Diverticulitis  

Not quite what Dora's colon looks like... some peoples' sigmoid colon isn't quite that short and straight.

Click on photo for more photos of barium x-ray of Dora's bowel

 

This page is color coded.   Unfortunately, it was not possible to for instance give articles on asacol and inflammation their own section because discussion pops up in many articles.   

Yellow pertains to the role of inflammation in diverticulitis.

Green pertains to treatment of diverticulitis with asacol and with boswellia (which has its own section).  

Teal/ blue pertains to the risk of recurrence after surgery (substantial but minority) and to the strong role of amount of bowel removed in reducing that risk.   

Orange, purple and other colors pertain to other issues that have importance to me.

 

Standard medical-encyclopedia type discussions.  

Jackson GI:  Diverticulosis.   

EmedicineHealth:  Diverticulosis and Diverticulitis

PubMed Health:  Diverticulitis.   

WebMD:  Understanding Diverticulitis: the Basics.  

WebMD: Digestive Disorders Health Center - Diverticulits Topic Overview

Coviden: Diverticulitis and Diverticulosis  

Advances in the management of uncomplicated sigmoid diverticulitis.  Coastal Surgery Specialists.   Good if slightly outdated general discussion of diagnosis and medical treatment of diverticulitis; basically a patient handout..

Best Books:

Peter Cartwright.   Coping with Diverticulitis (London:  Sheldon Press, 2007).   Excellent.   Even includes chapters on how to plan surgery and how to deal with a colostomy.   Also discusses causes of recurrent pain.   His discussion of recurrence of diverticulitis after surgery and how to avoid it is below.

Joan McClelland.   How to Cope Successfully with Diverticulitis (Wellhouse Publishing, 2009)  Not as good, and she seems somewhat possessed by the notion that diverticulitis is psychosomatic, but she does cover the basics of how to treat it.   

 

Articles:

American Society of Colon & Rectal Surgeons  Diverticulitis.  Up to date review written for physicians.  

Patterns of recurrence in patients with acute diverticitis.  Abstract of statistical study.  One of the studies behind the notion that an initial attack of uncomplicated diverticulitis is relatively unlikely to blow into a need for emergency surgery.   

Family Doctor:  What are the complications of diverticular disease?  Not as analytical.   

The timing of elective colectomy in diverticulitis:  A decision analysis.  Leon Salem, et al.  Journal of the American College of Surgeons.   199 (6), Dec 2004, pp 904-912.  

Practice Parameters for Sigmoid Diverticulitis.   Janice Rafferty, MD, et al.   2006.   Published online.  

Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study.  H Goh, R Bourne.  Ann R Coll Surg Engl 2002; 84: 93-96.

Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding.  Lisa L Strate et al.   Gastroenterology 2011 May; 140(5); 1427-1433.  

Colonic Diverticular Disease.  H Nail Aydin et al.  Cleveland Clinic Center for Continuing Education.   Review article.  

Long term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon.   Mueller MH.  European Journal of Gastroenterology and Hepatology.  June 2005 - Vol 17 issue 6, pp 649-654.   Abstract only.   

Complicated diverticulitis:  Is it time to rethink the rules?   Jennifer Chapman et al.   Ann Surg 2005 October; 242(4); 576-83.   

Level of anastomosis and recurrent colonic diverticulitis.  Paul L Benn et al.   American J of Surgery 151(2), Feb 1986, 269-71.   

Clinical and functional results after elective colonic resection in 75 consecutive patients with diverticular disease.  Thorn Magnus et al.  

Final study cited as supporting Jennifer Chapman's argument; The 5-Year natural history of complicated diverticular disease.   N. Farmakis et al.  British Journal of Surgery 81(5), May 1994, pp 733-735.   

Complicated Diverticulitis: It is not yet time to rethink the rules!  Andreas M Kaiser.  Ann. Surg 2006 May; 243(5):  707-8.   

Peter Cartwright, Coping with Diverticulitis - bibliographic information see above.  Book.   

Advances in the management of uncomplicated sigmoid diverticulitis.   James A. Harris, M.D., FACS  Coastal Surgery Specialists.   

