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Saturday, 26 October 2013

Diverticulitis


Diverticulitis is defined as condition of inflammation of the small, bulging sacs or pouches of the inner lining of the intestine that bulge outward through weak spots as a result of small pieces of stool (feces) trapped in these pouches. In most cases, the disease is found of in the large intestine (colon). According to the statistic, appraximately, About 10 percent of Americans older than 40 have diverticulosis.
In the examination of the data fom January 2004 to June 2005 of 796 consecutive patients referred for total colonoscopy to 17 physicians included age, gender, presence and localization of diverticula. This population was compared with a cohort of 133 consecutive patients who were admitted for colonic diverticular bleeding, showed that the prevalence of colonic diverticula increased from less than 10% in adults under 40 to about 75% in those over 75 years. Of these patients, nearly one third presented with right-sided involvement(1).

I. Types of Diverticulitis(2)
1.  Uncomplicated and Simple Diverticulitis
In most case, simple, uncomplicated diverticulitis respond to conservative therapy with bowel rest and antibiotics, accotding to the study of data between 2007 and 2009 of a total of 103 patients consecutively enrolled at the first attack of uncomplicated right colonic diverticulitis. 40 patients underwent an outpatient management regimen consisting of oral antibiotics (for 4 days), and 63 patients underwent an inpatient management regimen that included bowel rest and intravenous antibiotics (for 7-10 days), researchers found that outpatient management with short-term oral antibiotic therapy for the treatment of uncomplicated right colonic diverticulitis is as effective as inpatient management in regard to preventing disease recurrence(3).

2. Complicated Diverticulitis
In complicated diverticulitis, antibiotics are found to be less effective, with no evidence supporting their routine use(4). But other study of patient with right colonic diverticulitis classified according to treatment modality; 135 patients (85.4%) underwent conservative treatment, including antibiotics and bowel rest, and 23 patients (14.6%) underwent surgery. The mean follow-up length was 37.3 months, and 17 patients (17.5%) underwent recurrent right-sided colonic diverticulitis, found that conservative management with bowel rest and antibiotics could be considered as a safe and effective option for treating right-sided colonic diverticulitis. This treatment option for right-sided colonic diverticulitis, even if the disease is complicated, may be the treatment of choice(5)

II. Symptoms
Most people with diverticulitis are experience no symptoms, but in some bloating and cramping in the lower part of the belly. Although, it is rarely, but some may notice blood in their stool or on toilet paper, as right-sided localization was associated with a significant risk of bleeding independent of the patients' age, accordingto the study by University Hospital, Grenoble, France(1).
1. Tenderness
Symptom of tenderness in some cases is resemble to acute appendicitis. According to the study by the Erciyes University Medical Faculty, Department of Radiology, there is a report of 2 case of right-sided diverticulitis that presented with marked right iliac fossa tenderness with guarding and rebound and laboratory parameters resembling acute appendicitis. The imaging findings suggested diverticulitis in both cases(6).

2. Abdominal discomfort, bloating, and altered bowel habit
Patients with diverticular disease may experience a variety of chronic symptoms, including abdominal discomfort, bloating, and altered bowel habit, according to the McMaster University(7).

3. Abdominal pain, fever and chills, melena, vomiting
In the study to determine the management guidelines for symptomatic duodenal diverticulum, by reviewing medical records of 26 patients.with the Complicated duodenal diverticulum was the only possible cause of symptoms-abdominal pain, fever and chills, melena, vomiting-in 18 patients(8).

4. Painful constipation, painful abdominal distension, abdominal cramps, and frequent painful diarrhea
Others after elective sigmoid resection for diverticulitis, according to the study by University of Bern, the persistent symptoms, including painful constipation, painful abdominal distension, abdominal cramps, and frequent painful diarrhea((9).

5. Processed foods
Other in the study of suggested that factors previously uncommon in the area may now be operating to cause the disease in the population, and the highly processed food products of the supermarkets may be an important contributor to the development of this new disease entity(10).

