Posts Tagged ‘Treatment’

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: The Fibre Story

Thursday, September 14th, 2017

In the early part of the 20th century constipation was not generally related to any individual illness. The idealised achievement of daily defaecation meant constipation was common particularly in the elderly. Treatment was not free until the NHS came along and natural and herbal laxatives were well used medications. Diverticular disease (DD) became recognised more before WW11. The distinguishing symptoms were pain, fever and diarrhoea. A low residue diet was recommended to reduce diarrhoea and give the bowel rest. Serious pain sometimes resulted in surgery. Infection and inflammation (diverticulitis) were not always present but pieces of food and faeces were trapped in diverticula. Avoidance of coarse fruit and vegetables, seeds and pips was recommended.

Hospital diet sheet for diverticulitis 1961………”forbidden foods – all fried foods, pips and skins of fruits, pastry, suet puddings, coarse stalky vegetables, salads, onions and celery, chunky marmalade, jam with pips or skins, wholemeal or brown bread, coarse biscuits-Ryvita, digestive, Allbran, oatmeal, Weetabix, Shredded Wheat, fruitcake or scones, nuts, dried fruit.”

A significant change in diet started about 1970 when treatment for diverticular disease (DD) was suddenly reversed.

Hospital diet sheet for diverticulis 1982………..”you can eat a normal varied diet but include…… (all of the forbidden foods from 1961 except fried food)….SUPPLEMENT meals with 2 teaspoonfuls of unprocessed bran twice daily. EAT LESS white flour in any form and white and other sugars. DIETARY FIBRE ….by helping to restore normal function of the digestive tract, fibre can be useful in the treatment of constipation and diarrhoea”

  • Who persuaded health professionals that wheat bran was good for diarrhoea?
  • What was the evidence for this complete reversal of treatment?
  • Did anyone ask patients if this helped them?
  • Who was behind this change?

(more…)

Diverticulitis: a wind of change

Sunday, December 2nd, 2012

There have been many changes over the years in the approach to diverticular disease (DD), even in the names used. Diverticular disease is the overall name. The presence of the grape-like diverticula on the outside of the colon results in a diagnosis of diverticulosis. Diverticulitis occurs when there is infection and inflammation of the diverticula but is often used when there are any symptoms caused by the disease.

Diverticulosis can have episodes of diverticulitis or complicated diverticulitis when problems such as bleeding, abscess, fistula or blockage need surgical treatment. This is a simplistic explanation of what might happen in DD in decreasing numbers, so that only a small fraction of people with DD ever need surgery. Any progression in the disease can stop and revert to symptomless diverticulosis at any time, some people with diverticulosis do not even know that they have it.

There has been confusion over many years about the symptoms with DD. (more…)

Diverticular Disease in Healthcare Systems, part 2, community

Monday, December 6th, 2010

 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. (more…)

Diverticular Disease in Healthcare Systems, part 1 hospitals

Monday, December 6th, 2010

Diverticular disease (DD) is not the sort of complaint where a distinct diagnosis is obvious without investigation. Nor is there a well established treatment regime which prevents or slows down a foreseeable progression. DD is not predictable in its effects, it may or may not progress and there is no treatment which is universally successful. The place of DD in the healthcare system is not clear-cut. (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…)

All in a name – medical terms

Thursday, September 9th, 2010

 

Diverticular disease is an umbrella term which covers the physical changes in the colon wall and the effects from diagnosis to life-threatening complications and all the different symptoms which result from the disease. The muscular deformity with the characteristic bulging hernia or pouches called diverticula is known as diverticulosis. This definition is of a visible physical abnormality and does not indicate the extent of damage to the colon or describe its effects. Some people do not know that they have diverticulosis but after diagnosis about ¾ of patients have some type of symptoms. (more…)

Getting Personal With Diet

Friday, August 20th, 2010

When somebody is diagnosed with a disease, after months of symptoms and tests, they quite reasonably expect that a treatment is available for their condition. For example, inhalers for asthma, nitrates for angina, drugs to control Parkinson’s disease symptoms or vitamin C for scurvy. 30 years ago diverticular disease (DD), like scurvy, was considered a deficiency disease which could be prevented and treated by increasing the amount of fibre in the diet with wheat bran. Diet sheets and recipes were handed out and, with a few existing bowel drugs for symptoms, the disease was sorted out. Nothing could be done about the diverticula once they had been formed, so a high fibre diet was and often still is the treatment on offer.

     This is 2005, has anything changed since the 1970s? (more…)

What is Diverticular Disease

Thursday, August 5th, 2010

What is diverticular disease

 The large bowel becomes deformed in diverticular disease. The muscles appear to be permanently contracted so that the colon can be shortened and more corrugated. The bowel wall becomes ruptured particularly next to it’s blood vessels and pressure forces the inner layers to protrude through the wall to produce the characteristic grape-like pouches on the outside of the colon. There can be few of these pouches – called diverticula – or the whole colon can be affected. Similarly there can be a wide range of symptoms, but nobody knows how to stop the possible progression of the disease from symptomless, to a chronic, debilitating and recurring syndrome and on to life-threatening complications. Death rates in this country started at nil and have risen throughout the 20th century. With any other complaint, this statistic alone would prompt an outcry for research into causes, prevention and treatment. (more…)