Archive for the ‘Symptoms and Problems’ Category

Diverticular Disease: Treatments After a Century

Saturday, July 25th, 2020

THE BEGINNING

Diverticula on the colon were a curiosity until increasing reports lead to official recording of deaths in 1923. This newly discovered disease of the elderly was only seen by surgeons trying to alleviate pain or correct the complications due to infection. Some pathologists were also interested in this phenomenon they found during postmortems. They did not know the patient’s problems which had preceded the serious condition, but their observations gave insight into how diverticula were formed.

Thickened wall muscles, concertina-like shortening of the sigmoid colon and narrowing of the lumen were the precursors of the appearance of diverticula. They did not know why this had happened but they did find that the damaged colon could give rise to pain needing surgery just as severe as the result of complications. The diverticula contained hard pellets of faeces (faecoliths) which could have been responsible for the pain and infection. Their observations appropriately led to recommendations for a diet, not necessarily low fibre, but a “softage” diet without pips, seeds or hard roughage. Only 20% of these patients were constipated.

WORLD WARS

With the advent of radiology, diverticula on the sigmoid colon (diverticulosis) were found in increasing numbers of people in the period between the two wars. There was speculation about the cause but no research was done. Advances in anaesthetics, blood transfusions and antibiotics made surgery safer. After WWII elective surgery was available to 10-20% of patients to remove the affected colon part to avoid future serious complications. How these patients were selected has not been reported. Risk/benefit considerations over the years have seen surgery more used as a treatment rather than a prophylactic.

How fortunate I am having the opportunity of having this operation while I am fit and healthy”

     “I have seen many doctors and they all refuse me an operation so I am left suffering constant pain and discomfort every day”

In the UK deaths from diverticular disease (DD) increased up to 1939 then the rate was static until the 1950s. There was loss of interest in DD. This pause in mortality was later taken as evidence that the wartime diet in the UK, presumed to have more fibre, would prevent the diseases of the western world including DD. It was in fact due to the recording of deaths of civilians only. In the 1950s DD was beginning to be noticed again. The NHS was in its infancy. People resorted to herbal and traditional medicines. Laxatives were big business, people with or without DD were trying to conform to the daily toileting ideal of that era.

—it was in 1948 when I first had stomach problems, and our dear old doctor, that we had then, explained to me why I was getting pain and wind, and on occasions blood, these were his words. Once when you were a little girl you ate too much, and your stomach couldn’t take all the food at once, so a part of it stretched a bit like a balloon and now you have a sort of pouch there which sometimes gets a bit packed out with food and causes all your problems, nothing can be done about this, so you must just be careful what you eat.”

     “I was told that I was part of a whole generation brought up during the war with a weekly purging of Syrup of Figs on a Saturday night therefore making a lazy bowel” 

WESTERN DISEASES

Dr. Birkitt was a surgeon with missionaries in Africa. His work has been described in “The Fibre Story” on this website. He did not encounter or treat the diseases prevalent in developed countries but noted their absence in Africa. Intrigued, he collected data from around the world to show where these “western” diseases of affluence could or could not be found. What he called ‘geographic medicine’ was a picture of the epidemiology of DD in the 1960s/1970s period. The western diseases included obesity, gall stones, hiatus hernia, varicose veins and haemorrhoids. Particularly interesting were coronary heart disease (CHD), arteriosclerosis, appendicitis, and colon cancer. Their appearance early in the 20th century followed by increasing prevalence and mortality were parallel to DD and were all considered to have a common cause. Crohn’s disease was also new at the beginning of the 20th century but death rates were not so noticeable. Appendicitis affected mainly people of a younger age group, with an appendix blocked by trapped faeces or muscle spasm, similar to diverticula. The early surgeons thought appendicitis was a precursor to DD, appearing at an age around 20 years compared with diverticula about 40 years of age. Recently the link between appendicitis, DD and smoking has been demonstrated.

FIBRE TREATMENT

Wheat bran as a dietary supplement to ease constipation was well known in the middle of the 20th century. Birkitt demonstrated how it worked. Higher levels of undigested fibre in the diet gave quicker passage through the colon and larger softer faeces – a natural biological effect which can be used by anyone if it makes them more comfortable. However, Birkitt believed that low levels of dietary fibre, compared with diets in Africa, was the cause of the western diseases. The bowel disease, DD, was an obvious target and has been the last to question the theory. DD patient’s diets were changed suddenly around 1970 and they were overwhelmed by wheat bran “medication” whether it was needed or beneficial for them or not.

