Diverticular Disease
In this section, Mary and Geoffrey keep sufferers up to date with the latest Diverticular Disease news.
Geoffrey Hutchinson, Consultant Surgeon (MD FRSC Eng FRCS ED) for 21 years with an interest in gastroenterology, has his own private practice in the
North West.
Mary Griffiths, Retired Pharmacist and Biologist (PhD CBiol) who herself was diagnosed with diverticular disease at the age of 32 and has had over 30
years experiencing and researching its problems.
Key topics - treatment, research and management methods (including diet)
Constipation, Diarrhoea and a Normal bowel habit
The affect of a diet change over the festive period
www.diverticulardisease.needs.you
Getting personal with diet
The overlap between IBS and Diverticular Disease
How diet affects Diverticular Disease
Constipation, Diarrhoea and a Normal bowel habit
Mary Griffiths (PhD CBiol (Retired Pharmacist and Biologist)) explains what is �Constipation�, �Diarrhoea� and a �Normal� bowel habit.
Scientists desperately try to put values on body functions to measure and classify symptoms. This enables statistical comparisons to evaluate the
effects of diseases and treatments. Defaecation is a good example of this and also of the influence of history, fashions and personal opinions.
For example, faeces are currently fitted into seven categories according to their appearance as shown in Table 1. Types 3 to 5 are considered
�normal�. Types 6 & 7 indicate �diarrhoea� and Types 1 & 2 are the result of slow movement through the colon giving �constipation�.
�Normal� performance as measured by the number of daily visits to the toilet has changed with fashion over the years. In the good old days when
laudanum (opium tincture) was a favourite tipple, its constipating effects might have lead to the use of laxatives to meet a once-a-day ideal. A range is now recognised
as normal � not more than 2-3 times a day but more than 2-3 times a week. Some writers suggest that after every meal is the ideal frequency, but people with this as a
type of Irritable Bowel Syndrome (IBS) would certainly not agree.
Comparisons made between Western and African diets in the 1970s lead to an ideal faeces daily weight of 500g. This hardly seems achievable compared
with the usual values shown in Table 2. Endemic dysentery does not appear to have been considered in the promotion of African values as the western goal. More recently,
one English gastroenterologist has written that the passage of more than 200g of stool a day should be considered diarrhoea. This would include the effects of most
vegetarian diets.
In the 1970s years of fibre frenzy it was suggested that not enough fibre was being eaten if faeces did not float. However undigested fat can have
the same effect, so that theory did not last long.
The problem is that colons don�t read text books, and even if their owners do, bowels don�t always do what is expected. Is �expectation� part of
the problem in deciding what is normal and what is not. Other body functions vary according to what is required and so will defecation be influenced by lifestyle and
eating habits. An upbringing trying to conform to standards such as daily performance may lead to greater use of laxatives which was sometimes encouraged by health
professionals and still is in some �detox� therapies of alternative medicine. Even in the 1972 trial of wheat bran for diverticular disease, the aim was a once-a-day
visit to the toilet. By today�s definition, the frequency was normal even before the trialists started taking bran.
The convenience of bowel habits is also important in deciding if treatment is needed. Frequent calls to stool in a morning is not a problem at home
but devastating if setting out on a long journey or attending an important social function. Urgency and its opposite are not often mentioned, or quantified by the
scientists. Finding public toilets is a problem for the mobile, the problem of urgency is magnified in the frail, arthritic or bed-bound. Most people would include
frequent, urgent or accidents as diarrhoea. A long time needed for defecation might be called constipation or contribute to this if inconvenient.
The time taken for food to pass from mouth to anus is known as �transit time� and can be measured in hours/days. This has been used to measure the
effects of diets, treatments and diseases such as diverticular disease. Control groups, if they were used, could be student volunteers or people of the same age with
other diseases and their drugs. Is this really a measure of normal? We know that eating more fibre produces a shorter transit time with larger, less dried stools. This
could help reduce straining � another problem which cannot be quantified which people call �constipation� More dietary fibre can change the appearance of faeces from Type
1 or 2 towards Type 6 or 7 (see Table 1). This is a normal physiological response to the extra work given to the colon, but even a healthy person has to decide when
�normal� changes to �diarrhoea� If the colon is not functioning correctly and input exceeds output, then extra fibre could lead to pain, discomfort or bloating which
would be considered �constipation�. Thus personal comfort becomes another critical factor in deciding what is �normal� and nobody else can put a value on this.