Diverticulitis.  M. Shane McNevin, MD.  American Society of Colon & Rectal Surgeons.   

Diverticular Disease of the Colon.  Tonia M. Young- Fadok, MD.  Mayo Medical School, Division of Colon and Rectal Surgery.   American Society of Colon & Rectal Surgeons.   

Patterns of recurrence in patients with acute diverticulitis.   Elginton T et al.   British Journal of Surgery, 97(6), 952-957, June 2010.  

Prophylactic surgery following conservatively managed diverticulitis is increasingly controversial.  

Long-term outcome of patients presenting with acute complications of diverticular disease.  Sanjeev Sarin and Paul Boulos.   American R Coll Surg Engl 1994; 76:  117-120.  

Incidence and risk factors of recurrence after surgery for pathology-proven diverticular disease.  Caroline Andeweg et al.  World Journal of Surgery, July 2008, 32(7), 1501-1506.   

New Paradigms in the Management of Diverticular Disease.   Hall, J et al.   Curr Probl Surg. 2010 Sep; 47(9): 680-735.   

Diverticular Disease: Reconsidering Conventional Wisdom.  (Abstract)  Anne F. Peery, Robert S. Sandler.   Division of Gastroenterology and Hepatology, Dept of Medicine, U North Carolina, Chapel Hill, NC.   

Post Diverticulitis Irritable Bowel Syndrome

Note:  This section relies on the research on inflammation below under prescribing Asacol.  This is not the same thing as diverticulitis, like diverticulosis, as part of the same disease process as irritable bowel syndrome.   

Researchers describe new form of irritable bowel syndrome.  (Abstract)  MedicalXpress.  

Increased Risk for Irritable Bowel Syndrome After Acute Diverticulitis     (received article from author)  Erica Cohen et al, includes Brennan Spiegel, appears to report on the same study.  Request copies from Brennan Spiegel, Dept of Gastroenterology, VA Medical Center, LA.  bspiegel@mednet.ucla.edu   Clinical Gastroenterology and Hepatology, 11 (12), Dec 2013, pp 1614-1619.  

Postinfectious irritable bowel syndrome. (abstract)  Robin Spiller, Klara Garsed.   Gastroenterology.   136(6) 1797-1988.  

Role of infection in irritable bowel syndrome.  (abstract) Robin C. Spiller.   Journal of Gastroenterology.   January 2007, 42(17), Suppl, 41-47.  

Post inflammatory damage to the enteric nervous system in diverticular disease and its relationship to symptoms.  J. Simpson.  Neurogastroenterology and Motility.   21(8), pp 847-e58, Aug 2009.  

Diverticular disease of the colon:  New perspectives in symptom development and treatment.  Antonio Colecchia, et al.  U Bologna, Italy.  World Journal of Gastroenterology 2003 Jul; 9(7):  1385-1389.   

Role of nerves in enteric infection.  R.C. Spiller.   Gut. 2002 December 51(6):  759-62.

Recent advances in understanding the role of serotonin in gastrointestinal motility in functional bowel disorders. Robin Spiller.   Neurogastroenterology and Motility.   Published online, 6 Jul 2007.   19 (Issue Suppl s2, 25-31, Aug 2007.

Increased rectal mucosal enteroendocrine cells, T lymphocytes, and increased gut permeability following acute Campylobacter enteritis and in post-dysenteric irritable bowel syndrome.   R C Spiller et al.   Gut 2000 47: 804-811 47(6)  (The article is there but the abstract contains enough information.)

Activation of the mucosal immune system in irritable bowel syndrome.   Vinton S Chadwick.   Gastroenterology 122(7) June 2002, 1778-1783.   

Visceral hypersensitivity in symptomatic diverticular disease and the role of neuropeptides and low grade inflammation.  Humes, DJ (Spiller) et al. Neurogastroenterol Motil 2012 Apr 24(4) 318-e163.

Relative importance of abnormalities of CCK and 5-HT (serotonin) in Giardia-induced post-infectious irritable bowel syndrome and functional dyspepsia. Dizdar, V (and Spiller) et al.  Aliment Pharmacol Ther 2010 Apr; 31(8): 883-91.   

