Western civilization prides itself on its medical achievements. The incidence of many infectious diseases, for example, has been reduced through improved public sanitation standards and other public health measures. It is a praiseworthy accomplishment.

Such success has not been universal, however. While western civilization has seen a marked decline in the incidence of some diseases, it has also witnessed the emergence of diseases unknown to other cultures and times. One example is diverticulosis.

A diverticulum is a bulge or out-pouching in the manner of an inner tube protruding through a weak spot in a tire wall. A diverticulum is a single out-pouching; multiple bulges are called diverticuli.

Diverticuli can occur in many locations. They can be found in the esophagus, the stomach, and the urinary bladder. A diverticulum of the small intestine, called a Meckel’s diverticulum, can become inflamed and cause the same picture as appendicitis. The most common location for diverticuli, however, is the large intestine. When diverticuli are present, the individual is said to have a condition called diverticulosis.

Diverticulosis of the colon (large intestine) was unknown prior to the twentieth century. It was first reported in the United States and occurs most commonly in industrialized societies. Diverticulosis is rarely encountered in developing countries or in Asian and African nations.

Dietary differences are generally believed to account for the geographic distribution of diverticulosis. Diverticulosis is rare in societies in which the diet is high in fiber from vegetables and unrefined grains and common in societies in which diets are comprised of meats and refined foods, which are low in fiber content.

The incidence of diverticulosis in the United States rises with age. It is estimated that 10 % of Americans over the age of 40 have colonic diverticuli. The percentage rises to 50 % by the age of 60. It is believed that nearly everyone over the age of 80 has some diverticuli.

The formation of a diverticulum begins with constipation. As the muscles of the large intestine contract to move hard stool, pressure levels inside the colon increase. The increased pressure causes the intestinal lining to begin to bulge through sites where blood vessels enter the muscle wall of the colon. Over time these forces increase the bulging and diverticuli result.

Avoiding constipation, therefore, is a key to preventing diverticulosis. Ideally, a soft bowel movement that does not require straining should occur after each meal, or at least twice daily.

This is not the norm in our society. Many people in the United States could identify with the college student who asked me about the ideal frequency of bowel movements. When I informed him that he should be having two daily, he was stunned. As he attempted to regain his composure he whispered, “That can’t be right! I have less than two bowel movements in a week!”

Several steps can and should be taken to avoid constipation. Adequate amounts of water should be drunk each day. Optimum hydration is needed to keep the stools soft and capable of moving smoothly through the intestinal tract. A good indication that the body is well-hydrated is that the urine is pale. Urine that is bright yellow or dark in color is produced when the body is behind on fluids and is trying to hold onto as much water as possible.

Maintaining a good intake of dietary fiber is a crucial factor in preventing constipation. Fiber cannot be digested and therefore passes directly though the body without being absorbed. Fiber provides bulk to stools to keep them moving smoothly. I wrote about the various types of dietary fiber and their importance in the October, 2002 issue of Health By Design.

The major dietary sources of fiber are legumes (beans and peas), crucifers (broccoli, cabbage, Brussel’s sprouts, and cauliflower), whole grains (bran cereals, whole wheat bread), fruits and vegetables with skin (tomatoes, pears, apples, peaches, and potato skins), nuts, and berries.

Twenty to thirty grams of fiber daily will generally be enough to prevent constipation. Fruits and vegetables will provide, on average, 2 grams of fiber per serving while a serving of beans may provide as much as 6 grams of fiber. Whole grains such as brown rice and oatmeal will provide approximately 3 grams per serving.

Supplements that provide fiber from sources such as psyllium husk are available. These contain approximately 3 grams of fiber per tablespoon.

Optimum levels of magnesium and vitamin C will also help prevent constipation. This usually requires supplementing 400 to 800 mg. of magnesium daily and 1000 to 2000 mg. of vitamin C daily.

While it is best to eat a diet that is likely to prevent the development of diverticuli, the mere presence of diverticuli is not a cause for alarm. Most diverticuli are “just there”; they do not cause any symptoms and are only discovered when the colon is being examined for other reasons. Diverticuli are, under normal circumstances, harmless.

