Dear Friends,

Diverticulosis and Diverticular Disease:  What to do outside the hospital.

By Artemis Morris ND

Diverticulosis is a condition of bulging pockets of potential inflammation and infection. Diverticulitis may develop in the large intestine (colon), and is characterized by severe abdominal pain and fever.  These pockets, or diverticula, are common in the Western world but are rare in areas of Asia and Africa that are consuming a traditional high-fiber diet.  74 % of people over 80 years old have diverticular disease and the risk of developing these pockets increases with age, especially after 40 years old.1 You may have diverticulosis and not even know it since the symptoms can be mild (abdominal pain, diarrhea, constipation, mild bleeding) unless infection occurs. Infection with diverticulosis usually requires hospitalization and can present as severe abdominal pain. Fortunately, acute diverticulitis doesn’t need to reoccur, especially when changes in diet and supplementation are implemented along with conventional care. Outpatient treatment is safe and effective for approximately 90% of patients with uncomplicated diverticulitis and allows important costs saving to health systems without a negative influence on quality of life for patients with uncomplicated diverticulitis, and reduces health care costs by more than 60%.6

The current standard of care in the US for acute diverticulitis is antibiotics and a low fiber/residue diet with a high fiber diet recommended later for prevention.  Some recent studies have brought standard of care with antibiotics under question, such as, the study by Lanas et al. (2013) in Spain.  Lanas et al.’s epidemiological study of 228 patients who received the antibiotic riflaximin with fiber or fiber alone, found that there was a 20% recurrence when receiving antibiotics and fiber and only a 10% recurrence when receiving fiber alone.2 Surgery may also not be the best option for patients. Tursi’s (2012) study showed that 25% of patients who had elective surgery for diverticulitis experienced persistent abdominal symptoms.5

The biggest risk factors for developing diverticular disease are a low fiber diet and history of constipation.  Chronic constipation can increase the pressure in pockets of the colon until they bulge, causing diverticuli, which is a weakening and herniation of the colon wall.  Addressing chronic constipation early on with diet changes and probiotics may also be preventative. The contributing factors to developing diverticular disease include diet, colonic wall structure, intestinal motility and possible genetic predisposition.2

A Medline and Cochrane Database review of studies on diverticulitis between January 1, 2000 and March 31, 2013 found that diverticulitis presents with altered gut motility, increased luminal pressure, and a disordered colonic microenvironment (microbiome). They concluded that studies demonstrate a lesser role for aggressive antibiotic or surgical intervention for chronic or recurrent diverticulitis than was previously thought necessary.So what do you do if antibiotics and surgery are not warranted? The role of probiotics and fiber along with dietary changes may be your best choice for treatment.

25-30 grams a day of fiber is recommended by the ADA even though more clinical studies are still needed for diverticular disease. Fibers that are incompletely or slowly fermented by the microflora in the large intestine are best for treating constipation and preventing the development of diverticulosis and diverticulitis. The ADA asserts that “a diet adequate in fiber-containing foods is also usually rich in micronutrients and nonnutritive ingredients that have additional health benefits and a fiber-rich diet is associated with a lower risk of colon cancer.”9 A review article found that insoluble fiber, especially the cellulose in fruits and vegetables, may be especially important in preventing diverticulosis. The ADA’s Manual of Clinical Dietetics states, “Fiber can lower postprandial intraluminal pressure, and although there is no evidence that decreasing the pressure will prevent diverticulitis, it is a rational therapy until a definitive answer is found”. 10

Besides diet, the bacterial balance in the colon plays an essential role in the development of diverticulitis and diverticular disease. Probiotics, which are beneficial bacteria found in highest concentrations in the colon, can protect the gastrointestinal wall against infection, help promote normal stool development, and act a protective barrier to pathogenic bacteria. Tursi (2012) found that “probiotics inhibit pathogen adherence, improve mucosal defense by enhancing the integrity of tight junctions, decrease bacterial translocation, stimulate immunoglobulin A secretion in Peyer patches, enhance immune system activity by controlling the balance of pro and anti-inflammatory cytokines, interfere with pathogen metabolism, and have the ability to restore balance to enteric flora, primarily by decreasing the number of pathogenic gram-negative bacteria.”5

A double-blind placebo controlled trial of 210 patients receiving 10 days of treatment for 12 months found that a combination of mesalazine plus 24 billion active Lactobacillus case DG (0% reoccurence) was more effective than mesalazine alone (14% reoccurence) at preventing reappearance of abdominal pain for at least 24 hours. Furthermore, patients taking mesalazine alone has a similar results to patients taking the probiotic alone (13.7% vs 14.% respectively.)4 A study by Giaccari et al. (1993) using Lactobacillus sp. following rifaximin in 79 patients with colonic stenosis post-diverticulitis, found that most remained symptom-free for a period of one year. 7  Another study found that a combination of balsalazide and a broad-spectrum probiotic called VSL#3 was better than VSL#3 alone in preventing recurrence of diverticulitis, even though they were not statistical significance (73.33% versus 60%, P,0.1).8  The use of polybactertial lysate suspension has also shown promise in clinical trial of diverticulitis.

Beta Glucan High Potency Synbiotic is one of my favorite products to use for diverticular disease because it is easy-to-use, it combines the best of both worlds in terms of prevention and management of diverticular disease, and is formulated with soluble and insoluble fiber prebiotics and probiotics.  It contains a broad spectrum probiotic, prebiotics, and fiber: 33 billion cfu/tbl of certified strains of pedigreed probiotic with Therapeutic Foods in a synbiotic formula of L. acidophilus, B. longum, L. rhamnosus, L. plantarum, S. thermophilus and 5 grams of patented oat bran (75%) with high levels of beta glucan (10%), organic whole red beet root (15%) and organic inulin derived from chicory fiber (10%).  A patented heat shearing technology is used to liberate the soluble beta glucan fiber, while disabling phytate’s ability to block the absorption of minerals. Advanced freeze-drying technology is used to dry the remaining components.