     “I get the impression that the medical profession takes the line that it is a ‘self–inflicted’ problem. The usual comment is that the patient should have eaten better in his youth, implying that we live on junk food”

     “like most of us sufferers they just seem to put up with things. The medical profession don’t seem to know much about it – only fibre and more fibre. About 50 years ago I knew a gentleman who had it but it wasn’t fibre then – he had everything mashed up very fine but he never had it many years after that and lived well into his 80s – so it does get a bit confusing.”

     “In 1998 I was diagnosed having diverticulitis . . .  practically no help from either my GP or the dietitian at the local hospital whose advice was to eat lots of fibre which gave me terrible diarrhea and wind making matters worse”

Hours of research and trials have been spent trying to support the theory that DD was caused by diets low in fibre and that increased dietary fibre could prevent and treat the disease, stop diverticulitis infections, complications and mortality. What the theory has done is discourage research into any other help for people with DD. What Painter said about the “low” residue diet in the 1970s could now apply equally to the “high” residue diet still promoted today in the 2020s. “This diet remained in vogue for nearly 50 years until it was realized that it failed to relieve and often exacerbated the symptoms that it was intended to prevent”

CIGARETTE SMOKING AND NICOTINE

The appearance of the 20th century diseases was rightly attributed to a common environmental cause. Two of them, lung cancer and coronary heart disease (CHD) were known to be strongly related to cigarette smoking. Because of the fibre theory an opportunity was missed to relate the other 20th century diseases to cigarette smoking. The pharmacology of nicotine was known and some long term effects were being revealed in the 1960s. Medical research concentrated on lung cancer, showing that it could take 20 years before the consequences of smoking were apparent.  The same delay with the formation of diverticula was not recognized. Birkitt considered his high fibre diet would be as beneficial to the health of western nations as would be the elimination of cigarette smoking. This has not happened. DD marched on in the west and other countries have followed with the availability of cigarettes. Studies show that smoking can affect all stages and problems of DD (see this website). Perhaps the most useful treatment for DD would be to stop smoking cigarettes and use the modern devices to overcome nicotine addiction rather than satisfy it.

AFTER A CENTURY

Treatments now recommended for DD are antibiotics and surgery. Neither a high fibre diet nor IBS type treatments such as antispasmodics can be effective consistently. Paracetamol is the recommended pain treatment. People are largely left to their own devices. This is not easy. Effects of DD are unpredictable, different between people and even in the same person at different times and ages. So any treatment can only be symptom based. Advice on diets, foodstuffs and recipes is overwhelming. Finding causes of symptoms may take years, if ever. Both constipation and diarrhoea need to be defined and considered. People often look outside orthodox medicine for advice and treatments.

     “- – – I was at the end of my tether, a doctor who thought I was literally a pain in the bum, a family who I am sure secretly got tired of me saying ‘I can’t eat this or that’ and refusing to go out for meals, even having to give up holidays, and all because the hospital said that I had diverticulitis, but it wasn’t life threatening and there was not a lot they could do”

      “We are all so different that I do feel sympathy for doctors, It’s all trial and errors”

Do researchers and health professionals know about and have sympathy for people’s problems? Little information is available about DD at primary care level. Data flows down the healthcare pyramid but does it go in the opposite direction? DD has in the past been beset by dismissive opinions – so many people have it so should it be called a disease, it’s just ageing and constipation, it’s just the same as IBS, psychological factors are important in recurrent pain (chicken and eggs?)

     “He was a young doctor who seemed to think that DD was just part of growing older, either you suffered or you had an op”

     “I have had diverticulitis for almost 25year and I really thought that not many people had it. When I was first diagnosed they told me I had an ‘old person’s bowel’. I was just 40years old.”