III. Causes and Risk factors
A. Causes
Accoutring to the study by Dr. Ryan P, in the study in Changing concepts in diverticular disease, Conventionally, acquired diverticular disease of the colon has been regarded as a single entity, so far as complications go. Experience at St. Vincent's Hospital, Melbourne, suggests that there are two kinds of diverticular disease, one with the classic muscle abnormality, chiefly confined to the left colon and characterized by inflammatory and perforative complications and the other without muscle abnormality, but with diverticula throughout the colon, in which bleeding is common, perhaps due to a connective-tissue abnormality which, on the one hand, allows development of diverticula in the absence of abnormal intraluminal pressure and, on the other, provides inadequate support for vessels in the diverticular wall or for vascular malformations, which are therefore likely to bleed(11).
Others, according to the srticle by C-health, It's believed that most diverticula are caused by unnoticed muscle spasms, or by pairs of muscles that don't contract in a synchronized manner. This puts brief but intense pressure on the mucosal layer, causing pressure at the weakest points. The weakest points are the areas around blood vessels that pass through the inside of the wall of the large intestine (also called the colon). Older people have frailer tissue lining the bowel - this is probably why they have more diverticula(12).

B. Risk factors
1. Deficiency of dietary fiber diet, obesity and red meat intake
Deficiency of dietary fiber diet such as American typical diet, obesity and red meat intake are associated to increased risk of diverticolosis(13).

2. Smoking
Although the finding in inconsistence, but researchers suggested that smokers are at increased risk for complications, particularly perforation(14).

3. Alcohol
Alcohol may increase the risk of asymptomatic diverticulosis and diverticulitis(15).

4. Physucal inactive and over weight
In the study to investigate the association between obesity and physical inactivity and diverticular disease in a population-based cohort of women, conducted by the Danderyd University Hospital, The National Institute of Environmental Medicine, showed that Overweight, obesity, and physical inactivity among women increase diverticular disease requiring hospitalization(16).

5. Age and race
The disease prevalence is largely age-dependent: the disease is uncommon in those under the age of 40, the prevalence of which is estimated at approximately 5%; this increases to 65% in those > or =65 years of age. Of patients with diverticula, 80-85% remain asymptomatic, while, for unknown reasons, only three-fourths of the remaining 15-20% of patients develop symptomatic diverticular disease, according to the study by University of Parma, Parma(17). Other study indicated that in Western countries diverticular disease predominantly affects the left colon, its prevalence increases with age and its causation has been linked to a low dietary fibre intake. Right-sided diverticular disease is more commonly seen in Asian populations and affects younger patients(18).

6. Etc.

IV. Complication and diseases associated with Diverticulitis
A. Complications
Diverticulosis and its complications, particularly diverticulitis, are extremely common in western countries. The major factor in the development of diverticulosis is a lack of adequate fiber intake. Diverticulitis may be complicated by abscess formation, fistula formation, peritonitis, or obstruction(19).
Other study indicated that diverticular disease is a common problem in the western population and sometimes leads to serious complications such as hemorrhage, bowel stenosis, obstruction, abscesses, fistulae, bowel perforation, and peritonitis. The severity of these complications can differ, and it is not always clear which procedure is indicated in each case and what measures should be followed before bringing the patient into the operating room(19a).
1. Bowel obstruction
there is a report of a neonate who presented with acute intestinal obstruction secondary to a large, mobile Meckel's diverticulum which due to a direct compression effect on the adjacent small bowel caused mechanical intestinal obstruction(20). Other study reported the clinical case of a 65-year-old female patient with a diagnosis on hospital admittance of acute appendicitis and a intraoperative finding of diverticular disease of the small intestine, accompanied by complications such as intestinal perforation, bleeding and abdominal sepsis(21).

