Why mucosal pockets form and what to do about them
Colonic diverticula, or diverticulosis, are the most common finding in colonoscopy examinations, and one of the common gastrointestinal diagnosis I treat in practice. Diverticula are sac-like protrusions of the colonic mucosa through weak points in the muscular wall of the colon. Diverticula can be asymptomatic or develop into diverticulitis (which is inflamed diverticula), diverticular bleeding, or colitis (inflamed lining of the colon).
My goal as a naturopathic doctor is to not only stop the progression of diverticulosis to a more serious condition such as diverticulitis, but to also heal the mucosa. In order to heal, the root cause of why the diverticula formed must first be identified.
Causes of Diverticulosis
The potential causes of diverticulosis are:
Aging - because everything happens when we age! No, but seriously, diverticulosis is more prevalent in patients over the age of 60 years old.
Diet, specifically reduced fiber intake, contributes to an increased risk of diverticulosis. Fiber bulks up stool mass which can improve its ability to pass through the colon. According to the USDA, the average American consumes 16g of fiber/day, which is far below the recommended 25-30g per day.
Lifestyle behaviors such as smoking, alcohol, and reduced physical behavior have been linked with diverticulosis.
Pharmaceuticals such as oralcorticosteroids, opiate analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and anti-cholinergic medications have been associated with complicated diverticulitis.
Gut microbiome imbalance with an increase in the following microbes: Akkermansia municiphilia, Enterobacteriaceae, Roseburia hominis, and the gut virome had a higher propensity for Cytomegalovirus.
Abnormal colonic motility expressed as exaggerated contractions of segments of the colon. This causes increased pressure within the lumen of the gut, weakening the mucosa and pushing it through the muscle wall.
Structural changes in collagen. Collagen is the main structural protein in the extracellular matrix found in the body's various connective tissues. Hereditary diseases such as Marfan or Ehlers-Danlos syndrome result in collagen structural changes, but collagen changes can happen in autoimmune disease, due to inflammation, hormone changes, nutrient depletion and other factors.
Naturopathic treatment for diverticulosis treats the root cause by identifying the contributing factors and then either removing it or rebalancing it.
The average American consumes 16g of fiber/day, which is far below the recommended 25-30g per day.
Diverticulitis: when diverticula become inflamed
One of the potential risks of diverticulosis is that the pockets become inflamed, leading to diverticulitis. Symptoms of diverticulitis include:
Abdominal pain, most commonly in the left lower quadrant, with tenderness when touched
Change in bowel habits, with constipation being more common than diarrhea
And less common is urinary urgency, frequency or pain
The above symptoms are diagnosed as uncomplicated diverticulitis. Complicated diverticulitis is when the diverticula results in bowel obstruction, stricture, abscess, fistula, or perforation. These conditions are much more serious and require immediate conventional medical care.
There are multiple factors that cause diverticula to become inflamed, and they overlap with the factors that contribute to the diverticula initially forming. From my clinical experience, I see food intolerances, diet, lifestyle, microbiome imbalance, colonic motility dysfunction and stress as being the largest contributors.
Patients used to be told to avoid seeds, nuts and popcorn because theses food particles could get lodged in the diverticula and cause inflammation. We know now that isn't true - two studies found that a vegetarian lifestyle and nuts and popcorn consumption actually reduced the risk for diverticulitis. Another study found that diverticulitis was found in individuals with low levels of vitamin D and in men who consumed a high quantity of red meat. (See Resources below for links to research studies).
Hippocrates stated that "All disease begins in the gut." Naturopathic medicine shines in treating gastrointestinal health because we treat the root cause of the disease and personalize treatments to the individual. This produces exceptional results that not only helps the patient avoid surgery and life-long pharmaceuticals but also restores the patient's total health. I have had success with multiple patients with diverticulosis and will share a case with you here to show how naturopathic medicine works.
