Dietary Management of Diverticular Disease and Diverticulitis
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Transcript of Dietary Management of Diverticular Disease and Diverticulitis
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7/31/2019 Dietary Management of Diverticular Disease and Diverticulitis
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Dietary
Management of
Diverticular
Disease
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Chapter 1:
Diverticular disease,Diverticulosis and
Diverticulitis- What is
the difference?
Diverticular disease is a disorder of the
gastro-intestinal tract that particularly
affects the colon (however studies have
shown that it can affect any part of the
gastrointestinal tract).
This disorder is characterised by the
development of pockets or diverticula
within the colon wall. These diverticula
tend to develop in the weak areas of the
bowel, in particular, sites where a large
number of bloods vessels penetrate the walls
of the bowel and in areas that are generally
narrower than most others- such as thesigmoid colon.
It is believed that the development of
diverticula is a result of the adoption of
western diets, which tend to be low in
fibre.
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This is evident in developed or
industrialised countries. Due to the large
amounts of refining processes implemented
within the food system, the amount of fibre
contained in many foods is severelydiminished. A diet low in fibre results in
the production of stools of a different
consistency to normal. This consistency
requires a higher pressure to be present in
order to move the stools through the bowel.
It is the presence of these high pressures
that result in the bowel expanding or
pocketing outwards through the surroundingmuscle, consequently forming the pocket like
structures known as diverticula.
Diets high in beef and animal products as
opposed to plants foods are also shown to
result in diverticular disease. This is due
to similar reasons as mentioned above.
Animal products contain little amounts of
fibre, whereas plant products are the mainsupply for fibre in the diet. Should an
individual limit the amount of plant foods
they consume, whether intentionally or
unintentionally, they limit the amount of
fibre in the diet, resulting in an increase
in pressure in the bowel and consequent
development of diverticula.
Studies have shown that diets high invegetable foods, such as those in developing
countries, decrease the chances of
developing diverticular disease, as these
foods are high in fibre and thus decrease
the amount of pressure required to move
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stools through the bowel.
It has also been identified that there may
be a genetic component affecting the
development of diverticular disease. This
suggests that raised pressure in the bowel
may be hereditary.
Another factor associated with diverticular
disease is age. Diverticular disease is
commonly found in individuals over the age
of forty.
It is estimated that one third of the
population at forty years of age and two
thirds of the population at eighty years of
age have diverticular disease.
Individuals already suffering form colonic
mobility problems or from defects in the
strength of the colon wall are also at risk
of developing diverticular disease. This is
due to the presence of sections of the colon
that do not work effectively, resulting inisolated segments with high levels of
pressure which consequently lead to the
development of diverticula within these
segments.
Diverticular disease does not affect people
based on gender. Studies have shown the male
to female ratio of the incidence of
diverticular disease to be equal.
Generally, the condition does not
discriminate race-wise if the individuals
have adopted the same culture and consequent
diet (i.e. a western diet), however will
affect according to race if different
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cultural diets have been adopted.
The term diverticula disease is an overall
description of the condition, and
encompasses the two phases of the disease,
diverticulosis and diverticulitis.
Diverticulosis: This term refers to the
presence of diverticula (pockets) within
the colon. A person with diverticulosis
may have no symptoms and it is possible
that they may never develop the active
phase of the condition.
Diverticulitis: This term describes the
active phase of the disease, in which the
diverticula become inflamed. Current
belief is that diverticulitis occurs when
bodily fluids or faecal matter becomes
trapped in the diverticula. This creates
a perfect environment in which bacteria
can manifest and consequently cause
infection. The infection may proceed inone of four ways.
4 The infection may spontaneously
resolve itself without medical
intervention.
5 The infection may progress,
leading to more serious
complications (mentioned inchapters 2 and 3).
6 The infection may cause partial
or complete obstruction of the
bowel. This generally must be
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addressed via surgery.
7 The infection may fistulize. If
the infection is not treated the
site of infection will spread andconsequently break through to
another organ or cavity of the
body, creating a tunnel or
fistula (explained in chapter 3).
Diverticulitis does not occur in every
individual with diverticulosis. In reality
only a small proportion of those withdiverticulosis will develop diverticulitis.