2. Peritonitis
Peritonitis is defined as an inflammation of the peritoneum, the thin tissue that lines the inner
wall of the abdomen covering most of the abdominal organs. According to the study of Thirty-eight patients (3.7%) were pathologically diagnosed with acute appendiceal diverticulitis among 1,029 cases of appendectomy. The mean age of patients in the diverticulitis group was significantly older than that of the appendicitis group (49.0 ± 15.2 years vs. 25.4 ± 14.2 years, P < 0.05). Mean duration of preoperative symptoms was longer in the diverticulitis group (3.6 ± 3.8 days vs. 1.8 ± 3.2 days, P < 0.05). The site of abdominal pain, fever, signs of localized peritonitis, accompanying gastrointestinal symptoms, and white blood cell count showed no differences between the two groupsby(22),

3. Abscess
According to the study by Westfälischen Wilhelms Universität, Münster, Normally colonic diverticulitis presents itself clinically with symptoms. Pyogenic liver abscess was the primary finding of a concealed perforation of sigma colon diverticulitis(23).

4. Fistula
Colouterine fistula is an extremely rare condition because the uterus is a thick, muscular organ. There is a report of an 81-year-old woman was referred to the emergency department with abdominal pain and vaginal discharge. Computed tomography showed a myometrial abscess cavity in the uterus adherent to the thick sigmoid wall. Upon contrast injection via the cervical os for fistulography, we observed spillage of the contrast into the sigmoid colon via the uterine fundus(24).

5. Bleeding
Colonic diverticular bleeding cases account for 30-40% of the lower gastrointestinal bleeding, among which, 3-5% appear to be massive bleeding, according to the study by Seoul National University Bundang Hospital(25).

6. Etc.

B. Diseases associated with Diverticulitis
1. Stenosis
The incidence of colonic diverticulosis with or without diverticulitis has increased in the Japanese population due to the modernization of food and aging. The rate of diverticulitis in colon diverticulosis ranges from 8.1% to 9.6%. However, few cases of stenosis due to diverticulitis have been reported(26).

2. Advanced colonic neoplasia
According to the study of 1,326 patients-56% male (n=741), 44% female (n=585), mean age 64 (+/-11.83 SD)-with a resection due to colonic cancer, the documented findings of colonoscopy, colonic contrast enema, and/or histopathology were analysed with regard to the prevalence of colonic diverticulosisby, showed that  the diverticulitis group revealed a statistically significant decreased rate of advanced colonic neoplastic lesion in nearly all age categories and all age-stratified analyses (corresponding OR 0.13-0.43)(27).

3. Obesity
There is an association between diverticular disease and obesity exists, there is no evidence suggesting that obese patients should be managed any differently from the non-obese(28).

4. Bacteremia
There is a report of two cases of bacteraemia with the anaerobic bacterium Ruminococcus gnavus. In both cases the bacteraemia was associated with diverticular disease. Preliminary conventional identification suggested peptostreptococci and MALDI-TOF analysis did not produce scores high enough for species identification. Finally the bacteria were identified with 16S rRNA gene sequencing(29).

5. Segmental colitis
Diverticular disease-associated segmental colitis is a unique variant of chronic colitis limited to segments of the left colon that harbor diverticula, according to the study by the University of Arkansas for Medical Sciences(30).

6. Etc.

IV. Misdiagnosis and diagnosis
A. Misdaignosis
1. Glioma
There is a report of a case of a 64 year old woman with diverticulitis complicated by a metastatic cerebral abscess is reported. Presentation was atypical and investigations were misleading; the computed tomographic scan was interpreted as showing a glioma(31). 

2. Crohn's disease
Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal system. there is a report of a 19-year-old case with Meckel's diverticulum operated with ileus while under followup, who was assumed to have Crohn's disease(32).

3. Acute prostatitis
According of the study by, abdominal abscess resulting from a perforated diverticulitis has never been reported as a cause of acute urinary retention. There is a report of an atypical presentation, the patient was initially misdiagnosed and treated as having acute prostatitis(33).

4. Appendicitis
The clinical diagnosis of appendicitis and diverticulitis remains challenging. There is a report of a case of a patient with right-sided diverticulitis misdiagnosed as appendicitis both clinically and on plain film radiography(34).

5. Prostate abscess
There is a report of a case report of sigmoid diverticular abscess presenting as prostate abscess. Helical computed tomography (CT) scan revealed the prostate abscess but failed to demonstrate the underlying diverticular abscess(35).

