Do your patients have diverticular disease? There are actually three different variations of diverticular disease that depend on the stage of disease progression. Patients can fall into any of the three categories. Diverticulosis is when this disease is asymptomatic, so patients may not know there is anything wrong with their digestive health. On the other hand, diverticulitis is what we call it when symptoms are present due to inflammation. This is typically when patients start coming to you for help. Complicated diverticular disease represents an increased severity of disease progression. This group of patients absolutely need help, sometimes immediately.

Although most people with diverticulosis will remain asymptomatic, up to 25% of people will experience at least one episode of diverticulitis, which makes up about 200,000 hospitalizations every year in the U.S. This prevalence stresses the importance of regular lab testing for people with diverticular disease as identifying the contributing factors to diverticulitis can help manage and decrease the risk factors of disease progression.

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What is Diverticular Disease?

Diverticular disease is the medical term for when there are issues with the diverticula causing symptoms. Diverticula is characterized by the occurrence of small pouches herniating the lining of the intestinal wall. These herniated pouches generally form in the lower section of the large intestine or the sigmoid colon but can also form anywhere in the gastrointestinal tract. They typically develop in the vascular region of the colonic mucosa, where the lining is considered generally weaker. 

There are three categories of diverticular disease. They include diverticulosis, diverticulitis, and complicated diverticular disease. Diverticulosis is usually asymptomatic, but there is a presence of diverticula. In comparison, diverticulitis is the inflammation of the diverticula causing symptoms. Complicated diverticular disease is when this condition is more severe due to perforations into the bowel, abdominal cavity inflammation, obstruction, bleeding, abscess, or if the intestinal tract goes into another organ, forming a fistula.

What Causes Diverticular Disease? 

Diverticulosis is common in Western populations and becomes more prevalent as people age. Several factors increase the risk of developing diverticular disease. Aging leads to weakened intestinal walls that are more susceptible to forming pouches. This condition is more common in those over 40, particularly males, smokers, overweight individuals, and those with a sedentary lifestyle. Alcohol consumption and the use of certain drugs, such as NSAIDs, also raise the risk.

Abnormal colonic motility and increased colonic pressure contribute to diverticular disease development. Those with symptomatic uncomplicated diverticular disease show altered digestive tract motility and a "spastic colon." This alteration is caused by fewer pacemaker cells in the bowel, leading to slowed transit and increased pressure.

Diet plays a significant role in diverticular disease, especially low fiber intake. Individuals with low-fiber diets, favoring processed foods and factory-raised meats over fruits, vegetables, legumes, whole grains, and nuts, are more prone to the condition. Insufficient fiber leads to constipation, straining the colon walls and causing pouches to form. Other dietary risk factors include food reactions which can increase intestinal inflammation and constipation. 

Chronic low-grade intestinal inflammation, microbiome imbalances, and changes in digestive tract motility contribute to diverticular disease. Small intestinal bacterial overgrowth (SIBO), dysbiosis, and inflammation are common in this condition. Maintaining a balanced microbiome is crucial for reducing inflammation and promoting healthy gut function. A healthy microbiome produces substances like short-chain fatty acids (SCFA) that nourish the intestinal lining and prevent inflammation through fiber intake. Imbalances lead to chronic inflammation and an unhealthy gut lining. Healthy bacteria also prevent constipation, which negatively affects the microbiome and increases diverticular disease progression.

Another lifestyle factor that may negatively impact diverticular disease includes elevated stress levels. An investigation showed that elevated stress levels have a bidirectional relationship with an increased size of the diverticula, in which stress can increase its size, which in turn elevates stress. However, more studies are needed to assess this relationship further.

Additionally, diverticulitis arises when the diverticula becomes inflamed or infected. Infection often starts from stool bacteria entering the pouches. Increased colon wall pressure can also cause erosion and inflammation. Trapped matter in the pouches results in swelling, compromised blood flow, inflammation, and potential perforation.