     “The presence of diverticula in myself accepted, the similarities of the symptoms of IBS and diverticulitis have led the medics to rule out the latter on the basis of my age, 46, even though during the time of two flare-ups with fever – – – (one hospitalized with iv antibiotics)- – -they now say it must have been something different – like a viral infection. (because of) frustration and depression they now want me to go down the road of psychotherapy. Do you remember the film ‘One Flew Over the Cuckoo Nest’ well for me it feels like that – I’m on the inside but only the sane one in all this”

COLON STRUCTURE CHANGES NEED CONSIDERATION

DD is diagnosed by the appearance of diverticula on the colon by whichever of the modern internal examination, X-ray or scanning technique is used. Recognition of diverticula is often considered the beginning of the disease in many surveys, and hospital admission as the measure of symptoms. The other known characteristic of DD, particularly seen in the sigmoid colon, which was recognized a century ago, has not had much attention. The shortened corrugated colon which eventually bore diverticula was permanent, narrowed internally and with walls less extensible. It looks like it had shortened to push out faeces then not been able to relax afterwards. Searching for the cause of DD, even by dietary experiments on animals, has not produced such damage. Researchers have reported changes in structural collagen and muscle elastin as relevant. This is not IBS, nor is the thickening of the wall due to inflammation. Hereditary diseases which change collagen structure can result in diverticula formation.

Fifty years ago research by Painter showed that this affected area of the colon behaved differently from unaffected parts and also from the colon of healthy people. The reaction to selected drugs indicated that nerve control of the muscles had changed giving altered movements. Even the gastro-colic reflex (the effect of eating on colon movement) produced a different reaction. More recent research shows that the colon with diverticula is not in tune with the autonomic nervous system and its neurotransmitters, particularly acetylcholine and nitric oxide, reflecting nicotine toxicity. The seratogenic system and other hormones and neurotransmitters are also being revealed as being different in the affected colon area. The gut brain, in the colon bearing diverticula, has been damaged.

THE DAMAGED GUT BRAIN

The DD affected colon may well also react differently to bioactive chemicals in foods and the environment. There are ‘safe’ concentrations of insecticides, herbicides and other toxic substances in foods and the environment. They are not tested on humans to give the limits, but on animals and fish. Is the colon with diverticula sensitive to such chemicals? When trying to find the reason for symptoms, looking further than diet might be a useful addition to health diaries. Some drugs are known to increase the risk of complications such as bleeding or bowel perforation. Not often considered are the many classes of drugs which have constipation as a side effect of their treatment for a range of other conditions. Diagnosis by barium enema because of symptoms peaked at retirement age and was attributed to the ageing colon. How many of the symptoms are caused or made worse by drugs for complaints common in old age?

     “The hospital staff insisted on me taking codeine as pain killers and iron tablets. I explained about my DD but they did not take any notice and I became so constipated that I was in agony and being sick. They did not give enemas unless you hadn’t been for at least four days – – – they have no idea of diverticula problems”

     “- – – have been having problems with constipation through BP medication which the hospital has been changing every 2 or 3 weeks. For the first time in 9 years I have had pains which no one wanted to do anything apart from ‘eat more fibre’”

The colon with DD might be affected by other diseases themselves and their treatments if they involve neurotransmitters present in the brain and gut brain. Migraine, with its fluctuating levels of serotonin can give a pattern of a few day of constipation followed by catch-up relief. Looking for migraine triggers could be useful. Have the serotonin drugs used for the headache relieved gut symptoms as well?

THE FUTURE?

The century has not been good for DD. Only the general advancements in surgery and antibiotics have helped and they have certainly been needed. DD has continued unabated to become a considerable drain on health services and hospitals in many countries. This belies the idea that DD is simply a dietary disease of old age. This opinion, a relic of the fibre theory, has left people with little help, no recommended treatments and confusion. Even the medical nomenclature ‘diverticulitis’, used by patients and others, does not match the ever changing names of the different causes of symptoms used by researchers. There seems to be more emphasis on the number of people who do not have symptoms rather than those who do. Experts can disagree, advice is inconsistent or nonexistent. Is any other disease so chaotic?