6. Ruptured aortic aneurysm
The rupture of an abdominal aortic aneurysm is one of the most dramatic event in the daily clinical practice. It is often easily suspected when the classical signs of hemorrhagic shock are associated with an anterior (mesogastric) abdominal pain and an expanding mass, especially in the non-obese patients(36). There is a report of a misdiagnosis of ruptured aortic aneurysm in diverticular disease(36).

7. Etc.

B. Diagnosis
After recording the complete physical examination and family history, including the examiation of the abdomen, if you are experience abdominal pain  and some of the symptoms mentioned above, the tests which your doctor ordered with an aim to rule out other similar symptomed diseases, such as Appendiciti,s Pelvic inflammatory disease, Irritable bowel syndrome, Stomach ulcers, Pregnancy outside of the uterus (ectopic), Colon cancer, etc., inclued  (Please refer to the misdiagnosed section for more information.
1. Blood test
The aim of the yest is to check for any infection.

2. Computed tomography (CT) scan and other proposeded tests
The image test is to examine the abdomen pelvic region and will reveal localized colon wall thickening, with inflammation extending into the fat surrounding the colon, if diverticulitis exists. According to the study of diverticulitisof a patient by Robert Ballanger Hospital, Boulevard Robert Ballanger, indicated that  Physical exam showed a 10 x 15 cm mass in the left lower quadrant. Computed tomography (CT) scan showed a left-sided SH containing a small bowel loop and a sigmoid loop. The SH was reduced easily with bed rest and external pressure. Under laparoscopy, a Gore-Tex mesh was stapled on the posterior side of the anterolateral abdominal wall so that it widely covered the abdominal wall defect. Ultrasound (US) scan or a CT scan that shows the defect in the abdominal wall, the hernial sac, and its contents is an easy means of confirming the diagnosis of SH. SH can be treated through a direct approach or through a midline laparotomy(36a). According to the statistic, CT scan is very accurate (98%) in diagnosing diverticulitis.

3. Etc.
 
V. Preventions
A. The do and do not's list
1. Increase intake of vegetable
Vegetable intake, a strict vegetable diet, and increased fiber intake are associated with the decreased risk of diverticolosis(37).

2. Increased intake of nuts and corn
According to the study by the University of Washington School of Medicine, Harborview Medical Center, Seattle, cotrary to a long-standing belief, a large prospective study found that nuts and corn did not increase the risk of diverticulitis or diverticular bleeding(38).

3. Physical activity but not Vigorous activity
In the study of 47,228 US males in the Health Professionals Follow-up Study cohort who were aged 40-75 years and free of diverticular disease, gastrointestinal cancer, and inflammatory bowel disease at baseline in 1986, found that  physical activity lowers the risk of diverticulitis and diverticular bleeding. Vigorous activity appears to account for this association(39).

4. Lose weight
There is an associated of  Diverticulitis with obese patients(40).

5. Stop smoking
Although there are conflict result in study, smoking is associated to Diverticulitis in some studies(41).

6. Avoid excessive drinking
Alcohol may increase the risk of asymptomatic diverticulosis and diverticulitis(42).

7. Reduced intake of carbohydrates
 Epidemiologic studies have demonstrated an association between diverticulosis and diets that are low in fiber and high in refined carbohydrates(42a).

8. Avoid Low level of folate and vitamin B12
There is a report of an elderly man in whom hereditary spherocytosis (HS) had been diagnosed many years previously. He also had diverticulitis and was referred because of increasing anaemia (Hb 7.7 g/dl). He was suffering from diarrhoea and anorexia, and was taking a very poor diet. Serum investigations showed low folate and vitamin B12 levels, according to the Haematology Department, University Hospital(42b). Other study found that bacterial production of cobamides, both de novo and from ingested CN-Cbl bound to intrinsic factor, occurs in humans with bacterial overgrowth states and results in a significant loss of vitamin B12 to the host(42c).

9. Drink plenty of water to ease passage through the colon to prevent constipation of that may cause severity of the disease.