Inulin stimulates the production of Bifidobacterium species and is considered a soluble prebiotic fiber, which by definition, resist digestion in the human small intestine and reaches the colon where they are fermented by the gut microflora (preferentially consumed by the Bifido and Lactobacillus genuses. As was stated previously, both probiotics and soluble fibers such as inulin have been found to be beneficial in diverticular disease.

The choice of beta-glucan fiber, derived from oats, has immunomodulating properties which may aid in further supporting a fortress of biofilm health in the gastrointestinal system. Beta-glucan, similar to the slippery oats from which it is derived, may act as a demulcent to the digestive tract, which can help to imbed the probiotics in the biofilm and build back the disrupted biofilm lining of the digestive tract that is essential for optimal gastrointestinal health.

In addition to the safety and scientific support for the use of probiotics and fiber in diverticular disease, the most important reason why I have confidence in using Beta Gluten High Potency Synbiotic for my patients is the clinical benefit I have seen in my patients over time.  I have collected numerous case studies finding Beta-Glucan to be safe and effective in my patients with diverticular disease and would like to see more clinical studies on the subject to test my findings.  Most people also find the taste slightly sweet and pleasant and enjoy the convenience of adding 2 tbs of powder to water and drinking it before bed, rather than needing to swallow capsules.  The only types of patients which I am cautious in using Beta-Glucan are those with Celiac Disease since the beta glucans are derived from oats, which has negligible amounts of gluten (0.02%), but may sometimes find it to be incompatible due to cross-reactivity.

While every patients’ needs should be individualized, probiotics, prebiotics, and fiber is found to support a healthy biofilm, and in combination with an anti-inflammatory diet are essential components in restoring health and digestive function. The treatment will also relieve the intense pain and unpredictability that is a source of stress in patients with diverticular disease, and very importantly, will help to prevent reoccurrence of acute symptoms.

Inflammation in diverticulitis can be detected by testing fecal calprotectin.  Future studies aimed at testing products, such as Beta Glucan High Potency Synbiotic, that combine probiotics, prebiotics, and fiber may be a novel and safe approach to addressing diverticular disease in the future.

References:

1.  Diverticulitis Diet.http://www.webmd.com/digestive-disorders/diverticulitis-diet. Reviewed by Jennifer Robinson, MD on January 24, 2015. Accessed on April 30th, 2015.

2.  Lanas A, Ponce J, Bignamini A, Mearin F. Rifaximin plus fiber supplementation
versus fiber supplementation alone to prevent diverticulitis recurrence: a proofof-concept study. Digestive and Liver Disease. 2013;45:103–8.

3.  Arden M. Morris, Scott E. Regenbogen, Karin M. Hardiman, Samantha Hendren . Sigmoid Diverticulitis: A Systematic Review. JAMA. 2014 ;311(3): 287-297, <http://ejournals.ebsco.com/direct.asp?ArticleID=49598939BED8B820649B>

4. Tursi A, Brandimarte G, Elisei W, Picchio M, Forti G, Pianese G, et. al.  Randomised clinical trial: mesalazine and/or probiotics in maintaining remission of symptomatic uncomplicated diverticular disease – a double-blind, randomised, placebo-controlled study.  Alimentary Pharmacology & Therapeutics. 2013;38(7):741-751.

5. Tursi, A. Advances in the management of colonic diverticulitis. CMAJ. 2012, 184(13):1470-1476.

6. Tursi, A. Efficacy, safety, and applicability of outpatient treatment for diverticulitis. Drug. Healthcare and Patient Safety. 2014; 6:29–36.

7. Giaccari S, Tronci S, Falconieri M, Ferrieri A. Long-term treatment
with rifaximin and lactobacilli in post-diverticulitic stenoses of the
colon. Eur Rev Med Pharmacol Sci. 1993;15(1):29–34

8. Tursi A, Brandimarte G, Giorgetti GM, Elisei W, Aiello F. Balsalazide
and/or high-potency probiotic mixture (VSL#3) in maintaining
remission after attack of acute, uncomplicated diverticulitis of the colon.
Int J Colorectal Dis. 2007;22(9):1103–1108.

9. Position of the American Dietetic Association: Health Implications of Dietary Fiber
Judith A Marlett, PhD, RDa, Michael I McBurney, PhDb, Joanne L Slavin, PhD, RDc. Journal of the American Dietetic Association. 2002; 102 (7): 993–1000.

10. Van Duny MA, Pivonka E. Overview of the health benefits of fruit and vegetable consumption for the dietetics professional: Selected literature. J Am Med Assoc. 2000; 100: 1511-1521.

Disclosures: Dr. Artemis Morris is on the advisory board for Bioimmersion, but is not receiving any monetary gain for writing this article.

I hope you enjoyed and learned from Dr. Morris’ article!

Sincerely yours,

Seann Bardell
BioImmersion.com

Clinical Note:

Suggested use of the Beta Glucan High Potency Synbiotic: two tablespoons in a tall glass of water. Mix and drink.
We have also found out from other doctors that adding the Phyto Power and/or the Blueberry Extract helps reduce inflammation in the gut. For extra fiber, the Energy Sustain is excellent! Take one heaping tablespoon in water. You may add it also to the Beta Glucan mix. The Energy Sustain is smooth to drink (like the Beta Glucan) and is gluten free.

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