Something needs to change but in what direction and how? There may be a long wait for a drug for the variety of symptoms but drug use for other complaints should consider effects on  DD. Research into the microbiome with DD has shown some unique patterns, but colon structure and diet have not been ruled out. This research area might shed some light on the change from diverticulosis to diverticulitis. What changes or causes infection is not known but diverticulitis episodes are a key to more serious problems. Research in primary care is needed for answers. Like other bowel diseases have in this century, DD needs to come out of the shadows. Publicity and support is needed. People should not feel alone and be gagged by embarrassment and a derogatory medical image. Surveys and statistics do not show the effects on people’s daily lives.

     “I do not look forward to a holiday, which rather irritates my husband who is as fit as a flea. In between bouts I look fine and sadly realise that I am suspected of hypochondria – I wish”

     “- – – as the years went on my children and my husband got quite used to ‘Mum’ having a funny tummy. I didn’t get a lot of sympathy, in fact the ‘funny tummy’ was more of a b***** nuisance really coming on at all sorts of awkward times, holidays, Christmas, messing up days out as we had to stay close to toilets, and causing lots of raised eyebrows and sighs for being so ‘picky’ when out for a meal (Go on, it won’t hurt you just for once!!)”

© Mary Griffiths 2020

The quotations are from contributions to the newsletters of a former support group.

Painter N.S. Diverticular disease of the colon. 1975, William Heineman Medical Books Ltd. London. ISBN 0 433 24660X

Diverticular Disease: Progression, Smoking and Nicotine

Sunday, April 14th, 2019

 

Diverticular disease (DD) can progress from changes in the gut nerves and muscles to formation of diverticula (diverticulosis), to symptoms of colon dysfunction, to infections and inflammation (diverticulitis), to chronic symptoms, and to serious abdominal complications. The number of sufferers along this pathway diminishes greatly at every stage, only a minority ever need surgical treatment. On the other hand, progression and ageing go hand in hand.

The causes and risk factors of progression after diverticulosis are as varied as the people with DD.  Nobody knows what brings on diverticulitis which can be a gateway to problems. Historically, a diet low in fibre was thought to be responsible for all of the disease spectrum and could be easily remedied. This is no longer accepted. In the second half of the 20th century nobody considered an effect of smoking on the gut. Most Western adults smoked despite the risks of lung cancer and heart disease. Cigarettes had calmed the soldiers of the war, they were glamorous and macho, and nicotine was strongly addictive.

Cigarette use was aligned much closer to the appearance of DD in the world than diets which were variable and often assumed. Articles on this website in 2012 and 2013 have details of this epidemiology and also explain the pharmacology of nicotine where chronic use can cause the damage to the colon characteristic of DD.

Diverticula on the colon have to be identified before a diagnosis of the disease can be made. This happens in a hospital setting when symptoms or severe illness leads to investigative scans, x-rays or colonoscopies. Diverticula have already been formed then. The development of diverticula was described by interested pathologists early in the 20th century. Recent genetic and epidemiology research confirms that nerve and collagen changes are involved (1,2). These are the chronic effects of nicotine.

Hospital researchers have used diagnosed patients and their memories to produce “risk factors” and “associations” for DD based mainly on diets. Now, screening for colon cancer by colonoscopy around 50 years of age uncovers symptom-free diverticula. Participants can provide data on their lifestyles. Including smoking is a new opportunity to see if this was relevant to the presence or absence of diverticula. Also, increasing numbers of surveys are providing clinical evidence that cigarette smoking has a major effect on DD and its potential progression.

DIVERTICULA FORMATION

Data about smoking in 18-20 year old military conscripts in 1969-1970 was compared with Swedish national registers in 2009. Smoking increased the diagnosis of DD (3). The use of tobacco was greater in the 41.7% of colonoscopy outpatients found to have diverticula. The traditional risk factors for the presence of diverticula (low dietary fibre, constipation, red meat intake, low physical activity) were not confirmed (4).These authors thought that diverticula were most certainly present for many years before they were observed. Other American researchers (5) also considered that diverticulosis was longstanding before it was revealed. Two Japanese studies (6,7) related smoking to finding diverticula in outpatients. A history of smoking was revealed in Ulcerative Colitis patients who had diverticulosis (8). Recently in China (9) smoking was associated with diverticula in men (odds ratio = 2.14) and even more so in women (odds ratio = 10.2). Pooling together the data from several surveys (meta-analysis)  increases the validity of results. Two such studies (10,11) implicated smoking with diverticulosis and also increased risk of complications of the disease.