10. Other comsicerations
According to the study by Groote Schuur Hospital, South Africa, indicated  that a weight loss of greater than 30% accompanying a variety of diseases was associated with a reduction in pancreatic enzyme secretion of over 80%, villus atrophy and impaired carbohydrate and fat absorption. Finally, specific nutrients can induce disease, for example, gluten-sensitive enteropathy, whilst dietary factors such as fibre, resistant starch, short-chain fatty acids, glutamine and fish-oils may prevent gastrointestinal diseases such as diverticulitis, diversion colitis, ulcerative colitis(43)

A. Diet to prevent diverticulitis
1. High-fibre dietary
Although many professionals suggested that high-fibre diet is associated to decreased risk of diverticulitis(44a), in the study to assess the treatment of diverticular disease or the prevention of recurrent diverticulitis with a high-fibre diet, showed that high-quality evidence for a high-fibre diet in the treatment of diverticular disease is lacking, and most recommendations are based on inconsistent level 2 and mostly level 3 evidence. Nevertheless, high-fibre diet is still recommended in several guidelines(44).

2. Low-residue diet
Low-residue diets have been recommended for diverticulosis because of a concern that indigestible nuts, seeds, corn, and popcorn could enter, block, or irritate a diverticulum and result in diverticulitis and possibly increase the risk of perforation. According to the study by the Division of Gastroenterology, Mayo Clinic, indicated that there is no evidence supporting such a practice. In contrast, dietary fiber supplementation has been advocated to prevent diverticula formation and recurrence of symptomatic diverticulosis, although this is based mostly on low-quality observational studies(45).

3. Probotics and fruit and vegetables
According to the study by University Hospital Lozano Blesa, changes in intestinal microflora could be one of the putative mechanisms responsible for low-grade inflammation. In patients with uncomplicated diverticulosis, a diet abundant in fruit and vegetables is recommended. The current therapeutic approaches in preventing recurrence of symptoms are based on nonabsorbable antibiotics, mesalazine, and/or probiotics(46).

4. Low fat diet
In the study to examine the association between dietary fiber, sources of fiber, other nutrients, and the diagnosis of symptomatic diverticular disease, showed that for men on a high-total-fat, low-fiber diet, the RR was 2.35 (95% CI 1.38, 3.98) compared with those on a low-total-fat, high-fiber diet, and for men on a high-red-meat, low-fiber diet the RR was 3.32 (95% CI 1.46, 7.53) compared with those on a low-red-meat, high-fiber diet. These prospective data support the hypothesis that a diet low in total dietary fiber increases the incidence of symptomatic diverticular disease. They also provide evidence that the combination of high intake of total fat or red meat and a diet low in total dietary fiber particularly augments the risk(47).

5. Peas
Pulses, including peas, have long been important components of the human diet due to their content of starch, protein and other nutrients. According to the University of Florida, peas contain a variety of phytochemicals once thought of only as antinutritive factors. These include polyphenolics, in coloured seed coat types in particular, which may have antioxidant and anticarcinogenic activity, saponins which may exhibit hypocholesterolaemic and anticarcinogenic activity, and galactose oligosaccharides which may exert beneficial prebiotic effects in the large intestine(47a).

6. Chickpea
Chickpea (Cicer arietinum L.) is an important pulse crop grown and consumed all over the world, especially in the Afro-Asian countries. According to the study by International Crops Research Institute for the Semi-Arid Tropics, chickpea is rich in nutritionally important unsaturated fatty acids such as linoleic and oleic acids. β-Sitosterol, campesterol and stigmasterol are important sterols present in chickpea oil. Ca, Mg, P and, especially, K are also present in chickpea seeds. Chickpea is a good source of important vitamins such as riboflavin, niacin, thiamin, folate and the vitamin A precursor β-carotene. As with other pulses, chickpea seeds also contain anti-nutritional factors which can be reduced or eliminated by different cooking techniques. Chickpea has several potential health benefits, and, in combination with other pulses and cereals, it could have beneficial effects on some of the important human diseases such as CVD, type 2 diabetes, digestive diseases and some cancers(47b).

B.  Phyutochemicals and Antioxidants to prevent diverticulosis
1. Decaffeinated green tea extract
According to the study of  the immunomodulatory effects of decaffeinated green tea extract on rainbow trout, with a 30-day feeding trial, showed that decaffeinated green tea in lower doses of administration could be optimum to enhance the immunity of rainbow trout(48).

