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Eberhardt F, Crichton M, Dahl C, Nucera R, Jenkins J, Marx W, Marshall S. Role of dietary fibre in older adults with asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD): Systematic review and meta-analysis. Maturitas 2019; 130:57-67. [PMID: 31706437 DOI: 10.1016/j.maturitas.2019.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/28/2019] [Accepted: 10/07/2019] [Indexed: 12/31/2022]
Abstract
Dietary fibre and probiotics may play a role in the management of diverticular disease. This systematic review synthesises the evidence on the effects of dietary fibre modifications, with or without the use of probiotics, on the incidence in older adults of asymptomatic (AS) or symptomatic uncomplicated diverticular disease (SUDD), as well as on gastrointestinal function and symptoms. Five electronic databases were searched for studies through to December 2018. The body of evidence was appraised using the Cochrane Risk of Bias tool and GRADE. Nine studies were included, with mean sample ages ranging from 57 to 70 years, and three meta-analyses were performed. Only one study, with high risk of bias, measured the effect of dietary fibre on the incidence of diverticulitis. Dietary fibre supplementation improved stool weight (MD: 42 g/day, P < 0.00001; GRADE level of evidence: low), but had no significant effect on gastrointestinal symptoms (SMD: -0.13, P = 0.16; GRADE level of evidence: low) or stool transit time (MD: -3.70, P = 0.32 GRADE level of evidence: low). There was "very low" confidence for the body of evidence supporting symbiotics for AS or SUDD. A high dietary fibre intake, in line with dietary guidelines, may improve gastrointestinal function and is recommended in patients with AS or SUDD. Dietary fibre supplementation should be considered on an individualised basis to improve bowel function, while any recommendation on symbiotic supplements requires further well-designed research. Future studies should also measure the impact on the incidence of diverticulitis.
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Farmer AD, Wegeberg AML, Brock B, Hobson AR, Mohammed SD, Scott SM, Bruckner-Holt CE, Semler JR, Hasler WL, Hellström PM, Drewes AM, Brock C. Regional gastrointestinal contractility parameters using the wireless motility capsule: inter-observer reproducibility and influence of age, gender and study country. Aliment Pharmacol Ther 2018; 47:391-400. [PMID: 29210098 DOI: 10.1111/apt.14438] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 09/26/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The wireless motility capsule concurrently measures temperature, pH and pressure as it traverses the gastrointestinal tract. AIMS To describe normative values for motility/contractility parameters across age, gender and testing centres. METHODS Healthy participants underwent a standardised wireless motility capsule assessment following an overnight fast and consumption of a meal of known nutritional content. Traces were divided into regions of interest and analysed using 2 software packages (MotiliGI and GIMS Data Viewer). Inter-observer agreement was independently assessed by 2 investigators. RESULTS Normative data for motility/contractility parameters (maximum amplitude, mean peak amplitude, contraction frequency and motility index) are presented for 107 individuals (62 male, median age 40 years, range 18-78). MotiliGI-Gastric, small bowel and colonic maximal contraction amplitude correlated with age (r = .24, P = .01; r = .22, P = .02; and r = .2, P = .04 respectively). Small bowel motility index was higher in females than males (150.4 ± 12 vs 122 ± 7.6, P = .04). Inter-observer agreement was excellent for transit times, pH and contractility/motility parameters. GIMS Data viewer-Gastric, small bowel and colonic loge motility index correlated with the respective area under the contraction curve, total contractions, sum of amplitudes and contraction frequency (all r>.35, P < .0003) but not with transit times. CONCLUSIONS Our analysis provides normative data for motility/contractility parameters. Log motility index summarises a number of measures. In future, the measurement of contractile activity with the wireless motility capsule may potentially aid in the diagnosis of disease states such as visceral myopathic disorders.
