Diverticulitis: A Functional Medicine Approach with Dr. George Papanicolaou

Coming up on this episode of the Doctor's Pharmacy.

And we do this before people develop diverticulitis. We help them arrange their diet and their lifestyle because stress plays a big role in diverticulitis.

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Welcome, George.

Mark, it's a pleasure. Thank you for having me today. So on this special episode of House Call, the Doctor's Pharmacy, we're going to dive into a topic that is not on everybody's radar, but it should be because we are living in a world where we torture our guts and the gut is so important to our overall health. And for many reasons, obviously the microbiome we've been talking about a lot. But, you know, one of the things that I remember from medical school, you probably remember this, was a guy named Dennis Burkitt, who was a physician from England who went to Africa. And he studied the difference between the populations that were hunter-gatherers and the same genetic crew that had moved to the city and were living in urban African cities. And he found that the average stool weight for the Hunter-gatherers was two pounds a day because they ate so much fiber and the average stool weight for the city dweller was four ounces. So four ounces versus 32 ounces. And he found that it correlated with all these chronic Western ailments, things like cancer and heart disease and diabetes. But he also noted that the hunter-gatherers had no diverticulitis or diverticulosis, which was fascinating. So this is an entirely Western disease and is a really reflection of the lack of our quality diet. The lack of fiber. I mean, we've had about 8% of our diet now is fiber. It used to be 100, sorry, 8 grams of fiber a day for lucky, maybe 15 if we are on the high end of the American population. And in hunter-gatherer times, it used to be 100 or 150 grams a day, which seems like a lot, but it's actually what our guts and bugs like. And that's led to this problem of diverticula. So, George, take us through what are diverticula, how do they form, and why are they a problem? And who gets it?

Yeah, before I get to that, I just want to say that the Dennis Burkitt story is a great one. And, you know, he was a phenomenal, you know, doctor. And nothing's changed because they did recent research that compared Ugandan, Ugandan, population to the United Kingdom. They looked at 1200 people, Ugandan versus 1200 in the UK, and they looked at gastric transit time and stool weight. And the gastric transit time for Ugandan is 34 hours for somebody in the UK, a Western population, it was 80 hours. Okay, 80 hours.

Oh, my God.

To pass through your gut. And the stool weight was again, that phenomenal numbers that you just talked about, 110 grams of school weight for the average UK population. And for the Ugandan, it was 400 grams, four times heavier.

Wow.

So nothing's changed since Dr. Berkowitz made his first observations. It's still the same. And our diets have just gotten worse. So to just start this conversation, just a couple definitions like what are diver, what is, you know, where does this hazel start? So diverticula are little pouchings in your colon. So your colon is this long tube and it's wrapped with mucosa on the inside and on the outside layers, it's multiple layers of muscle and then another final layer. And so it's like, you know, you've heard of hernias. Hernias are again out pouching of your, your internal organs through the fat and the muscle layers until it's sticking out in your abdomen. Most people are aware of those. Well, the same thing happens inside the colon. You have the inner lining starts to push through and form a sac and that sac is a diverticula. Now, you're actually born with diverticula. So you're going to have maybe one or two diverticula when you're born. But as you get older, you begin to have more. And so research has said that at least 35% of people that are under age 50 have multiple diverticula and have diverticulosis. And then above the age of 60, you're looking at closer to 70 to 80% of people have diverticulosis. And then 5% of people, adults, will go on to have diverticulitis. What's diverticulitis? That's when those diverticula become infected. And so you get bacteria that gets in there and you have now an infection and that can spread to multiple diverticula. And it usually happens on the left side of your abdomen where your colon, your large intestine, is descending and then it goes to the sigmoid colon and then the rectum and that's where the stool comes out. It's that lower third of the descending colon and sigmoid that are typically affected. And if you've ever had it and unfortunately I've had it, and it is extraordinarily painful. They call it the appendicitis on the left side. So left sided appendicitis. Yeah. It's that painful. And you can get nauseous, and you can get fevers, and you can get chills, and you lose your appetite, you get constipated, and it's just really, really.

Oh, it sounds like fun.

Yeah, it's not. And so, like fun. Yeah, I'm not a very fun patient, so I don't think anybody in my house is having fun when I had it. I certainly wasn't.

