Posts Tagged ‘Treatment’

Diverticular Disease: Men and Women

Wednesday, February 9th, 2022

 

Diverticular disease (DD) is an acquired disease that was first demonstrated early in the 20th century. Its appearance and increasing importance occurred in cigarette-smoking western countries, particularly the USA and UK, where the habit and nicotine addiction was widespread in the population. These countries are the main source of reports and statistics. DD can no longer be considered the inevitable diet related disease of the elderly. DD can be a long term (26872402), progressive (13444546) and chronic disorder (22777341) as well as the acute infection of diverticulitis and its complications. Differences between males and females have always been apparent in hospital and mortality statistics where females predominate.

Diverticula – the small grape-like hernia – need to be seen on the colon before the disease can be diagnosed. Once they are present they are there for life. The data used to describe DD is in effect a measure of investigations, where and when they took place in the disease progression. For example, the same person could figure in post-mortem, mortality and hospital admission data but the diverticula could have been there for 40 -50 years. Similarly, ‘risk factors’ are for symptoms resulting in investigations revealing DD but are not the cause of DD. The current interpretation of data show DD in more men than women up to the age of 50 – 60 years, then proportions are reversed with more women in surveys measuring investigation of DD. No explanation has been offered for this effect (33727769) except hormone differences which of course cannot be disputed.

Eastwood (873339) considered factors which might influence a decision to investigate symptoms for a diagnosis of DD. Does a complicated selection process operate for a family doctor’s referral to a hospital consultant for an investigation? The presentation of symptoms or the seeking of medical advice, or social or geographical factors may affect data. Other influences mentioned in reports are costs and hospital capacity.

Because of low risk of colon cancer, internal examination, now usually by colonoscopy, are not considered necessary below the age of 50 years unless there are potentially dangerous symptoms. However, both diverticulosis, where diverticula are found without symptoms, and their infection ie diverticulitis, are found before the age of 50 years (15882243, 20604970). CT scanning for suspected appendicitis revealed 14% of the under 20 yrs. And 40% of those between 20 and 39 yrs. had evidence of diverticulosis. (33727769). Anybody with diverticulosis could get diverticulitis infection and nobody knows why. Symptoms of pain and dysfunction in males is more conspicuous than in females where it is part of their biology Males get investigation and diagnosis and earlier surgical treatment for DD than females (9860333).

Women with abdominal pain and bowel dysfunction are diagnosed quickly with Irritable Bowel Syndrome (IBS) (9262978). IBS is based on symptoms, but women have many symptoms peculiar to them that are not included in the research criteria for IBS (9096434). There are many potential causes of abdominal pain unique to females (31943595) that without relief can prompt repeated consultations more than males – a characteristic of IBS. Females can be told they have IBS as young adults, until after the menopause and even in old age. IBS will include people with diverticulosis and diverticulitis (19861955) but if found this does not change the diagnosis of IBS, some researchers think that only infected diverticula can cause pain (16678561). Data on the number of people with DD up to the age of 50 to 60 yrs. will show more males than females because more males are investigated and diagnosed.

Around the age of 50 yrs. screening for colon cancer by colonoscopy occurs. Finding diverticulosis is common and does not show different rates for males and females although females are slightly older. In older patient groups without significant symptoms, there is again no difference between the sexes (22573184). Symptoms such as constipation related to colon ageing at 60 to 70 yrs. old also appear to be the same. Differences between males and females appear if and when symptoms of DD become problematic and potentially serious. Females outnumber males when investigations are needed for episodes of diverticulitis or chronic complications of DD. This can be the first diagnosis of DD and younger age and female gender are independent risk factors (30647541). Frequently the female patients were found to have previously been diagnosed with IBS. Females and a preoperative diagnosis of IBS were also independent risk factors for persistent symptoms after sigmoidectomy (32077416).

For decades since the 1960s DD was considered a diet related disease of the elderly. Eating a low level of dietary fibre for at least 40 years produced diverticula. Adding wheat bran to meals was recommended to prevent the constipation then later any type of dietary fibre. This was supposed to prevent diverticula and diverticulitis development – now disproved. DD research concentrated in detail on diet and on hospital treatment for severe diverticulitis and life – threatening complications needing surgery. If and when dietary fibre was not helpful there were no other effective treatments for persistent, recurring or non-relenting, low grade inflammation symptoms that are now recognized (33727769, 22777341). Such symptoms have been described as ‘smoldering DD’ or ‘SUDD – symptomatic uncomplicated DD’ or the misnomer ‘post-diverticulitis IBS’ More females than males were diagnosed with SUDD in a survey (30023071) and this was a long-term condition (17431721). This is a painful part of some unfortunate patients’ experience of DD affecting quality of life and which does not reach the level of hospital treatment.

There is little information about DD in primary care (22572678). Extensive research at hospital level does not address the problems before patients see the specialists (17681003, 10601059). The number of diverticula can increase with age as can the extent if colon affected. There is no data on this aspect of DD to see if there is a difference between males and females. There are suggestions that more women than men are troubled by long term symptoms. In New Zealand NHS primary care, women had notably more antibiotics prescribed for them than men, particularly those under the age of 60 years, for 5 yrs. before they needed hospital attention for acute or non-acute problems. More antibiotic prescribing for women also continued for the next 5 yrs. of the survey (31314796). Chronic aspects of DD in women also appear in data from hospitals. Females were on average 5 years older than males when seen and had more chronic diverticulitis and strictures, but less bleeding than males (12907908).

This pattern continues in mortality studies. 300 unselected pathology colons found a higher incidence of DD in women and also the onset occurred at an earlier age. Before the age of 50, 21.7% of women and 4.2% of men had DD and diverticula were scattered along the colon in women (5679019). Men were more likely than women to have had surgery and have a surgical complication of diverticulitis as a secondary cause of death and are more likely to die in hospital. Women are more likely than men to die from chronic complications such as sepsis, obstruction or pelvic fistula and are more likely to die at home, in care or in a hospice (33216498, 33216487). Research is not providing reasons for these differences (30046356).

The situation with DD may be like emergency presentation at hospital for colon cancer (30734381). In 2 to 12 months before emergency, twice as many women than men had received a diagnosis of IBS or DD. This increased the risk for women aged 40 – 59 yrs. 20% of women had alarm symptoms before the emergency. These authors cite reports of longer diagnosis intervals, a higher risk of 3 or more consultations before specialist referral of women, different interpretation of symptoms in women compared with men and possible misattribution of symptoms in women to benign causes. New onset of ‘IBS’ in middle aged women was also of concern. Sex differences in health and medicine are increasingly recognized and women are disadvantaged (22699937). This includes DD were women appear to suffer a longer and chronic symptomatic disease which is less acknowledged or treated if and unless it becomes serious.

© Mary Griffiths 2022

REFERENCES

The numbers in the text are PMID references. PubMed is a free resource supporting search and retrieval of biomedical and life science literature with aim of improving health – both globally and personally. It is available at     https://www.pubmed.ncbi.nlm.nih.gov

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

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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?

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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…)