Chapter 7. Diverticular Disease

“Constipation makes the muscles strain to move stool that is too hard. It is the main cause of increased pressure in the colon. This excess pressure might cause the weak spots in the colon to bulge out and become diverticula.”
Diverticulosis and Diverticulitis; National Institutes of Health [1]

If evolution had anticipated today’s dietary dogma and lifestyle, it would have designed our large intestines very differently. The colon’s pouch-like architecture is the reason behind the existence of diverticulosis, a condition where the haustrum (colonic bulges) protrudes further outward between the teniae (ribbon-like muscles), and forms sacs known as diverticula (plural from the Latin “a turn aside”).

The colon’s original architecture was perfect for hunter-savages, whose lifelong diet was virtually fiber-free. But it’s proved disastrous for Westerners, who’s diet is loaded with fiber from the moment they start chewing. According to The National Institutes of Health:

Based on the U.S. Census 2000, “half of all people over the age of 60” translates into 23 million victims of diverticular disease. Once you factor in people under sixty and the undiagnosed, just as with hemorrhoidal disease the actual number is much greater.

Diverticulosis starts developing during the latent stage of fiber-related constipation which, as you may recall, is primarily characterized by straining, hemorrhoids, and type 1–3 large stools on the Bristol Stool Form Scale. The smaller diverticula range in diameter from 3 mm to 3 cm, and are usually multiple. The ones that are really large are most likely single (the singular is diverticulum), and range in diameter from 3 to 15 cm. When fiber-laden fecesget “diverted” into diverticula, they tend to get lodged there, and then lump together and harden up.

Diverticulosis can be reliably seen and diagnosed by radiography (X-ray, nuclear scans[3]) or colonoscopy long before most patients experience any symptoms. Overall, smaller diverticula are harmless, as long as feces remain small, soft, and moist, because fecal matter with these properties won’t get trapped inside small cre­vices. But when feces are continuously large, hard, and dense, they may keep even tiny diverticula clogged indefinitely for the same reasons a tight cork keeps liquid inside a vessel turned upside down, even if the neck has multiple crevices on the inside.

As more and more fecal matter gets jam-packed inside each diverticulum, they may enlarge further by the sheer force of outward pressure. Eventually, the epithelium inside one or more diverticulum gets lacerated and infected. The infection may cause inflammation, ulceration, rectal bleeding, excruciating pain, and/or the perforation of the colon wall—collectively called diverticulitis.

Besides fiber, other factors and conditions typical for the latent stage of constipation contribute to the development of diverticular disease:

• Flatulence. Colonic gasses are a by-product of fiber fermentation in the large intestine. The more fiber in one’s diet, the more gas. The pressure, created by gas, is often sufficient to cause a small diverticulum to enlarge and protrude.
• Straining. The extra pressure from abdominal and pelvic muscles, especially in the presence of gases and a large volume of feces, is often sufficient to cause protrusions in the posterior (back) and lateral (side) regions of the colon. The effect is similar to what happens to an air balloon when you squeeze it—the unconstrained segments bulge, and the more you squeeze it, the larger the bulges become.
• Hemorrhoidal disease. Internal hemorrhoids constrict the anal canal, and prevent the complete elimination of stools. The resulting fecal impaction causes an enlargement of stools and further protrusion of diverticula.
• Medication. Numerous drugs that cause relaxation of the smooth muscles (hypertension, anxiety, antispasmodic) may also inhibit intestinal contractions, propulsion and the timely elimination of feces. This leads to the formation of diverticula, caused by outward pressure from enlarged, impacted stools. Ironically, muscular relaxants are the drugs of choice for the ongoing treatment of diverticular disease.
• Age. As we get older, the colon walls become less and less elastic, and more prone to stretching. Obviously, diverticulosis isn’t likely to occur if you avoid its causes, regardless of age. The lucky 50% of still unaffected Americans over the age of sixty are living proof of it.

As you can see, understanding diverticulosis is an easy task: if you blow too much air into a tire, it explodes; if you stuff a casing with too much ground meat, the sausage bursts; if you have gases and bulky stool, the colon wall, unable to resist the pressure, protrudes and forms a pouch (diverticulum). And there’s just one known nutrient that causes bulky stool and excessive gases at the same time: indigestible fiber.

For as long as you use dietary fiber to prevent and/or treat diverticular disease, the situation is guaranteed to get worse. Even more problems arise when enlarged, impacted feces finally cause inflammation and ulceration of diverticulum: severe pain and rectal bleeding at best, and abscesses, colorectal obstruction, perforation of the bowel wall, or peritonitis at worst. 20% to 25% of all people affected by diverticulosis develop these conditions, which often requires long-term treatment with antibiotics or emergency surgery. To keep this from happening to you, consider the following key points:

Summary

• Constipation contributes to the progression of diverticular disease, because like fiber, it stimulates straining and the accumulation of stools in the large intestine.
• Most medical authorities in the West, particularly in the United States, advocate the use of fiber for the prevention of diverticular disease.[4],[5] This advice is a primary reason behind the dramatic increase in the number of its sufferers.
• The use of dietary fiber for prevention and treatment of diverticular disease is based on unproven theory. In fact, the effective treatment of complications from diverticular disease relies on a fiber-free diet.[6]
• The treatment of diverticular disease with dietary fiber on the one hand, and antispasmodic drugs to counteract fiber’s effect on the other, worsens the prognosis and outlook for patients who follow this advice.[7]
• The avoidance of indigestible fiber, the absence of constipation, and maintaining type 4–6 stools on the Bristol Stool Form Scale is the most effective form of prevention and treatment of diverticular disease.
• Men and women over the age of 50 are particularly vulnerable to diverticular disease, and should avoid indigestible fiber more than any other age group.
• The presence of internal and external hemorrhoids predicts a high probability of developing diverticular disease because the pathogenesis of both conditions are similar.
• Early-stage diverticulosis will not turn into diverticulitis if patients maintain a low-fiber diet and avoid constipation.
• Always consult your doctor and pharmacist regarding possible side effects of the medicines you are taking. Do not abandon prescribed medications without consulting a physician.

Footnotes