SYMPTOMS

Past and current smokers had increased risk of symptomatic disease in Swedish women (12). In Swedish men, heavy smokers had increased risk of developing symptoms and there was some evidence of a dose/response relationship compared with non-smokers (13). The risk of changing from diverticulosis to diverticulitis was significantly higher in cigarette smokers in a report from Italy (14). Red meat was associated with increased risk of diverticulitis (15) but red meat eaters smoked more, used NSAID drugs and paracetamol, and had less vigorous exercise.

HOSPITAL ADMISSION

Present and previous smoking increased the risk for women of hospital admission for acute diverticulitis (16) and recurrent episodes (17). Compared with patients with no or minor symptoms, smoking was associated with hospital admissions because of complicated diverticulitis and severe infections (18,19).  Health conscious participants were used in a study by Crowe et al (20) to compare hospital and death records of DD between vegetarians and non-vegetarians. Smoking levels were only between 10% and 15%. Vegetarians and high dietary fibre intake gave a lower risk of hospital admission than meat eaters, but the vegetarians were younger. Compared with non-smokers, the increased risks for former smokers, light and heavy smokers were 31%, 34% and 86% respectively.

SURGERY

A Canadian survey of patients who underwent a partial colectomy found that current and former smokers had increased risk of surgery compared with non-smokers (21). Smoking was a risk factor for leakage of the join in the colon after part of it had been removed (22).

Removal of the sigmoid colon affected by DD was needed at a younger age in smokers compared with non-smokers, and the complications had developed more rapidly in smokers (23).

STUDIES SHOWING NO EFFECTS OF SMOKING

Some studies have not found any link between smoking and DD (24,25,26,27). These can be difficult to assess with gaps in details such as patient selection and their particulars, and ages. End points can be right sided disease or bleeding. Bleeding has so far not been related to smoking, but age, condition of blood vessels and drug side effects are relevant (28). The most quoted study is that of Aldoori et al (29) and their analysis of US male health professionals followed since 1986. In the 4 years between 1988 and 1992 there were 500 new cases of DD, 382 with symptoms and 118 without. Smoking was positively associated with the risk of symptoms, increasing with the number of cigarettes smoked per day and decreasing with the time since stopping smoking. These results were attenuated when dietary data was included in the analysis. The authors concluded that smoking was not associated with any substantial increased risk of symptomatic DD.  Another recent statistical assessment of the same group of health professionals found that smoking was independently associated with increased risk of diverticulitis (30).

DISCUSSION

This collection of reports is not exhaustive and more studies are likely. Some reviewers do not include data but an author’s opinion is cited. A mixture of positive and negative results is also found for other risk factors for DD. Bohm (31) emphasises the importance of differentiating risk factors between those for diverticulosis and for the other effects of the disease. This separation has been attempted here. The end point of a study is also relevant. For example, eating nuts, grains, corn and popcorn had no effect on hospital admissions for complications. Dietary avoidance of these foods was dismissed as irrelevant (32), but the long-standing avoidance of these foods for DD was based on pain. Many patients suffer from chronic and severe pain outside the hospital setting which is rarely researched. In fact, information about less serious symptoms and their treatment dealt with at primary care level is largely absent (33).

Age, sex and genetics are risk factors which cannot be changed, but many lifestyle choices, co-existing diseases and drug treatments also affect DD. Increasing opinion is that diverticula take years to form and are evident through symptoms a long time, even decades, after their cause by smoking. The cause of DD is distinct from many other factors which cause symptoms and complications. However, smoking is detrimental to all aspects of the disease and this should be reflected strongly in patient information.

Computer statistical assessments are used to uncover factors relevant to diseases, symptoms and progression, but the data used is subject to human choices and interpretation of results. The effect of smoking on DD was only included as a confounding factoring in studies relatively recently. Are older dietary studies still relevant if this was not included? The article by Labos (34) and its on-line comments are recommended reading on the subject. He considers a result found in several patient populations carries weight when the trials cannot be accurately replicated. In the case of smoking and DD, there is world-wide epidemiology, the pharmacology of chronic nicotine use and now, increasing clinical evidence of its profound effects.

