A 61-year-old woman, who lives alone, has suffered recurrent bouts of diarrhoea, wind and bloating for many years. One attack 18 months ago was accompanied by severe lower abdominal pain and cystitis. A barium examination undertaken five years ago indicated diverticular disease. A high-fibre diet containing large quantities of fruit, salads and bran-rich cereals makes her symptoms worse. What sort of diet does she need? Diverticular disease affects one person in four over the age of 40, but as it is difficult to treat successfully doctors are reluctant to talk about it. However, as complications of diverticular disease may be serious and as its presence may obscure other diagnoses, it is important that people with this trouble should be well briefed. They should also feel free to talk to their doctors about their troubles, especially when there’s any change in the symptoms, without sensing that they are going to be regarded as one of the surgery’s “heart sink” patients.
Diverticular disease is divided into diverticulosis and diverticulitis. A diverticulum is a pouch or sac that forms in a weakened area of the bowel wall. When diverticula are present in the colon but are not inflamed, the condition is known as diverticulosis. Diverticula appear in the gut wall because of abnormalities in the action of the muscles of the gut that result in spasm and increased pressure within the colon.
These changes in the gut wall can be demonstrated and so the discomfort of diverticulosis is not all in the mind. The patient suffers pain, wind and bloating, just as our reader does.
Sooner or later the entrance to one or more of the diverticula (the pouches) may become blocked and as a result, the diverticula and the surrounding tissue become inflamed, and the diverticulosis then becomes diverticulitis. The pain of diverticulitis, such as our reader suffered 18 months ago, is usually but not always felt on the left side of the lower abdomen, and is similar to that of early appendicitis but on the other side of the body. If an abscess forms around the inflamed diverticulum the pain becomes more severe, is associated with severe tenderness and other symptoms similar to those of appendicitis including a rising temperature.
If a diverticular abscess perforates there may be generalised peritonitis. If the inflamed, infected gut lies against the bladder there will be symptoms of cystitis and if the abscess perforates the bladder wall the patient will pass wind, and less frequently faeces, through the urethra.
If the channel between the gut and the bladder becomes permanent it is known as a fistula; fistulas may also run between the large and small intestine. Inflamed diverticula may also bleed, or the inflammatory mass may cause obstruction. Fortunately, although diverticular disease is common, serious complications are rare.
Treatment is with a high-fibre diet but, as our reader has discovered, this also may cause wind. The usual advice is to choose wholemeal bread and flour rather than pure bran (although bran and bulk-expanding laxatives such as Fybogel are recommended if a patient is constipated).
Vegetables and fruits vary in terms of the amount of wind they cause: onions, beans, tomatoes, artichokes and even salads are notoriously windy. Patients may do better to stick to simple old-fashioned school foods such as peas, cabbages, apples, pears and plums. Those who suffer from wind should also avoid excessively rich or fatty food. A barium meal, such as our reader has had done, should be carried out only after any inflammation has subsided. Colonoscopy is less traumatic and less likely to damage the gut wall. Antibiotics are useful in an acute attack and surgery can be employed if need be to remove the affected area if the diverticulitis is segmental, or if there is obstruction.
The obstetric adventures of a 56-year-old mother of three children have left her with a weakened pelvic floor, and a prolapsed, protruding vaginal wall overlying a prolapsed bladder and rectum. Despite her troubles — our reader can have her bowels open only by holding her pelvic floor in position — her gynaecologist doesn’t think that these yet warrant surgical intervention. The reader went through the menopause three years ago.
A prolapse tends to become worse after the menopause so a case can be made for postponing surgery if this is due, and the patient’s symptoms are not severe. As it is impossible to judge an individual case without seeing the patient’s condition and assessing her, it would be a mistake to pontificate. However, from this reader’s description, it sounds as if she must already be having constant, dragging discomfort and intermittent problems with defecation and urination.
Sooner or later she will inevitably suffer urinary tract infections and incontinence. A sex life would, as she has surmised, be difficult and embarrassing. Although she is apparently a candidate for surgery because of her symptoms, this is not always totally effective. However, it is always worth doing and the overwhelming majority of people have their problems corrected. Postponing surgery increases the likelihood of long-term complications as the tissues are further stretched, and like an elastic band can be stretched beyond the point of return. As there are already difficulties with defecation, repair of the posterior vaginal wall to correct the rectocele is also called for, but this is more complex than an anterior repair that she also needs. The reader should discuss with her GP the possibility of going to a specialist team that deals with problems of this sort. These do exist even if not in every town, and include a colorectal, urological and gynaecological expert.
- Many thanks to the readers who have given information about intermittent electrical currents for the treatment of sweaty hands after last week’s reply. The treatment is known as iontophoresis and wouldn’t be helpful for those such as the Prime Minister who also suffer from sweaty armpits, elbows and elsewhere. The replies we received were all similar but one letter which covered all the points came from Dr Alison Bedlow. She writes: “The patient immerses their hands or feet into an iontophoresis machine, which is essentially a small bath filled with either water or sodium glycopyrrolate, and the low current is turned on for about 10 to 15 minutes. Patients start with two or three treatments a week and later maintain the effect with a visit once weekly.”
If the treatment is effective, patients can then purchase a machine for home use for around £250. Dr Bedlow has found it extremely successful and the treatment of choice for sweaty hands and feet, but Botox is now the favoured treatment for sweaty armpits. Our thanks to Dr Bedlow.
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Newspaper Q&A: Send your questions to drstuttaford@thetimes.co.uk or to times2, The Times, 1 Pennington Street, London E98 1TT. Please include the following: the symptoms (and how long they have been present), the person’s age, sex and marital status. Dr Stuttaford’s replies cannot apply to individual cases but should be taken in a general context.