There are situations which do not fit in with the statistics and traditions.
- Passing small hard faeces 4 or 5 times a day is not diarrhoea but an indication of the bowel struggling to overcome constipation.
- Watery faeces with urgency when call to stool has been infrequent may not be diarrhoea but caused by hard and stuck faeces (impaction)
with excess mucous lubrication and a result of constipation.
- Drugs such as loperamide, sometimes taken before a social occasion can stop bowel movement for 1 or 2 days. Some people call this
constipation. Catch-up day, with several visits to the toilet when the drug effects have worn off is sometimes referred to as diarrhoea. A migraine attack, even
without head pain, can have the same effect.
- If the colon has been emptied by a bout of diarrhoea there may be no call to stool for 1 or 2 days until faeces build up again. Some
people consider this period to be constipation.
A survey was completed in 2001 by 230 people with diverticular disease (DD) which examined their interpretation of bowel habits. 95% of these
people had pain but constipation was not the prominent and persistent characteristic so often attributed to DD. The majority had variable habits even when they considered
themselves to have constipation, diarrhoea or were regular. (Table 3) This variation with DD is a great cause of difficulty in finding diets, treatments and lifestyle
which provide predictability, stability and comfort. These variations and their interpretation are shown in the table.
Diarrhoea needs treatment when prolonged and serious, non-infectious diarrhoea can be self-limiting. Constipation is best approached by long term
prevention. What is meant by �constipation� �diarrhoea� or �normal� appears to be a very personal interpretation. It is essential when consulting a health professional to
make sure that both of you are talking about the same problem. Changes in habit, persistence or increase of symptoms, new symptoms such as fever, weight loss or bleeding
from the back passage should be reported and investigated. Also consider that if laxatives and antidiarrhoea drugs regularly appear on your supermarket shopping list then
perhaps professional advice is needed.
� Mary Griffiths 2005
TABLE 1. CATEGORIES OF FAECES BY APPEARANCE
TYPE |
APPEARANCE |
1 |
Small separate hard lumps |
2 |
Like lumps stuck together |
3 |
Sausage shaped with cracks and lumpy surface |
4 |
Soft sausage shaped, smooth surface |
5 |
Soft blobs with definite shape |
6 |
Mushy blobs |
7 |
Watery with no solid parts |
TABLE 2. AMOUNT OF FAECES PRODUCED DAILY WITH DIFFERENT DIETS
TYPE OF DIET |
WEIGHT (g) OF FAECES PER DAY |
PROLONGED FASTING |
10 � 25 |
MEAT DIET |
50 � 70 |
MIXED DIET |
60 � 250 |
VEGETARIAN DIET |
200 � 370 |
RURAL AFRICAN DIET |
500 |
TABLE 3. HOW 230 PEOPLE WITH DIVERTICULAR DISEASE DESCRIBE THEIR BOWEL HABITS.
CHOSEN CATEGORY |
NUMBER OF PEOPLE |
% OF TOTAL |
NOTES |
REGULAR |
25 |
11% |
Nobody had frequency less than twice weekly, most were once daily. Only these people did not have type 1 faeces, most were
like type 4. Straining reported by 3 people |
CONSTIPATED |
31 |
13% |
Nobody had frequency less than twice weekly, most were variable or daily. 3 people had type 7 and 11 had type 1 faeces,
others were �normal� 12 people had straining |
DIARRHOEA |
41 |
18% |
1 person less than twice weekly, most were more than 3 times daily or variable frequency. 4 people had type 1 faeces, most
were types 5 � 7. The was the only category with no straining |
VARIABLE |
133 |
58% |
1 person less than twice weekly, 8 people daily, most were variable. Most varied between both extremes of faeces types. 42
people reported straining. |
� Mary Griffiths 2005
The affect of a diet change over the festive period
�Spring is nearly in the air and the Christmas celebration seems a distant memory. Every gastroenterologist sees an influx of patients in the
clinic in the first few weeks of the New Year. We are all tempted to change our diets during the festive season with nuts, fruits and exotic chocolates and mincemeat.
Never mind the calories and inevitable weight gain, the change in roughage content and colonic fermentation often leads to bloatedness and a change in bowel habit, even
without any diverticular disease. In the presence of colonic out-pouchings and cul-de-sacs the gas production can lead to acute pain and colic or even an attack of
diverticulitis with inflammation and bacterial infection. Diverticular disease patients often do best if they adhere to a regular diet, which suits their own system.
