Diverticulosis and Diverticulitis

by Konstantin Monastyrsky

A high fiber diet is broadly recommended for the prevention of diverticular disease based on unconfirmed, unproven, untested, and speculative "theories" that a low fiber diet causes this pathology. In fact, it's the complete opposite — a high fiber diet is the primary cause of diverticular disease and related complications.

Diverticular disease has two distinct phases — diverticulosis and diverticulitis. The first phase simply means that you‘ve already acquired one diverticulum (singular) or several diverticula (plural) inside your large intestine. Because it has no symptoms, diverticulosis is usually discovered during a routine colonoscopy or radiography exam.

The moment diverticulosis turns into diverticulitis — inflammation of one or more diverticula, and the second phase, — the conventionally-recommended treatment causes even more harm because it is based on a combination of antibiotics and fiber. It subjects patients to the unnecessary risks of abdominal surgery to remove the affected colon, impaired immunity, uncontrollable bleeding, ulcers, and strokes. This guide describes how to prevent diverticulitis without resorting to fiber and antibiotics.

Well-known Facts About Diverticulosis

Diverticular disease isn‘t caused by genes or aging — two popular and widely believed misconceptions or intentionally told lies:

● Genetics. If one of your parents had diverticular disease, and you get one too, it has nothing to do with your genes, but with sharing the same table with them for a good third of your life, and, thereafter, bringing up the same eating habits into your adulthood.

● Aging. If you get diverticular disease by the age 50 or 60, a good half of other people in the same age group is still spared. Thus, it isn't like getting age-related gray hair, wrinkles or the menopause, but some other causes.

These “other causes” are hard stools (either large or small), constipation, and straining:

 —  But I've never been constipated! My doctor diagnosed diverticular disease anyway. Why?

 —  Hard stools, that's why. People who have hard stools (either small or large), and strain to move the bowels, however slightly, never consider themselves constipated.

The classical definition of constipation is “hard, large stools,” not frequency or regularity of stools. Alas, most people nowadays, including medical professionals, confuse constipation with frequency of stools. In this erroneous worldview, only a person who hasn‘t had a complete bowel movement for more than three days is considered constipated, everyone else is just normal or "irregular."

A few generations ago the term “costivity” was broadly used to describe large, hard stools and straining, while the term “constipation” was used to describe irregularity. Unfortunately, both terms have blended into one, and the distinction is no longer made.

For these reasons I reclassified constipation (see Fiber Menace, p.p. 97-128) into three distinct stages: functional (still reversible), latent (hidden), and organic (irreversible):

Functional constipation. This condition commonly follows surgery, colonoscopy, diarrhea, temporary incapacity, food poisoning, treatment with antibiotics — the circumstances that commonly damage intestinal flora and interfere with intestinal peristalsis. A person becomes irregular, stools enlarged, and may need to strain to complete moving the bowels. The person resorts to fiber or laxatives for help.

Latent constipation. If the intestinal flora, stools, and peristalsis aren't properly restored following the adverse event, functional constipation turns into the latent form (i.e. hidden), because fiber‘s or the laxative's effects on stools creates the impression of normality. The stools become larger, heavier, and harder, straining more intense, but there is an impression of regularity.

Organic constipation. As time goes by, large and  hard stools along with straining enlarge internal hemorrhoids. This, in turn, reduces the diameter of the anal canal, and causes anorectal nerve damage. At this juncture, the person no longer senses a defecation urge, and becomes dependent on laxatives to complete a bowel movement.

All through these three transformative stages, the degree of straining increases, while the frequency of stools may remain regular “thanks” to the laxative effect of dietary fiber. That‘s why you can develop diverticular disease without any apparent “constipation.” In reality, your constipation was already latent or organic, but rendered invisible by laxatives or a laxogenic diet (i.e. high-fiber).

So it all boils down to English-language definitions. If constipation was defined as “having large stools regularly that may require a certain degree of straining” or “a condition requiring a high-fiber diet and laxatives,” rather than “not having stools for three days in a row,” you wouldn‘t have asked that question, and wouldn't have developed diverticular disease in the first place.