Antibiotic Treatment of Diverticulitis

The Medical and Nonoperative Treatment of Diverticulitis.   Heath Beckham and Charles B. Whitlow.   Clinics in Colon Rectal Surg.  2009 August, 22(3):  156-160.

What are the Different Antibiotics for Diverticulitis?  WiseGeek

What antibiotics are used to treat diverticulitis?  Ehow.   By Andrea Helaine, eHow Contributor.   

Diverticular Disease - a patient's guide.   FamilyDoctor.co.nz  Dr. Cliff Tasman-Jones, Gastroenterologist.  

Diverticulosis and diverticulitis.  Health24.  10 February 2011.

Oral antibiotic therapy for acute uncomplicated diverticulitis.  Paul S. Auerbach MD.   Healthline.   Sep 29, 2011.

Gastroenterology Associates.   Diverticulitis.  

Alternatives for treating diverticulitis

These focus on mesalzine (asacol, 5-ASA, 5-aminosalycilic acid), rifaxaimin, and probiotics.   The use of asacol and probiotics comes from a new understanding of the nature of diverticulitis, especially diverticulitis that recurs and causes problems between attacks.   The possiblity exists that people who ever get just one or two attacks of diverticulitis have a different disease; it is very common in medicine for several causes to cause diseases that have highly similar symptoms.

Mesalazine   Aspirin variant aimed at colitis and diverticulitis.   Asacol has the part of sulphasalazines removed that causes the worst side effects and causes reactions in people allergic to sulfa.   

Rifaximin - Wikipedia article.  

Drug of the Month:  Mesalazine   Mesalzine or Asacol widely used for inflammatory bowel disease.   

Mesalazine. What Doctors don't tell you.   Asacol is Smith Klein and French's answer to sulphasaline; has fewer side effects.  

Diverticular disease and diverticulitis.  Anish A Sheth et al.   American J of Gastroenterology, 2008; 103: 1550-1556.  

Floch MH Management of diverticular disease is changing.   World J Gastroenterol 2006 May 28; 12(20); 3225-8.   (Article received from Dr. Floch.)  

Clinical Review, Management of diverticulitis.  Letters to editor.  Clinical management of colonic diverticulitis.   30 June 2006.   Antonio Tursi.

Diverticular disease as a chronic illness:  evolving epidemiologic and clinical insights.  Lisa L. Strate et al.  Am J Gastroenterol, 2012.   (Article received from Dr. Strate.)  

Preventing recurrent acute diverticulitis with pharmacological therapies.  Antonio Tursi.   Thereapeutic Advances in Chronic Disease.  2013.   Not yet published, I got a copy from Dr. Tursi.   

Results of NCBI NLM search.   

Note:  I haven't included all of Tursi et al's review articles.

Use of mesalazine in diveriticular disease.  De Mario F et al.  J Clin Gastroentrol.  2006 Aug; 40 Suppl 3: S155-9.   Inflammation plays a role in all forms of diverticular disease.   Inflammation seems generatied by prinflammatory cytokines, reduced ant-inflammatory cytokines, and enhanced intramucosal synthesis of nitric oxide.  Mechanims of action of mesalezine not well understood.  Inhibits factors of the inflammatory cascade (such as cyclooxygenase) and free radicals, antioxidant effect.   Some recent studies confirm efficacy in diveritculitis both in relief of symptoms in uncomplicated forms and prevention of recurrence of symptoms and main complications.

Prevention of complications and sympotmatic recurrences in diverticular disease with mesalazine: a 12-month follow-up.  Comparato G et al.  Dig Dis Sci 2007 Nov; 52 (11):  2934-41.   Efficacy of mesalazine for relief of symptoms of uncomplicated diverticulitis.   268 people; random controlled, 4 treatment schedules.   Some got only rifaxim, two doses, some got mesalazine instead, two doses, noone got none.   Those treated with mesalazine had fewer symptoms than those treated with rifaximin.  Cyclic administration; 800 mg bid. caused greater improvement than smaller doses.   

