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

Posted Nov 22 2012 1:31pm

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

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