TREATS ARE NICE BUT YOU MAY PAY THE PRICE.
In January and February, TV and glossy magazines bring the usual rush of holiday adverts demanding a bikini figure. There is always a corresponding
crop of diets to reduce weight and fulfill the dreams of all those long forgotten New Year resolutions. Calorie controlled diets often include bulk forming cellulose
which we find difficult to digest (unlike cows!) and this may also cause sever gas production. Many of you will have tried every sort of diet known to mankind but still
find it hard to lose weight, with or without the help of �Slimming World� or �Weight Watchers�. Some may find so called very low calorie diets much more effective, but
close medical supervision is required. I often recommend LIPOTRIM as a total food replacement diet where weight loss can be achieved safely and rapidly (www.lipotrim.demon.co.uk) even in patients with diverticular disease.
We always try to raise the �glamour rating� for diverticular disease by spotting celebrities in the news having treatment. Many thanks to all of
you who wrote to let me know that John Cleese of Monty Python and Fawlty Towers fame underwent tests and surgery for diverticulitis in Santa Barbara, California last
autumn. Cleese retained his sense of humour and told friends that he was auctioning the removed part of his colon on his website! What about �I�m a celebrity colon �..
get me out of here!��
www.diverticulardisease.needs.you
Mary Griffiths (PhD CBiol (Retired Pharmacist and Biologist)) explains how Diverticular disease sufferers can help push for better treatment and badly needed research,
and how to look after DD through diet.
�Ask an internet search engine what the world-wide web has on diverticular disease and it will give over 80,000 answers. A lot of information is
repeated about the changes to the colon, treatment by a high fibre diet and eh serious complications which can be caused by the disease. Some medically based sites
emphasise the complications, others minimise the complications and many sites sell all kinds of products to �help prevent� the complications.
With all this information and knowledge directed to the sufferer of diverticular disease, why do they have any problems? You will not find any
sites where the information flows in the opposite direction, where the experience of fellow sufferer with day-to-day problems is both comforting and invaluable. Unlike
other disease such as IBS, colitis and Crohns or celiac disease, there does not appear to be any patient support group or charity taking on diverticular patients anywhere
in the world except Incontact.
When first diagnosed, many people particularly the elderly do not have internet facilities and do not realize that there are thousand of people
around the world just like them. If sufferers could get together, exchanging information, support and friendship through Incontact, by letter, phone or e-mail then there
would be a powerful voice to push for better treatment and badly needed research. As a group they could also help with that research.
For example, in July 2003, there was a summary of research paper on the internet * which examined the quality of life of patients with diverticular
disease compared with healthy people. Four aspects were measured � bowel symptoms, general body symptoms, emotional symptoms and social function. The quality of life of
diverticular disease patients were significantly reduced in all these ways, particularly in bowel and emotional symptoms. Many individual patients have known this for a
long time before 2003, but as a group would have had more chance of being listened to.�
* Diverticular disease has an impact on quality of life � results of a preliminary study. Bolster LT, Papagrigoriadis S. Colorectal Dis. 2003 Jul:
5(4): 320-3
Getting personal with diet
�When somebody is diagnosed with a disease, after months of symptoms and test, they quite reasonably expect that a treatment is available for their
condition. For example, inhalers for asthma, nitrates for angina, drugs to control Parkinson�s disease symptoms or vitamin C for scurvy. 30 years ago diverticular
disease (DD), like scurvy, was considered a deficiency disease which could be prevented and treated by increasing the amount of fibre in the diet with wheat bran. Diet
sheets and recipes were handed out and, with a few existing bowel drugs for symptoms, the disease was sorted out. Nothing could be done about the diverticula once they
had been formed, so a high fibre diet was and often still is the treatment on offer.
This is 2005, has anything changed since the 1970s?
Reviews show that the old trials and drugs were not up to today�s standards and there is no clinical evidence to show that they work. Wheat bran
has fallen out of favour � even a food supplement can have side-effects when used disproportionately. Wholegrain cereals are now recommended. People who have few or
no problems with DD do not need different diets or recipes. They can follow the �5 portions a day of fruit and vegetables� currently promoted as a healthy diet for
everyone. The importance of variety and plenty of fluids should be emphasized and food should be enjoyed.