2. Quercetin and epigallocatechin gallate
Found adbundantly in green tea,  the Quercetin and epigallocatechin gallate  capacity of the tested polyphenols is due to their stabilizing effect on the cell membranes, thus contributing to cell protection in various pathologies and as adjuvant therapy in highly toxic treatment regimens(49).
 Other study indicated that  all dietary flavonoids studied (epicatechin, epigallocatechin gallate, gallic acid and quercetin-3-glucoside) show a significant antioxidant effect in a chemical model system, but only epigallocatechin gallate or gallic acid are able to interfere with the cell cycle in Caco2 cell lines(50).

3. Polyphenols
Polyphenols possess beneficial features such as antioxidant, immunomodulatory, anti-cancer and antibacterial activity. According to the study by Uniwersytet Łódzki, ul. Banacha,  the ability of phytochemicals to induce apoptosis of cancer cells and bacterial cell damage may be, at least partly, due to their prooxidant properties. Phytocompounds enter the body through the digestive system where they undergo metabolic processes that often change their chemical features. The gastrointestinal microbiome interacts with phytochemicals and influences their bioavailability and absorption in the gut. Except for biochemical changes of plant polyphenols in the host, the achievement of therapeutic concentration in vivo may be the main problem in the determination of their real efficacy(51).

4. Etc.

VI. Treatments
A.1. In conventional medicine perspective
According to the study by American Family Pgysician, hospitalization is recommended if patients show signs of significant inflammation, are unable to take oral fluids, are older than 85 years, or have significant comorbid conditions(52).
A.1.1. Non surgical treatment
1. Antibiotics
Also according to tthe study byUnit, Department of Surgery, Hospital Universitario del Mar, All patients diagnosed with uncomplicated diverticulitis based on abdominal computed tomography findings from June 2003 to December 2008 were considered for outpatient treatment. Treatment consisted of oral antibiotics for 7 days (amoxicillin-clavulanic or ciprofloxacin plus metronidazole in patients with penicillin allergy). Patients were seen again at between 4 and 7 days after starting treatment to confirm symptom improvement(53). Side effects are not limit to rash, diarrhea, abdominal pain, nausea/vomiting, drug fever, hypersensitivity (allergic) reactions, etc.

2. Anti-inflammatory medicine
Mesalazine is an anti-inflammatory drug used to treat inflammatory bowel disease. According to ths study by the University of Parma, Inflammation in such diseases seems to be generated by a heightened production of proinflammatory cytokines, reduced anti-inflammatory cytokines, and enhanced intramucosal synthesis of nitric oxide. The mechanisms of action of mesalazine are not yet well understood. It is an anti-inflammatory drug that inhibits factors of the inflammatory cascade (such as cyclooxygenase) and free radicals, and has an intrinsic antioxidant effect. Some recent studies confirm the efficacy of mesalazine in diverticular disease both in relief of symptoms in symptomatic uncomplicated forms and in prevention of recurrence of symptoms and main complications(54). Side effects are not limit to Diarrhea,  Nausea,  Cramping,  Flatulence, etc.


A.1.2. Surgical treatments
According to the WGO 2007 guidelines, 15-30% of patients admitted for management of diverticulitis will need surgery during their admission, with an 18% surgical mortality rate(55).
1. Laparoscopic lavage
Traditionally the management of acute diverticulitis complicated by perforation has been the Hartmann's procedure, which may be associated with significant morbidity and mortality and the unpleasantness of a colostomy(56). According to the study by John Flynn Gold Coast Hospital, Gold Coast, Queensland, Australia,  In the data of Treatment with laparoscopic lavage was performed in only 38 patients in ten hospitals, found that lavage was successful in controlling sepsis in 31 of the 38 included patients, with 32 per cent morbidity (10 of 31 patients) and fast recovery. Overall, 17 of 38 patients developed complications, of whom two had a missed overt sigmoid perforation(57). Other study suggested that the Hartman modification consists of the creation of a distal mucus fistula rather than suturing the rectum closed. To facilitate the creation of a distal mucus fistula, it is suggested that less sigmoid colon be resected at the time of the initial operation. The colon can be assessed for residual diverticular disease later and more resected at the later closure operation if required(58).

