Diverticular Disease of the Colon

A Deficiency Disease of Western Civilization

Neil S. Painter

• Publisher: Butterworth-Heinemann
• Year: 2013
• ISBN:
  9781483162751
• Topic: Medicine
• Subtopic: Clinical Medicine

Diverticular Disease of the Colon: A Deficiency Disease of Western Civilization presents a study of colonic physiology and the symptoms of colonic diverticulosis and diverticulitis. The book also discusses the etiology and pathogenesis of the disease and its treatment by dietary means. The monograph is divided into 22 chapters, discussing a wide range of topics that provide greater insight into the diverticular disease of the colon. The book initially provides the definitions and etymology of words used, the history of the disease, and its detection and recognition. Several chapters are also devoted to the examination of the colon; the effect of certain drugs and stimuli to the colon; clinical manifestation and classification of the disease; treatment and prognosis; and the epidemiology and etiology of diverticulosis and its relationship to dietary fiber. This book will be of benefit to physicians, surgeons, epidemiologists, and medical students.

Chapter 1

Definitions

Publisher Summary

This chapter explains that a colonic diverticulum is a herniation of the colonic mucosa through the muscular wall of the colon, and hence, diverticular disease is an acquired condition. Diverticulosis implies that diverticula are present but they are not inflamed. Patients with diverticula may complain of symptoms even in the absence of true inflammatory diverticulitis and the symptoms may be cured by changing the diet or by Reilly’s operation.. Diverticulitis means that diverticula are both present and inflamed. It usually means that pericolitis is also present as the inflammatory process is not confined to one or more of the mucosal pouches once the patients complain of symptoms of sufficient severity to merit this diagnosis. The term “low residue diet” means a diet that is absorbed by the bowel and consequently leading to a small quantity of feces being passed. The term “high residue diet” implies that the diet contains all those constituents that are not absorbed by the gut so that the stools are large and usually soft.

A Colonic Diverticulum is, for all practical purposes, a herniation of the colonic mucosa through the muscular wall of the colon and hence diverticular disease is an acquired condition, (Fischer, 1900–1901). True diverticula of the colon containing all coats of the colonic wall have been described, but they may well have been exaggerated haustra (Edel, 1894). Fifield (1927) found no true diverticula in 10,167 consecutive autopsies at the London Hospital (Fig. 1).

FIG. 1 Longitudinal section of colon bearing diverticula. The colonic wall on the left side of the illustration isapparently normal but it abruptly changed to bowel that is obviously abnormal on the right. The muscle coat on the right is thrown into folds of reduplicated muscle between which the mucosa has herniated to form two diverticula, only one of which has been sectioned so as to show its neck.
The change of structure from the normal to the diseased bowel is sudden and it is not difficult to see why the apparently normal bowel in diverticulosis produces a different pattern of pressures from that part of the bowel that isnarrowed and is beset with diverticula. (from Painter, 1964)

The term “diverticulum” is derived from the Latin “diverto” which means “I turn aside”. The -culum is a diminutive which corresponds to the English—icle, as in follicle or cubicle. So the English equivalent to “divericulum” is “divertick” meaning a “small turning aside” that is a pouch of limited size (Edwards, 1939). The former name is hallowed by official usage although the English “diverticle” is used colloquially.

Diverticulosis implies that diverticula are present but that they are not inflamed. It was once thought thatthey did not cause any symptoms unless they were inflamed. This is still probably true but diverticulosis may be associated with symptoms as these are caused by some abnormal action of the colonic muscle of which diverticula are only the outward visible sign. Patients with diverticula may complain of symptoms even in the absence of true inflammatory diverticulitis and, furthermore, these symptoms may be cured by changing the diet or by Reilly’s operation, and neither of these procedures remove the diverticula. Consequently, it is safer to say that symptoms are associated with diverticulosis as it may well be that they owe their origin to that part of the intestine that is proximal to the colon (Painter 1968 and 1972; Painter, Almeida and Colebourne, 1972).

