Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
21 November 2007

THE MOST COMMON BOWEL DISEASE:  DIVERTICULOSIS

            By far the most common bowel symptom is constipation.  But constipation has many different causes and isn’t really a disease but rather a common symptom that comes from a number of different causes.  There are a large number of bowel aids to help a person treat constipation.  Included in this list would be MiraLAX, Lactulose, Milk of Magnesia, Senokot S, Dulcolax, or even local enemas.

            But when it comes to something structurally abnormal about the bowel, by far the most common abnormality is a condition called diverticulosis.  The large bowel is a six foot long tube whose job it is to absorb the last six quarts of water from the digestives juices.  The stool is then concentrated down to a relatively small amount.  As most everyone knows, there is some pressure inside of the colon.  That pressure can be most easily experienced by those who pass gas.  That pressure is also felt by those who are constipated with pressure on the inside of the colon pushing out.  With a long enough time, pressure pushing out on the wall of the bowel, a balloon-like pouch called a diverticulum can pouch out on the side of the bowel.  These diverticula tend to occur more frequently with age affecting perhaps 10% of those 40 years of age but more than 70% of those 80 years of age.  The number of diverticula can be relatively few or there can be as many as 50 pouches on the bowel wall.  The more diverticula there are pouching out from the bowel wall, the more likely the person is to have problems with this condition.  Fortunately, most of the time, these diverticula do not cause symptoms.  But when they do, the problem can be very disruptive as illustrated by the gentleman below. 

            The gentleman in question had not really known of any major bowel problems all his life.  He was in his 70’s and things had been going relatively well.  Over several months time, he noticed a discomfort in the left lower quadrant of the abdomen.  He came to the office concerned about what this might represent and workup was started.  The same kind of pain on the right side of the abdomen would almost certainly represent appendicitis but on the left side of the abdomen it most likely represented an inflammation of the diverticula that a person often has.  This inflammatory process is called diverticulitis. 

            Initial work-up showed that he had substantial tenderness in the left lower quadrant and a low grade fever.  Several blood tests were done and it was seen that there was a substantial infection occurring some place.  His urine was checked and it was found to be very infected with foreign matter in the urine consistent with there being stool in the urine itself.  It was then that he volunteered that he was passing gas through his urine, a very unusual symptom.  X-rays demonstrated that there was indeed gas in the bladder, again a very abnormal situation.  It was at this point, that the diagnosis of diverticulitis with a perforation of the diverticulum into the urinary bladder.  This gentleman had had one of his diverticula become abscessed and the abscess had eroded into the urinary bladder so that he had a hole between his colon and his bladder. 

            This is a nightmare to take care of.  Almost always, the eventual answer is surgery to seal the hole in the bladder and separate that from the colon.  In the process, a colostomy is often placed while healing occurs for 3 to 4 months.  Subsequently, the bowel can usually be re-established in the normal manner but his ordeal is very substantial.

            Many patients will have an episode of diverticulitis with pain in the left lower quadrant  effectively treated with oral antibiotics and the condition resolves.  The diverticula that are there don’t go away but at least the infection that occurs in them can be effectively treated almost always.  Antibiotics need to be used about ten days to heal the infection and it is important the person have a stool softener so that constipation is avoided. 

            Invariably after a person has gone through an episode of diverticulitis, they ask what is causing the problem and how did they get it.  Unfortunately, we don’t have any clear idea of what causes diverticulosis.  It seems to be much more common in those that are overweight and inactive.  A high refined carbohydrate diet as opposed to natural fruits and grains also seems to be predisposing to this condition as people in third world countries have a very low incidence of diverticulosis.  Smoking cigarettes also seems to be much more common among people with diverticulosis and is a suggested contributor. 

            Usually once a person has had their first episode of diverticulitis, they know the symptoms and will come for attention early to avoid progression of the problem.  Occasionally, the problem becomes recurrent and the inflammation of the colon too extensive.  In those situations, the surgical removal of the distal portion of the colon where the diverticula are may be necessary.  This will especially be true if the person is getting strictures in the colon and obstructions causing worsening constipation or if they rupture a diverticular free into the peritoneal cavity or if they develop an abscess.  Sometimes, the diverticula bleed silently and the person will present with an iron deficiency anemia.  In these people, replenishment of iron can restore the blood count but removal of a portion of the colon probably will be necessary there also.

            The healthcare professionals at your local clinic are well aware of the problems that diverticulosis and diverticulitis can present and know very well what that vague left lower quadrant discomfort with constipation probably represents.  Treating the condition early and avoiding constipation can often avoid a surgical outcome at a later time.  Unfortunately, with our obesity and inactive lifestyle epidemic occurring in our country at this time, this is going to be a much more common condition in the future.

This and other columns available at www.macpierre.com.