You probably wouldn’t trade places with someone living in a developing country. Your doctor might tell you however, that you’d probably be healthier if you were eating the diet many people eat in third world countries. In the United States, we eat too much fat, too many calories, and not enough bulk.
Probably because of diet, diverticular disease is a phenomenon peculiar to developed countries. A similar prevalence to that of the United States can be found in England, Western Europe and Australia. In third world countries of Asia and Africa, on the other hand, the disease is rare, with a prevalence of only .2 percent. Compared to Western countries, the diet in these developing countries is much higher in fruits, vegetables, whole grains and fiber. And studies show that persons from third world countries who migrate and start eating a Western diet have a high risk of developing diverticulitis within 10 years. In the United States, the disease was first diagnosed in the early 1900s, at a time when new milling technology allowed a reduction of the fiber content of grains and the introduction of refined food products.
What is Diverticulosis
Diverticulosis is a condition in which small pouches develop in the colon. The colon bulges outward as the contents inside press against weakened spots in the bowel wall. About 10 percent of American adults develop diverticular pouches by the age of 40. More than half are believed to be affected by age 60.
While these pouches may not cause any dramatic symptoms right away, waste matter can become trapped in them. Trapped waste matter can make the pouches vulnerable to infection and cause a fairly serious condition known as diverticulitis. Diverticulitis is an inflammation of the colon. It may lead to bleeding, tears or blockages in the bowels. About 20 percent of persons with diverticulitis eventually develop complications serious enough to require surgery. Serious complications such as pelvic abscesses or peritonitis can also occur.
What Causes Diverticular Pouches?
Diverticular pouches can develop anywhere in the gastrointestinal tract. They are most common in the large intestine. The most likely explanation is that weak spots in the bowel wall give way due to increased pressure–usually because of hard stools and constipation. Smoking and regular intake of NSAIDs (nonsteroidal antiinflammatory drugs) are other risk factors.
How is Diverticulitis Treated?
A high-fiber diet keeps stools soft and moving rapidly through the bowels. Drinking plenty of fluids and exercising also helps. The recommended goal to prevent or treat diverticulosis, however, is 25 to 30 grams of fiber a day. It’s not easy to take in that much fiber with the typical American diet. A medium apple has 3.3 grams; a cup of cooked oatmeal, 4 grams; a slice of whole wheat bread, 1.95 grams. Most Americans would feel virtuous eating that much fiber, even though it’s less than a third of what they really need. In addition, many are discouraged by the bloating and gas that occur with a drastic change in fiber intake. This dietary change requires gradual implementation.
How and When is Diverticulosis Detected?
With aging, intestinal walls may become weaker, but diverticulosis can occur at any age. Early signs may include cramps, bloating and constipation. But the pouches themselves are generally no problem except as a possible source of infection.
The first sign of diverticulitis may be rectal bleeding–which can also be a symptom of hemorrhoids or colon cancer. The bleeding may come from rupture of a blood vessel in the diverticular pouch and, even if it seems rather severe, may stop by itself. Any bleeding is reason to see a doctor and persistent bleeding could be a medical emergency.
Other symptoms of diverticulitis, such as pain, tenderness or cramping, vary according to where they occur in the colon and are easy to mistake for other medical problems, such as appendicitis, peptic ulcer, pelvic inflammatory disease or inflammatory bowel syndrome. To make a diagnosis, a doctor usually relies on a blood test and imaging scans as well as a history.
A simple infection may clear up with oral antibiotics. Other treatment includes: bowel rest, at first, followed by a high fiber diet, sometimes combined with a fiber product such as Citrucel or Metamucil.
Traditionally, doctors have advised patients to avoid nuts, seeds and popcorn on the theory that particles could enter and irritate the pouches. There is no scientific evidence for this belief, however, and many doctors are reconsidering it. Keeping a food diary helps patients discover what tends to make the condition worse.
What are the Possible Complications?
If infection is neglected too long or becomes severe, an abscess may form with pus, swelling and destruction of tissue. When small holes develop in the bowel wall, pus can leak into the abdominal cavity. At times, it’s necessary for a doctor to drain an abscess with a needle inserted through skin or through surgery. If an infected or inflamed pouch ruptures, intestinal waste is released into the abdominal cavity, leading to peritonitis–a life-threatening emergency.
Another possible complication is a fistula. A fistula occurs when damaged or infected tissues come into contact with each other and stick together–such as intestinal tissue with the bladder or abdominal wall.
About one of five patients with diverticulitis requires surgery–either on an emergency basis or to treat recurrent attacks. When there’s a blockage, a fistula or a severe abscess, emergency surgery may be required. The affected part of the colon is removed and the surgeon usually creates a temporary colostomy, with stool going into a bag attached to an opening in the abdomen. The severed ends of the colon can then be rejoined at a later time, once the infection has cleared. When a procedure is performed for recurrent, but not life threatening, problems, the two ends of the colon may be stitched together during the initial surgery.
While diverticulosis is rarely a serious problem, careful attention to the possible complications can help prevent them. Most importantly, lifestyle changes which prevent the condition are essential and simple solutions.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director
Richmond Apothecaries, Inc.