Getting �personal� is perhaps the key to looking after DD by diet because the aim is to achieve �personal� comfort with bowel habits. The symptoms
of DD can vary between one and none and serious complications. A person can have distinct painful attacks (not always due to infection), frequent minor problems, daily
incapacitating pain, an variation of constipation/diarrhea and any combination of these over time. It is not surprising that there is no universal diet, drug or
complementary therapy that works for everybody or, indeed, the same individual over time, or could be demonstrated in a trial. It still makes sense to use dietary fibre
as the first option to avoid constipation but not if there is infection and inflammation (diverticulitis) when the bowel needs rest.
When problems do occur, a lot of �personal� detective work is needed. A survey of over 200 people with DD showed that the main dietary offenders
were:-
- GAS-PRODUCING VEGETABLES � sprouts, cabbage, onions
- FRUIT � citrus fruits and juices
- RICH AND SPICY FOODS � curry, Chinese
- FATTY FOODS � processed, chocolate, pastry
- DAIRY FOODS � milk, cream, yogurt, cheese
Some people could eat seeds and nuts, others could not. Different brands can have different effects e.g. if a probiotic drink also contains a
soluble fibre. Reducing portion size and frequency, and finding alternatives may be the answer rather that having a restricted diet. Keeping a diary is a constructive
way of sorting out what causes painful gas and diarrhea, but also look for causes of constipation. Not all bowel upsets can be explained by diet and a diary may reveal
other relevant circumstances, activities or occasions. The aim is to be able to avoid and predict problems and this gives less worry and stress, and a sense of
control.�
Consultant Surgeon and Gastroenterologist Geoffrey Hutchinson (MD FRCS Eng FRCS ED) looks at the increase in western society of
Diverticular disease in a younger population.
�In past articles we have identified that diverticular disease (D.D.) is regarded as an acquired disorder of the colon induced by a relative lack
of dietary fibre. Most think that hypersegmentation, produced by delayed colon transit and disordered peristalsis (the �sausaging� process that moves stools and residue
in the bowel), and high intra luminal pressures in the �inner tube� which is the large bowel, result in mucosal �blow outs� or pulsion diverticula.
Diverticular disease is increasing in incidence generally, in western society, and appears to be affecting a younger population. This is amply
illustrated by the case of a family friend whom I visited on holiday in Barbados last week. He is 33 years old and developed what the surgeons at the Queen Elizabeth
Hospital in Barbados thought was acute appendicitis. They operated via a small skin crease incision in the right lower abdomen only to find a normal appendix but pus
in the pelvis from an inflamed diverticulum of the sigmoid colon, which in this case was situated centrally in the abdomen rather than on the left side. The incision
was extended and the whole area washed out with diluted hydrogen peroxide. The wound was closed and he was allowed home a few days later on antibiotics. Unfortunately
he did not settle and was re-admitted after a week with a high temperature, signs of peritonitis and septicemia. The abdomen was re-explored and the diverticulum had
perforated and our young friend required resection of the affected bowel and the contained abscess and a temporary transverse colostomy to rest the affected area. He
quickly settled and in about 6 months time he will have the colostomy closed and continuity restored.
Interestingly diverticulitis is often described in terms of �left sided appendicitis� and the two problems can be confused in the acute stages. Of
course, the appendix itself is really a rather long and thin diverticulum and about one person in 6 or 7 develops appendicitis at some time.
Even on holiday in sunny, tropical Barbados, I can�t escape the problems of D.D.�
The overlap between IBS and Diverticular Disease
Surgeon and gastroentorologist Geoffrey Hutchinson explores the overlap between symptoms of the disease and irritable bowel syndrome (IBS).
�Diverticular Disease (DD), where out-pouchings, or benign cul-de-sacs develop from the lining of the colon (diverticulosis) is extremely common in
Western society. Probably more than half those aged 60 and over have these colon pockets which herniate through the muscle coat of the large bowel. However, although it
is irreversible, the diverticula (plural of diverticulum) only very rarely cause symptoms. Only 1 in 5 affected will ever suffer symptoms and signs of illness
(diverticulitis) and only a tiny minority endures serious of life-threatening complications. Less than 1 in 10,000 have DD contributing to fatality.
There is, however, an overlap with irritable bowel syndrome (IBS) symptoms and many people have both DD and IBS. IBS is a functional bowel disorder
and four symptom patterns are common:
- Visible abdominal distension
- Pain relieved by bowels opening
- Looser stools with pain bouts
- More frequent bowel movements with pain onset
Over 90% of IBS patients have two or more of 1-4, whereas the majority with true DD or have only one or two of 1-4. IBS accounts for more than one
million GP consultations per year in the UK and more than 25% of the population have IBS symptoms. IBS ranks close to the common cold as a leading cause for absences
from work. IBS is also known as mucous colitis, spastic colon or irritable colon.