From the above information, it can be
concluded that diverticular disease is the
encompassing term for diverticulosis (the
inactive phase of the disease in which the
diverticula exist, but are not infected or
inflamed) and diverticulitis (the active
phase of the disease in which thediverticula are inflamed and infected due to
the presence of bodily fluid or faecal
matter trapped inside).
Diverticular disease can be diagnosed via
one of three procedures:
1) Colonoscopy: This procedure involves a
thin, lighted tube being passed throughthe rectum in order for a doctors to
obtain a thorough look at the bowel wall.
This also enables the removal of small
pieces of the bowel wall for further
investigation via biopsy.
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2) Single ContrastBarium Enema: A thin tube
is passed through the rectum in order to
feed a white liquid known as barium into
the bowel. The presence of the barium
allows for the outline of the walls ofthe bowel to show in an x-ray. If over
activity due to presence of the disease
is prevalent, the bowel wall will appear
thickened.
3) Double Contrast Barium Enema: If it is
believed that an individual may have
diverticular an enema (thin tube passed
through the rectum) may be implemented toview the wall of the colon. The double
contrast enema is more accurate than a
single contrast enema.
An enema is not used if there is any
possibility of diverticulitis (inflamed
diverticula) as this may increase the
risk of perforation of the diverticula.
4) Computerised Tomography (CT) Scan: This
procedure is less invasive than the
aforementioned as it does not required a
tube to be passed through the rectum.
Instead a scan is used to produce a 3D
image on a computer screen in which the
bowel can be viewed. If possible, Ct
scans are used where possible due to the
high degree of accuracy in diagnosing
diverticula disease and identifying the
development of abscesses.
5)Water-soluble contrast enema: Another
form of enema- this enables imaging of
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the intraluminal space and consequent
diagnosis of diverticular disease.
6) Ultrasonography: This test is equally as
accurate and non-invasive as a CT scan in
diagnosing acute colonic diverticulitis
if the operator of the machinery is well
trained and reliable. Ultrasonography
involves the use of a skin probe that
emits sound waves. Like an ultrasounds,
these sound waves produce echoes which
form a picture of organs and tissues
inside the body on an ultrasound machine.
For those diagnosed with diagnosed with
diverticular disease, many will find that
their diverticula will cause them no
problems and that they never develop the
active phase of the disorder
(diverticulitis). Some may develop this
phase once or very rarely and will recover
very quickly form the event via treatment
through optimal diet and antibiotics. There
are however the rare cases in which the
diverticular disease and consequent
diverticulitis are more severe.
Approximately ten to twenty percent of those
with diverticulosis will develop the active
phase of the disease (diverticulitis).
Doctors are unsure as to the exact cause of
diverticulitis, which can occur suddenly and
without warning. As mentioned above current
belief is that inflammation occurs when
stools or bacteria become caught in the
diverticula, which consequently becomes
infected.
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Chapter 2: Thesymptoms of
diverticular disease.
Many individuals who develop diverticulardisease will no display symptoms. In a small
percentage of individuals diverticulitis
(the active phase of the disease) might
occur and the following symptoms may present
themselves:
1) Diarrhoea: Diarrhoea is characterised bylarge, frequent, watery bowel movements.
Constant loss of fluid via diarrhoea may
lead to dehydration. If this symptom is
severe replenishing of fluids is
necessary. If this cannot be done in the
home an individual my require
hospitalisation.
OR
Increased constipation: Constipation is
characterised by failure of the body to
eliminate faecal matter, despite the
individual feeling the urge to do so.
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Constipation can result in feeling
bloated and lethargic and in extreme
cases (if left untreated) may even
results in toxicity in the body. If
constipation remains untreated if mayalso worsen or cause diverticulitis in an
individual.
2)Abdominal Pain or cramps: This is
commonly the feeling of pain or
tenderness around the abdominal area
(the stomach region or belly). Abdominal
pain is the most common symptom of
diverticulitis and tends to present astenderness around the lower left side of
the abdomen- this is typically
indicative of inflammation of the
diverticula due to infection.
The severity of the pain is not always
indicative of seriousness of the
condition as a mild condition may result
in extreme pain, whereas a seriouscondition may result in mild pain.
Rather the suddenness of the onset
should be used to judge severity of the
condition. Abdominal pain caused by
diverticulitis tends to be steady, sever
and deep.