So.

It'S an issue. Now, I'm not the only person that gets it. About 200,000 people per year get it, and many of them end up in the hospital, although now we do a lot more treatment outpatient. So what are some of the risk factors? So if you're over 40 and you're male and you're heavy, overweight, or obese, if you eat a low fiber diet, we've already talked about that, if you eat a diet that's high in inflammatory fats, you're going to have a problem. If you don't exercise, and if you take non-steroidal anti-inflammatory drugs like aspirin, ibuprofen, which is Motrin or Advil, or you use steroids or opioids, or you smoke. those are some of the major risk factors for going on developing diverticulitis.

Amazing. And so, George, you know, we really figured out that, you know, this is a common problem that's preventable, mostly from lack of fiber and a healthy gut. The traditional treatments are basically surgery and antibiotics. Then it just keeps coming back. So, from a conventional perspective, what can we do to prevent it? And what do we do to treat it differently? So take us through what that would look like.

Well, I think you mean from a functional medicine perspective.

Yeah, from a functional medicine perspective.

Yeah, because conventional medicine doesn't prevent it. And that's the big difference. Conventional medicine does what it does best. It treats disease and it does that really well if it's acute disease. And so you have these diverticula floating around. You know you're going to have tons of them by the time somebody turns 60. And you know that at least 5% of those people are going to end up with diverticulitis, but we'll just let it happen and we'll treat it with anybody and if there's a complication, like an abscess or an obstruction or a fistula forms, you have a tract that goes from your intestine to your bladder or intestine to your uterus because we let that infection fester and get out of hand, then you're going to need surgery. That's how conventional medicine deals with it. Functional medicine, we don't think of it as just a fiber issue. There are more things going on. We start to think about the gut microbiome and imbalance in the gut microbiome and how that can lead to leaky gut and inflammation. That whole process can be avoided. We think about gastric motility. Yes, fiber can improve gastric motility, but there are other things that play a role in gastric motility. Some people once they hit that point where they have irritable bowel syndrome with constipation, their gastric motility is oftentimes beyond improvement with fiber. And we have to be addressing that. And so we look at motility, we look at the gut microbiome balance, we look at the gut permeability, we look at the possibility for inflammation. So we look for, you know, stealth infections. And we do this before people develop diverticulitis. We help them arrange their diet and their lifestyle because stress plays a big role in diverticulitis. I know the time I had it, I was under enormous amount of stress. And of course, my diet wasn't as good as it should have been at the same time, but stress plays a big role because we know that cortisol produced by the adrenal glands can impact the makeup of the gut microbiome. You can have less favorable bacteria that can cause inflammation, that can push out the good bacteria that can protect us. And so when that happens, cortisol can also trigger leaky gut. And when that begins to happen, when that process happens, now you're starting that cascade towards inflammation that will lead to the infection that results in diverticulitis. So that's how we approach it. We look at it much deeply, much more deeper, and we're attempting to prevent and to maximize and optimize gut function, that prevent disease and maximize and optimize gut function.

That's really amazing. And so what are the kinds of things you would do diagnostic wise to look at things differently? And can you maybe share, you know, some case story of a patient's.

