Monday, September 10, 2007

Ken's Colon


Poor Ken Griffey, Jr. Seems like his body keeps letting him down, one thing after another. I was there at the beginning of his career in Seattle, and he was a joy to watch. Now [I began this post a few months ago] he's been having trouble with diverticulitis for the past several months. Guy his age? He's gonna need it out one of these days.

Among the design flaws of the human body (the hemorrhoidal veins and pilonidal dimples are also on the list) is the fact that the blood supply to the colon travels on the outer surface, feeding the inner lining (the mucosa) by sending little branches diving through the muscle layer to get there. Each hole-for-an-artery in the muscle represents a weak spot through which the mucosa can pooch outward, forming a pocket known as a diverticulum. In some people, it happens.



In the US, more than a third -- maybe half -- of people over fifty have at least a few diverticula. Most never know it. For some, it becomes a problem. Unusual in someone his age, Ken Griffey's diverticulitis is likely, according to the odds, to be a recurring problem. Instead of the occasional pocket here and there, I'm guessing his colon shows the typical sawtooth pattern of extensive diverticulosis. (Terminology time: having diverticula is called "diverticulosis, not in and of itself always a problem. Having an infected diverticulum is "diverticulitis. A problem.) The problems diverticula can cause are in two categories: bleeding, and infection. Because, by developmental definition, each diverticulum abuts an artery, it's easy to understand why inflammation or irritation in one can cause erosion into and bleeding from the vessel. Similarly, infection of a little pocket containing hardened stool isn't hard to figure, either. ("Inspissated" is the medical term for some substance that gets dried out and hardened, and it happens to be among my favorites of words learned in medical school. All those sweet and steamy sibilants, stippled by a percussive "p" and a tensile "t." Inspissated. Great word. And "bezoar." Already wrote about that, but feel like saying it again. Bezoar.)

Surgery for diverticular disease involves navigating numerous grey-zones, and a few of crystal clarity. Seeing someone exsanguinate is a sure signal to swing the scalpel. Bleeding from a diverticulum can be steady and severe. But even when the need to operate is obvious, the target may not be; so the extent of the operation can be in doubt, going in. Less likely nowadays, with better imaging and shorter delays in obtaining it, going to the OR with uncertainty as to which part of the colon contains the bleeder wasn't rare only a few years back. And the nature of diverticular bleeding is that it can stop and start randomly. The stopping, perversely, seems to like to happen just as the patient enters the imaging suite. So, short of unrelenting bleeding, there's a certain degree to which deciding when and if to operate is a crap-shoot. (Pun intended? You decide.)

By far the most common site for diverticula, and for bleeding there-from, is the sigmoid colon. (This probably has to do with pressure generated in having a bowel movement, and is why constipation and diverticulosis have an association; and why high fiber intake is really good for people who have it.) There are times when you find yourself in the patient's belly with a less than clear idea of where the bleeding is coming from: a negative or equivocal imaging study; no time to have gotten one. Then what? It might depend on how localized or extensive that person's diverticula are. You might resect the sigmoid if it has the dense concentration that one often sees; maybe even send it right to the lab to see if the pathologist can identify the culprit pocket. Some people advocate dividing the colon at about its half-way point, and seeing if blood keeps flowing from the upper half. Having been impressed with how well-tolerated is the removal of most of the colon (as long as there's a decent amount of rectum -- which never has diverticula -- left), I've not been reluctant, when the chips were down, to do a sub-total colon resection.

With diverticulitis, there are lots of decisions as well. It takes a residency and then some to understand the issues and the choices. Some easy (perforation with peritonitis; fistula -- these need surgery for sure, even if the perfect one might be a matter of opinion), some not (mild attacks, repeatedly -- how many, how severe, is enough.) Timing of surgery, and what exactly to do, are decisions into which judgment and experience are at play. For example, after a severe attack which subsides, it's nice to wait several weeks for things to cool down before operating; but recurrent attacks might occur in the interim. The ideal is to be able to do a one-stage operation -- meaning take out the bad part and sew the ends together. When forced to operate in the middle of a flare-up, it may or may not be necessary to make a temporary colostomy. That's crystal ball stuff. In the really old days, it was three stages: diverting colostomy, followed by resection, followed by a final operation to put everything back together. One of the signs that even surgeons respond -- if reluctantly -- to evidence is that a three-stager almost never is done any more, and many one-stage operations are now considered safe when, not long ago, two would have been the obvious choice.

