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.
| TABLE 1SYMPTOMS OF 230 PEOPLE WITH DIVERTICULAR DISEASE- = NOT REPORTED | ||
| SYMPTOM | % WITH SYMPTOM WHEN DIAGNOSED | % WITH SYMPTOM AT SURVEY |
| CONSTIPATION | 9.6 | 13.5 |
| DIARRHOEA | 31.7 | 17.8 |
| BLOATING | 10.4 | 74.3 |
| CHANGED/ERRATIC BOWEL HABIT | 5.7 | 61.7 |
| EXCESSIVE GAS | 3.0 | 67.0 |
| DIFFERENT STOOL APPEARANCE | 3.0 | – |
| UPPER GASTRIC SYMPTOMS | 6.1 | – |
| INDIGESTION | – | 55.7 |
| NAUSEA | – | 37.0 |
| GENERAL MALAISE | 4.3 | – |
| RAISED TEMPERATURE | – | 27.0 |
| FATIGUE AND HEADACHES | – | 7.0 |
| PAIN | 67.8 | 94.8 |
| ANAL BLEEDING | 15.2 | 23.5 |
| ANAL MUCUS | – | 34.8 |
They were asked about their current symptoms and also what symptoms they had when they were diagnosed with DD. Only 13 out of the 230 were found to have DD during investigations for other reasons, the majority were diagnosed following gut-related symptoms with abdominal pain predominant. At the time of the survey most (94.8%) of the contributors had pain, along with increased levels of former and new problems. They also described where their pain was located and what it felt like (Table 2).
As a measure of pain with DD it can be argued that these findings are biased because only people who have a lot of problems would contact a support organisation. Indeed, a survey of DD patients a few years after hospital diagnosis or treatment recorded only 55.5% or 69.2% with some type of pain. The latter increase was in patients who had had an episode of diverticulitis which is thought to affect colon nerves. (1) With further diverticulitis episodes over the years, an increase in pain might be expected. The NADD survey was based on a total of 2,081 years of patient experience and is certainly not a testament to effective treatment of DD.
| TABLE 2 PAIN CHARACTARISTICS OF 230 PEOPLE WITH DIVERTICULAR DISEASE | ||
| % OF PARTICIPANTS | ||
| LOCATION OF PAIN IN ABDOMEN | LEFT SIDE ONLY | 40.4 |
| RIGHT SIDE ONLY | 7.8 | |
| BOTH SIDES | 34.3 | |
| OTHER THAN SIDES | 26.5 | |
| DESCRIPTION OF PAIN | COMES AND GOES | 51.7 |
| DULL AND NAGGING | 42.2 | |
| SHARP | 26.5 | |
| CONTINUOUS | 21.7 | |
| VARIES | 39.6 | |
The colon is normally insensitive to pain, it can be cut or burned without pain and powerful movements of the bowel cannot be felt. This explains why diverticula can form without any indication of their presence. What does cause pain is stretching of the colon walls and infection/inflammation. How to distinguish between these two reasons for pain is a dilemma for patients since both can be severe and particularly frightening on the first occasion. The survey showed symptoms related to both scenario.
One group of researchers have taken duration of pain greater than 24 hours to indicate diverticulitis (1). Other clues are that the pain continues in the same place where there are diverticula. The area can be tender to touch and can hurt on movement. There will be a general feeling of being unwell and body temperature may be raised. A clinical thermometer is a useful tool for people with DD. This type of pain can be sudden and severe or dull and prolonged and needs urgent medical treatment.
Pain not related to infection and inflammation is described as “functional” in that it relates to the bowel not working properly. Colon walls can be stretched by build-up behind spasms of muscles, partial obstructions or slow movement of faeces. Such pain can occur anywhere along the colon, not just where diverticula are located. Adhesions or strictures, if present, can cause normal bowel movement to be painful. People are not often told where or how much of their colon is affected by permanent muscle deformity which might contribute to malfunction. Functional pain can come and go, move along, be short and sharp or related to defaecation habits.