3)Abdominal Bloating: This symptom is
characterised by feelings of tightnessand fullness within the abdominal area
and is usually due to a build up in
pressure or gas.
4) Steatorrhoea: This term refers to the
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presence of excess amounts of fat in the
stool due to malabsorption in the
gastrointestinal tract. Stools appear to
be bulky, light in colour and tend to
float in surrounding water. Diarrhoea isa common symptom accompanying
steatorrhoea.
8Nausea: An uneasy sensation in the
abdomen that occurs as a result of the
inflammation of the diverticula and the
presence of infection within them.
9Vomiting: The expulsion of food stuffs
or bile via the oesophagus and through
the mouth. Vomiting generally follows
nausea.
10 Fever: A condition marked by elevated
temperatures, sweating, cold clammy
hands and in extreme circumstances the
individual may become delirious.
11 Excessive flatulence and Distension:
Excess passing of gas and accompanied by
bloating around the abdominal area may
indicative of diverticulitis.
12Polyuria, Dysuria and Pyuria:
a. Polyuria: An increase in frequency of
urination i.e. a person finds
themselves needing to go to the
toilet more often.
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b. Dysuria: Pain upon urination.
c. Pyuiria: The presence of pus or white
blood cells in the urine, urine often
presents as cloudy if pus is present.
These symptoms occurs if the bladder or
ureters have been irritated in someway
due to the presence of inflamed
diverticula.
The severity of any of these symptoms is
dependent on the degree of inflammation andextent of infection of the diverticula.
If a person is experiencing any of the
aforementioned symptoms, a visit to the
doctor would be recommended. Self-diagnosing
is not wise as these symptoms are similar to
those of other gastro-intestinal disorders.
Most doctors will treat these acute symptomswith a course of antibiotics and a liquid
diet until the diverticula cease to be
inflamed.
Chapter 3:
Complications of
diverticular disease.
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Without the correct treatment (if any is
required), serious cases of diverticular
disease can lead to:
1) Infection: Infection occurs when bodily
fluids or faeces becomes trapped in the
diverticula and begin to stagnate. This
provides an optimal environment for the
growth of bacteria and consequently the
development of infection.
13 Rectal Bleeding: Bleeding from the
rectum can occur if diverticula present
in the colon begin to bleed due to the
bursting of a blood vessel.
Rectal bleeding will present in one of
two ways:
a) Small amounts of blood will bepresent in the stool over a few days.
This generally rectifies itself.
b) A large of blood is produced over a
small amount of time due to the
bursting of a blood vessel. The onset
of this type of bleeding is generally
painless, immediate and accompaniedby the urge to defecate. This symptom
is usually only present in those with
extreme cases of diverticulitis and
requires hospitalisation and possible
surgery or the implementation of a
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device up through the rectum to burn
the bleeding wound shut. In some
cases the bleeding may stop
spontaneously without the requirement
of medical intervention.
14 Haemorrhage: The presence of rectal
bleeding or bloody stools is generally
indicative of internal bleeding or
haemorrhage. Internal haemorrhage will
present as red or burgundy coloured
stools.
4) Fistulas: A fistula is an abnormal tunnel
or connection between two organs that
develops as a result of infection (in the
case of diverticulitis this infection is
present with the inflamed diverticula).
There are many areas in which fistulas
can occur. The main areas affected by
diverticular disease are the areas
surrounding the bowel (the genitals andthe anus).
Fistulas may link and of the surrounding
organs or cavities with the bowel. The
most common occurrences in individuals
with a gastrointestinal are as follows:
15 Enterocutaneous: Pathway leading form
the gut, to the area of infection andfinally to the skin.
16 Enteroenteric: Any fistula involving
the intestines.
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17 Enterovaginal: A fistula creating a
pathway to the vagina. Symptoms of
this fistula include vagina discharge
containing faecal matter. Feculent
vaginal discharge can also be aresults of a fistula developing
between the sight of infection and
the uterus.
18 Enterovesicular: A fistula creating a
pathway form the site of infection to
the bladder. Symptoms of the
development of this type of fistulainclude frequent urinary tract
infections, pneumaturia and the
passing of gas from the urethra
during urination.
