Hutchinson Clinic Articles
Articles written by Geoffrey Hutchinson, Consultant Surgeon and Gastroenterologist, for incontact magazine
- How Diet Can Affect Those With Diverticular Disease?
- The Increase In Western Society Of Diverticular Disease In A Younger Population
- The Overlap Between IBS And Diverticular Disease
- The Effect Of A Diet Change Over The Festive Period
- Diverticular Disease Digest
How Diet Can Affect Those With Diverticular Disease?
About 3% of all NHS prescriptions are for laxatives and purgatives (medicines that clear the bowels) and many millions are spent on ‘over the counter’ purchases to treat constipation. Constipation is uncommon in populations with a high intake of bran, non-starch polysaccharide (dietary fibre). In rural Uganda in Africa, stool weights are around 500gm daily and bowel transit times around 40 hours. In the UK, stool weights in non vegetarians are around 100gm and transit times are longer. Stool consistency is related to water content which is normally around 75%. The most important effect of bran is probably its water-holding capacity.
A possible causative link with low dietary fibre diets and diverticular disease was implicated from striking geographical variations in prevalence: low in Africa, high and increasing in Western Europe.
Dietary fibre refers to the complex polysaccharides and other ploymers that escape digestion in the stomach and the small bowel and reach the colon. Fibre obviously increases stool weight and shortens bowel transit time and may increase inner pressures in the intestine. A high fibre diet always emphasises whole grain breads and cereals, fresh fruit and vegetables – we all know this also means more fermentation, more bloatedness and the passage of increased flatus (wind) – so there has to be a balance in the diet. Of course, for many with established diverticular disease it may be too late to adopt this type of high fibre diet. It may have prevented the development of the pockets in the colon if we had adhered to this diet from youth, like our African counterparts, but once we have diverticular disease, too much roughage may make the colicky pains worse and many patients do better on a low fibre diet if they suffer an attack or flare up.
One thing is for certain. The more information we have about how the colon works and the diet we enjoy, the better equipped we will be to understand how diverticular disease affects us long term. We hope to keep Incontact readers well informed with future articles and updates on this important topic.’
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The Increase In Western Society Of Diverticular Disease In A Younger Population
‘In past articles we have identified that diverticular disease (D.D.) is regarded as an acquired disorder of the colon induced by a relative lack of dietary fibre. Most think that hypersegmentation, produced by delayed colon transit and disordered peristalsis (the “sausaging” process that moves stools and residue in the bowel), and high intra luminal pressures in the “inner tube” which is the large bowel, result in mucosal “blow outs” or pulsion diverticula.
Diverticular disease is increasing in incidence generally, in western society, and appears to be affecting a younger population. This is amply illustrated by the case of a family friend whom I visited on holiday in Barbados last week. He is 33 years old and developed what the surgeons at the Queen Elizabeth Hospital in Barbados thought was acute appendicitis. They operated via a small skin crease incision in the right lower abdomen only to find a normal appendix but pus in the pelvis from an inflamed diverticulum of the sigmoid colon, which in this case was situated centrally in the abdomen rather than on the left side. The incision was extended and the whole area washed out with diluted hydrogen peroxide. The wound was closed and he was allowed home a few days later on antibiotics. Unfortunately he did not settle and was re-admitted after a week with a high temperature, signs of peritonitis and septicemia. The abdomen was re-explored and the diverticulum had perforated and our young friend required resection of the affected bowel and the contained abscess and a temporary transverse colostomy to rest the affected area. He quickly settled and in about 6 months time he will have the colostomy closed and continuity restored.
Interestingly diverticulitis is often described in terms of “left sided appendicitis” and the two problems can be confused in the acute stages. Of course, the appendix itself is really a rather long and thin diverticulum and about one person in 6 or 7 develops appendicitis at some time.
Even on holiday in sunny, tropical Barbados, I can’t escape the problems of D.D.’
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The Overlap Between IBS And Diverticular Disease
‘Diverticular Disease (DD), where out-pouchings, or benign cul-de-sacs develop from the lining of the colon (diverticulosis) is extremely common in Western society. Probably more than half those aged 60 and over have these colon pockets which herniate through the muscle coat of the large bowel. However, although it is irreversible, the diverticula (plural of diverticulum) only very rarely cause symptoms.
Only 1 in 5 affected will ever suffer symptoms and signs of illness (diverticulitis) and only a tiny minority endures serious of life-threatening complications. Less than 1 in 10,000 have DD contributing to fatality.
There is, however, an overlap with irritable bowel syndrome (IBS) symptoms and many people have both DD and IBS. IBS is a functional bowel disorder and four symptom patterns are common:
- Visible abdominal distension
- Pain relieved by bowels opening
- Looser stools with pain bouts
- More frequent bowel movements with pain onset
Over 90% of IBS patients have two or more of 1-4, whereas the majority with true DD or have only one or two of 1-4. IBS accounts for more than one million GP consultations per year in the UK and more than 25% of the population have IBS symptoms. IBS ranks close to the common cold as a leading cause for absences from work. IBS is also known as mucous colitis, spastic colon or irritable colon.