Thus, with the correct definitions of constipation, you and your doctors would logically concentrate on reducing stool size and preventing straining — the essence of my recommendations, — instead of attaining stools at least once every three days. Those who have small stools and never strain to move their bowels never develop diverticular disease, regardless of their age or gender.

It‘s apparent, then, that the life-long avoidance of large stools and straining is key to the prevention and treatment of diverticular disease, and it‘s particularly paramount for aging adults. 

The alternatives to not treating the underlying causes of large stools, constipation, and straining are more fiber in the diet, more laxatives, more antibiotics, more pain and suffering, invasive surgeries, substantial expense, and simply more of the same time and again — where there is one diverticulum, there is often another lurking nearby, and the only way to get rid of them all is to surgically remove the entire colon, which is not exactly a safe or desirable option.

Diverticular disease gains in “popularity” with age: 10% are affected by the age of 40, over 50% by age 60, and almost 90% beyond 80 years of age. No surprise here: constipation and straining are particularly widespread among aging adults. Also, more women than men are affected by diverticular disease because constipation affects significantly more women than men.

It‘s sad, but true: unless you eliminate large stools or straining and restore the natural functioning of the large intestine, diverticular disease ALWAYS gets worse. This guide explains why it gets worse and how to avoid it. Read on.

Prognosis: Most Often From Bad To Worse

Diverticulosis is irreversible, meaning that once you‘ve developed even a single diverticulum it‘s yours for life, because the body can‘t stretch back a protruded intestinal wall any more than it can grow back new teeth.

Fortunately, if you restore the normality — intestinal flora and small stools — inside the affected colon, and no longer need to strain to move your bowels, diverticulosis most likely will remain dormant for the rest of your life, and is no more harmful than the crevices on an aging face — not necessarily a desirable outcome, but still benign.

If, on the other hand, you don‘t restore intestinal flora and small stool size, and continue straining, the diverticula may get filled by stagnant stools, become infected, and turn into diverticulitis — an inflammation or ulceration of one or more diverticula.

When diverticula get  infected, you may experience high fever, sense pain in the lower abdomen, observe blood in the stools, or begin suffering from paradoxical diarrhea — a symptom of intestinal obstruction.

When that happens, anything is possible: from an abscess obstructing the colon to perforation of the intestinal wall; from deadly peritonitis to an even deadlier sepsis. And that‘s what you really want to avoid, because a large share of people don't survive this experience, even when surgeons and hospitals are nearby and first class.

This applies particularly to the uninsured, underinsured, or people far away from a major metropolitan area, who are commonly relegated to overloaded, understaffed, under-equipped, and low-rated community hospitals, where the experience of general surgeons may not be as high as in the major teaching or specialized, gastric hospitals.

In these cases, an emergency operation to treat peritonitis by a general surgeon instead of an experienced gastric surgeon with a similarly top-notch surgical team, usually has an outcome similar to asking a professional cabbie to substitute a Formula One pilot.

So even if you are Mr. Buffet or Mr. Gates, and you happen to be somewhere in the ?boondocks‘ (even with a fuelled jet standing by to whisk you out, which is too late in this case), your chances of surviving a perforation of an infected diverticula aren't very high, considering that even in the best hospitals mortality rates are sky-high — upwards of 25%.

I don't write this to convince you that diverticulitis is dangerous (it is), but to tell you — don't be an idiot hoping that your good insurance, good doctors, or loads of money may help you to get away with this deadly ailment.

Recovery Guidelines: Pay and Pray vs. Think and Act

There are two diametrically opposed approaches to remedy lifestyle diseases, and diverticular disease is no exception:

Pay and Pray. It means attack the disease directly, and hope it goes away. The standard treatment protocol for diverticular disease relies on dietary fiber, laxatives, antibiotics, systemic muscular relaxants, immunodepressants, and finally, surgery to remove the affected portion of the large intestine. Patients experience pain and suffering, and incur hefty expenses in the process. After one diverticulum is patched up, another one may flare up again at any time. “Pay and pray” is clearly not effective, not safe, and not cheap.

Think and Act. It means eliminate the causes of diverticular disease. First — to prevent diverticulosis from ever happening to you. Second — since diverticulosis itself is irreversible, it may remain dormant as long as the causes of infection (large, stagnant stools) are kept at bay. It‘s also possible to recover from mild symptoms of diverticulitis, and, most importantly, never again develop new diverticula.