Yeah. So, so, you know, once the diverticulitis happens, I can tell you I've seen it enough that in an outpatient setting, just a clinical presentation is usually enough. because most people have had, by the time they have their diverticulitis, I'd say three-quarters of my patients have at least had a colonoscopy, and they know they have diverticula. So I get the call, hey, my gut's killing me. What side's left? How old are you? I know their age. I'm usually looking at their chart. And I can pretty much know that, yeah. And did you have a colonoscopy? Yeah, I had one two years ago. Did you have particular, yeah, I remember he told me that. It's a left-sided pain, it's a really painful, they're really struggling. I mean, it can be as simple as just using your powers of observation, your experience, and the art of medicine that you've developed through your years as a doctor to make that diagnosis. It can be done as simple as that. If I need further confirmation, I can get a blood count to look for elevated white blood cells. If I think there might be the possibility something else, maybe a bladder infection, it might get a UA, urinalysis. Ultimately, if I need to confirm what's going on, you get a CAT scan. That's the definitive way to diagnose it. And then on the CAT scan, you'll see swelling and inflammation of that lower third of the colon and maybe sigmoid. And that's how the diagnosis of diverticulitis is finally made. And then the treatment is typically going to be antibiotics. There are a host of different pharmaceutical agents. that would be used and they can be done orally and you can stay at home. Or if you're really that sick, you'll get IV antibiotics in the hospital. And then hopefully you don't have any of the complications like a development of an abscess or obstruction or possibly even a bursting of your abscess. So now you have all this pus and bacteria flooding into your abdominal cavity. That's bad. and if any of those complications happen, you might be getting surgery done. That surgery can be either laparoscopic, where they enter in with tubes and are able to take out a piece of your colon, or it might be open surgery to clear out the abscess or clear out your abdomen if the abscess is burst. So those are, that's the sort of the horizon, the playing field of treating diverticulitis. And that's the acute diverticulitis. Now, if you have a mild case, like I had my really bad episode, but I had, you know, after that I had another episode where I just knew it was coming on. I could just feel it starting to happen. And so, if you're getting there, you don't have to wait. There are things that you can start to do. So, I did. and I ended up getting better within like five days, didn't move on to becoming an all-out problem. And what I did was, is I used bone broth. Bone broth has an enormous amount of nutrients, has antibacterial capabilities. So, I stopped eating a solid diet and I made a big batch of bone broth. You get water, you get a antibiotic, pets, you know, hormone free chicken, you dump it in, you chop up some root vegetables, you put in some great herbs, you know, thyme or rosemary, you put in garlic and onion, you put in carrots and celery, and you just let that boil and simmer it for 24 hours, adding water, and then you have, you know, a lot of bone broth. Then I would just drink it like it was coffee or tea throughout the day. I also did drink clove tea. Clove tea. Really high in polyphenols. It's one of the botanicals. Peppermint and clove have some of the highest levels of polyphenols. Why are polyphenols important? They are really good at restoring your gut microbiome. Phenols are really important to the health of your bacteria. And so, I was doing clove tea, my bone broth, and I was juicing. I was just using some fresh juice, taking the pulp out. And I did that for about 48 hours, about 72 hours. I really felt like the pain was starting to diminish.

And the clove tea, you just put cloves in water and boil them up.

Yep, that's exactly what I did. I have a little tea basket and I just crushed up the clothes, put in a tea basket, put it in the hot water and there you go. It's really good.

Amazing. Amazing.

Yeah, and so and then you can slowly begin to add in some vegetables, raw vegetables, some quinoa, unrefined grains, fermented black rice, fermented grains like barley spelt. I added those things in slowly. Then by day four, I was feeling really good. I started adding in more fiber. Now, two things I want to mention. In the conventional world, you hear, hey, if you have diverticula, don't eat seeds.

Right.

Well, a lot of research has been done. Recently, seeds, nuts, and seeds are not the cause of diverticula. In fact, because—what is with that advice?

Because we're all told, oh, you have diverticula, I can't eat fruit, I can't eat raspberries. I can't eat seeds. Is that really true?

No, it's not true. The research shows it's already, you know, you can, you know, pretty much now, if you read anything on diverticulitis, you know, you'll be told you can eat seeds. I think it was more of a mechanical issue that these things get stuck that even the smallest seeds from berries can accumulate inside the diverticuli. become, you know, then block bacteria in there, and then you get the diverticulitis. That's been debunked. You can eat seeds. In fact, because of the high levels in nuts and seeds of alpha-linolenic acid that becomes omega-3s, they actually have an anti-inflammatory effect, and it's shown to have a benefit for helping you avoid diverticulitis and also as you're getting better from it, it can help the healing process. So, nuts and seeds, and the other one is fiber. So, fiber is, you know, it has been said, don't eat fiber because, during your acute diverticulitis, because it's going to build bulk and it can potentially stretch the colon, you might get a rupture. And so, or the seeds will get.

Caught in the diverticula and cause problems.