The effect of smoking on DD and other diseases will be more difficult to asses in the future when people replace tobacco cigarettes (smoking) with e-cigarettes (vaping) for their nicotine fix. Many countries have banned e-cigarettes but some official organisations and powerful charities seem to be advising their use. Avoiding the carcinogenic chemicals from tobacco smoke is welcomed to reduce the risks of cancer, but people are then classed as ‘non smokers’ in surveys. The number of smokers will reduce, but the effects of continued use of nicotine should not be dismissed lightly. E-cigarettes are not regulated and long-term effects have still to be revealed. E-cigarettes are not medical devices, they will not overcome addiction to nicotine without commitment, determination and any help available. Retail outlets are increasing to make vaping commonplace and accessible. Its use by under 18s is increasing. Tobacco companies view e-cigarettes as their next generation products and aim to increase promotion and sales, just like they did in the mid 20th century for cigarette smoking.

Déjà vu.

© Mary Griffiths 2019

REFERENCES

1.      Schafmayer C. et al. Genome-wide association analysis of diverticular disease points towards neuromuscular, connective tissue and epithelial pathomechanisms. Gut, 2019, Jan, 19th Epub.

2.      Broad JB et al. Diverticulosis and nine connective tissue disorders: epidemiological support for an association. Connect Tissue Res. 2019, Feb 5th. Epub.

3.      Jarbrink-Sehgal ME et al. Lifestyle factors in late adolescence associated with later development of diverticular disease requiring hospitalization. Clin Gastroenterol Hepatol. 2018, 16, 1474.

4.      Peery AF. et al. A high-fiber diet does not protect against asymptomatic diverticulosis. Gastroenterology, 2012, 142, 266.

5.      Strate LL. Diverticulosis and dietary fiber: rethinking the relationship. Gastroenterology, 2012, 142,205.

6.      Tarao K. et al. Recent trends in colonic diverticulosis in Yokohama City: a possibility of changing to a more western profile. Intern med, 2015, 54, 2545.

7.      Nagata N. et al. Alcohol and smoking affect risk of uncomplicated colonic diverticulosis in Japan. PloS One, 2013, 8, e81137.

8.      Kinnucan J. et al. U.S. patients with ulcerative colitis do not have a decreased risk of diverticulosis. Inflamm Bowel Dis. 2015, 21, 2154.

9.      Yang F. et al. Sex differences in risk factors of uncomplicated colonic diverticulosis in a metropolitan area from Northern China. Sci Rep. 2018, 8, 138.

10.  Wijarnpreecha K. et al. Smoking and risk of colonic diverticulosis: a meta-analysis. J Postgrad Med. 2018, 64, 35.

11.  Aune D. et al. Tobacco smoking and the risk of diverticular disease – a systematic review and meta-analysis of prospective studies. Colorectal Dis. 2017, 19, 621.

12.  Hjern F. et al. Smoking and the risk of diverticular disease in women. Br J Surg. 2011, 98, 997.

13.  Humes DJ. et al. PTU-230 Smoking and the risk of symptomatic diverticular disease: a Swedish population based cohort study. Dis Colon Rectum. 2016, 59, 110.

14.  Usai P. et al. cigarette smoking and appendectomy: effect on clinical course of diverticulosis. Dig Liver Dis. 2011, 43, 98.

15.  Cao Y. et al. Meat intake and risk of diverticulitis among men. Gut, 2018, 67, 466.

16.  Jamal Talabani A. et al. Risk factors of admission for acute colonic diverticulitis in a population-based cohort study: The North Trondelag Health Study, Norway. World J Gastroenterol. 2016, 22, 10663.

17.  El-Sayed C. et al. Risk of recurrent disease and surgery following an admission for acute diverticulitis. Dis Colon Rectum. 2018, 61, 382.

18.  Papagrigoriadis S. et al. Smoking may be associated with complications in diverticular disease, Br J Surg. 1999, 86, 923.

19.  McGarr S. et al. Cigarette smoking increases the risk of infectious complications associated with diverticular disease of the colon. Am J Gastroenterol, 2000, 95, 2543.

20.  Crowe FL. et al. Diet and risk of diverticular disease in Oxford cohort of European prospective investigation into cancer and nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ, 2011, 343, d4131.