My approach to eliminating the causes of diverticular disease is simple and inexpensive. Just follow these three logical steps:

Step #1. Eliminate dietary fiber

Considering everything you‘ve previously read, heard, or known about diverticular disease, you must first eliminate dietary fiber and fiber laxatives from your diet! There are three key properties of fiber — bulk, acidity, and gases (the last two from fermentation) — that make it such a disastrous choice for the prevention of diverticular disease:

Bulk. Large stools create pressure inside the colon, congest and obstruct the infected diverticula, and require straining to expel them. The issue of congestion and obstruction is an important one — how can one heal inflammation or an ulcer inside the diverticulum, when the inner surface of its mucosal membrane is “encrusted” by fibrous, acidified, gaseous, decaying stools and pathogens that have no way of getting out?

Acidity. The colon‘s environment is mildly alkaline. The continuous acidity from fiber‘s fermentation causes mucosal inflammation, decimates desirable bacteria, and provides a good breeding ground for infectious bacteria inside the colon.

Gases. Anyone who experiences flatulence knows how painful gases can be, especially when you can‘t let them out in social settings. The gases create permanent pressure inside the colon, and contribute to pain and suffering. When these gases become trapped inside the infected diverticulum, the pain is often unbearable.

Nonetheless, fiber is still recommended because it's the only “soft” laxative considered suitable for long-term (years instead of just days or weeks) use. In essence, fiber is a lesser kind of evil vis-?vis other types of “hard” laxatives.

Not that medical professionals or even patients aren't well-aware of fiber's significant side effects — patient notes (which describe them) are inserted into every single package of fiber laxatives:

And it makes no difference whether the fiber comes from a capsule, powder, shake, wafer, or one‘s diet — once inside your gut, fiber is still fiber regardless of how it was processed and packaged.

Even if none of these side effects bother you, once you're hooked on fiber, straining becomes inescapable for the following reasons:

Fiber's bulking properties. Doctors and nutritionists refer to indigestible fiber as a 'bulking laxative' or 'roughage' because it makes stools? rough and bulky.

Stool weight. 'Bulky' means that the stool's weight increases from a normal 75-150 g to 300-500 g per day.

Stool size. 'Rough' means that the stool's size (diameter) increases from a normal 15-20 mm to 30-35 mm or more. The fiber itself isn‘t necessarily “rough,” but the large stools are definitely rough on the delicate tissues of the colon, rectum, and anal canal.

And that‘s how the problems commence. Because the maximum opening (aperture) of an adult anus is tiny — 3.5 cm (1.4”) — large stools can‘t easily pass. If you already have enlarged internal hemorrhoids — and about two thirds of people over fifty do — the anal opening is even smaller. Straining becomes the only way to expel large stools through the narrow pathway.

Next comes the possibility of inflammation inside the diverticula, because soluble fiber (mucilage, hydrophilic mucilloid) is a potent inflammatory and diarrhea-causing agent. Inflammatory bowel disease (IBD) directly contributes to the development of alternating patterns of diarrhea and constipation, straining, formation of new diverticula, and diverticulitis.

But here comes the Catch 22: once you‘ve eliminated all kinds of fiber, constipation may grow even worse because now stools are starting to become small, hard, and dry, and you need to strain even harder to expel them. This phenomenon is well familiar to anyone who tried and failed the Atkins Diet, which is fiber-free by design.

To break this vicious cycle of strain if you do, strain if you don‘t, follow my recommendations in Overcoming Fiber Dependence guide.

Step #2. Restore intestinal flora

Healthy bacteria reside and procreate inside the protective layer of the mucosal membrane, and derive their nutrients from mucus. To give them a good home and head start, your mucosal membrane must be healthy, well-nourished, and populated with beneficial bacteria. To accomplish this goal, follow my recommendations in the Restoring Intestinal Flora guide.

Step #3. Eliminate straining

Straining is a “side effect” of large stools, hard stools, irritable bowel syndrome, anorectal nerve damage, impaired peristalsis, and constipation.