Yeah, seeds in diverticula, and then during your episode, you should avoid all fiber. Well, when I started feeling a little bit better, I didn't want to have fiber because I wanted to start moving stool through. I was constipated, and I knew that to get better, I needed to get those toxins out of my bowels. Then I started adding in fiber, and I added in both the soluble kind of fiber, like the oat bran and nuts, seeds, and beans, and lentils, because that absorbs lots of water, It gets gel-like in its quality. It actually slows things down, but it allows all the nutrients from those fiber foods to be absorbed by the gut because those nutrients are very healing. So, you get a super high saturation of good compounds and nutrients from those types of soluble fibers. Then, insoluble fiber, I add in because that's going to absorb water and move bulk through and allow me to detox and clean out. So about that third or fourth day when you're feeling better, it's only a mild episode, you can start adding in soluble fiber and then also soluble fiber because they do two different things. And the insoluble fiber is going to be more of like your grains, your cruciferous vegetables. You can even find it in avocados, in some fruits, you'll find certain levels of the insoluble fiber that will bulk up your stool, make it nice and soft, and pass through. Now that's what you should be eating all the time because you want those nice full bowel movements. That's why fiber is so important. That's a way that you can treat mild early diverticulitis if you want to really try and keep it from getting worse to the point that you're going to end up in the doctor's office the emergency room and they're going to start doing all types of bad things to you. There are some targeted supplements that you can use that can help the gut heal, glutamine, some of the other things I use, marshmallow root, those are some of the targeted supplements that you can use that are healthy for the gut. I'm just having a little bit of a mind blank on some of the other ones. slippery elm, marshmallow root, glutamine. So you can apply those too as well when you're starting out with your mild early diverticulitis.

That's great. So basically we're getting people on a gut health program, right? And we're looking at things that help. So talk to us through that patient you had, the 52-year-old with our thyroid.

That's a really interesting patient.

What you found and how you treated her and helped her.

So, this is a 50-year-old female who had arthritis in her right hip that was planning on a hip replacement. She had longstanding constipation. She had recurrent diverticulitis. I think it was over like a three, maybe four-year period. She had at least one episode a year. It may have been less than four years, maybe three. So, that occurred prior to seeing me, and she was coming to me. primarily because of those recurrent diverticulitis episodes and the fact that she'd been constipated for most of her life. So, interesting case. The things that were running through my mind were like, why would this woman have so many episodes of diverticulitis? And so I asked her, of course, about her hip, and the pain had really gotten a lot worse. She, as I said, was planning to have hip replacement, but she was eating Advil all day. Oh, wow. And so Advil is one of those triggers for inflammation in the colonic tissue, and she had diverticula. And so now with the constant use of the NSAIDs that had increased over the last three, four, five years, she was triggering diverticulitis. And on top of that, she'd been constipated most of her life. so the test that I ran, I ran a stool test. So the stool test is again always looking at the gut microbiome, giving us the balance between good and bad bacteria. It's giving us information about how well you're digesting, you have everything you need to digest well, it's letting us know if you have any stealth infections that you've picked up along the way, parasites, viruses, protozoas that may be impacting your health. That test also has an inflammatory marker called Calprotectin. Calprotectin can tell us if you have this chronic ongoing inflammation, which is not uncommon. In the diets we have today, it's not uncommon to have this stealth inflammation that you just don't know about. I checked her Calprotectin because she had irritable bowel constipation. 50 to 60% of those patients have small intestinal bacterial overgrowth. And that overgrowth can lead to constipation, can lead to slower gut motility. And then that becomes that setup as you get older, one of the pieces to the puzzle that might give you diverticulitis. So, I tested her for that and I did some gluten and food sensitivity testing. so what we found on her was that her Calprotectin was indeed elevated, so she had market inflammation. She did have SIBO, so. And it was methane producing bacteria. Ah. And methane producing bacteria have a significant impact on gut motility, particularly on something called migrating motor complex. So I want to mention that because I think it's really fascinating and it's part. of what we try and do with our diet. But when you eat, you know you get that rumbling in your stomach, your intestines start to move, that's peristalsis, that's taking your food, that's being broken down, moving it through your system, having it broken down, getting it digested, and then finally it's going to leave your body. That's the peristalsis engaged when you eat. But when you stop eating, about 90 to 120 minutes later, there's a signal that happens. that triggers something called the migrating motor complex. There's no food in your stomach or in your, you know, or traveling through your intestine, but your brain tells your intestines to start moving. And so you might notice that you get this, like, growling in your stomach or you're, you're, you notice that your intestines are moving and you haven't eaten. That's the migrating motor complex. And it's, it's the street sweeping effect. It's doing that secondary cleanup in your of any food that hasn't left. It's really important, particularly in the small intestine, because if food particles stay there, they become a nidus for bacterial overgrowth. And that bacterial overgrowth leads to SIBO. SIBO leads to either diarrhea or constipation. It leads to inflammation. It leads to nutritional deficiencies, malabsorption. It can trigger it can actually have an upstream effect where it will cause less gastric acid in your stomach, it might impact the ability of your pancreas to appropriately discharge pancreatic enzymes to break down fats and carbs. So it's an important thing to understand. And why do I say that? Because if you have problems with constipation and even diarrhea, you're probably having a migrating motor complex issue, you have to let them turn on and do their job. And that takes about four hours. So snacking between meals, when you have your go bowel, is not a good idea. You want to give yourself at least three to four hours between meals so that you can get this migrating motor complex to do that secondary peristaltic sweep up. So that's why I wanted to mention that. so that any of our listeners might have that issue. That's a key fact is gut motility when you're dealing with either IBS, constipation or diarrhea is a big deal. And a lot of people don't know about that migrating motor complex. They need for it to be triggered and do its work. So what do I do with this young woman? I basically found out that she had the SIBO, I treated her SIBO. I used botanical antibacterials. I gave her some gut motility activators. I used 5-HTP. I used ginger and artichoke to get her motility to work. I told her to stop snacking between meals and we were able to clear up her SIBO for her inflammation. I just had to clean up her diet. Really a lot of information was coming from her diet and her n-sets. So there are two things I did. One is I started to give her really high doses of fish oil and then I used something called SPM. Those are special pro-resolvins that are I call them super concentrated fish oil. It's derived from fish oil. have a very potent anti-inflammatory and inflammatory modulating effect. So SPMs, high dose fish oil, I put her on four to six grams a day. I put her on some curcumin that was really high end curcumin that's readily absorbed. And I had her using that instead of NSAIDs for her pain. I also added in some CBD oil and between those things. She was able to stop using her Advil, reduce her inflammation as we treated her SIBO. Wow. And those are the major things that turned her around.