In diverticular disease, the resultant
fistulas are generally faecal or anal
fistulas, meaning the fistula may cause
faeces to pass through openings otherthan the anus. Fistulas are formed from
abscesses (in this case the diverticula)
which do not have a chance of healing due
to being constantly filled with bodily
fluids or stools. If these abscesses
remain untreated they will consequently
break through to the skin or another
organ, creating a tunnel or connectionbetween the two structures.
The types of fistulas that may develop
include:
19 Blind fistulas- only one end of the
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fistula has an opening
b) Complete fistula- Both ends of the
fistula are open
20 Horseshoe fistula- the anus is
connected to the surface of the skin
via a tunnel around the rectum.
d) Incomplete fistula- is only attached
to one organ, generally the skin.
Symptoms of a fistula include pain,feeling ill, fever, tenderness or itching
and severity will range depending on the
location of the fistula itself.
5) Large Bowel Obstruction: This
complication only occurs in a small
amount of individuals suffering from
diverticulitis as a result of the
swelling due to inflammation onconsequent development of scar tissue.
Blockage due to inflammation will settle
as the inflammation is treated, however
blocking due to scar tissue remains.
These blockages can occur as partial or
total blockages. Partial blockages are
not urgent, and therefore corrective
surgery can be planned. Total blockagesare urgent and must be addressed via
surgery immediately.
6) Development of an Abscess: These are pus
filled areas of infection and may form if
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initial infection remains untreated.
Due to the destruction of tissue by an
abscess, small holes often develop, these
are known as perforations, and allow the
leakage of pus out of the colon into theabdominal area. Perforations may cause
the individual to develop pain in the
back or lower extremeties.
Whilst small abscesses may rectify
themselves without the administration of
antibiotics, large abscesses may have to
be drained in order to allow for
sufficient time and conditions to healappropriately. Abscesses are drained via
the insertion of a catheter. If drainage
is not successful surgery may be required
to clean the abscess.
If excessive amounts of infection leak
out of the contaminated area into the
abdominal cavity, peritonitis may occur
in which case the individual will beginexperiencing severe, generalised
abdominal pain. Peritonitis refers to the
infection of the walls of the abdominal
and requires immediate surgery to clean
the abdomen. Peritonitis can be fatal
without treatment. Treatment involves an
operation by which the abdomen is cleaned
and infected parts of the colon areremoved.
Chapter 4: Treatment
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of Diverticular
disease.
In many cases, diverticular disease presents
with no symptoms and thus no treatment is
required, however it is ideal that the
individual adopt an optimal diet to ensure
no symptoms do occur.
In the event that symptoms appear, the main
form of treatment of diverticulosis is
through the adoption of an optimal diet
(addressed in chapters 5 and six).
In some cases medications are required.
For an individual who develops
diverticulitis (the active phase of thedisease) treatment is more intense. Should
symptoms or complications of diverticulitis
become severe enough, an individual may
often require hospitalisation. In hospital
they are treated with changes to diet and
appropriate antibiotics. Surgery is the
final option, and is only implemented for
individuals who suffer from recurring
diverticulitis. Surgery generally involves
the removal of certain sections of the bowel
and consequent resection and is generally
suggested if a patient has two or more
occurrences of diverticulitis or if a large
perforation or peritonitis is present.
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Surgery is generally performed via two
operations. The first operation aims to
remove the diseased section of the colon and
clean the abdominal cavity. During this
operation, it is not appropriate to rejointhe colon due to the high risk of the
patient developing infection or a bowel
obstruction. Instead surgeons divert the
path of the faecal matter via a colostomy. A
colostomy involves the attachment of the
colon to the skin in which faeces are passed
through a hole into a bag stored externally.
After a period of time has elapsed and theinfection in the colon has been successfully
treated and subsided, the bowel is
reattached, thus enabling normal bowel
functions and the patient to cease the use
of the colostomy bag. The hole that was
previously made in the skin is surgically
closed..
Chapter 5: Dietary
Management of
Diverticular disease.
All current literature recommends that the
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most effective way to prevent or manage
diverticulosis is through the adoption of a
diet high in fibre.
Fibre is the indigestible portion of plant
foods which aids in bulking up the stool (by
forming the bulk or the roughage) to assist
it in passing through the body to assure
regular bowel movements.