Whatever you happen to have, all of these conditions are addressed in depth in the Restoring Normal Bowel Movements and Restoring Anorectal Sensitivity guides. If you are affected by IBS, please also study the Irritable Bowel Syndrome guide.

It goes without saying, that all of these guides are interrelated, and all three steps are usually executed in parallel.

That‘s all there is to my method: stay clear of fiber, normalize your stools to prevent straining, eliminate disbacteriosis, restore the biological function of your large intestine, and help the bacteria to take hold inside your gut. Simple, safe, inexpensive, efficient, and good for your health.

Finally, let me warn you in the least ambiguous terms: when you are experiencing diverticulitis — an acute form of diverticular disease — DO NOT FOLLOW ANY OF THESE RECOMMENDATIONS. At this point you'll need professional medical help. Only once you are stable — no bleeding and no sharp pain — you can start relying on the above guides to prevent a relapse.

Also, I recommend informing your doctors as forcefully as possible about this site and Fiber Menace. Don't be embarrassed — it's your health and life on the line, not your self-esteem. Dead patients don't blush. The doctors aren't shrinking violets either — they'll take your advice in stride because they too don't want to get embarrassed by prescribing you a wrong and harmful treatment.

And if they ignore your pleas to review this information, and continue to insist that you keep using fiber and antibiotics to prevent and treat diverticular disease, they will, at the very least, violate the code of medical ethics (Hippocratic Oath) which says:

 —  I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

 —  To please no one will I prescribe a deadly drug nor give advice which may cause his [patient] death.

 Amen!

P.S. This analytical essay was published back in 2005. As expected, it was universally ignored, dismissed, and ridiculed by patients and doctors alike. Six-and-a-half years and millions of harmed lives later, I was finally proven right. Judge for yourself:

Fiber Not Protective Against Diverticulosis

Contrary to popular medical wisdom, following a high-fiber diet has no protective effect against developing asymptomatic diverticulosis, according to a colonoscopy-based study presented at the 2011 Digestive Disease Week (DDW) meeting (abstract 275). In fact, the study showed that patients who ate more fiber actually had higher prevalence of the disease. [Gastroenterology and Endoscopy News, July 2011, Volume: 62:07]

Fiber May Not Prevent Diverticular Disease

For decades, doctors have recommended high-fiber diets to patients at risk for developing the intestinal pouches, known as diverticula. The thinking has been that by keeping patients regular, a high-fiber diet can keep diverticula from forming. But the new study suggests the opposite may be true. [WebMD, January 23, 2012]

A High-Fiber Diet Does Not Protect Against Asymptomatic Diverticulosis

A high-fiber diet and increased frequency of bowel movements are associated with greater, rather than lower, prevalence of diverticulosis. Hypotheses regarding risk factors for asymptomatic diverticulosis should be reconsidered. [Gastroenterology; Volume 142, Issue 2, Pages 266-272.e1, Feb. 2012]

Frequently Asked Questions

Q. Why aren‘t doctors using your method to treat and prevent diverticular disease?

Because it isn‘t based on the kind of interventional therapy doctors traditionally perform, but on basic preventive principles available to anyone. Just as you don‘t need a prescription for a bar of soap to keep your hands germs-free, you don‘t need a doctor to prevent diverticular disease.

The sole objective of my method is to keep a person with a case of preexisting diverticulosis from turning into diverticulitis. Once that happens, it‘s too late for prevention, and you‘ll need a doctor. In an ideal world, after patching you up, doctors would suggest using this method to prevent a relapse. And as doctors learn more about it, some of them certainly will.

Q. Why does fiber seem to help some people with diverticular disease?

It doesn‘t. At best, fiber is a placebo. At worse, it‘s the main cause of diverticular disease. In between, it creates a false sense of security and postpones proper treatment, because fiber may temporarily reduce the symptoms of irregularity by increasing the size and weight of stools, and create the illusion that you‘re no longer constipated. It may also cause diarrhea or semi-soft stools, which, for a while, may clear out the content of an infected diverticulum.

When a person experiences mild diverticulitis, doctors invariably prescribe antibiotics, pain relievers, and anti-inflammatory drugs. The resulting remission results from medication therapy, and not from fiber.