2. Colostomy
Colostomy is a surgical procedure to bring one end of the large intestine out through the abdominal wall. There is a report by the University of Pittsburgh Medical Centre of a  62-year-old Caucasian woman with a history of sigmoid diverticulitis presented to our facility with a three-week history of abdominal pain, fevers, chills, loss of appetite and fatigue. Her laboratory test results showed leukocytosis and elevated alkaline phosphatase. A computed tomography scan revealed portal vein thrombosis and a sigmoid diverticulitis with an abscess. Our patient was given pipercillin-tozabactam followed by sigmoid colectomy and loop transverse colostomy(59).

3. Ileostomy
Ileostomy is surgical procedure to bring the end or loop of small intestine (the ileum) out onto the surface of the skin. According to the study by the Surgical Specialists of Spokane, the use of diverting loop ileostomy in patients undergoing colon and rectal surgery with high-risk anastomoses is beneficial. Their selected use has resulted in a 1% anastomotic loss rate with an acceptably low rate of complications related to the ileostomy(60).

4. Other surgical procedure such as the classic 3-stage surgical approach is no longer mention,  as a result of high associated morbidity and mortality.

B. In Herbal medicine perspective
1. L. usitatissimum (flaxseed/linseed)
The fixed oil of L. usitatissimum (flaxseed/linseed) inhibited PGE2-, leukotriene-, histamine- and bradykinin-induced inflammation. Dual inhibition of arachidonic acid metabolism, antihistaminic and antibradykinin activities of the oil could account for the biological activity and the active principle could be alpha-linolenic acid an omega-3 (18:3, n-3) fatty acid, according to the study by the Allahabad Agricultural Institute-Deemed University(61).

2. Mexican yam did not inhibit radical generation by inflamed biopsies. Slippery elm, fenugreek, devil's claw, tormentil
Herbal remedies used by patients for treatment of inflammatory bowel disease include slippery elm, fenugreek, devil's claw, Mexican yam, tormentil and wei tong ning, a traditional Chinese medicine.  According to the study by the Queen Mary's, School of Medicine and Dentistry, All six herbal remedies have antioxidant effects. Fenugreek is not a superoxide scavenger, while Mexican yam did not inhibit radical generation by inflamed biopsies. Slippery elm, fenugreek, devil's claw, tormentil and wei tong ning merit formal evaluation as novel therapies in inflammatory bowel disease(62).

3. Aloe vera gel, wheat grass juice, Boswellia serrata
Several types of medications are used to control the inflammation or reduce symptoms used to treat UC, may be used to treat diverticulitis. Herbal medicine includes a wide range of practices and therapies outside the realms of conventional Western medicine. However, there are limited controlled evidences indicating the efficacy of traditional Chinese medicines, such as aloe vera gel, wheat grass juice, Boswellia serrata, and bovine colostrum enemas in the treatment of UC(63).

Etc.

C. In traditional Chinese medicine perspective
1. Acupuncture
According to the article by Dr. Shan Kong, the aim of acupuncture treatment is to improve the immune function to decrease inflammation and reduce bacterial counts, enhance blood flow to bowel that speeds healing and strengthens mucosa. The treatments also reduce transit time (amount of time stool remains in colon), of that lead to reduction of irritation/inflammation, and strengthen bowel muscle and decreases the likelihood of forming diverticula(64).
Beside acupuncture, the below Chinese herbs may be suggested to reduce inflammation with patients of diverticular  disease depending to differentiation, according to the article at Acupuncture.com(65).
1. Tumeric
Turmeric is a perennial plant in the genus Curcuma, belonging to the family Zingiberaceae, native to tropical South Asia. The herb has been used in trditional medicine as anti-oxidant, hypoglycemic, colorant, antiseptic, wound healing agent, and to treat flatulence, bloating, and appetite loss, ulcers, eczema, inflammations, etc.
a.Anti inflammatory effects
In a systematic review of the literature was to summarize the literature on the safety and anti-inflammatory activity of curcumin, found that curcumin has been demonstrated to be safe in six human trials and has demonstrated anti-inflammatory activity. It may exert its anti-inflammatory activity by inhibition of a number of different molecules that play a role in inflammation, according to "Safety and anti-inflammatory activity of curcumin: a component of tumeric (Curcuma longa)" by Chainani-Wu N (66)

