Antibiotics don’t work for diverticulitis, so what does?

Diverticular disease is a condition characterised by the presence of small out-pocketings in the wall of the large bowel. The condition is common in the western World, and is usually symptomless. However, if one or more of the pockets becomes inflamed or infected, symptoms such as diarrhoea, pain, abdominal bloating and the passing of blood in the stool can occur. Sometimes a pocket can burst, leading to infection within the abdomen (peritonitis), with potentially dire consequences.

It is possible to have diverticular disease with no symptoms or problems whatsoever. However, when complications arise, these are usually described as ‘diverticulitis’. A common medical approach here is to prescribe antibiotics. The idea here is that bacterial organisms such as E. coli are causing infection in and around one or more pockets, and antibiotics will help eradicate the infection and the problem. However, a recent review [1] finds that antibiotics therapy “[makes] no difference to complications, length of stay, need for surgery, or recurrence.” In other words, the best available evidence shows that a mainstay treatment here doesn’t work. We can perhaps add this to the long and ever-growing list of things we do in medicine that are simply not ‘evidence-based’ (though we doctors might like to believe they are).

Over the years, I’ve seen a fair few individuals with diverticular disease and symptoms that may well be due to diverticulitis. My focus has usually been to suggest measures to ensure a healthy ‘ecosystem’ in the gut, principally through the use of health bacterial supplements known as ‘probiotics’. My thinking was that by doing this, less healthy organisms would be less likely to get a hold in the gut and the out-pocketings characteristic of the condition. The hope that this would help reduce the risk of complications.

One thing I can say for certain is that this approach really did seem to bring dividends in practice, with the great majority of sufferers reporting much fewer problems using this approach. Today, though, I decided to see if any published evidence exists for the use of probiotics in diverticular disease.

I came across one study in which probiotics were used in a group of sufferers who were having an average of 1.2 symptom episodes per month [1]. The trial lasted 6 months, and the results were that the treatment was ‘effective’ or ‘very effective’ in 78 per cent of individuals, and that 68 per cent of individuals were entirely symptom free.

These are, by my estimation, great results. Some will say that we can’t learn much from this study because it lacked a ‘placebo’ group. However, others might argue that it’s unlikely that placebo would be responsible for such a dramatic improvement. In a comment piece which accompanies the study [3], a Dr Eamonn Quigley writes:

While one has to remain cautious in the interpretation of such observations in a non-randomized, non-placebo controlled study in a symptom-based disorder, a complete remission rate of this magnitude sustained for such a long period of time is impressive and indicates that this approach, at the very least, deserves further study.

I appreciate Dr Quigley’s caution, though I was pleased to see him not get too stuck on the idea that the benefits might be entirely due to placebo. One reason for that is that some might argue that even if the placebo response is at work here, who cares (it’s the end result that counts)?

References:

1. Shabanzadeh DM, et al. Antibiotics for uncomplicated diverticulitis Cochrane Collaboration published 14 November 2012

2. Lamiki P, et al. Probiotics in diverticular disease of the colon: an open label study. J Gastrointestin Liver Dis. 2010;19(2):31-36

3. Quigley EM. Gut microbiota, inflammation and symptomatic diverticular disease. New insights into an old and neglected disorder. J Gastrointestin Liver Dis. 2010;19(2):127-9

19 Responses to Antibiotics don’t work for diverticulitis, so what does?

  1. Joe Wrigley 22 November 2012 at 7:38 pm #

    I would like to know what kind of probiotics you prefer for this (and other issues)? There are so many, and in so many formats, it’s hard to know which are most beneficial (as with most things, marketing is mostly hype).

  2. Bill 22 November 2012 at 9:54 pm #

    I would recommend a grain free diet (high fat, low carb) and adopting a proper squatting position when using the toilet for anybody with bowel diseases and problems as well as probiotics – full fat live yogurt.

  3. Dr. Bill Wilson 23 November 2012 at 12:45 am #

    Diverticular disease is clearly associated with the modern western diet. I personally suspect that excessive fructose from sugar and HFCS and high glycemic carbohydrates mainly from grain play a role in this common disease.