There is no doubt that many DD patients also have IBS and the most troublesome symptoms may arise from the IBS.’
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The Effect Of A Diet Change Over The Festive Period
“Spring is nearly in the air and the Christmas celebration seems a distant memory. Every gastroenterologist sees an influx of patients in the clinic in the first few weeks of the New Year. We are all tempted to change our diets during the festive season with nuts, fruits and exotic chocolates and mincemeat. Never mind the calories and inevitable weight gain, the change in roughage content and colonic fermentation often leads to bloatedness and a change in bowel habit, even without any diverticular disease. In the presence of colonic out-pouchings and cul-de-sacs the gas production can lead to acute pain and colic or even an attack of diverticulitis with inflammation and bacterial infection. Diverticular disease patients often do best if they adhere to a regular diet, which suits their own system. TREATS ARE NICE BUT YOU MAY PAY THE PRICE.
In January and February, TV and glossy magazines bring the usual rush of holiday adverts demanding a bikini figure. There is always a corresponding crop of diets to reduce weight and fulfill the dreams of all those long forgotten New Year resolutions. Calorie controlled diets often include bulk forming cellulose which we find difficult to digest (unlike cows!) and this may also cause sever gas production. Many of you will have tried every sort of diet known to mankind but still find it hard to lose weight, with or without the help of “Slimming World” or “Weight Watchers”. Some may find so called very low calorie diets much more effective, but close medical supervision is required. I often recommend LIPOTRIM as a total food replacement diet where weight loss can be achieved safely and rapidly (www.lipotrim.demon.co.uk) even in patients with diverticular disease.
We always try to raise the “glamour rating” for diverticular disease by spotting celebrities in the news having treatment. Many thanks to all of you who wrote to let me know that John Cleese of Monty Python and Fawlty Towers fame underwent tests and surgery for diverticulitis in Santa Barbara, California last autumn. Cleese retained his sense of humour and told friends that he was auctioning the removed part of his colon on his website! What about “I’m a celebrity colon ….. get me out of here!””
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Diverticular Disease Digest
In the Spring I was preparing for a trip to Uganda and was suffering the consequences of multiple vaccinations for exotic tropical diseases. Our medical team from the charity Just Care spent some time at the Wellspring Children’s Medical Centre in rural Kamutuuza (Fig 1) as well as visiting the wards and theatre at Masaka Hospital in West Buganda and Kitovu Charity Hospital.
As you know from past articles we always preach that diverticular disease is extremely rare in rural Africa because of the high fibre content in the diet. You will not be surprised to hear that my first question to every surgeon I met was, “Do you see any diverticular disease locally?”. Their answer was always, “None.” However, immediately all went on to say that there was a very high incidence of sigmoid volvulus, which is uncommon in the West. Diverticular disease very often affects the S-shaped loop of bowel in the left lower part of the colon, and it is the same sigmoid colon that is affected by volvulus. In Uganda, volvulus seems to occur more commonly in males and involves a rotation or twisting of the sigmoid loop, just like a kink in the garden hose-pipe (Fig 2). Volvulus constitutes a leading cause of intestinal obstruction in East Africa. Patients present with marked abdominal distension and constipation, and if left long enough begin to develop vomiting and dehydration. At operation a knot of bowel has to be untwisted before the loop of colon can be excised, to prevent recurrent knot formation and kinking. Sigmoid volvulus does occur in the UK but usually in the 70+ age group and frequently in patients who are bed-bound in long-term care facilities, where they become chronically constipated. In Uganda, the surgeons tell me it is the result of eating too much mutoki, a very high residue mash of green bananas, which, over the years, results in lengthening of the loops of colon (megacolon) making them more prone to volvulus.
The message, as always, is a balance in the diet – possibly too little roughage in developed countries, possibly too high a fibre intake in Africa. Stool bulk is governed by many factors – cellulose, hemicelluloses, lignins, pectins, gums, mucilages, non-starch polysaccharides, luminal bacteria, colon length, peristaltic activity, water intake, etc, etc. Fibre is always thought to increase stool bulk and reduce bowel transit time by stimulating peristalsis (bowel contractions and sausaging). Too much fibre appears to cause megacolon and volvulus. Therefore, it would seem an absolute nonsense to add fibre bulk to hard stools in chronically constipated colons. Yet this is often the advice given out! Surely chronic constipation sufferers may benefit from less rather than more fibre. Similarly with IBS, insoluble fibre may increase pain, gas formation and bloatedness. I urge all InContact readers to adopt an open mind on fibre and to experiment with the roughage content of their own diets to see what suits them as individuals.
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