Diverticular disease is a relatively new condition of the colon, characterised by the formation of “pockets” along segment(s) of, or the entire colon. When we become more successful in preventing and curing colorectal cancer in the next decade or so, diverticular disease will replace cancer as the greatest colorectal problem afflicting Singaporeans in the future.
The most important paper on diverticular disease in Singapore, and in Asia, was published in 1986 by Prof. Lee Yoke San from the Department of Pathology, National University of Singapore. He found that 19% of Singaporeans above the age of 14 had diverticular disease, and it was predominantly of the right colon. In Western populations, the disease affects mainly the left colon. He attributed this to genetic differences. There is no doubt that the incidence of this disease in Singapore will increase because the population is ageing and because of the large-scale consumption of fast, convenient but low-fibre foods by our children in the last 30 years.
Most people with diverticular disease do not have symptoms or complications. Only 10% of patients complain of abdominal “bloatedness”, cramps, constipation or frequent but not satisfying bowel movements. These symptoms are similar to those of Irritable Bowel Syndrome (IBS). Thirty percent of patients with IBS have diverticular disease.
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TREATMENT
Treatment for symptomatic diverticular disease is entirely medical, dietary and lifestyle changes to reduce symptoms and to re-establish normal bowel habit. Surgery is not indicated Complications of diverticular disease occur in 1% of patients. They include infection causing diverticulitis, bleeding which can be massive, obstruction or bowel blockage and colonic perforation causing life-threatening abdominal infection (peritonitis) or fistula (communication of colon to bladder, skin or vagina). |
Emergency surgery is life saving for cases of uncontrollable massive bleeding and peritonitis from perforation. Elective surgery is indicated for obstruction and fistula. |
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Diverticulitis and minor bleeding are treated with antibiotics and supportive care. If they resolve, surgery is not necessary. But one third of the patients will have a repeat attack within five years. Patients with repeated attacks should consider surgery.
Surgery cures diverticular disease. It involves the removal of a segment or theentire colon bearing the disease without the need for a permanent stoma. With laparoscopic or key-hole surgery, post-operative recovery is faster and less traumatic than with conventional surgery.
The right-sided diverticular disease seen in Singapore poses a unique clinical problem as it is often mistaken for appendicitis. It is often diagnosed only during emergency operation for appendicitis. Diverticulitis usually does not require surgery, so junior doctors in particular should be vigilant. When in doubt, CT scan can differentiate the two conditions before operation.
HEALTHY, BALANCE DIET
The problem of diverticular bleeding in Singapore is increasing because more people are prescribed bloodthinning medications like Warfarin, Plavix and Aspirin for treatment and prevention of heart disease and strokes. This increases the risk of severe diverticular bleeding. Experience and sound judgement are very important to weigh the benefits and risks of managing not just the immediate problem of bleeding, but the probability of recurrence and the impact on existing heart and stroke problems as well.
Patients who travel overseas frequently for business should also consider surgery after the first attack especially if it is moderately severe. This is to avoid the dilemma and anxiety of needing surgery or blood transfusion outside of Singapore when they have another attack.
There is no evidence to suggest that avoiding nuts like peanuts, or vegetables and fruits with seeds like tomato or guava would prevent complications like diverticulitis. But intuitively, reducing the high pressure in the colon and having a good bowel habit would probably help. The best way to prevent diverticular disease is to have programmes to educate kindergarten and school children with the aim of converting them to eating a healthy balanced diet. |