    Cultures that don’t consume these dietary elements don’t seem to get a lot of diverticular disease. Sugar and grains likely disrupt the normal gut flora and grains, especially wheat, are known to break down the gut barrier. I recommend a low carbohydrate, moderate protein, high fat diet. Eat plenty of healthy fats like coconut oil. Coconut oil also has been shown to have anti-bacterial properties–a good thing when dealing with diverticulitis.

    I admit many patients to the hospital for treatment of acute diverticulitis. They are usually treated with antibiotics but I suspect that bowel rest (NPO) does more to treat the condition than antibiotics.

  4. Yossi 23 November 2012 at 2:05 am #

    John, could you let us know which brand of probiotics you use or recommend. Thanks.

  5. John Briffa 23 November 2012 at 11:50 am #

    Joe and Yossi

    The probiotics I use in practice are made by the company BioCare here in the UK.

  6. hedleypaul 23 November 2012 at 4:10 pm #

    Some twelve years ago I was rushed to hospital with agonising diverticulitis, having never suffered symptoms previously. Seven days on water, plus anti-biotics seemed to fix the problem. I enjoyed a high fibre diet anyway, albeit quite heavily wheat based. Some six months later after I had felt a few twinges, I resorted to echinacea and vitamin C (my cure-all for many ailments) and the twinges abated. Since then, due to onset of type 2 diabetes, I avoid wheat, and adopted what Dr Briffa calls the ‘Paeolithic diet’. Never since have I felt a twinge, and blood sugar controlled by diet. Incidently, having abandoned Metformin and Simvastatin I feel much much better and more alert.
    Was it my imagination, or could the echinacea actually have helped?

  7. Dr. Georgia Ede 23 November 2012 at 7:39 pm #

    I am very interested in your personal clinical experiences with probiotics in your own patients, as that kind of information is at least as important as research-based data. I am curious to know what kinds of dietary advice you offer to patients with diverticulitis or if any of your patients have reported improvement making specific dietary changes. As a psychiatrist I have not had the opportunity to work specifically with people suffering from diverticulitis, but have worked with folks who have IBS, for whom dietary changes can be very helpful, so I would love to hear your take on food and diverticulitis. Thanks as always for the great posts!

  8. HIlda Glickman Nutritionist 23 November 2012 at 8:10 pm #

    People with this condition should avoid food with hard bits such as nuts, crisps, hard cereal, raw carrots as the bits acn drop into the pockets and lie there. Gelatinous foods such as psyllium can sweep the bowel clean.

  9. bill 24 November 2012 at 2:23 am #

    Hi John,

    my sister takesw the tablet form. Would you recommend tablet or drinks form.

  10. Peter Andrews 24 November 2012 at 2:42 am #

    My wife had three separate diverticulitis ‘attacks’ over two years and the doctors convinced her that she needed surgery and scheduled it. I convinced her to wait, because we had recently significantly increased our vitamin D intake. She had one small bout a while back and took some extra vitamin D but otherwise remains healthy. Similarly, she has far fewer sinus infections than a few years back although she believes this is due to septoplasty to correct a slightly deviated septum.

  11. Jackie O'Connor 25 November 2012 at 11:31 pm #

    This year I had a kidney transplant. I am not allowed probiotics or organic yoghurts and I am not sure what vitamin supplements I can take.
    I recently developed diverticulitis and piles out of the blue having all my life had a robust constitution.
    I am now undergoing invasive tests for colon problems ( they will leave no stone unturned !) although I am convinced that I exacerbated my digestive problems with too much roughage ( I was obsessed with avoiding constipation) and I simply need to calm it all down as naturally as possible. The kidney team refuse to believe such a simple reason and for my own good will examine me in horrifying detail. Which is a good thing I suppose. Does anyone have any suggestions regarding the best way to deal with this digestive problem?

  12. jane 17 December 2012 at 8:13 pm #

    Has anyone tried Symprove? I have recently been diagnosed with diverticular disease and have been taking this since October….i think it’s made a huge difference (for me) but i still don’t feel 100%…i do think there is something in the gut-flora dysbiosis theory though. Kings College are apparently running another trial on probiotics and diverticular disease next year.