I should add this: surgery for diverticular disease is gratifying. It's rare to have further problems after having the diseased area removed, and the comparatively small section that's typically taken out leads to no side effects at all. So it's a pretty happy group of patients. It is that for which we surgeons shoot.

56 comments:

rlbates said...

Nice post Dr Sid! I'm going to send it to my Mom who had a partial colon resection due to diverticulitis (perforation, but no colostomy--thankfully). She is doing great these days. Thanks.

Sid Schwab said...

A reader asked me, in an email, to clarify about the precariousness of the blood supply to the colon. I'll answer here, so others can read it. As opposed to the richly endowed small bowel, the colon's blood supply is, in some areas, less generous. It's fine for normal use: it's mainly when operating that one has to take particular care. Any bowel operation necessarily interferes with circulation to the area removed; with colon, one has to take care that if a significant vessel is removed, the remaining circulation to the bowel where it's sewn back together is adequate. That's true no matter where you operate, of course; it's just that certain areas of the colon require close attention. Or else the area of connection (anastomosis) can leak, or scar down and become obstructive.

Alexandra Lynch said...

My husband has diverticulosis. Most of the time it's not an issue, but we have discovered the hard way that cashews, uncooked green peppers, and large amounts of cantaloupe are Right Out. It makes sense that the cashews would do it, but he can eat vast amounts of pecans or peanuts without trouble.

People's insides are strange.

beajerry said...

Remember Doug and Wendy Whiner?

(SNL moment)

Klari said...

It's such a cool word (bezoar) that's it's been, unsurprisingly, harrypotterised.
I just read your blog post about bezoars, i tremendously enjoyed that part: "word sequence cautery, suction (...) how gross!".

RoseAG said...

Can they tell you if you've got them when they do a colonoscopy?

Sid Schwab said...

Rose: Yes, they can be seen on colonoscopy. Remember, they are very common, and in most people who have them, they cause little or no trouble. I told my patients who had diverticula with minimal or no symptoms to take plenty of fiber to avoid constipation; no need to do more unless there are specific symptoms. (That's what I told my patients: readers here need to hear from their own doctors, and not take my advice for this or ANYTHING!)

prairie mary said...

So how does all this relate to Gardner's Syndrome, the tendency to have polyps that can develop into trouble? I lost a step-daughter who had the genetic proclivity. They told her children not to get a genetic analysis because if they have it, too, it might damage both their health insurance and their job prospects.

Prairie Mary

Sid Schwab said...

PM: there's no relation between Gardner's syndrome and diverticular disease. The former is a genetic trait -- a consequence of an abnormal gene -- and the latter is, as I put it, a design flaw to which everyone is potentially subject, partly preventable by having plenty of fiber in the diet and avoiding constipation.

The genetic testing thing is complicated, all right.

Tom said...

A recent barium enema showed that my diverticulosis was not confined but extended throughout the colon. How unusual is this? Does this raise any additional concerns.

I was recently hospitalized with diverticulitis that responded to antibiotics

Sid Schwab said...

It's not rare that there are diverticula throughout. It depends on how extensive. It's still most common that the problems occur in the sigmoid colon, so often if surgery is necessary, that's the part that's removed (assuming it's known that that's where the problems have been) and the rest are left alone. But surgery isn't always necessary; especially after only one episode that responds easily to antibiotics; it's not possible for me to say much more from this far away.

Melissa said...

Sid,

My husband is a 34 year old otherwise healthy and fit male who has suffered from what he calls mild diverticulitis for the about a year now. Stared out as two severe bouts of diarrhea (could be unrelated), and then an attack of diverticulitis about three months later. He calls it mild because the pain isn't all that great, and each time it happens it responds well to antibiotic treatment.

He's now had five attacks over the past 8 months. If this stuff responds well to antibiotics, is surgery advisable? I realize you can't provide a medical diagnosis over the Internet; I'm more interested in your general opinion.

He's not a big fan of having parts removed (who is), so he'd like to avoid surgery. However, we're also pragmatic, and would also like to avoid taking antibiotics once a month for the rest of his life. There must be some sort of middle ground.

Sid Schwab said...

Melissa: it's a crystal-ball sort of thing. If he's doing everything he can to avoid them (which, mainly, means having plenty of fiber in his diet) and is having attacks at that rate, the odds are they will keep happening. The potential is there for things to get significantly worse. For an otherwise healthy person the risk of surgery is very low, and the chance of side effect from losing the sigmoid colon (assuming that's what the operation would be) is really small, and the chances of being relieved permanently (assuming the diverticula are mostly limited to that area) is high. I can't diagnose or recommend. I can just say most people like him sooner or later need surgery, and are glad they did, when they get to that point. If one indeed had a crystal ball, one would like to do surgery before complications of the disease occurred, if one could see they would.

