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.
Diagnosis
Entry into the system often begins with a visit to a GP with abdominal pain or discomfort, or changes in bowel habits. Such signs can be caused by gynaecological or urinary complaints as well as several bowel problems. There will be plenty of questions about symptoms and abdomen prodding before the GP decides that your colon needs a closer examination. Age is an important factor here. Both Inflammatory Bowel Disease (IBD = Crohn’s disease and ulcerative colitis) and Irritable Bowel Syndrome (IBS) are mainly first found in young adults and IBS can be diagnosed by symptoms without colon examinations. After the age of 50, onset of bowel symptoms could be caused by early stages of colon cancer so referral for investigations is likely. Some people of this age group privately (not NHS) have regular colon examinations to screen for polyps and cancer. DD can be discovered in such tests and sometimes people are told that they are lucky it was DD and not cancer. On the other hand, some people with prolonged and painful DD have remarked that if it was cancer then at least something would have been done about it. Another way of finding that you have DD is during an abdominal operation for another condition and diverticula are seen on the outside of the colon.
A dramatic, but fortunately far less frequent introduction to DD, happens when a person is taken to the emergency department of the hospital with severe pain, fever and feeling very poorly. This can occur out-of-the-blue with a bad attack of diverticulitis, maybe with bowel perforation. This can happen to older people who know they have DD, or to people in their 30s and 40s who did not think that there was anything wrong with them. The same urgency applies with extensive bleeding from the back passage. DD is a common cause of this.
Complications
A diagnosis of DD can only be made when diverticula are seen on the colon and this can only happen in hospital. The situations which can lead to diagnosis, as described above, can be very different, as can the state of heath of the person. Hospitals are involved in the diagnosis and also have to deal with the complication of DD. Blockage of the colon with scar tissue, fistula into other organs, abscesses, colon perforation and peritonitis are all emergency situations which are, thankfully, not common. With such variation presented to the hospital each patient needs individual treatment.
Surgical treatment
The American Society of Colon and Rectal Surgeons (ASCRS) has documented practice parameters for the treatment of sigmoid diverticulitis(1). These are not inclusive or exclusive of other methods of treatment and the guidelines are not rules but give surgeons freedom but direction. A European attempt to reach consensus on the diagnosis and treatment of DD (2) found that proper trials to support therapy decisions were largely missing. There are no published guidelines for the management of acute diverticulitis in the UK. A survey found major differences in practice in the UK compared with the American guidelines (3). In March 2006 the British Society of Gastroenterology produced a report “Care of patients with gastrointestinal disorders in the UK: A strategy for the future”(4). In a comparatively brief section, DD was described as rising in incidence and an underestimated cause of significant morbidity and mortality. Complications of the condition are a major cause of death. They considered that cases of difficult DD should be managed between primary care and a colorectal surgeon with experience in the condition and that early surgery may prevent complications. There is a lot of research assessing the efficiency of diagnostic procedures for DD. Surveys have investigated the appropriateness of differing surgical methods and the effectiveness, short and long term, of hospital treatments for the complications of DD. Apart from emergencies, there seems to be great variation in how problematic DD has to be before surgery is offered as a treatment.
The burden on hospitals
DD is a major burden on hospital resources. In the USA, DD was the 5th most costly gastrointestinal disease (5). In the UK, hospital admissions for DD have risen in the last decade of the 20th century by 16% for males and 12% for females (6). At a Devon hospital, DD increased significantly as a reason for emergency admission between 1974 and 1998 (7). In a large district hospital in the UK, DD accounted for 5.3% of the total annual budget for general surgery (8). These authors concluded that more research was needed on prevention of complications and management in the community. Thompson et al (9) in an article about IBS, recognised that patients in hospitals may be atypical but research and teaching about disease is based on these. As specialists, they could not claim an understanding (of IBS) unless they knew the characteristics of patients in general practice. This situation also applies to DD.
© M Griffiths 2006
REFERENCES
1 The American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of sigmoid diverticulitis. March 2000. http://www.fascrs.org
2 Kohler L et al. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999,13,430.
3 Munikrishnan V et al. Management of acute diverticulitis in the East Anglian region: results of a United Kingdom regional survey. Dis Colon Rectum 2006, Epub, Aug 8.
4 British Society of Gastroenterology. Care of patients with gastrointestinal disorders in the UK: a strategy for the future. 2006, March 14. www.bsg.org.uk
5 American Gastroenterological Association. The burden of gastrointestinal diseases. http://www.gastro.org/clinicalRes
6 Kang JY et al. Diverticular disease of the colon – on the rise: a study of hospital admissions in England between 1989/1990 and 1999/2000. Aliment Pharmacol Ther 2003, 17, 1189
7 Campbell WB et al. A 25-year study of emergency surgical admissions. Ann R Coll Surg Engl 2002, 84,273.
8 Papagrigoriadis S et al. Impact of diverticular disease on hospital costs and activity. Colorectal Dis 2004, 6, 81.
9 Thompson WG et al. Irritable bowel syndrome in general practice: prevalence, characteristics, and referral. Gut 2000, 46,78.
Note This article appeared in Incontact magazine, Winter issue, 2006/2007