21.  Diamant MJ. et al. Smoking is associated with an increased risk for surgery in diverticulitis: a case control study. PLoSOne 2016, 11, e0153871.

22.  Baucom RB. et al. Smoking as dominant risk factor for anastomotic leak after left colon resection. Am J Surg. 2015, 210, 1.

23.  Turunen P. et al. Smoking increases the incidence of complicated diverticular disease of the sigmoid colon. Scandinavian Journal of Surgery. 2010, 99, 14.

24.  Storz C. et al. Characteristics and associated risk factors of diverticular disease assessed by magnetic resonance imaging in subjects from a Western general population. Eur Radiol. 2018, 29, 1094.

25.  Adamova Z. et al. Recurrent diverticulitis – risk factors. Rozhi Chir, 2013, 92, 563.

26.  Jamieson CG. et al. An investigation into the relationship between cigarette smoking and diverticular disease of the colon.  Can J Gastroenterol. 1990, 4, 193.

27.  Lin OS. et al. Dietary habits and right sided colonic diverticulosis. Dis colon Rectum. 2000, 43, 1412.

28.  Jansen A. et al. Risk factors for colonic diverticular bleeding: a Westernised community based hospital study. World J Gastroenterol. 2009, 15, 457.

29.  Aldoori WH. et al. A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Ann Epidemiol 1995, 5, 221.

30.  Liu PH. et al. Adherence to a healthy lifestyle is associated with a lower risk of diverticulitis among men. Am J Gastroenterol. 2017, 112, 1868.

31.  Bohm SK. Risk factors for diverticulosis, diverticulitis, diverticular perforation and bleeding: a plea for more subtle history taking. Viszeralmedizin, 2015, 31, 84.

32.  Strate LL. et al. Nut, corn and popcorn consumption and the incidence of diverticular disease. JAMA , 2008, 300, 907.

33.  Humes DJ. Changing epidemiology: does it increase our understanding? Dig Dis. 2012, 30, 6.

34.  Labos C. Epidemiology: separating the wheat from the chaff. Aug 14th 2018. https://www.medscape.com/viewarticle/900381

Diverticular disease AND/OR irritable bowel syndrome

Friday, June 29th, 2018

Information about diverticular disease (DD) is available in fact sheets on many internet sites, but these should be assessed. Is it up to date, does it help day-to-day problems, is it a charity or a business? Discussions on forums show a variety of experiences of DD and no general approach on what can be done to help. DD is sometimes mentioned by charities which support younger people with, for example, Crohn’s and ulcerative colitis (IBD) or Irritable Bowel Syndrome (IBS). In the last few years some people with DD have been told that they also have IBS. This can be very confusing because DD and IBS are different complaints sometimes with conflicting treatments and certainly different potential outcomes. Some researchers propose that any symptoms without diverticulitis must be IBS. This ignores or denies the colon damage which resulted in diverticula forming. Sources of information about IBS do not cover an IBS/DD diagnosis, never mind any differences which should be considered. (more…)

Is diverticular disease making you housebound?

Monday, November 14th, 2011

THE PROBLEM

DD affects people in many different ways, some have few or no symptoms and their lifestyle is unaffected. Others are simply too ill to even think about leaving their home. These extremes can be a permanent or temporary situation for many sufferers. Older, retired people with DD sometimes have a different problem. An organiser of outings for an over-60s club said that people with DD could not go on their trips because they dare not go away from a toilet. That was 3 decades ago and not much has changed since then. Some coaches now have on-board toilets but public transport and car journeys also present problems. Apprehension and nervousness before a holiday, meal or outing, even a pleasurable one, sends their guts into overdrive. There is no mention of this problem in medical or self-help books or websites. It is not a topic of conversation even with close relatives and comedian’s jokes do not help. (more…)

Pain with diverticular disease

Thursday, September 9th, 2010

In 2001, 230 members of a previous organisation for DD sufferers (NADD) completed a questionnaire about their symptoms. The results are shown in Table 1. (more…)

What is Constipation, Diarrhoea and Normal

Thursday, August 12th, 2010

 

Scientists desperately try to put values on body functions to measure and classify symptoms. This enables statistical comparisons to evaluate the effects of diseases and treatments. Defaecation is a good example of this and also of the influence of history, fashions and personal opinions. (more…)