  13. Jean Payne 14 September 2013 at 12:33 pm #

    For the past two years I have had diverticulitis and have been taking a clove of fresh garlic with each meal. For the past year I have been on the specific carb diet and also take 48 billion probiotics each morning on an empty stomach. Recently (because of putting a tsp. balsamic vinegar on my salad), the pain is increasing drastically. I am allergic to all prescription antibiotics, plus the contrast used in the barium diagnostic. GFSE cured my only other incidence nine years ago. Thanks so much for any advice.

  14. Peter Andrews 16 September 2013 at 2:20 pm #

    Recent article about Vitamin D role in reducing diverticulosis severity:

    Maguire LH, Song M, Strate LE, Giovannucci EL, Chan AT. Higher Serum Levels of Vitamin D are Associated with Reduced Risk of Diverticulitis. Clin Gastroenterol Hepatol. 2013 Aug 15.

    http://www.ncbi.nlm.nih.gov/pubmed/23954650

    Roughly, those with the lower levels were about twice as likely to need hospitalization.

  15. Ryan 6 October 2013 at 4:26 pm #

    I have a lot of experience with diverticulitis, as I had it for a few years, and had frequent diverticulitis infections, before having surgery in 2011 to remove the effected portion of my colon. Although antibiotics do not work to cure diverticular disease, they certainly do work to cure the diverticulitis infection. I have had more than 20 diverticulitis infections, and in every case I was prescribed two antibiotics, and in every case the antibiotics cured the diverticulitis infection.

  16. tracy 13 October 2013 at 8:05 am #

    hi. im 33 just come out of hospital for third time in three weeks. with diverticular desease. i completed a full five days on iv antibiotics. this time i feel ok few twinges and nausea. but im ok. but ive not been givin types of food i can eat just told wat to avoid. and im only young with three children i dnt want to end up with a bag. so i want to have all the right things. anyone with ideas to stop further attacks. x

  17. wrw 2 November 2013 at 12:58 am #

    I had my first mild case at around age 12. Mild cases on and off over the next 20 years or so, then I got on a binge of eating air popped popcorn by the gallon (no oil, no butter = no satiation. I then had my first severe bought with diverticulitis. It seems that the dry popcorn had caused a IBS reaction in the lining of the intestine. Being thus sensitized, I have had to totally avoid popcorn forever. I tried a small handful a couple of years back and the next day here comes the diverticulitis pain.

    In the past few years, I have, for many reasons, become radical in my a rejection of grains, simple carbs and sugars. I eat a high fat and high protien diet with some occasional raw garlic. I take raw organic coconut oil and drink an expensive fermented coconut milk drink. I eat as much that is fermented as I can as this is conducive to helping probiotics colonize the gut.

    So you can imagine my dismay when last week I was hit with the worst attack of diverticulitis I have ever had. I thought it was some obstruction. I went to the hospital emergency room. A CAT scan revealed diverticulitis. I was dumbfounded.

    I believe that my gut has become sensitized and can have an inflammatory reaction e.g. gastritis with no infection present. But what caused it? I do not know. The only thing I remember out of the ordinary was a slice of raw purple onion and a glass of wine that had turned somewhat to vinegar. But this is a fermented beverage and vinegar, I used to take it all the time as a dietary supplement. I have read the health wonders of apple cider vinegar.

  18. wrw 2 November 2013 at 1:08 am #

    I forgot to mention that I am a 52 year old male and also that I take

    40,000 IU of vitamin D along with the requisite

    2400 mcg of vitamin K2/ 100 mcg K1 complex

  19. CindyP 17 December 2013 at 9:24 pm #

    I have dealt with IBS for the last 35 years. Four yrs ago diverticulii was found in my colon during a routine colonoscopy. About a month ago I had a bout of what I thought was the worst IBS attack I had ever had. As always, I immediately went on a clear liquid diet to calm down the colon. In a day it worked (the usual IBS attack duration). This past Saturday night I began to have the same symptoms, a very hard gassy pain occurred on the left side of my abdomen every time I consumed anything and constipation. I have been on a liquid diet for 3 days now and the pain is lessening. I too am allergic to antibiotics. I have not seen a doctor because I refuse to go to a hospital for something I feel I can handle myself. Sunday the pain level was an 9, today I would say a 3 bu the pain occurs less often. Only twice so far today. What do you feel can help me to manage this situation. Is it imperative to see a doctor?

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