Mesalazine and/or Lactobacillus casei in preventing recurrence of symptomatic uncomplicated diverticular disease of the colon; a prospective, randomized, open-label study.  Tursi, A et al.   antotursi@tiscali.it   90 patients previously stabilized on 800 mg/d rifaximin plus mesalazine 2.4 tg/d for 01 d, followed by mesalazine 1.6 g/d for 8 wk, 12 month followup.   Mesalazine and L. Casei DG.  Both are effective in preventing recurrence of symptomatic uncomp-licated diverticular disease.   It does not say how they compared their success rates to rates of recurrent symptoms if they did nothing.

Mesalzine for diverticular disease of the colon - a new role for an old drug.  A. Tursi.  Expert Opin. Pharacother.  2005 Jan; 6(1); 69-74.   Discussion.  Mesalazine with or without antibiotics significant superiority in improving severity of symptoms and preventing symptomatic recurrence of diverticulits over antibiotics alone.   

Gatta L.  Efficacy of 5-ASA in the treatment of colonic diverticular disease.   J Clin Gastroenterol.  2010 Feb; 44(2):  113-9.   Systemic review of literature.   6 randomized control trials or a controlled clinical trial with parallel group design using 5-ASA as 1 treatment arm.   Patients had uncomplicated diverticulitis in all studies.   Those treated with 5-ASA had significantly better outcomes.  Daily mesalazine better than cyclic administration to prevent relapse.   

Long term treatment with mesalazine and rifaximin vs rifaximin alone - Tursi A.   Dig Liver Sis.  2002 Jul; 34(7); 510-5.   Compared patients treated with 400 mg rifaxoin bid plus mesalazine 800 mg tid for 7 days, then rifaximin 400 mg bid plus mesalzine 800 mg bid for 7 days/ month.  Group B got only rifaxin.   Group A had significantly less recurrence of diverticulitis.

Petruzziello L et al.  Review article:  Uncomplicated diverticular disease of the colon.   Alment Pharmacol Ther. 2006 May 15; 23(10); 1379-91.   Pathophysiology of divertiuclar disease complex and related to abnormal colonic motility, changes in the colonic wall, chronic mucosal low-grade inflammation,imbalance in colonic microflora and visceral hypersensitivity.   May be genetic factors.   Use of nonabsorable antibiotics .   Mesalazine acts as a local mucosal immunomodulator, improves symptoms, prevents recurrence of diverticulitis.   

Strate, LL Diverticular disease as a chronic illness: Evolving epidemiologic and clinical insights.   Am J Gastroenterol, 2012 Oct:  107(10) 1486-93.  From low dietary fiber and fecalith obstruction model, growing knowledge shifting paradigm of diverticular disease from acute surgical illness to chronic bowel disorder.   Role for low grade inflammation, sensory-motor nerve damage, dysbiosis, in clinical picture that mimics irritable bowel syndrome.  These developments prompt shift from widespread antimicrobials and supportive care to use of probiotics, mesalamine, and gut-directed antibiotics.   I got this article from the author, and it is summarized above, as well as I can privately e-mail it to people.

Cohen HD, The metabolism of mesalamine and its possible use in colonic diverticulitis as an anti-inflammatory agent.  J Clinc Gastroenterol 2006 Aug; 40 Suppl 3.   5-aminosalicylic acid (5-ASA) is the mainstay of therapy for inflammatory bowel disease (IBD).  5-ASA is active moiety in sulfasalazine.  Many of side effects linked to sulapyridine, several druges that contain 5-ASA but lack sulfasalzine developed.   Several recent studies have suggested that 5-ASA drugs are useful for treating uncomplicated acute diverticulitis.  

Tomita R  Role of nitric oxide in the left-sided colon of patients with diverticular disease.   Hepatogastroenterology.   2000 May-Jun; 47(33); 692-6.   Non-adrenergic non-cholinergic inhibitory nerves the most important nerves in the enteric nervous system of human gut.  They release nitric oxide.   Diverticular colon more strongly innervated by them than the normal colon.   They act on the normal colon and to a lesser extent in the diverticular colon.  Nitric oxide mediates the relaxation reaction of non-adrenergic non-cholinergic inhibitory nerves in the normal colon and to a lesser extent in the diverticular colon.   Cholinergic nerves are dominant in the left-sided colon with diverticula.   This may add to high intraluminal pressure by colonic segmentation observed in left sided colon with diverticula.