There are two type of fibre in the diet,
soluble and insoluble fibre, both of which
aid in the creation of a stool and prevent
constipation.
1) Soluble fibre: dissolves easily in water
and takes on a soft texture in the
intestines. This fibre is the bodies main
means of bulking the stool.
2) Insoluble fibre: passes through the
gastro-intestinal tract virtually
unchanged.
As plant materials are passed through the
body, the removal of water, protein, fats,
carbohydrates and essential nutrients
occurs.
Upon entering the colon, all that remains to
be digested is water. The colon should
remove this remaining water, thus forming
the stool.
If an individual is not eating sufficient
amounts of fibre containing foods, a very
dry, hard stool is produced. Stools of this
consistency have difficulty moving through
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the bowel and require higher amounts of
pressure to be passed through. Gradually the
body becomes incapable of creating these
high amounts of pressure, and begins to rely
on the force of the movement of theabdominal walls to transport stools through
the bowel. This is known as straining, and
puts an excessive amount of pressure on the
abdominal wall, resulting in the formation
or aggravation of diverticula.
On the other hand, diets containing
sufficient amount of fibre end in the
production of a softer, bulkier stool, whichis easily moved through the bowel without
requiring high pressures to do so.
By ensuring an adequate amount of fibre in
the diet it is possible to prevent the
occurrence diverticular disease or to manage
existing diverticular disease by reducing
the required pressure for stools to pass
through the bowel.
Current recommendations for fibre intake per
day are:
21At least 25 grams of fibre per day for
adult women.
22At least 30 grams of fibre per day for
adult men.
2328 grams of fibre per day for pregnant
women over the age of eighteen.
2427-30 grams of fibre per day for women
who are breastfeeding.
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Another requirement for the formation of a
soft, bulky stool is an adequate fluid
intake. This will ensure that the stool
retains sufficient water to be soft and that
the bowel is able to produce mucous. Thesecretion of mucous allows the stool to pass
easily through the bowel rather than
sticking to the wall of the colon.
Chapter 6a: Tips on
Optimising your diet
to prevent or manage
diverticulosis.
Diets are very individualised factors of
life and will vary from person to person. A
decision about diet should be made by the
individual depending on what works for them
in regards to amounts and types of food they
will consume.
In general, the following tips may provehandy in order to optimise diet and achieve
adequate fluid and fibre intake:
1) Increase the fibre of your content
gradually, especially if you are prone to
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constipation. This will avoid further
gastrointestinal upset and will allow
your body to gradually adjust to any
changes. A sudden change in fibre can
result in flatulence and abdominal pain-so take it slowly.
2) Consume plenty of plant foods as opposed
to meat or dairy. These include:
a) Wholegrain breads and cereals: Breads
and cereals are the main source of
fibre in the diet. Choose from this
food group regularly throughout theday.
During the processes of refining
foods, much of the fibre in a food
product will become depleted. When
selecting breads and cereals opt for
the wholegrain versions, as these are
less refined and thus contain higher
amount of fibre. Try to selectcereals that contain barley, wheat or
oats.
If wholegrain breads are not to your
liking it is possible to purchase
high fibre white breads and cereals.
25 Fruit and vegetables: These food
groups also provide fibre in the
diet, particularly those in which the
skin of the fruit or vegetable is
consumed.
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3) Drink plenty of fluids each day. Aim for
two litres (eight standard drinking glasses)
to ensure sufficient fluid in the body for
bulky, soft stools. Be aware that he term
fluid does not just apply to water. Manyitems constitute a fluid. These include:
Water
Milk
Juice
Sports drinks
Tea
Coffee
Soft drink
Ice cream
Custard
Soup
Previously, many doctors recommended the
avoidance of nuts, popcorn, pumpkin, caraway
seeds and sunflower seeds as they believed
they may become stuck in the diverticula and
cause infection and inflammation.
These recommendations have since beendiscontinued as there is no scientific
evidence that these foods may have this
effect.