There is no doubt that many DD patients also have IBS and the most troublesome symptoms may arise from the IBS.�
All in a name � Mary Griffiths (PhD CBiol (Retired Pharmacist and Biologist)) explains the difference between diverticulosis and diverticulitis.
�Diverticular disease is an umbrella term which covers the physical changes in the colon wall and the effects from diagnosis to
life-threatening complications and all the different symptoms which result from the disease. The muscular deformity with the characteristic bulging hernia or pouches
called diverticula is known as diverticulosis. This definition is of a visible physical abnormality and does not indicate the extent of damage to the
colon or describe its effects. Some people do not know that they have diverticulosis but after diagnosis about three-quarters of patients have some type of symptoms.
Awareness of diverticulosis is sometimes the result of the first attack of diverticulitis which is when diverticula become infected. This
gives severe, continuous pain and often a raised temperature; the sufferer feels poorly and needs medical attention, sometimes in hospital, to stop the infection getting
out of control and leading to serious complications or surgery.
Many people have other symptoms ranging from an exaggeration of normal colon responses to frequent severe pain and bowel dysfunction. This could be
the result of damage caused by repeated attacks of diverticulitis. There are changes in nerves, neurotransmitters, electrical activity patterns and sensitivity to drugs
which are also characteristic of the colon with diverticular disease. A few years ago this condition was called painful diverticular disease and in research
reports it is also known as uncomplicated diverticular disease or symptomatic diverticular disease. When such symptoms are severe, it is difficult to
distinguish them from diverticulitis and this name is often used. Because the diverticula themselves are not the cause of such symptoms it is fashionable at the moment to
call them Irritable Bowel Syndrome (IBS) even if this diagnosis should exclude conditions with recognised colon changes.
Another name increasingly found in research reports is diverticular colitis. This is when no infection is present but the bowel lining is
inflamed similar to inflammatory bowel disease (IBD) i.e. ulcerative colitis and Crohn�s disease.
It is important to know which of these facets of diverticular disease is causing the symptoms and not to confuse similar names because the
treatment needed may be different. For example, laxatives are obviously taken for constipation and not for diarrhoea. High fibre diets, bran, laxatives and antispasmodics
recommended for diverticulosis should not be taken when infection and inflammation is present � diverticulitis needs a low fibre fluid diet to rest the
bowel. Antibiotics may be needed and bed rest, sometimes in hospital.
The difference between diverticulosis and diverticulitis is far more than just two letters in a name.�
How diet affects Diverticular Disease
Consultant Surgeon and Gastroenterologist, Geoffrey Hutchinson explains how diet can affect those with diverticular disease.
�About 3% of all NHS prescriptions are for laxatives and purgatives (medicines that clear the bowels) and many millions are spent on �over the
counter� purchases to treat constipation. Constipation is uncommon in populations with a high intake of bran, non-starch polysaccharide (dietary fibre). In rural Uganda
in Africa, stool weights are around 500gm daily and bowel transit times around 40 hours. In the UK, stool weights in non vegetarians are around 100gm and transit times
are longer. Stool consistency is related to water content which is normally around 75%. The most important effect of bran is probably its water-holding capacity.
A possible causative link with low dietary fibre diets and diverticular disease was implicated from striking geographical variations in prevalence:
low in Africa, high and increasing in Western Europe.
Dietary fibre refers to the complex polysaccharides and other ploymers that escape digestion in the stomach and the small bowel and reach the
colon. Fibre obviously increases stool weight and shortens bowel transit time and may increase inner pressures in the intestine. A high fibre diet always emphasises whole
grain breads and cereals, fresh fruit and vegetables � we all know this also means more fermentation, more bloatedness and the passage of increased flatus (wind) � so
there has to be a balance in the diet. Of course, for many with established diverticular disease it may be too late to adopt this type of high fibre diet. It may have
prevented the development of the pockets in the colon if we had adhered to this diet from youth, like our African counterparts, but once we have diverticular disease, too
much roughage may make the colicky pains worse and many patients do better on a low fibre diet if they suffer an attack or flare up.
One thing is for certain. The more information we have about how the colon works and the diet we enjoy, the better equipped we will be to
understand how diverticular disease affects us long term. We hope to keep Incontact readers well informed with
future articles and updates on this important topic.�
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