The impact of diverticular disease (DD) in the hospital situation was discussed in the Winter 2006/2007 issue of the magazine. This area is well researched to update and optimise the diagnosis of DD and the expert treatment of complications on an individual basis. This research also shows that DD is an increasing burden on hospitals in terms of number of admissions and costs. Better management in the community is critical in reducing this burden. Prevention of complications of DD would benefit both NHS budgets and patients.
One gastroenterologist (1) has recognised that (IBS) patients in hospitals may be atypical but research and teaching about a disease is based on these. He did not know the characteristics of patients in general practice. This area is not monitored for DD but the opinions of hospital based experts are passed down the healthcare hierarchy. Accounts of people’s experiences at grass root level vary from helpful and satisfying to useless and dismissive.
Are these expert opinions helping to promote better treatment of DD? For example, the gastroenterologist above (2) considers that diverticula are “innocent little bystanders” rather than the result of damage to a colon structure and function. Other experts consider six episodes of abdominal pain per year as normal but patients know the difference between DD pain and the effect of last night’s curry. Perhaps also relevant is the widespread belief, for many years in medical literature, that unless you are one of the 10% to 25% of DD patients admitted to hospital, then you do not have any symptoms (3-7). A survey of the effects of DD on the quality of life tells a different story (8). After an initial attack of diverticulitis 69% of patients had recurring pain, 35% on a daily basis (9). These authors noted the severity of the symptoms suffered by elderly patients. In a recent trial in Italy (10), different patients showed repeated attacks of diverticulitis or mild but recurring symptoms or continuous symptoms or no symptoms. This was during a 12 months trial of two types of treatments! DD effects can be irregular, unexplainable and unpredictable, such variation is not always appreciated.
Perhaps more emphasis should be applied to those with known DD and their problems rather than to a theoretical proportion of the population who might have diverticulosis but don’t know it. People diagnosed with DD are sometimes not told about its possible complications because it might frighten them. This is like not telling people with high blood pressure about heart attacks and strokes and negates patient- centred health care initiatives. After diagnosis with DD, people can be told to learn to live with their problems without information, help or treatments which work. DD needs a far higher profile, sweeping it under the carpet will not reduce the burden on hospitals or patients.
It is not surprising that drug companies are not interested in a disease which supposedly does not have symptoms. Costs of DD in terms of drug treatments are minimal (11) and no drugs available have proven effectiveness (12). Drugs for other complaints can increase the risk of DD complications (13,14) and the side effects of drug combinations commonly prescribed for the elderly can cause constipation (15) to aggravate DD as can some over-the-counter medicines for bowel pain.
Patients are told to decide for themselves the best treatment for diverticulosis (16) but these authors think serious complications of DD are found in self diagnosing/treating readers of web sites and magazines. Being between rocks and hard places comes to mind. People will not find any research into or answers to what changes diverticulosis into diverticulitis. A high fibre diet did not prevent this (17). They will find all kinds of alternative therapies and remedies offering expensive ‘help’.
Retirement villages, residential and nursing homes would be an ideal setting for research into DD – compact populations most likely to have DD, its problems and complications. A textbook on nursing older people describes DD as a highly symptomatic disease giving morbidity to women in later life and a common cause of constipation (18). There is no mention of any treatment. Another text book for use in care homes (19) had only one mention of DD. It noted that some older adults, as a result of a life-long diet deficient in fibre, develop DD and have diarrhoea. Constipating agents such as Lomotil, codeine phosphate and Imodium can be used in such cases. A normal bowel pattern can then be developed by sitting the patient on the toilet after breakfast to try to defaecate. So we have a patient who may have diverticulitis, given drugs which are contra-indicated for DD because they can stop bowel function for days, being seated on a toilet for unspecified times and occasions until they manage to defaecate. This is obviously for the benefit of the staff and not the patient. A recent poll by the Patients Association (20) found that 74% of elderly people living in nursing homes had been experiencing pain for more than a year but 85% of these had never had a doctor or nurse talk to them about it. Such conversations were between the GP and nursing staff and seldom involved the patient. DD in this part of the health care system certainly needs investigating.
DD has been described as too common to be a disease, an inevitable part of ageing and an incidental, irrelevant result of investigating bowel symptoms. In government initiatives it is not considered a chronic disease or a cause of long term disability. A rise in hospitalisation is hardly surprising after years of disparagement. There are reasons somewhere in the healthcare system why somebody with known DD can get complications such as fistula, strictures etc which must have been preceded over a long period by pain and bowel symptoms. All parts of the western world are equally afflicted by DD, so why, in the USA in 2000 there were 3,290 deaths from DD out of a population of 281 million, and in England and Wales there were 1,826 deaths out of a 53 million population?
REFERENCES
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2 Thompson WG Diverticula, diverticulosis, diverticulitis: what’s the difference. http://www.aboutibs.org/publications/diverticula.html (accessed 05.04.2004)
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6 Somasekar ME et al. The natural history diverticular disease: is there a role for elective colectomy? J R Coll Surg Edinb 2002, 47, 481
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8 Bolster LT et al. Diverticular disease has an impact on quality of life – results of a preliminary study. Colorectal Dis 2003, 5, 320
9 Simpson J et al. Patterns of pain in diverticular disease and the influence of acute diverticulitis. Eur J Gastroenterol Hepatol 2003,15,1005.
10 Tursi A et al. Balsalazide and/or high-potency, probiotic mixture (VSL#3) in maintaining remission after attack of acute, uncomplicated diverticulitis of the colon. Int J Colorectal Dis. 2007, March 28 (Epub ahead of print)
11 American Gastroenterological Assocciation. The burden of gastrointestinal disease. http://www.gastro.org/clinicalRes
12 Simpson J & Spiller R Colonic diverticular disease 01.09.05. http://www.clinicalevidence.com
13 Morris CR et al. Anti-inflammatory drugs, analgesics and the risk of perforated colonic diverticular disease. Br J Surg 2003, 90, 1267
14 Mpofu S et al. Steroids, non-steroidal anti-inflammatory drugs, and sigmoid diverticular abscess perforation in rheumatic conditions. Ann Rheum Dis 2004, 63, 588
15 Ness J et al. Anticholinergic medication in community-dwelling older veterans: prevalence of anticholinergic symptoms, symptom burden, and adverse drug events Am J Geriatr Pharmacother 2006, 4, 42
16 Black PK and Hyde CH Diverticular disease. 2005 Whurr Publishers Ltd. London. ISBN 1 86156 446 5
17 Painter NS et al. Unprocessed bran in the treatment of diverticular disease of the colon. Br Med J. 1972, April 15, 137.
18 Redfern SJ & Ross FM editors. Nursing older people. 2003 (3rd Ed) Churchill Livingstone. ISBN 0 443 05874 1
19 Nazarko L. Nursing in care homes 2002 2nd Ed. Blackwell Science Ltd. ISBN 0-632-05226-0
20 The Patients Association. Pain in older people – a hidden problem. 22.03.2007 http://www.patients-association.org.uk/news
© Mary Griffiths 2007
Note This article appeared in the Summer 2007 issue of Incontact magazine
Tags: Drugs, Statistics, Symptoms, Treatment