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Affiliation(s)
- A D Farmer
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark.,Neurogastroenterology Group, Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - A-M L Wegeberg
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark.,School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - B Brock
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | | | - S D Mohammed
- Neurogastroenterology Group, Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - S M Scott
- Neurogastroenterology Group, Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - C E Bruckner-Holt
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | | | - W L Hasler
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | - P M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark.,Department of Pharmacotherapy and Development, University of Copenhagen, Copenhagen, Denmark
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Carabotti M, Annibale B, Severi C, Lahner E. Role of Fiber in Symptomatic Uncomplicated Diverticular Disease: A Systematic Review. Nutrients 2017; 9:nu9020161. [PMID: 28230737 PMCID: PMC5331592 DOI: 10.3390/nu9020161] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/03/2017] [Accepted: 02/14/2017] [Indexed: 02/05/2023] Open
Abstract
Symptomatic uncomplicated diverticular disease (SUDD) is a syndrome characterized by recurrent abdominal symptoms in patients with colonic diverticula. There is some evidence that a high-fiber diet or supplemental fibers may reduce symptoms in SUDD patients and a high-fiber diet is commonly suggested for these patients. This systematic review aims to update the evidence on the efficacy of fiber treatment in SUDD, in terms of a reduction in symptoms and the prevention of acute diverticulitis. According to PRISMA, we identified studies on SUDD patients treated with fibers (PubMed and Scopus). The quality of these studies was evaluated by the Jadad scale. The main outcome measures were a reduction of abdominal symptoms and the prevention of acute diverticulitis. Nineteen studies were included, nine with dietary fiber and 10 with supplemental fiber, with a high heterogeneity concerning the quantity and quality of fibers employed. Single studies suggest that fibers, both dietary and supplemental, could be beneficial in SUDD, even if the quality is very low, with just one study yielding an optimal score. The presence of substantial methodological limitations, the heterogeneity of the therapeutic regimens employed, and the lack of ad hoc designed studies, did not permit a summary of the outcome measure. Thus, the benefit of dietary or supplemental fiber in SUDD patients still needs to be established.
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Affiliation(s)
- Marilia Carabotti
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy.
- Department of Internal Medicine and Medical Specialties, University Sapienza, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Bruno Annibale
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy.
| | - Carola Severi
- Department of Internal Medicine and Medical Specialties, University Sapienza, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Edith Lahner
- Medical-Surgical Department of Clinical Sciences and Translational Medicine, University Sapienza, Via di Grottarossa 1035, 00189 Rome, Italy.
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Abstract
BACKGROUND Diverticular disease of the colon is a common disorder, characterized by recurrent symptoms and complications such as diverticulitis, requiring hospital admissions and surgery. OBJECTIVE This study aimed to systematically review the evidence for medical therapy of diverticular disease in reducing symptoms and preventing acute diverticulitis. DATA SOURCES MEDLINE and Embase databases (1966 to February 2010). STUDY SELECTION The studies selected were prospective clinical trials on uncomplicated diverticular disease of the colon. INTERVENTIONS Four investigators independently reviewed articles, extracted data, and assessed study quality according to standardized criteria. MAIN OUTCOME MEASURES The main outcomes measured were improvement in symptoms, complete remission of symptoms, and prevention of acute diverticulitis. RESULTS We identified 31 studies, including 6 placebo-controlled trials. The methodological quality of these studies was suboptimal. Only 10 trials provided a detailed description of the patient history, 8 assessed symptoms by the use of a validated questionnaire, and 14 appropriately defined inclusion and exclusion criteria. Only one long-term double-blind placebo-controlled study was identified. This reported a significant improvement in symptoms and greater prevalence of symptom-free patients at 1 year with fiber plus rifaximin in comparison with fiber alone. The efficacy of treatment in preventing acute diverticulitis was evaluated in 11 randomized trials. Four trials compared rifaximin plus fiber vs fiber alone and failed to show a significant difference between treatments. However, cumulative data from these trials revealed a significant benefit following rifaximin and fiber (1-year rate of acute diverticulitis: 11/970 (1.1%) vs 20/690 (2.9%); P = .012), but with a number needed to treat of 57, to prevent an attack of acute diverticulitis. LIMITATIONS : Heterogeneity of the study design, patients' characteristics, regimens and combination of studied treatment, and outcome reporting precluded the pooling of results and limited interpretation. CONCLUSIONS The treatment for diverticular disease relies mainly on data from uncontrolled studies. Treatment showed some evidence of improvement in symptoms, but its role in the prevention of acute diverticulitis remains to be defined.
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Affiliation(s)
- Giovanni Maconi
- Gastroenterology Unit, Department of Clinical Sciences, L. Sacco University Hospital, Milan, Italy.