Nitric oxide-releasing mesalamine:  potential utility for treatment of inflammatory bowel disease.   Dig Liver Dis.  2003 May; 35 Suppl 2.   Nitric oxide can accelerate ulcer healing and exert anti-inflammatory effects.   Addition of  a nitric oxide-releasing moiety to mesalamine significantly boosts its anti-inflammatory activity.  NOreleasing mesalamine suppresses inflammatory cytokine production and reduces leukocyte infiltration.   

Tursi, A.  Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence.   Eur Rev Med pharmacol Sci, 2013 Feb; 17(3):  342-8.  Similar to his other studies, but he did clinical, endoscopic and histological studies, both before (after treatment of acute episode) and after to demonstrate that mesalazine decreased endoscopic and histological inflammation.   

Colecchia A, Efficacy of long term cyclic administration of the poorly absorbed antibiotic Rifaximin in symptomatic, uncomplicated colonic diverticular disease.   World J Gastroeneterol.  2007 Jan 14; 13(2): 264-9.   Compared dietary fiber alone to dietary fiber plus rifaximin, for 24 months.   Both treatments reduced symptom frequency, but Rifaximin more so.   Long term administration was well tolerated by patients.

Management of diverticular disease: is there room for rifaximin?   C. Papi et al. Chemotherapy 2005; 51 Suppl 1:110-4.    Review.    

 

Boswellia serrata - Indian frankincense tree

Diverticulitis forum at Topix:  User reports on mesalazine for diverticulitis  

Ulcerative colitis:  Boswellia for Ulcerative Colitis.   

Effects of Boswellia serrata gum resin in patients with ulcerative colitis.   Gupta I.   Eur J Med Res.  1997 Jan; 2(1): 37-43.  

Botanicals in the treatment of Crohn's Disease, from Crohn's.net   

Boswellia; from WholeHealthMD.  Boswellia, Indian frankincense, grows in dry hills of India.   Called Guggai.   

 Boswellia serrata: an overall assessment of in vitro, preclinical, pharmacokinetic and clinical data.  Abdel-Tawab M.   2011 Jun;50(6):349-69  Abstract.   

Boswellia serrata.  Alternative Medicine Review 13(2) 2008.  

Ancient Herb Suppresses Inflammation.   Vicki Brower.  Life Extension Magazine.  March 2007.  

Frankincense - Wikipedia article.   Four species of Boswellia; most attention is given to the other three, which are used for their scent.  .  

Boswellia Serrata - The Indian Frankincense.  Posted by Melodie Munro Jan 30, 2013 in Herbs, Plants and Spices for your Health.   City of Shamballa.net  Review.   

Boswllin PS contains Polysal.   Polysal primarily consists of galactose, arabinose, D-glucuronic acid, and 4-o-methyl-glucuronarabino-galactan.

Boswellia (Boswellia serrata).   Livingnaturally.com   Natural Standard (www.naturalstandard.com)   

Analysis of frankincense from various Boswellia species with inhibitory activity on human drug metabolising cytochrome P450 enzymes using liquid chromatography mass spectrometry after automated on-line extraction.    Frank A et al.   J Chromatogr A 2006 Apr 21; 1112(1-2); 255-62.   

Benefits of Boswellia.   Narda G. Robinson.   

Ulcerative Colitis; University of Maryland Medical Center.  Patient handout on ulcerative colitis.  Boswellia is discussed under herbal remedies.   


Diverticulitis diets:

Jackson GI:  Low Fiber Diet.   An actual low fiber diet.  

Mayo Clinic Diverticulitis Diet - Liquid diet, low-fiber diet.  

Jackson/ Siegelbaum Gastroenterology Full liquid diet - in between a clear liquid diet and a low fiber diet.  

