Ask the Pharmacist

Q) I have just recovered from another nasty bout of diverticulitis. I am so tired of this and hate having to keep going on antibiotics to treat it. How can I try and prevent this from reoccurring?

A) Diverticulitis is in fact the possible end-stage of a group of conditions called diverticulosis which are surprisingly common disorders considering so many have never heard of the term. The name of all of these conditions stems from the presence of Diverticula (diverticulum is the singular form) which are small balloon- like pouches that form within the walls of the large intestine or colon in some of us.

The inner layers of the intestine balloon outward, an appropriate analogy would be an inner tube pushing through a bike tire, leading to the formation of a sac or pouch. These sacs are usually about the size of a pea but on occasion can be much larger. It is believed that pouches are a result of excessive pressure caused by abnormal contractions and spasms within the colon.

No one seems to be quite certain what causes this high pressure but many scientists believe it is related to our Western diet as these disease states are rare in continents such as Africa and Asia where the diets tend to include much more fiber.

Other possible contributing factors include aging (it occurs in about 5% of those who are 40 or younger but the incidence rises sharply to at least 50% in those older than 50 and 75% of those older than 79), obesity, a sedentary lifestyle and a diet full of red meat and fats. Most people who have diverticula in the colon do not experience any symptoms and are in fact blissfully unaware of their presence until the pouches are detected during a colonoscopy performed for other reasons.

Diverticulosis is a benign disorder that does not require any medical attention. However, about 4-40% of these people will progress to more severe forms of the disease including diverticulitis. This occurs when the pouches become inflamed and infected causing patients to experience symptoms such as intense abdominal pain, bloating, nausea, rectal bleeding or fever. It is unknown as to why some go on to have this more severe form of the disorder where as others do not but the speculation is that, once again, diet probably plays a large role.  Most cases of diverticulitis are relatively mild and can be treated by initiating a low-fibre (only temporarily however) or clear liquid diet along with a 7 to 10 day course of antibiotics.

Recently, some physicians are counselling patients to try and hold off on antibiotics initially to see if the simpler diet alone will work and results have been encouraging for many. Unfortunately, while most cases of diverticulitis resolve without major issues some will experience unpleasant lasting complications from a flare-up including the creation of a fistula (a pus filled abscess on the bowel wall), obstruction of the intestine due to the accumulation of scar tissue, and peritonitis which may require surgery.

While you can’t get rid of diverticulosis, there are steps you can take that might help prevent these pouches from becoming inflamed. The most important one is to eat a diet high in fiber (remember this is only once the episode of diverticulitis has settled down). Fiber absorbs water as it passes through the intestine, causing stools to become more bulky and therefore to pass through the intestines quicker. This, therefore, reduces the likelihood of constipation and the increased pressure on the colon that constipation can induce.

A fiber rich diet should include a mix of whole grains, nuts, seeds, fruits, legumes (such as dried beans) and vegetables. Some might be surprised by some of these suggestions because at one point people with diverticulosis were advised to avoid nuts, seeds and popcorn due to concerns they might become trapped within the pouches and trigger a flare-up. Over time this idea has been disproved and all such restrictions have been removed.

For people who cannot consume enough fiber from food, there are many supplements available in capsule or powder form such as Metamucil, Citrucel with which to top up their fiber content. Both the diet and the supplements should be consumed with large amounts of fluids. The additional fiber should be gradually incorporated into the diet in order to minimize diarrhea, gas and bloating and people should aim to eventually consume 25 to 35 grams of fiber a day (to put this in perspective, a cup of All-Bran has 10 grams of fiber and an apple has 4.4 grams).

Exercise also seems to likely play a role in preventing flare-ups quite possibly due to its effects in maintaining bowel motility thereby preventing constipation. While the jury is still out on whether probiotics help, some initial studies look very promising as to their preventative effects. The same holds true for the nutritional supplement sodium butyrate which is a short-chain fatty acid that seems to provide relief from diarrhea.

With a little guidance, none of these are particularly hard or expensive changes to make in your lifestyle and all could have a significant impact on reducing your need to go back on multiple antibiotics whenever diverticulitis rears its ugly head