A Functional Medicine Approach to Diverticular Disease

Diverticular disease describes a range of conditions involving diverticula or outpouchings of the lining of the intestinal tract. Diverticula form when the lining of the digestive system bulges into small pouches. This most commonly occurs in the lower part of the large intestine or colon. When diverticula are present, it is known as diverticulosis.

Diverticula are common, especially in those over age 40. They may be present without any symptoms or problems. But sometimes, these outpouchings become inflamed or infected, causing abdominal pain, fever, nausea, and changes in bowel movements. This condition is known as diverticulitis.

Diverticular disease increases with age, with around 10% of people experiencing this condition at 40 years of age and increasing up to 50 to 70% in those older than 80. Overall, 10-25% of people with diverticulosis will experience at least one episode of diverticulitis. Every year, approximately 130,000 hospitalizations occur in the United States due to diverticular disease. About 20% of patients who experience diverticulitis have at least one additional episode of the disease flaring up.

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What is Diverticular Disease?

Diverticula form when outpouchings form as the lining of the intestines pushes through weak spots in the wall of the intestine. These small herniated pouches can range from 2 to 20 mm in size. They can occur deep within the intestinal wall's mucosa and submucosal tissue layers. These little sacs are like bubbles that form at weak spots when you fill an inner tube or tire with too much air. An increase in pressure inside the colon causes similar pockets or bulges (diverticula) to form in areas of the weakened intestinal walls.

Although they can form anywhere in the inner lining of your digestive tract, diverticula are most likely to form in the lower part of the large intestine or colon on the left side in the S-shaped segment of the colon known as the sigmoid colon. They generally form at weaker areas of the lining where blood vessels pass through the circular muscle layer to deliver blood to the colonic mucosa.

Categories of Diverticular Disease

Diverticulosis involves the presence of usually mostly asymptomatic diverticula.

Diverticulitis occurs when the diverticula become inflamed or infected, which leads to symptoms of pain, bleeding, and bowel changes.

Complicated diverticular disease can involve perforation or rupture through the wall of the bowel, peritonitis or inflammation within the abdominal cavity, fistulas where the intestinal tract forms a connection into another organ, obstruction or blockage of the bowel, bleeding, and abscesses.

What causes diverticular disease?

Diverticulosis is very common in Western populations, and the prevalence of the condition increases with age.

Several factors increase the risk of having diverticular disease (diverticulosis or diverticulitis). With age, the intestinal walls can weaken, losing their elasticity and becoming stiff and inflexible, which makes them more prone to developing these sacs. So, diverticular disease is more common in those over 40 years of age. Diverticular disease is also more common in males, smokers, and those who are overweight or are not physically active. Consuming alcohol and frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin, ibuprofen (Advil®, Motrin®) and naproxen (Aleve®), steroids, or opioids also increase risk.

Increased colonic pressure or abnormal colonic motility make diverticular disease more likely to develop. Research shows that those with symptomatic uncomplicated diverticular disease have altered motility of the digestive tract and a "spastic colon" in the areas affected by diverticulosis. This involves a decrease in the number of pacemaker cells (interstitial cells of Cajal) in the bowel which results in slowed transit through the bowels and makes constipation and built-up pressure more likely.

One of the most significant factors involved in the formation of diverticular disease seems to be dietary factors, especially not consuming enough fiber. Diverticular disease is more likely to develop in those who eat a low-fiber diet with more processed foods and factory-raised meats versus consuming plenty of fruit, vegetables, beans, legumes, whole grains, and nuts. A low-fiber diet predisposes you to slowed down bowel movements and waste building up in the colon. This constipation puts extra strain and pressure on the walls of the colon that can cause outpouchings or diverticula to form.

If these sacs become inflamed or infected, this leads to diverticulitis. The infection often starts due to bacteria in stool that get pushed into the diverticula. In other cases, the walls of the diverticula may erode from the increased pressure on the colon walls and become inflamed. Fecal matter or undigested particles can become trapped in the diverticula, causing swelling, compromised blood flow, inflammation, and possible perforation.

In addition to constipation, ongoing low-grade inflammation in the intestines and alterations in the balance of the bacteria living in the digestive system, known as the microbiome, contribute to the development of diverticular disease. Inflammation can occur due to chronic low-grade systemic inflammation, imbalances of intestinal microflora (the microbiome), and alteration in movement or motility of the digestive tract.

For example, small intestinal bacterial overgrowth (SIBO) is commonly found in people with diverticular disease. Bacterial overgrowth and a lack of stool motility can contribute to chronic dysbiosis and low-grade inflammation, so improving gut microbial balance is essential to reducing intestinal inflammation.

A healthy microbiome produces substances like short-chain fatty acids (SCFAs) that help to nourish your intestinal lining and balance inflammation. So when these microbes become imbalanced, unchecked chronic inflammation and an unhealthy gut lining are more likely. Further, healthy bacteria are important for normal stool bulking to prevent constipation. In turn, constipation can contribute to an unhealthy microbiome.

