The human bowel is a complex place in which there are many important structural elements including sphincters, valves, smooth muscles and mucosa (to name a few). Moral of the story – the digestive tract isn’t a basic food tube. There are lumps, bumps, and divots that are completely normal. However, there are also structural abnormalities that can be problematic in the bowel and prevent digestive processes from working properly.
What are diverticula?
One of these potential structural issues are called diverticula. Which are herniations (or pockets) that can form within the walls of the intestines. These pouches can be small or large, but are often only as small as 5 to 10 millimetres in diameter. Diverticula mostly develop in the sigmoid colon (the last part of the large intestine). But, they can develop throughout any part of the small or large intestines. For many, having diverticula is a big health concern. As the diverticula can become inflamed and infected. Resulting in gastrointestinal symptoms and poor quality of life.
Diverticulosis vs. Diverticulitis
Diverticular disease is an umbrella term we use to encompass two different disease states – diverticulosis and diverticulitis. Although these words look pretty similar, they are indeed quite different. Let me break it down for you:
Diverticulosis is simply defined as the presence of diverticula (those tiny pouches in the intestines). It is actually very common, especially with advancing age. Many people have diverticulosis without any significant symptoms or complications.
On the flip side, Diverticulitis occurs when the diverticula become inflamed or infected. About 10-25% of the population with diverticulosis go on to develop this inflammatory condition. We’ll be reviewing this particular disease state today. As well as how we can use diet and lifestyle to reduce symptoms and long-term risks associated with diverticulitis.
Symptoms of Diverticulitis
As mentioned above, many people go years (or even a lifetime) without showing any symptoms of diverticular disease. Many people don’t even know they have it!
However, when the pouches become infected and/or inflamed, the following symptoms can occur:
- Abdominal pain or cramping – often in the lower left abdomen
- Bloating & Distention
- Nausea and/or vomiting
- Blood in the stool
- Unintentional weight loss
With chronic and recurrent diverticulitis flare-ups, individuals are at higher risk of bowel obstruction, fistula, or abscess (pus collecting in the diverticula).
Flare-ups of diverticulitis can be very intermittent and acute or chronic and extended over a longer period of time.
Like many digestive disorders, the symptoms of diverticulitis are non-specific. It can be linked to a number of different conditions including irritable bowel syndrome, crohn’s or celiac disease.
Although the symptoms are very similar to IBS, the diagnosis of diverticulitis differs in that diverticula are structural and can be detected on imaging. IBS, on the other hand, is a functional gut disorder and is diagnosed symptomatically. It won’t have anything “show-up” in imaging. Diagnosis of diverticulosis (the non-inflamed state) often occurs during a routine colonoscopy. Such as the one many people get around age 50.
In contrast, diverticulitis is most often diagnosed after an acute attack causes symptoms such as the ones listed above. Due to the non-specific nature of these symptoms, diverticulitis can be difficult to pinpoint right away. Especially if someone is not aware they have diverticula in their bowel.
In order to diagnose diverticulitis, your healthcare team may do any or all of the following:
- Comprehensive assessment – looking at your past medical history, family medical history, symptoms, and lifestyle
- Physical exam
- Collection of blood samples to assess complete blood count and detect inflammation in the body
- Abdominal imaging including x-ray, CT, or ultrasound
- Referral to a gastroenterologist for a colonoscopy
Management of Diverticulitis
Treatment of diverticulitis can differ based on the severity of abdominal pain, fever and other symptoms and combines both dietary and antibiotic treatment. In extreme cases, people may also require hospitalization or surgery in order to adequately recover from an infection of the diverticula 2.
The initial dietary management of an acute flare-up of diverticulitis often consists of a short-term clear fluid diet. Meaning the patient consumes only liquids such as water, juice, jello, and broth. This allows antibiotics to start working and allows the gut to rest. Helping to clear out material that may be caught in their diverticula pouches, as this can cause bowel obstruction and pain. Being full of stool or constipated is often linked to poor diverticulitis outcomes. So, the goal of the clear fluid diet is to reduce the amount of fibre (and therefore fecal matter) in the colon.
From there, as inflammation and symptoms reduce, more solids and fibre can be added back into the diet gradually. The goal is to work toward a low fibre diet of about 10-15 grams fibre daily for a short period of time. Due to the specific requirements of this diet, it is highly recommended to work with a registered dietitian to understand the fibre content of different foods. As well as to get enough overall nutrition to support yourself and prevent unintentional weight loss.
Within a few weeks of an acute diverticulitis attack, most people can work toward a higher fibre diet as their symptoms continue to subside. For women, this is around 25 grams of fibre daily and for men, 38 grams.
What about the low FODMAP diet for diverticulitis?
Another emerging area of dietary research is on the low FODMAP diet for diverticulitis. Although the low FODMAP diet was developed for irritable bowel syndrome, there are some studies to suggest it could be beneficial for those with diverticulitis as well. The theory behind this is that diverticula can be irritated when there is increased pressure in the colon. Lots of pressure and gas in the bowel is likely to push on the mucosa of the colon and could then create pouches or enlarge the pouches that already exist. Therefore, a diet lower in fermentable carbohydrates such as the low FODMAP diet may also improve symptom outcomes for diverticulitis patients 4. However, this is still a relatively new area of research for diverticulosis. Consideration of a low FODMAP diet (or any elimination diet) should be discussed with a registered dietitian first.
Old beliefs about diverticulum
In the past, it was believed that small particles of food such as seeds, nuts and popcorn would worsen diverticulitis or increase the incidence of diverticulitis attacks. This has since been unfounded in the literature and these foods are considered safe to consume. Particularly during remission of diverticulitis. In fact, they are quite healthy for us! Nuts and seeds offer lots of healthy fats that actually help to reduce inflammation in the body.
That being said, it may still be beneficial to reduce our intake of these foods during diverticulitis flare-ups. As they are higher in fibre than other foods.
Key Take-aways about Diverticular Disease
- Having diverticula is common, particularly in the aging population and is often completely asymptomatic.
- Diverticulitis treatment in most cases requires dietary changes. Specifically a reduction in dietary fibre to allow the gut to rest and clear fecal matter from the colon.
- Working with a registered dietitian is highly recommended to help take care of those diverticular pockets. As well as to help manage symptoms associated with your diverticular disease.