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Zarate N, Mohammed SD, O'Shaughnessy E, Newell M, Yazaki E, Williams NS, Lunniss PJ, Semler JR, Scott SM. Accurate localization of a fall in pH within the ileocecal region: validation using a dual-scintigraphic technique. Am J Physiol Gastrointest Liver Physiol 2010; 299:G1276-86. [PMID: 20847301 DOI: 10.1152/ajpgi.00127.2010] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Stereotypical changes in pH occur along the gastrointestinal (GI) tract. Classically, there is an abrupt increase in pH on exit from the stomach, followed later by a sharp fall in pH, attributed to passage through the ileocecal region. However, the precise location of this latter pH change has never been conclusively substantiated. We aimed to determine the site of fall in pH using a dual-scintigraphic technique. On day 1, 13 healthy subjects underwent nasal intubation with a 3-m-long catheter, which was allowed to progress to the distal ileum. On day 2, subjects ingested a pH-sensitive wireless motility capsule labeled with 4 MBq (51)Chromium [EDTA]. The course of this, as it travelled through the GI tract, was assessed with a single-headed γ-camera using static and dynamic scans. Capsule progression was plotted relative to a background of 4 MBq ¹¹¹Indium [diethylenetriamine penta-acetic acid] administered through the catheter. Intraluminal pH, as recorded by the capsule, was monitored continuously, and position of the capsule relative to pH was established. A sharp fall in pH was recorded in all subjects; position of the capsule relative to this was accurately determined anatomically in 9/13 subjects. In these nine subjects, a pH drop of 1.5 ± 0.2 U, from 7.6 ± 0.05 to 6.1 ± 0.1 occurred a median of 7.5 min (1-16) after passage through the ileocecal valve; location was either in the cecum (n = 5), ascending colon (n = 2), or coincident with a move from the cecum to ascending colon (n = 2). This study provides conclusive evidence that the fall in pH seen within the ileocolonic region actually occurs in the proximal colon. This phenomenon can be used as a biomarker of transition between the small and large bowel and validates assessment of regional GI motility using capsule technology that incorporates pH measurement.
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Abstract
The aim of this review is mainly to show the high prevalence of diverticulosis and the clinical relevance of uncomplicated and complicated diverticular disease worldwide. The prevalence of diverticular disease is directly related to the aging of the population and in western countries is diagnosed in approximately 50–65% of adult subjects. The often more frequent adoption of an incorrect dietary style, such as a low-fiber diet, and the progressive increase in the average age of western populations will increase the prevalence of this pathology and the economic burden for health systems even more so. Furthermore, the management of uncomplicated diverticular disease, segmental colitis associated to diverticula and diverticulitis, which represent the different manifestations of the symptomatic spectrum of colonic diverticulosis, are reported.
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Affiliation(s)
- Federico Iacopini
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Alessandra Bizzotto
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Ivo Boskoski
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Milutin Bulajic
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
| | - Guido Costamagna
- Università Cattolica “A. Gemelli”, Digestive Endoscopy Unit, Department of Surgery, Rome, Italy
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Abstract
Diverticular disease of the colon is the fifth most important gastrointestinal disease in terms of direct and indirect health care costs in western countries. Uncomplicated diverticular disease is defined as the presence of diverticula in the absence of complications such as perforation, fistula, obstruction and/or bleeding. The distribution of diverticula along the colon varies worldwide being almost always left-sided and directly related to age in western countries and right-sided where diet is rich in fibre. The pathophysiology of diverticular disease is complex and relates to abnormal colonic motility, changes in the colonic wall, chronic mucosal low-grade inflammation, imbalance in colonic microflora and visceral hypersensitivity. Moreover, there can be genetic factors involved in the development of colonic diverticula. The use of non-absorbable antibiotics is the mainstay of therapy in patients with mild to moderate symptoms, and the effect of fibre-supplementation alone does not appear to be significantly different from placebo, although no definite data are available. More recently, alternative treatments have been reported. Mesalazine acts as a local mucosal immunomodulator and has been shown to improve symptoms and prevent recurrence of diverticulitis. In addition, probiotics have also been shown to be beneficial by re-establishing a normal gut microflora. In this study, the current literature on uncomplicated diverticular disease of the colon is reviewed.
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Affiliation(s)
- L Petruzziello
- Digestive Endoscopy Unit, Department of Surgery, Università Cattolica 'A. Gemelli', Rome, Italy.
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Abstract
BACKGROUND Fibre treatment often produces gaseous symptoms which have been attributed to fermentation by colonic bacteria with increased gas production. Effects of fibre ingestion on intestinal gas flow are unexplored. AIMS We aimed to test the hypothesis that consumption of a high fibre diet retards gas transit. SUBJECTS Ten healthy volunteers participated. METHODS To investigate the effects of fibre on gas dynamics, physiological gas mixtures were jejunally perfused at 12 ml/min x 2 hours after a standard diet for seven days with and without psyllium 30 g/day in a crossover fashion. Gas was collected from an intrarectal catheter to bypass the anus and evacuation was quantified in real time using a barostat. RESULTS On initiating gas perfusion under control conditions, an initial lag phase with no gas expulsion was observed (1129 (274) seconds). Thereafter, gas evacuation from the rectum proceeded with cumulative volumes of 1429 (108) ml by the end of the second hour. Evacuation was pulsatile with passage of 20.9 (2.5) boluses, with mean volumes of 68.2 (5.0) ml. Fibre prolonged the lag time (2265 (304) seconds; p<0.05) and reduced cumulative gas evacuation volumes (1022 (80) ml; p<0.05). Decreased gas evacuation resulted from reductions in the numbers of bolus passages (14.2 (1.1); p<0.05) but not bolus volumes (70.7 (3.4) ml; p = 0.66). CONCLUSIONS Consumption of a high fibre diet retards intestinal gas transit by decreasing bolus propulsion to the rectum. Thus, in addition to increasing gas production by colonic flora, fibre ingestion may elicit gaseous symptoms by promoting gas retention.