Diverticulosis Symptoms

Diverticulosis does not usually cause symptoms or need treatment, although some people may experience

• mild tenderness over the affected area
• cramping
• bloating
• constipation or other changes in bowel habits

Diverticulitis Symptoms

When these outpouchings become infected or inflamed, diverticulitis can cause pain and other symptoms that require attention.

The signs and symptoms of diverticulitis include:

• pain
• fever
• abdominal tenderness
• nausea and vomiting
• changes in bowel habits such as constipation or, less commonly, diarrhea
• blood in stool

The pain that occurs in diverticulitis is most commonly focused in the lower left side of the abdomen. It may be consistent and persist for several days.

Further complications may develop in around 25% of people with acute diverticulitis. Infected diverticula can develop abscesses or collections of pus in the pouches. If inflammation persists, scarring may form, which can block the bowels. Another potential consequence of the inflammation that occurs in diverticulitis is fistulas or abnormal passageways between sections of the bowel or the bowel and other organs like the bladder or vagina or with the skin. In very severe cases, peritonitis or inflammation within the abdominal cavity may occur during a diverticulitis flare if the infected or inflamed pouch ruptures, spilling intestinal contents into the abdominal cavity. This requires emergent hospitalization and care.

Functional Medicine Labs to Test for Root Cause of Diverticular Disease

Traditionally, diagnosis of diverticular disease is based on symptoms and confirmation of changes in the intestines via colonoscopy or imaging with a CT scan, MRI, or a barium enema to visualize the outpouchings in the bowel. Functional medicine testing can assess the extent of inflammation in the intestines and the rest of the body, along with cortisol imbalances, microbiome balance, and food sensitivities, to help identify underlying contributing factors.

Comprehensive Stool Analysis

A comprehensive stool analysis evaluates the colonic microbiome and level of gut inflammation. The GI-MAP assesses relative amounts of healthy and unbalanced gut bacteria, inflammation and leaky gut markers, parasites, and yeast overgrowth. Retesting a few months after treatment can guide an individualized approach to rebalancing the microbiome and colonic inflammation.

Assess Intestinal Inflammation

Advanced stool testing markers like calprotectin and secretory IgA can further assess inflammation levels in the digestive tract and help evaluate additional causes of gastrointestinal inflammation, like inflammatory bowel disease (IBD). For example, fecal calprotectin reflects levels of intestinal inflammation. It is elevated in those with symptomatic diverticular disease compared to those with functional digestive tract disorders like irritable bowel syndrome (IBS) and those with asymptomatic diverticular disease.

Testing for Food Sensitivities and Allergies

Food sensitivities can increase intestinal weakness and inflammation, leading to recurrent diverticular disease. Foods that an individual is sensitive to can be identified with food allergy testing or testing to look at reactivity to various food components.

Additional testing for gluten sensitivity or celiac disease with Genova Diagnostics Celiac Profile and evaluation of the leaky gut marker zonulin can also help identify inflammation sources and guide treatment.

Salivary Cortisol Testing

Both high and low cortisol can contribute to intestinal inflammation. High cortisol is associated with the weakening of the intestinal wall and gastrointestinal perforation and promotes chronic inflammation in inflammatory bowel disease. On the other hand, when cortisol is chronically too low, the brain is not signaled to reduce the overall body inflammatory response, which can contribute to chronic inflammation in the intestinal tract and increase the risk of diverticular disease.

Salivary cortisol can be measured at several points during the day to get an idea of the levels and pattern of cortisol secretion over a 24-hour period.

Other Lab Test to Check

Since diverticulosis is often asymptomatic, it is usually discovered incidentally during an unrelated diagnostic or screening procedure like a colonoscopy.

Imaging studies like abdominal x-rays, barium enemas, CT scans, MRIs, or abdominal ultrasounds can be used to visualize the intestines' diverticula and diagnose diverticular disease.

Conventional Treatment for Diverticular Disease

Conventional medicine generally approaches uncomplicated diverticulitis by starting a patient on a clear liquid diet to allow the colon to rest and providing antibiotics to fight infection, antispasmodics to relieve cramping, and analgesics to relieve pain.

In complicated diverticulitis, hospitalization with antibiotics, intravenous fluids, and/or surgery may be needed.

Mesalazine is an aminosalicylate medication that is used to reduce inflammation in inflammatory bowel disease that is sometimes used to improve symptoms and prevent the recurrence of diverticulitis.

Integrative Medicine Treatment for Diverticular Disease

A functional medicine approach can help to prevent diverticular disease through diet and lifestyle and address the inflammation that occurs once diverticulitis has occurred. These strategies can help to balance the gut microbiome, strengthen the colonic mucosal lining, and decrease inflammation. In fact, studies have found that in mild, uncomplicated diverticulitis, antibiotics do not accelerate recovery at all.