That's great.

And so, you know, that's great. So she has. Yeah. So she. And she's gone on. It's been almost two and a half years, and she hasn't had her diverticulitis return.

So basically, if you, if you don't have it and you want to prevent it, it's really focusing on all the things you mentioned, your diet, stress, motility, and dealing with those things before they become a problem. And then if you have it, if you have diverticulosis, which you'll find often on a colonoscopy, you want to make sure you're really up in the fiber and the food program that you mentioned, things like the increased fiber-rich foods of nuts and seeds and lots of fruits and veggies, and don't worry about all the seed thing, it's fine. And then if you get it, there's things you can do to actually deal with it acutely like bone broth and eating fruits and veggies and different grains and fibers and protein and so forth. So it's a very different perspective about how we address the problem of diverticulosis, which is really common. Like you said, it affects most people as they're older. So this has been great, George. This is hopefully helpful to those people who are suffering from this. If you listen to it and you have struggled with diverticulosis or diverticulitis, you should follow these guidelines. If you want to come see us, we're happy to see you at the Ultra Wellness Center. We see people from all over. We have a bit of a waiting list now, but we're hoping to try to get you in. And we've got a great team of five doctors and five nutritionists. And if you've struggled with diverticulosis and you know what's worked for you, share with us. We'd love to hear your experiences and comments. We'd love to hear from you and subscribe wherever you get your podcast. and we'll see you next week on the Doctor's Pharmacy. Hey, everybody, it's Dr. Hyman. Thanks for tuning into the Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter. And in it, I share my favorite stuff from foods to supplements to gadgets to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays. Nothing else, I promise. And all you have to do is go to drhyman.com/picks to sign up. That's drhyman.com/picks, P-I-C-K-S, and sign up for the newsletter and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer.

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