The cause of functional pain with DD is the subject of much debate. Constipation and erratic bowel habits are common chronic symptoms of DD (2). Some regard this type of pain as IBS with a perceived psychological origin. A statistical analysis found anxiety/depression and a history of acute diverticulitis as predictors of recurrent pain (3). (Perhaps if the computer had been asked what predicted anxiety/depression they may have found repeated diverticulitis and recurrent pain were the culprits.) Visceral hypersensitivity is considered to play a part (4) ie the people who get pain are more sensitive to abdominal malfunction. DD people with symptoms were associated with a higher perception of colon distension (5).Increased pressure and the presence of diverticulosis, were associated with pain when air was pumped into the colon for CT examinations (6). Some researchers found that distension of the colon with DD occurred because the walls stretched rather than reacting by increasing internal pressure (7, 8). Pockets of gas in the colon result in pain and bloating (9).
Researchers and patients appear to agree that excessive gas, bloating and erratic bowel habits give functional pain with DD. One way of self-help is to keep the gas moving along by diet, exercise, medically approved laxatives or even abdominal massage. Avoiding swallowing air and gassy drinks might help. Another way is to avoid dietary items which produce excessive gas. Peas, beans, onions, sprouts etc. are well known for this property. Bacteria in the guts of people vary and some are very good at producing gas when they ferment fibre, particularly soluble fibre as found in these vegetables or other foods.
Soluble fibre comes in many forms eg. bulk laxatives, prebiotics, probiotic products, in prepared foods as thickening and stabilising agents and in low-fat products to thicken and match the texture of their high-fat equivalent. Look out for inulin, xanthan gum, guar and other gums, oligofructose, ispaghula, psyllium, oligosaccharides, methyl cellulose, sterculia, carrageenan etc. A high fibre diet using psyllium at 30g per day was found to inhibit the transit of intestinal gas in healthy volunteers (10). Methyl cellulose can be used to treat constipation or diarrhoea depending on how much liquid is taken with it (patient information leaflet). This illustrates the need for a good fluid intake with fibre in treatments or in diet. An optimum amount of soluble fibre may well be a compromise between its positive (promoting regularity) and negative (gas production) effects.
It is always better to find the cause of abdominal pain and reduce or eliminate it rather than disguise pain with analgesics. Personal detective work and a symptom diary might help. If necessary, paracetamol can be effective but by reducing fever can mask diverticulitis. Non-steroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding with DD, while opioid analgesics such as codeine have constipation side effects which are sometimes made use of in some DD circumstances. Like many other aspects of day to day problems with DD, there is no universal way to treat DD pain, only an individual and their medical advisers can decide what is best for them.
© Mary Griffiths 2008
REFERENCES
1. Simpson J et al. Patterns of pain in diverticular disease and the influence of acute diverticulitis. Eur J Gastroenterol Hepatol. 2003, 15, 1005.
2. Hussain A et al. Complicated diverticular disease of the colon, do we need to change the classical approach, a retrospective study of 110 patients in southeast England. World J Emerg Surg. 2008, 3, 5.
3. Humes D J. et al. Psychological and colonic factors in painful diverticulosis. Br J Surg. 2008, 95, 195.
4. Simpson J et al. Origin of symptoms in diverticular disease. Br J Surg. 2003, 90, 899.
5. Clemens C H M et al. Colorectal visceral perception in diverticular disease. Gut. 2004, 53, 717.
6. Sosna J. et al. CT colonography: positioning order and intracolonic pressure. Am J Roentgenol. 2008, 191, 1100.
7. Smith A N. et al. Pressure changes after balloon distension of the colon wall in diverticular disease. Gut. 1981, 22, 841.
8. Parks T G. The pathogenesis of large bowel diverticula. Ulster Med J. 1971, 41, 45.
9. Harder H et al. Intestinal gas distribution determines abdominal symptoms. Gut. 2003,52,1708.
10. Gonlachanvit S. et al. Inhibitory actions of a high fibre diet on intestinal gas transit in healthy volunteers. Gut. 2004, 53, 1577.
Note This article appeared in the Winter 2009 issue of the Journal of the Bladder and Bowel Foundation and is available in the professional resources section of their website.
Tags: Bowel gas, Pain, Soluble fibre, Symptoms, Treatment