Diverticulosis Diet

To prevent diverticula and flares, an anti-inflammatory diet focused on whole foods and avoiding alcohol, spicy foods, coffee, processed sugars, and fats can help to keep the gut healthy and balance inflammation. Processed foods, chemical additives, added sugars, alcohol, and caffeine all increase inflammation, making future attacks of diverticulitis more likely. Avoiding gluten, dairy, and any foods you are individually allergic or intolerant to can also help decrease inflammation.

Outside of diverticulitis flares, fiber is an important component of the diet for nourishing a balanced microbiome and preventing constipation. It is important to gradually increase fiber intake to facilitate stool passage and reduce pressure in the colon. Soluble fiber helps retain water and turns into a gel during the digestive process to slow digestion and allow for greater absorption of essential nutrients, while insoluble fiber adds bulk to stools to help bowel movements occur more regularly. You can mix these fiber types by consuming gluten-free oats, quinoa, apples and pears, ground flax or chia seeds, legumes, and vegetables while avoiding irritating fiber like bran.

Diverticulitis Diet

During flares of inflammation with diverticulitis, a brief period of bowel rest may be helpful in some cases, focusing on clear liquids like bone broths and soothing teas like ginger or chamomile. In milder cases or as recovery progresses, a soothing diet consisting of easy-to-digest foods like bone broth, steamed vegetables, and fruits like stewed apples or pears (non-citrus) can help the digestive tract heal.

Hydration for Diverticular Disease

As you increase the amount of fiber in your diet, you must also ensure you drink enough water. Dehydration is a major contributor to constipation.

Reduce Gut Inflammation and Pain for Diverticular Disease

An imbalance of microbes within the gut microbiome is associated with diverticular disease. Restoring equilibrium in the gut microbiota by eating a variety of real whole foods and incorporating probiotic-rich foods like kimchi and sauerkraut that contain naturally-occurring probiotics and prebiotic-rich foods like artichokes, garlic, and beans that nourish healthy bacteria is critical for repairing the mucosal barrier and halting excess inflammation. Studies also suggest that probiotic supplements may help reduce the risk of diverticular disease.

Support Bowel Function and Prevent Constipation for Diverticular Disease

Consuming adequate amounts of fiber and staying hydrated are key ways to prevent constipation which helps to reduce intracolonic pressure. It is also important to establish healthy bowel emptying habits like responding to the urge and taking the time to properly empty your bowels without strain to avoid exacerbating existing diverticula or contributing to the development of new ones.

Exercise Regularly for Diverticular Disease

Regular exercise helps to promote a healthy weight, normal bowel function and motility, and balanced inflammation.

Avoid Smoking for Diverticular Disease

Smoking is associated with an increased risk of complications in patients with diverticulitis, so avoiding smoking can help reduce your risk.

Manage Stress for Diverticular Disease

Stress contributes to intestinal inflammation and disrupts a healthy microbiome. Regularly incorporating mind-body activities such as yoga, meditation, tai chi, and breathwork can help reduce chronic stress.

Herbs & Supplements for Diverticular Disease for Diverticular Disease

Magnesium supplementation can help prevent constipation and reduce cramping and intestinal spasms associated with diverticular disease.

Soothing and healing demulcent herbs like slippery elm, aloe vera, marshmallow root, and deglycyrrhizinated licorice (DGL) reduce mucosal damage and inflammation.

Butyrate is a short-chain fatty acid (SCFA) that fuels colonocytes, stimulates the growth and proliferation of healthy intestinal cells, inhibits inflammation and oxidative stress, and improves intestinal barrier integrity. Studies show that sodium butyrate reduced symptoms in people with diverticular disease and reduced the number of diverticulitis episodes they experienced.

Summary

The presence of small pouches known as diverticula in the wall of the large intestine is common with advancing age, especially in the lower part of the large intestine (colon). The presence of diverticula causes diverticulosis which is often asymptomatic. When these outpouchings become infected or inflamed, diverticulitis develops, which causes fever, pain, nausea, vomiting, changes in bowel habits, and potential bleeding.

Diverticulosis is very common in Western populations. The condition's prevalence increases with age as the intestinal walls weaken, losing their elasticity and becoming stiff and inflexible, making them more prone to developing these sacs. Increased colonic pressure and abnormal colonic motility make diverticular disease more likely to develop. In addition to constipation, ongoing low-grade inflammation and alterations in the balance of the bacteria living in the digestive system contribute to the development of diverticular disease.

Diagnosis of diverticular disease is based on symptoms and confirmation of changes in the intestines via colonoscopy or imaging with a CT scan, MRI, or a barium enema to visualize the outpouchings in the bowel. Functional medicine testing can assess the extent of inflammation in the intestines and evaluate cortisol levels, microbiome balance, and food sensitivities to help identify underlying contributing factors.

A functional medicine approach can help to prevent diverticular disease through diet and lifestyle approaches and address inflammation once diverticulitis has occurred by improving the gut microbiome, strengthening the colonic mucosal lining, and decreasing inflammation. Targeted interventions, including an anti-inflammatory diet, adequate fiber and hydration, exercise, stress management, probiotics, and supplementation with demulcent herbs, butyrate, and magnesium, may help decrease symptoms and improve diverticular disease.