Circumstances, unfortunately, are not always normal. Diverticuli can become inflamed or infected resulting in a condition called diverticulitis. Unlike diverticulosis, which is harmless, diverticulitis is potentially life-threatening.

The appendix, like a diverticulum, is a pouch on the large intestine. When either becomes blocked inflammation and often infection will develop. The two conditions are so similar that diverticulitis has been called “left-sided appendicitis”. Like an inflamed appendix, an inflamed or infected diverticulum can rupture or perforate spilling stool and pus into the abdomen and causing a potentially fatal condition called peritonitis.

Symptoms of diverticulitis include abdominal pain, which is usually on the left side, fever, and abdominal tenderness.

When diverticuli are present, drinking adequate amounts of water and consuming ample quantities of fiber becomes even more important. Inflammation and infection of a diverticulum develop when the opening of the pouch is blocked. Small clumps of hard stool, which are present in constipation, are the most common cause of blocked diverticuli.

I also recommend that individuals with diverticuli avoid eating foods such as popcorn or raspberries that contain hard seeds or husks. This recommendation was once standard, but it is now considered controversial. I have known far too many people who developed diverticulitis after eating seeds or husks to discard this practice, however.

The measures needed to correct diverticulitis are almost the opposite of those taken to prevent it from occurring. When a diverticulum becomes inflamed the bowel does not need a high fiber load, it needs rest.

The large intestine should be emptied, if possible. It is best not to use an enema to accomplish this, as the pressure could cause the inflamed pouch to rupture. If the bowel does not empty spontaneously, as it often does, a Dulcolax suppository, available without a prescription, will usually induce a bowel movement within a short period of time. If symptoms are mild it may be possible to eat soft, low-fiber foods such as mashed potatoes, bananas, soups, fruit sauces, and gelatin. In most cases, however, it is best to stop eating solids entirely. Omega-3 fatty acids, which are needed by the body in the production of anti-inflammatory compounds and systemic enzymes, which are needed to fight inflammation should be supplemented.

Broad-spectrum antibiotics are usually prescribed when diverticulitis is present, but I have learned that they are rarely necessary when optimum amounts of essential fatty acids and enzymes are provided at the onset of an attack.  I add an antibiotic when rapid improvement is not seen or if fever and chills are reported. It is very important to supplement lactobacilli or other types of protective bacteria following the antibiotic course to prevent an overgrowth of abnormal, disease-causing organisms.

The prognosis of diverticulitis is good. In a recent study, Japanese researchers reported that 68 of 70 individuals with mild to moderate diverticulitis recovered without hospitalization or surgery when given an oral antibiotic and intake was limited to sport’s drinks for 3 days followed by a liquid diet for an additional 4 days before resuming solid intake.

Diverticulitis may require surgery if the condition is severe or if perforation occurs. In those cases the involved segment of bowel is removed. In many cases the bowel ends are reconnected at the same time. If peritonitis is present a temporary colostomy in which the bowel empties through the abdominal wall will be created and the bowel reconnected when the abdominal infection is no longer present.

Inflamed diverticuli can erode into other tissues, including the bladder. This condition, called a fistula, requires surgical correction.

Diverticuli are also capable of bleeding. Constipation plays a role in triggering this complication just as it does in diverticulitis. Small arteries that supply blood to the intestine can be eroded by hard stool and begin to bleed into the bowel. Unlike diverticulitis, diverticular bleeding is generally painless, presenting with bloody stools. The blood is red or maroon in most instances, but can be black if the bleeding diverticulum is located on the right side of the colon.

Bleeding diverticuli should be addressed with bowel rest as described for diverticulitis. Colonoscopy is recommended to confirm the cause of bleeding, particularly during or following the first episode. If the bleeding is heavy or persistent, surgery may be required.

Diverticular disease can, in most cases, be prevented by drinking an adequate amount of pure water and consuming enough fiber to maintain soft stools that move through without straining. When diverticuli are present the same measures are generally effective in preventing complications of inflammation, infection, and bleeding, provided that hard seeds and husks are avoided in the diet. When complications do occur fluid intake should be continued, the bowel placed at rest, and systemic enzymes taken to reduce inflammation. Diverticulosis can be harmless rather than life-threatening.