The term ‘diverticulosis’ came into being when contrast radiology revealed that diverticula were commonand, as the name diverticulitis was already in common use, the word “diverticulosis” was coined independently by the German-speaking de Quervain, the American J. T. Case and by Sir Ernest Spriggs in England.

Diverticulitis obviously means that diverticula are both present and inflamed. In practice, it usually meansthat pericolitis is also present as the inflammatory process is not confined to one or more of the mucosal pouchesonce patients complain of symptoms of sufficient severity to merit this diagnosis. It was once assumed that colonic pain and other abdominal symptoms in patients with diverticulosis were caused by inflammation of the diverticula but it is now realized that excessive segmentation of the colon may cause recurrent pain or colic that is so severe that it may merit sigmoid colectomy. However, when resected sigmoid colons are examined, histological evidence of true inflammatory diverticulitis is often lacking (Morson, 1963). This condition is called Painful Diverticular Disease. It causes pain that is usually colicky in character as it is due to intermittent functional obstruction of the colon brought about by excessive segmentation, but it may be so severe that it may be mistaken for left renal colic and morphine or pethidine given for its relief (Painter, 1964 and 1968).

The term Low Residue Diet has been used since the nineteen-twenties and, although it may mean different things to those in differing disciplines, to doctors it means that such a diet is, in the main, absorbed by the bowel and consequently it leads to a small quantity of faeces being passed. Most doctors also understand it to mean that pips, seeds, skins and stalks and so-called “roughage” have been removed from any fruit and vegetables that form part of this diet.

The term High Residue Diet implies that the diet contains all those constituents which are not absorbed by the gut so that the stools are large and usually soft, whereas it has a different meaning to some dieticians. In this book, a High Residue Diet is synonymous with a High Fibre Diet. This latter term obviously means that the diet contains plenty of fibre. Dietary fibre is difficult to define but it will be seen, when the connection between diet and disease is under consideration, that cereal fibre probably has a special part to play in the physiology of the gastro-intestinal tract.

Chapter 2

The History of Diverticular Disease of the Colon

Publisher Summary

This chapter presents the history of diverticular disease of the colon. The diagnosis of diverticulosis depends on the demonstration of diverticula. Until radiological methods of examining the colon became available, the prevalence of diverticula was not realized and only the complications of diverticulitis had attracted attention. The changing pattern of the disease and the progress of medicine have divided the story of diverticular disease into six parts. The chapter discusses the colonic diverticula as a pathological curiosity and diverticulitis as a surgical problem Diverticulitis is not a new disease. It is the result of the changes that occurred in one’s diet and that altered the environment of the colon. The geographical distribution of the disease reveals that it is rare or unknown to this very day in the rural African and Asian countries and in all countries where traditional eating habits have not changed. The disease is unknown where the diet contains plenty of cereal fiber; however, it has become the commonest disorder of the colon in those countries whose food is processed and refined. The etiology of diverticular disease is linked to fiber-deficiency. Consequently, like scurvy, the disease should be preventable..

The diagnosis of diverticulosis depends on the demonstration of diverticula. Until radiological methods of examining the colon became available, the prevalence of diverticula was not realized and only the complications of diverticulitis had attracted attention. The profession became aware of the common occurrence of diverticula only when the radiological demonstration of diverticula had become a routine matter, and only then could the disease be classifiedand the symptoms and the complications of the condition be differentiated from those caused by other disorders. Thechanging pattern of the disease and the progress of medicine have divided the story of diverticular disease into six parts.

PART I COLONIC DIVERTICULA AS A PATHOLOGICAL CURIOSITY

Voigtel (1804) first described these acquired hernia of the large bowel. Fleishman (1815) used the term “divertikel” to refer to duodenal diverticula found at autopsy and also described single and multiple diverticula of the colon which he found mostly at the mesocolic border. He suggested that they were caused by distension of the gut by food, drink and air. Some have credited Matthew Baillie (1797) with the first description of diverticula but it appears that he described recto-vesical and rectovaginal fistula due to abscesses of the bowel.