b. Antioxidants
In the research of a literature search (PubMed) of almost 1500 papers dealing with curcumin, most from recent years, with ll available abstracts were read and pproximately 300 full papers were reviewed, found that curcumin, a component of turmeric, has been shown to be non-toxic, to have antioxidant activity, and to inhibit such mediators of inflammation as NFkappaB, cyclooxygenase-2 (COX-2), lipooxygenase (LOX), and inducible nitric oxide synthase (iNOS). Significant preventive and/or curative effects have been observed in experimental animal models of a number of diseases, including arteriosclerosis, cancer, diabetes, respiratory, hepatic, pancreatic, intestinal and gastric diseases, neurodegenerative and eye diseases, "Curcumin, an atoxic antioxidant and natural NFkappaB, cyclooxygenase-2, lipooxygenase, and inducible nitric oxide synthase inhibitor: a shield against acute and chronic diseases" by Bengmark S.(67).

c. Gastrointestinal diseases
In the explore more systematically in various diseases of curcumin's therapeutic promise,
indicated that curcumin may be particularly suited to be developed to treat gastrointestinal diseases. This review summarizes some of the current literature of curcumin's anti-inflammatory, anti-oxidant and anti-cancer potential in inflammatory bowel diseases, hepatic fibrosis and gastrointestinal cancers, according to "Therapeutic potential of curcumin in gastrointestinal diseases" by Rajasekaran SA.(68)

2. Ginger 
Ginger (Zingiber officinale) or ginger root is the genus Zingiber, belonging to the family Zingiberaceae, native to Tamil. It has been used in traditional and Chinese medicine to treat dyspepsia, gastroparesis, constipation, edema, difficult urination, colic, etc.

In the classification of the effect of ginger extract on the expression of NFκB and TNF-α in liver cancer-induced rats found that ginger extract significantly reduced the elevated expression of NFκB and TNF-α in rats with liver cancer. Ginger may act as an anti-cancer and anti-inflammatory agent by inactivating NFκB through the suppression of the pro-inflammatory TNF-α, according to "Ginger Extract (Zingiber Officinale) has Anti-Cancer and Anti-Inflammatory Effects on Ethionine-Induced Hepatoma Rats" by Shafina Hanim Mohd Habib,I Suzana Makpol, Noor Aini Abdul Hamid, Srijit Das, Wan Zurinah Wan Ngah, and Yasmin Anum Mohd Yusof (69)


3. Bromelain
Bromelain, a proteolytic enzymes found in pineapples (Ananas comosus) has been used in traditional medicine as inflammatory agent and to treat pains, strains, and muscle aches and pains and ease back pain and chronic joint pain, skin diseases, etc.
a. Digestive system and Diabetes
Bromelain
(BR), a cysteine protease has shown the inhibitory effects on intestinal secretion and inflammation, such function throught the induction of the antispasmodic effect. In vivo, BR preferentially inhibited motility in pathophysiologic states in a PAR-2-antagonist-sensitive manner as the result researchers suggested that bromelain could be a lead compound for the development of new drugs, able to normalize the intestinal motility in inflammation and diabetes according to the study of "Inhibitory effects of bromelain, a cysteine protease derived from pineapple stem (Ananas comosus), on intestinal motility in mice" by Borrelli F, Capasso R, Severino B, Fiorino F, Aviello G, De Rosa G, Mazzella M, Romano B, Capasso F, Fasolino I, Izzo AA., posted in PubMed(47)

5. Anti-inflammatory activity
In rat study, bromelain inhibits plasma exudation through inhibiting the generation of bradykinin at the inflammatory site via depletion of the plasma kallikrein system, according to the study of "Effect of bromelain on kaolin-induced inflammation in rats" by Kumakura S, Yamashita M, Tsurufuji S., posted in PubMed(71)


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