Furthermore, patients with acute diverticulitis aren‘t placed on high-fiber diets to “relieve” it, but on a zero-fiber liquid diet, because gastric surgeons, who are called in to manage the treatment at this stage, are well aware of fiber‘s danger, and prohibit patients from taking it.

Q. Why does the conventional treatment of diverticulitis may cause more harm than good?

The conventional treatment may certainly save you from lethal infection, but not from inevitable relapse and surgery. As odd as it may sound, the standard treatment protocol recommends a high fiber diet for patients who have just recovered from acute diverticulitis (underline mine):

“For the patient who is not very ill, treatment at home is reasonable, with rest, a liquid diet, and oral antibiotics (cephalexin 250 mg qid [four times daily]). Symptoms usually subside rapidly. The patient gradually advances to a soft low-roughage diet and a daily psyllium seed preparation. A barium enema 2 wk later can confirm the diagnosis. After 1 mo [month], a high-roughage diet is resumed.”

THE MERCK MANUAL, Sec. 3, Ch. 33, Diverticular Disease

The key reason behind this oddball strategy is the simple fact that after this intense treatment with antibiotics, the patients‘ intestinal bacteria are wiped out, and they become constipated. A “high-roughage” diet creates the illusion that there is normality, but, alas, this treatment (antibiotics + fiber) is bound to cause diverticulitis again (and not just diverticulitis).

The 17th edition of The Merck Manual finally acknowledged antibiotics-associated colitis: an “acute inflammation of the colon caused by Clostridium difficile [pathogenic bacteria] and associated with antibiotic use.” (3:33:29).

After a certain amount of time this condition may turn into chronic ulcerative colitis, which increases the risk of colon cancer up to thirty-two times, and, according to The Merck Manual, “nearly 1/3 of patients with extensive ulcerative colitis require surgery” (3:33:31), which usually means colectomy (the complete removal of the colon).

Nonetheless, doctors follow this absurd treatment protocol because that‘s the protocol they were taught while in medical schools, and any other approach may trigger a malpractice lawsuit..

This practice is even stranger when you consider that patients are initially (and properly) advised to adopt a fiber-free liquid diet to heal their acute diverticular inflammation. But once the acute stage has passed, their health and recovery is put in jeopardy again by exactly the same fiber that caused their diverticulitis in the first place.

 This is a systemic error that snuck its way into medical textbooks and still rules. My work on the adverse role of fiber in human nutrition and disease is the first substantial revision of this destructive doctrine and unhealthy practice.

Q. What are the most common misconceptions about fiber‘s role in diverticular disease?

The therapeutic and preventative role of fiber in diverticular disease is steeped in its own mythology. Let‘s review these myths, as detailed in the article entitled Diverticular Disease by the National Institutes of Health.

For starters, even the opening statement reveals that the beneficial role of fiber in the prevention and treatment of diverticular disease is just conjecture (a theory) without any proof:

“Although not proven, the dominant theory is that a low-fiber diet is the main cause of diverticular disease.” [link]

Here are the other “dominant” falsehoods from the same source:

“The [diverticular] disease was first noticed in the United States in the early 1900s. At about the same time, processed foods were introduced into the American diet. Many processed foods contain refined, low-fiber flour. Unlike whole-wheat flour, refined flour has no wheat bran.”

   Not true. The “disease was first noticed” in the early 1900s not because of dietary changes in the American diet, but because in 1895 Wilhelm Conrad R?tgen accidentally discovered X-rays. Before X-rays became commonplace, people were dying from undiagnosed and unknown internal diseases because there were no non-invasive diagnostic tools, no exploratory surgeries, and autopsies were extremely rare. Secondly, since diverticular disease affects primarily people over 50, dietary changes in the early 1900s wouldn‘t even show up in people until the late 1930s or early 1940s.

“Diverticular disease is common in developed or industrialized countries — particularly the United States, England, and Australia — where low-fiber diets are common.”

   Not true. Also common in these countries is watching television, drinking beer, and driving a car. But just like any other conjecture, it doesn‘t mean these activities cause diverticular disease. Diverticular disease is more common in developed Western countries not because the traditional Western diet is low in fiber, but because of excessive consumption of fiber and fiber laxatives. If Westerners consumed even more fiber, the incidence of diverticular disease would be even higher, as described in the next myth.