Divertulosis & Barley

 

Other Natural Treatments for Diverticulitis

DigHerbs page on Diverticular Disease Herbal treatments for diverticulitis  Slippery elm, coats colon, soothes inflammation.  1 tsp slippery elm in 1/4 cup water, drink 3 x/day before meals.  Chamoile, soothes inflammation and irritation of colon.  3 cups a day bef meals.  Marshmallow root. Soothes bowels.  1 cup tea 3x/ day for 2 weeks. Fight infection.   Cawaway.  Tincture or infusion relieves cramps.  Echinacea- boost immune system.  Linden tea.  Soothe stress, ease bowels.  Alternate with oat straw tea.   Goldenseal.   Antibacterial, helps w infection.  250 - 300 mg 2-3 x a day for a week.   Pau d'arco.  Antibacterial and anti-inflammatory.  Whle extract, 500 mg 3x a day for 6 weeks.   Aloe vera 1/4 cup twice a day.  

Diverticular Disease - University of Maryland Medical Center   Standard discussion of diverticulitis, includes natural treatments such as herbs.   Slipper elm (demulcent), 60-320 mg/day, or 1 tsp powder w water and drink 3-4 times a day.  Cat's claw (Uncaria tomentosa) 250 mg/day, anti-inflammatory, may interfere with medications.  Wild yam 2-4 g per day, 2-3 divided doses.  Hormonally active.  Marshmallow (althaea officinalis, demulcent and emollient.  1 cup tea 3 x/day.  2-5 g dried leaf or 5 g dried root in 1 cup boiling water, strain, cool.  Interferes with medications.  Avoid if diabetic.   

6 Home Remedies for Diverticular Disease, by Editors of Consumer Guide. How Stuff Works.  Barley.   Whole grain, flour, fakes, grits.   Brown rice.  Garlic.  1 clove 3x a day, can help prevent infection.   Not cooked.   Papaya, pear, potatoes.  

Woman's Weekly article recommends; 2 oz daily aloe vera juice mixed with orange or grape juice, a pear or a one cup serving of papaya/ day (enzymes shut down damaging intestinal inflammation), 30 minute walks each day, marshmallow root tea, 1/2 tsp each of turmeric and ginger a day.  Nuts and popcorn.  

I also have this list compiled from multiple sources; marshmallow root (althea officinalis, 1 cup tea 3x day, 2-5 g or 5 g root, 1 cp boiling water.   Licorice, slipper elm (1 tsp powder w water 3-4 x/day, 60 - 320 mg/day), Goldenseal (250-300 mg/day 2-3x/day) Catnip, fennel, ginger.  

I have personally found that Throat Coat tea is needed in addition to antibiotics to resolve these attacks.   Throat coat tea contains large amounts of licorice, slippery elm, marshmellow, fennel, and some other things.   

Research on best treatments for Krohn's disease and IBS recommend the following, with notes that people vary in their need for (as I milk substitutes) and ability to tolerate various things on the list.  For instance, if I want to see my lower digestive system go bonkers I can try more than 3 eggs in a week.   

Almond milk

Eggs

Oatmeal, well cooked

Vegetable soups, pureed

Salmon, shrimp, white fish (tilapia and flounder)

Papaya and mango, bananas

Avocado (soluble fiber)

Pureed chickpeas and lentils - allegedly this doesn't cause gas.   I personally find that highly alleged.   One of them is the ingredient of hummus, which I've seen recommended elsewhere.   

Chicken and turkey

Butter lettuce (Boston bibb) – more tender and easily digestible than other salad greens

Roasted red peppers, skinned.

White Rice

Smooth nut butters

 

Herbs for inflammatory bowel disease

 

Slippery elm

Fenugreek

Devil’s claw

Mexican yam

Tormentil

We tong ning (Traditional Chinese medicine)

Aminosalicylates (5-ASA)

 

Boswellia

Turmeric/ Curcumin – antibiotic as well as anti-inflammatory

Green tea

Marshmallow (herb) – may also reduce stomach acid and protect stomach lining

 

Garlic

Golden seal 1500 mg/day

Essential oils – oregano and anise, to reduce pathogenic bacteria in the gut.   Fresh, crushed garlic cloves or garlic powder product.  

 

Tablets containing boswellia 1200 mg, turmeric 2000 mg, celery 1000 mg, and ginger 300 mg, 4 per day.