Diverticular Disease Symptoms

Notably, most patients with diverticular disease are asymptomatic, and only 25% progress with symptoms.

Here are the common symptoms:

• Cramps
• Feeling bloated
• Changes in bathroom habits like constipation
• Pain
• Fever
• Tender abdomen
• Feeling nauseous and vomiting
• Blood in stool

In severe cases, that can occur in patients with diverticulitis, immediate emergency care may be required. It's possible that the infected pouch might burst, causing peritonitis and abdominal cavity inflammation.

Here are the signs to look out for if your patients have been previously diagnosed with diverticulitis:

• Stools with fresh blood
• Feelings of being weak
• Paleness in the face
• Extreme sensitivity in the abdomen when touched
• Urination irritation or frequency

What Are The Benefits of Regular Lab Testing For Patients With Diverticular Disease?

Since most patients are asymptomatic, regular lab testing can help patients with diverticular disease prevent more complicated or severe issues from arising, such as gastrointestinal bleeding, intestinal obstruction, fistulas, bladder inflammation, abscesses, or perforations that may need immediate medical attention. They can also help detect any underlying causes contributing to the onset of symptoms so preventative measures can be implemented. Practitioners will typically retest within one to six months after treatments are carried out to assess the effectiveness of their treatments so adjustments can be appropriately made to optimize the interventions.

Top Labs To Run Bi-Annually On Patients With Diverticular Disease

These are the labs that are used by clinicians to run regularly for their diverticular disease patients:

Comprehensive Stool Analysis

A complete stool analysis examines the gut's bacteria and inflammation levels. The Gut Zoomer is a stool test that measures beneficial and imbalanced pathogens, inflammation, and other signs of intestinal permeability and decreased digestive function. Imbalances in the microbiome are associated with an increased risk of diverticulitis, in which dietary solutions such as increased fiber intake can improve SCFA levels to help improve both microbiome health and diverticular disease. Retesting after treatment, usually done a few months later, can guide the optimization of targeted dietary and lifestyle management protocols that impact microbiome health.

Food Reaction Testing

Food reactions can lead to chronic low-grade intestinal inflammation and conditions such as constipation, increasing the risk of disease progression for individuals with diverticular disease. Reactions to foods can be tested through a food reactivity panel that measures different reactions, including food sensitivities and allergies. The results of this test can enable you to personalize your patient's nutritional plans that improve gut inflammation and overall gut health to decrease the risk of diverticulitis episodes.

Adrenal Stress Test

Elevated stress levels may be implicated in the progression of diverticular disease by increasing the size of the diverticula, potentially leading to diverticulitis or symptoms. Therefore, therapeutic strategies to reduce stress levels should be sought after in patients with this condition. The adrenal stress test can measure cortisol (stress hormone) levels over a 24-hour period to get a comprehensive analysis of stress levels by taking a look at imbalances in cortisol secretion. Regular monitoring of stress levels should be considered as a part of management protocols for diverticular disease.

Calprotectin

Assessing fecal calprotectin regularly is recommended for patients with diverticular disease. Calprotectin is an inflammatory marker of diverticular disease and its progression. Elevated levels can be a predictor of symptoms in those with asymptomatic diverticular disease, allowing for treatment and management strategies to be implemented based on these results. Retesting can assess those protocols' effectiveness in reducing gut inflammation levels.

Additional Labs to Check 

Conventional diagnosis of diverticular disease is typically accomplished through symptom analysis and a thorough intake and confirming intestinal changes via imaging such as colonoscopy, CT scan, MRI, or a barium enema to view the diverticula.

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Summary

Just because a person has diverticula doesn't necessarily mean that they will develop symptoms associated with it. The best approach is to stay on top of the contributing factors such as diet, managing cortisol levels, and other lifestyle approaches to prevent diverticulitis or worsening of diverticular disease. These preventative measures can be accomplished through bi-annual lab testing to identify any factors that may pose an increased risk of symptoms or disease progression.