“The [diverticular] disease is rare in countries such as Asia and Africa, where people eat high-fiber vegetable diets.”

   Not true. (a) High-fiber diets are prevalent only among the poor and very poor, usually in rural areas; (b) poor people in these regions die well before the age commonly associated with diverticular disease in the West; (c) no reliable healthcare system exists in rural Africa and Asia to provide reliable and relevant health statistic regarding diverticular disease; (d) when Africans do have access to hospitals, doctors have concluded: “The study shows that the African colon has a number of pathological lesions contrary to previous reported literature.” (Ogutu EO, at al; Colonoscopic findings in Kenyan African patients; East Afr Med J. 1998 Sep;75(9):540-3); and (e) affluent Africans and Asians consume very little fiber — as is apparent to anyone who‘s ever visited an authentic Asian (Japanese, Chinese, Thai, Korean, Indian) or African (Moroccan, Ethiopian, Kenyan, South African) restaurant, where the dominant dishes are meat, fish, and sea food, and the side dishes are primarily white rice, whose fiber content is a just 0.4%.

“Both kinds of fiber help make stools soft and easy to pass,” which is good for diverticular disease.

   Not true. Insoluble fiber is a bulking laxative. It makes stools large and hard to pass. That‘s why fiber is called “roughage.”  Soluble fiber is a hyperosmolar laxative and diarrhea-causing agent. It does makes stools watery, but it also causes bowel inflammation, bloating, and flatulence, and isn‘t suitable for extended use.

“Fiber also prevents constipation,” which is essential for diverticular disease.

   Not true. Fiber DOES NOT prevent constipation. Just like aspirin can relieve pain, natural and medicinal fiber can relieve constipation in people because it is a potent laxative. But fiber can‘t prevent constipation, just like aspirin can‘t prevent migraines or arthritis. In fact, if any aspirin manufacturer made such an outlandish claim, the FDA would shut it down.

   Also, note that fiber DOES NOT relieve chronic constipation, only sporadic constipation in healthy people. When a few legitimate attempts were made to prove fiber‘s effectiveness for “chronic constipation,” according to the American College of Gastroen?terology Functional Gastrointestinal Disorders Task Force (2005), they didn‘t pan out as explained in Fiber Menace's Introduction:

   Why? Because people who are affected by chronic constipation are also likely to be affected by hemorrhoidal disease and anorectal nerve damage. In this case, large, rough stools are not only undesirable, but are outright damaging. if you already have diverticular disease, your goal is not “large stools more often,” but small stools without straining, and fiber is never going to help you accomplish this reasonable and easily attainable goal.

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Q. What is the normal frequency of stools?

Ideally, you should move the bowels after each major meal. Eating and/or drinking stimulate(s) a wave of intestinal peristalsis (gastrocolic reflex) which always precedes defecation. The breaking of this natural pattern of elimination necessitates straining because withholding a bowel movement even once causes stools to enlarge and dry out. This, incidentally, is why you should never encourage children to withhold stools.

Also, stool withholding is the primary cause of “traveler‘s constipation.”  Fiber in this case becomes outright dangerous. First, it takes two to three days for fiber to reach an already congested colon. Second, by the time it does, fiber makes matters only worse, because the situation becomes similar to a police car trying to clear out gridlock by driving right into the middle of it. That‘s how some people “earn” diverticulosis — elastic intestinal walls can easily stretch, bulge, and prolapse to accommodate the arriving and expanding fiber.

Q. I don‘t strain, I‘m not constipated, I don‘t consume fiber, I have small stools, and I still have diverticulosis?

Even a single occurrence of intense straining years ago may have created one or more diverticula. And the chances of that happening grow as you get older because aging intestines aren't as elastic and resilient as before.

Q. What if I still require surgery?

Surgery resects (cuts out) the part of the large intestine affected by infected diverticula. If you go back on a high-fiber diet after the surgery, in a few years or even few months time you may develop another diverticulum, because all of the conditions that were in your colon before the surgery will repeat themselves again. Perhaps they‘ll get even worse, following the compulsory treatment with antibiotics. Besides, even if you need surgery, your stools and intestinal flora should be kept as normalized as possible to prevent complications and to speed-up recovery.