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Affiliation(s)
- S Gonlachanvit
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
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Abstract
BACKGROUND In addition to increasing stool weight, supplements of psyllium seed husk produce stools that are slick and gelatinous. OBJECTIVE Our purpose was to test the hypothesis that a gel-forming fraction of psyllium escapes microbial fermentation and is responsible for the characteristics that enhance laxation. DESIGN Fifteen healthy adults consumed controlled diets for two 7-d periods, one of which included 8.8 g dietary fiber provided by 15 g/d of a psyllium seed husk preparation. All stools were collected and evaluated and diet was monitored throughout. RESULTS Psyllium significantly increased the apparent viscosity of an aqueous stool extract, stool moisture, and wet and dry stool weights. A very viscous fraction, not present in low-fiber stool and containing predominantly 2 sugars that are also found in abundance in psyllium husk, was isolated from psyllium stool. CONCLUSIONS In contrast with other viscous fibers that are fermented completely in the colon, a component of psyllium is not fermented. This gel provided lubrication that facilitated propulsion of colon contents and produced a stool that was bulkier and more moist than were stools resulting with use of comparable amounts of other bowel-regulating fiber sources.
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Affiliation(s)
- J A Marlett
- Department of Nutritional Sciences, University of Wisconsin-Madison, 53706, USA.
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Abstract
Diverticular disease is worldwide in distribution, but the incidence is highest in industrialised countries. It is associated with aging and low intake of dietary fibre. There is a broad range of clinical manifestations--from asymptomatic diverticula to life-threatening complications. Elderly patients often present with complicated diverticular disease, and may lack typical symptoms and signs. Treatment includes fibre supplementation, drugs or antibiotics for complications, and surgery for refractory disease. Proper diagnosis and treatment requires knowledge of the full range of presentations and careful selection and timing of medical versus surgical intervention.
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Affiliation(s)
- L J Cheskin
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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Abstract
The digestibility of ispaghula, a mucilage from Plantago ovata composed mainly of arabinoxylans, and its faecal bulking effect were studied in seven healthy volunteers who ingested a low fibre controlled diet plus either placebo or 18 g/day of ispaghula for two 15 day periods. Whole gut transit time and gas excretion in breath and flatus were not different during the periods of ispaghula and placebo ingestion. Faecal wet and dry weights rose significantly, however, during ispaghula ingestion. Faecal short chain fatty acid concentrations and the molar proportions of propionic and acetic acids also increased. Most of the ispaghula had reached the caecum four hours after ingestion in an intact highly polymerised form. During ispaghula ingestion, the increase in the faecal output of neutral sugars was accounted for by the faecal excretion of arabinose and xylose in an intact highly polymerised form; the apparent digestibilities of these sugars were 24 (11) and 53% (6) respectively (mean (SEM)). In conclusion, ispaghula is more resistant to fermentation than previously reported in humans, and its bulking effect largely results from intact material.
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Affiliation(s)
- P Marteau
- INSERM U 290 Hôpital Saint-Lazare, Paris, France
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Abstract
"Dietary fibre" includes a range of relatively poorly digested food substances mainly composed of non-starch polysaccharides. Pectins and gums are multi-branched hydrophilic substances, forming viscous solutions that delay gastric emptying and nutrient absorption from the small bowel. They are used to delay gastric emptying and improve glycemic control in diabetes, as well as to alleviate constipation. Other fibres, including cellulose and lignins, are insoluble and have little effect on gastric emptying and small bowel transit. They markedly accelerate colonic transit and are frequently used as laxatives. Other important, less well-characterised effects of fibre include lowering of blood cholesterol, increase in satiety and possibly reduction in colon neoplasia.
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Affiliation(s)
- R C Spiller
- University Hospital, Queen's Medical Centre, Nottingham, U.K
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