Natural Treatments for The Diverticulosis Case of a Hail Mary
Hail Mary was a 57 year old female establishing care for three diverticulitis flares in the past 14 months that resulted in abdominal pain, disruptive stool changes, multiple trips to the ER and doctor visits, lost time at work, and lead to anxiety over food choices and depression over her change in health. She had been scheduled the following month for a colectomy, which is surgical removal of part of her colon. Hail Mary had never tried naturopathic medicine before, but her gut told her to try another approach to healing before undergoing surgery.
During her initial intake we reviewed her medical history, family history, diet, lifestyle, and reviewed the result of ther bloodwork and colonoscopy. I counseled her on how naturopathic medicine would treat her digestion and also ensured she was aware of the potential risks of delaying surgery. After consideration, Hail Mary decided to try naturopathic medicine. Her first treatment plan included a functional stool test, diet changes with a focus on increasing fiber, stress management techniques, and two supplements to reduce inflammation and heal her connective tissue. For this patient I used a combination of glutamine and curcumin powder and gotu kola, Centella asiatica.
Hail Mary returned a month later for a check-in appointment to review the results of her stool test and reported that her stool had returned to normal quantity and quality, however she admitted to bloating following some meals. She stated her other health complaints of low energy and back pain had also improved considerably. And she had committed to changing her eating habits. She was eating healthier foods and stated she felt positive about her health.
The results of her stool test were significant for extremely low beneficial flora, high Streptococcus, an elevated immune response and gluten sensitivity. Her treatment plan was revised to increase food choices that would build up her beneficial microflora, and a supplement was added to strengthen her immune system while continuing to reduce inflammation and heal her connective tissue.
Patient returned 6 weeks later for a check-in appointment and reported her digestion had improved with no bloating and normal stool. She was continuing to make health changes in her diet and lifestyle with increased exercise and stress management. Patient was told to continue treatment for another two months and to check in if needed. It has been 10 months since her last appointment and patient continues to have no digestive upset. Patient told me she was grateful to have not only avoided surgery but also to have taken control of her health and be on a healthier path.
Naturopathic medicine can not only help the patient avoid surgery and life-long pharmaceuticals, but most importantly it enables the patient to restore their total health.
Tursi, A. (2019) ‘Current and evolving concepts on the pathogenesis of diverticular disease’, Journal of Gastrointestinal and Liver Diseases, 28, pp. 225–235. doi:10.15403/jgld-184.
Pemberton, J.H. and Strate , L. (2023) Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis, UpToDate. Available at: https://www.uptodate.com/contents/colonic-diverticulosis-and-diverticular-disease-epidemiology-risk-factors-and-pathogenesis?search=diverticulosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 (Accessed: 26 May 2023).
Crowe FL, Appleby PN, Allen NE, Key TJ. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ 2011;343:d4131. doi:10.1136/bmj.d4131
Crowe FL, Balkwill A, Cairns BJ, et al. Source of dietary fibre and diverticular disease incidence: a prospective study of UK women. Gut 2014;63:1450–1456. doi:10.1136/gutjnl-2013-304644
Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci EL. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 2008;300:907–914. doi:10.1001/jama.300.8.907
Maguire LH, Song M, Strate LE, Giovannucci EL, Chan AT. Higher serum levels of vitamin D are associated with a reduced risk of diverticulitis. Clin Gastroenterol Hepatol 2013;11:1631–1635. doi:10.1016/j.cgh.2013.07.035
Cao Y, Strate LL, Keeley BR, et al. Meat intake and risk of diverticulitis among men. Gut 2018;67:466–472. doi:10.1136/gutjnl-2016-313082
Hoy, M.K. and Goldman, J.D. (2014) Dietary fiber intake of the U.S. population - USDA ARS, Fiber intake of the U.S. population What We Eat in America, NHANES 2009-2010. Available at: https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/DBrief/12_fiber_intake_0910.pdf (Accessed: 26 May 2023).
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