Samuel Gross (1845) of Philadelphia described colonic diverticula and illustrated those of the small intestine. “Sac like tumours … are sometimes found in the bowel, caused by protrusion of the mucous and cellular tunics across the muscular fibres, in the same manner as pouches are occasionally formed in the urinary bladder … Their number ranges from one to several dozens … Professor J. B. S. Jackson of Boston … has met with them most frequently in the large bowel, in aged and corpulent persons. Their development seems to depend on some mechanical obstacle to the passage of faecal matter by which the muscular fibres are separated from each other so as to permit the mucous … membranes to protrude through the resulting intervals.”

Thus the earliest writers put forward the two theories of the pathogenesis of diverticula. The former believed thatpassive distension was to blame for their appearance, but the latter was proved right more than a century later when functional obstruction of the colon was shown to cause diverticulosis (Painter, 1962 and 1964).

Rokitansky (1849) described colonic diverticula and their contained faecoliths. Cruveilhier (1849) blamed the hardening of the faeces and straining at stool for their appearance and realized that faecal matter in the mucous pouches might lead to inflammation and to perforation. This complication probably occurred without being recognized at this time as Virchow (1853) described “chronic adhesive peritonitis” usually with fibrosis that usually affected the sigmoid colon and might be accompanied by abscess formation that was not tubercular in origin.

Bristowe (1854) exhibited a typical case of sigmoid diverticulitis to the Pathological Society of London and described the tendency of the mucosal herniations to enter the appendices epiploica. On microscopic examination, he failed to find muscle fibres covering the pouches and concluded that they were herniations of the mucous membrane. He looked for, but failed to find, any mechanical obstruction of the bowel distal to the diverticula and concluded “thatthe cause producing the abnormal condition must have resembled that operating in the case of the sacculated bladder; very likely habitual costiveness may have brought about some of the ill effects which might be expected to follow on actual obstruction”.

Haberschon (1857), physician to Guys’ Hospital, described diverticula very accurately in a chapter on constipation contained in what is probably the first textb...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Preface
• Acknowledgements
• Foreword
• Chapter 1: Definitions
• Chapter 2: The History of Diverticular Disease of the Colon
• Chapter 3: Pathological Anatomy
• Chapter 4: The Radiology of Diverticular Disease
• Chapter 5: The Incidence of Diverticular Disease in the Sexes and in the Young
• Chapter 6: Factors that have been Considered Responsible for Diverticulosis
• Chapter 7: The Pressures in the Human Colon in Health and in Diverticulosis
• Chapter 8: The Effect of Certain Drugs and other Stimuli on the Pressures in the Human Colon
• Chapter 9: The Segmentation Mechanism of Pressure Production
• Chapter 10: The Effect of Drugs in Diverticular Disease of the Colon and the Role of Segmentation in the Pathogenesis of Diverticula
• Chapter 11: The Epidemiology and Aetiology of Diverticulosis and its Relationship to Dietary Fibre
• Chapter 12: The Clinical Manifestations of Diverticular Disease of the Colon: their Classification, Traditional Treatment, and Prognosis
• Chapter 13: Uncomplicated Diverticular Disease
• Chapter 14: Complicated Diverticular Disease: Diverticulitis and Abscess Formation
• Chapter 15: Complicated Diverticular Disease: General Peritonitis
• Chapter 16: Complicated Diverticular Disease: Fistula Formation
• Chapter 17: Complicated Diverticular Disease: Obstruction
• Chapter 18: Complicated Diverticular Disease: Haemorrhage
• Chapter 19: Diverticular Disease of the Caecum, Ascending and Transverse Colon
• Chapter 20: Reilly’s Operation of Sigmoid Myotomy
• Chapter 21: The Treatment of Diverticular Disease of the Colon with a High-Fibre Diet
• Chapter 22: Dietary Fibre, Diverticulosis and its Associated Diseases
• References
• Index