Foods high in fibre to include in the diet:
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26Pears
27Apples
28Bananas
29Dried fruit
30Peas
31Potato with the skin
32Broccoli
33Cabbage
34Spinach
35Asparagus
36Squash
37Carrots
38Baked Beans
39Lentils
40Chick peas
41Kidney Beans
42Lima Beans
43Wholegrain or wholemeal bread (Or
alternatively high fibre white bread)
44Whole-wheat pasta
45Breakfast cereals containing barley,
wheat or oats
46Dried Beans
47Soy milk
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48Psyllium
49Brown Rice
Whilst it may be tempting to include a fibre
supplement in the diet, try to avoid this
where possible as this may exacerbate or
cause diarrhoea in the event that an
individual is not drinking sufficient
fluids. Aim to obtain all fibre requirements
by eating a healthy diet.
Chapter 6b: Dietary
Management of
Diverticulitis.The treatment of diverticulitis is the
opposite to that of diverticulosis. During
the inflamed stage of the disease care
should be taken to limit fibre in the diet
to avoid further upset or inflammation and
to allow the bowel time to rest. In manycases a fluid diet may be prescribed to ease
the burden on the bowel during times of
inflammation.
Decreasing fibre in the diet during this
stage of the disorder aid in limiting the
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substances passing through the inflamed
section.
The individual is required to continue on a
low fibre diet over a month long period,
after which symptoms should have subsided.
At this point in time a high fibre diet may
be resumed.
Previous studies have revealed that in some
cases, those suffering from a colonic
disease such as diverticulitis may
consequently suffer from lactose
malabsorption. This means that the body isunable to absorb lactose from foods or
fluids.
Lactose is a form of sugar present in milk
and other dairy products. In the event that
the body is unable to absorb lactose the
individual may suffer from diarrhoea,
abdominal pain and abdominal bloating after
eating dairy products.
For this reason it may be necessary for an
individual to select lactose free dairy
products whilst diverticulitis persists.
Once the condition has been appropriately
treated and subsided, the individual should
be able to resume dairy products, as studies
have shown that lactose malabsorption
subsides once diverticulitis has been
treated.
Very few studies have been done in the area
of lactose malabsorption resulting from
colonic disease, therefore current evidence
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is still slightly controversial. If you find
you are suffering from any of the
aforementioned symptoms of lactose
malabsorption it would be wise to inform
your doctor.
As mentioned in the previous chapter,
adopting a diet low in fibre during the
onset and duration of diverticulitis will
aid in managing and alleviating any symptoms
that may occur. The following tips may be
useful in decreasing fibre in the diet:50Consume white breads and cereals:
During the process of refinement, foods
tend to lose much of their fibre
content. Breads and cereals based on
white flour are particularly low in
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fibre and are the optimal choice for
someone suffering from diverticulitis.
51Limit (but do not completely eliminate)
the amount of plant foods consumed: Asfibre is mainly obtained from these
types of foods it makes sense to limit
these in the diet for the duration of
diverticulitis.
52Remove the skin from fruits and
vegetables before consumption. Most of
the fibre contained within these foodsis held within the skin.
53Avoid seeds, nuts, popcorn, and legumes
as these may further exacerbate the
condition.
Foods that are low in fibre include:
White breads and cereals
Skinless fruits and vegetables
Fruit Juice
Vegetable Juice
Meat and dairy products
5) In some individuals it may be necessary
to select lactose free dairy products,
if lactose malabsorption is present.
Appropriate dairy foods that are low in
lactose include:
54Soy milk (ensure you select a soy milk
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fortified with calcium)
55Most cheeses
56Lactose free milk
57Lactose free yoghurt
Chapter 8: Summing
it all upFrom all the information provided we can see
that the management of diverticulosis (the
inactive phase of the condition) can be
managed through the adoption of a diet high
in fibre.
It is worth noticing that this is also theway in which the development of diverticular
disease is prevented.
With the complications that may result from
having diverticular disease it would be
optimal to start on a high fibre diet before
the disease can develop, rather than allow
it to form and treat it later, when risks of
further complications evolve.
Those with diverticular disease who
successfully adopt a high fibre diet as
recommended severely decrease any chances of
developing further complications of the
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disease and are able to live a normal life.
For the small proportion of people who do
develop diverticulitis, treatment is
generally as simple as altering the diet to
limit fibre for a one month period after
which the normal high fibre diet is resumed.
Individuals who disregard the advice offered
by professionals are at risk of developing
severe complications and symptoms.