverticulosis. Two thirds of people develop diverticulosis, and most of these people have no symptoms. The pockets in the colon or large bowel of people with diverticulosis are just little holes that stool goes in and out of. Many people have been told that because they have diverticulosis they cannot eat fruits with seeds, have to strain their tomatoes and cucumbers, and cannot have a poppy seed bagel. This is not the case! The real problem is evident on the thousands of colonoscopies I have performed. The wall of the left side of the colon called the sigmoid colon and descending colon in people with diverticulosis is very thickened and narrowed. Think about a bulky body builder’s muscles bulging. You do not want this in your colon or large intestine. As the muscles thicken, the opening of the colon, called the lumen, like a garden hose that acquires debris, narrows. The thick muscles and the thin lumen lead to greatly increased pressures pushing on the thin walled diverticulosis. This leads to rupture of the pocket like a ruptured aneurysm or like a tire that has ballooned and then blows out. This is how diverticulosis becomes diverticulitis.
So how do we prevent diverticulitis with focus on our diets? The goals are to decrease the pressure in the colon that pushes on the thin walled pockets. We are not concerned about what goes in and out of the pockets. Fiber can be found in many foods, especially whole grains, vegetables and the skins of fruits. Fiber is like a sponge, and needs a lot of water to have its benefits. You cannot clean a table with a dry sponge. Fiber can be supplemented with high fiber cereals, psyllium, flax seed, miller bran, oat bran. Many brands of supplements are available. I recommend Nutrifi available from Pharmanex (refluxstore.com) because of the balance of water soluble and insoluble fibers. Others available in stores include Benefiber, Metamucil, Konsyl, Citrucel, Fibercon, and others come in powders, tablets, capsules, or chewable bars. Some can be mixed into yogurt, cereals, coffee, or other foods. Our goal is 25 to 30 grams of fiber, with two quarts of fluids. Read labels, as they are very enlightening. Replace white carbohydrates with whole grains.
Diverticulitis fortunately only occurs in 5% of people with diverticulosis. Many who have diverticulosis believe they have diverticulitis because of confusion over the terms. When you think of the name diverticulitis, think of appendicitis. The “itis” means it is an inflammation and like appendicitis can rupture, this is a serious problem. Failure to seek medical attention may lead to the need for surgery, and occasionally, lead to a colostomy bag and a second surgery to reverse the colostomy. The most common mistake I see is failure to completely treat the diverticulitis. 7 to 10 days of antibiotics is inadequate. The pain goes away, but the fire continues to smolder and then recurs weeks to months later, necessitating surgery. I usually recommend two antibiotics for 3 weeks, monitoring of the degree of inflammation with a blood test called Sedimentation rate or ESR, along with 3 to 4 weeks of a low residue diet before slowly reintroducing the fiber in the diet. The low residue diet avoids all fresh foods and vegetables and salads and seeds and nuts. Indigestible and fibrous vegetables as corn and broccoli are avoided. Well cooked tender vegetables without seeds or skins may be eaten including alfalfa sprouts, avocado, beets, green/yellow beans, carrots, celery, cucumber, eggplant, lettuce, mushrooms, green/red peppers, potatoes, squash, tomatoes without seeds, zucchini. Pastas, farina, low fiber cereals such as corn flakes, and soft meats, poultry and fish are allowed. This diet sounds like the opposite of the diet I recommend for diverticulosis, but in diverticulitis, you do not want sand paper going over the inflamed, swollen, narrowed, tender bowel. Give it an opportunity to heal!
Diverticulitis is especially aggressive in young people under the age of 40. The need for surgery and the likelihood of recurrence are particularly high.
A small percentage of patients with diverticulosis, primarily over 70 years old, develop gastrointestinal hemorrhage of maroon to red blood passing from the rectum. This is an emergency that can lead to severe blood loss, transfusion, and need for surgery. Hospitalization, with stoppage of all eating is required, and most often the bleeding stops on its own. Surgery, endoscopic staples called clips and angiogram with clotting of the bleeding vessel can be effective when conservative measures fail. Dietary prevention is not effective. The bleeding occurs because the pockets are always located near the blood vessels of the colon. Another cause of major bleeding of the colon in older patients is angioectasia of the bowel, also called angiodysplasia and Arteriovenous malformations (AVM) but the latter names are poor terminology. These bleeding vessels are like spider veins that you see on the face or skin of some individuals.
Diverticulosis is a common condition in older individuals, and over 2 out of 3 patients develop the pockets in the colon as they age. It is not as common below age 40, and can be more aggressive in younger patients. Most patients have no symptoms, but when it does cause symptoms they can be abdominal pain, or bowel changes such as thin stool or constipation. The problem is not so much the pockets as the increased pressure in the bowel and the thickening of the muscles of the colon called sigmoid muscular hypertrophy or mychosis (not to be confused with mycosis). The muscles build up on the inside of the lower colon like a body builders’ overdeveloped muscles. These muscles cause a high pressure zone and narrowing which can cause pain, constipation, or diverticulitis. It is not the nuts or seeds getting stuck as the old wives’ tales go, but rather the development of bulky muscles and high pressure in the bowel. It is not necessary to withhold tomato seeds or cucumber or poppy seeds. Remember that a handful of nuts is a good energy snack, but a can of nuts is not! No one actually digests corn, and it can cause unpleasant sensations in some, but you can eat a cup of popcorn, without the uncooked kernels as long as it does not bother you.
To reduce the high pressures and the muscular buildup in the colon, people with diverticulosis or resolved diverticulitis should eat a high fiber diet with whole grains, fresh fruits and vegetables and a daily fiber supplement such as Nutrifi. Saturated fats should be reduced. Water is necessary, as the fiber is a sponge. Remember, you can not clean a table with a dry sponge. You have to wet it. So drink up, eat your fruits and vegetables. Don’t worry about the seeds. Have a fiber supplement to reduce the pressure in your colon. Water soluble fiber mixes like Nutrifi will also stabilize blood sugar, lower cholesterol, and clear out carcinogens.
So remember in acute diverticulitis, have a low residue diet till the inflammation is resolved, because the fiber will be like sandpaper on the raw inflamed tissue. For resolved diverticulitis and for preventive health in diverticulosis, eat extra fiber and fluids to support your intestinal health as well as cardiovascular and cancer prevention.
Low Residue Diet [gview file=”http://refluxny.com/wp-content/uploads/low-residue-diet-2012.pdf” save=”1″ force=”1″]