Chucky said...

Hartman's procedure??

I have a question I hope you could give me some feedback on or tell me whether you ever heard of this happening.

I am a 43 yr. old male and thought I was healthy and fit until I began suffering increasingly chronic contipation (from 1-2x per yr. to 4-5) that seemed to be lasting longer and longer and responding less and less to OTC procducts like Ducolax. I'll try to make this as succinct as possible. Anyway, in mid july of this yr. I had a severe bout of constipation that would not respond to OTC products and I went to a after hours emergency clinic where I received x-rays that the Dr. found to reveal a partial blockage of the descending colon. She gave me some anti-spasmodics for IBS, oral Toradol, pain meds and recommended a Mg+ solution and Milk of Magnesia. Well the pain let up a little but the constipation persisted despite these interventions and enemas.

The next day the pain was so great (pretty much localized to the lower left abdominal quadrant) I had to go to the ER. I had a CT that confused the radiologist as well as the general surgeon and ultimately had to have a emergency explorative abdominal surgery. The general surgeon found a severe acute diverticulitis with an anastomosing infection and did a Hartmans procedure with an end colostomy. The Dr. plans to reverese the procedure in a couple of months. NB - unfortunately it was a open procedure and not laproscopic.

Since I was d/c'd from the hospital the ostomy site has been very painful and heavy feeling. A couple of weeks after being home the L. lateral border of the ostomy began to get very hard and indurated and there was severe pain when my bowels would move. This progressed until the ostomy would not move any more and I began to feel the same pain that I initially went into the ER with.

I went back to ER and they found an increased signal near the ostomy, I was running a fever in the low 100's and my WBC's were elevated to over 15K. I was admitted and received Cipro IV for 4 days until the ostomy began to work again and my fever and blood work normalized. My Surgeon said that he had never seen this before and figured that it was an iatrogenic infection.

Since then, the same thing happened again, back to the ER where I was given oral Cipro for 10 days and it cleared up again.

That being finished, the same thing is happening again and when I try to push on the swollen part there is some is one part on the lower medial aspect of the ostomy that oozes or squirts what looks like a mix or pus, stool and blood. It is not very viscous and when pressed it literally squrits out of one little area about the size of pencil lead. With this I am running a low grade fever, getting chills, my inguanil lymph nodes are swollen and tender on the L and the ostomy feels heavy and painful again.

So, I am curious if you ever heard of this. My surgeon has been pretty passive about this and I'm wondering if you think it is cause for concern??

It seems like there must be a preforation somewhere that is leaking into the muscle/fascial layer or something since its so recurrent. I don' t like the idea of being on antibiotics long term and I am concerned about abdominal infections once the procedure is reversed.

I would appreciate any insight or thoughts you may have regarding this and would be happy to answer any further questions you may have.


Thank you in advance.

Sid Schwab said...

chucky: it's hard for me to be specific, because I don't know the situation well enough. I agree that high among the possibilities is that there's a fistula from near the stoma; or inadequately drained infection. Possible options include open exploration of the area, or a contrast study (injecting soluble contrast medium into the stoma and taking an xray, or possibly looking in with a scope. Chronic antibiotic use without knowing more about what's going on seems unlikely to be sufficient.

A couple of general and non-useful comments: without knowing what your initial xray in the ER looked like, I can't really say; but giving powerful laxatives when there appeared to be a partial colon blockage was, shall we say, gutsy. And don't feel bad about open vs laparoscopic surgery in this situation. I'd call it the right call, once again acknowledging I don't know the details. I do think your surgeon needs to be very directly involved in the current stoma problems you are having.

I also find it interesting that he said he'd never seen anything like that before; it makes me wonder what kind of training/experience he's had. That's pretty snarky of me, I realize: but if you're not getting satisfaction, another surgical opinion wouldn't hurt.

Chucky said...

thank you for the reply and insight, I appreciate. Your book sounds like an interesting and entertaining read.

Anonymous said...

I had a foot of my colon removed last Sept. due to recurring diverticulitis. Done via lap . Three months later I had hardness and pain around the naval area and a low grade fever. CT showed inflammation consistent with diverticulitis. I still don't believe it was diverticulitis because I still have hardness a lot. I can move it around. I don't even have constipation at the time. I was wondering if it could be an internal hernia??? If it is or not is there a reason for me to be concern??

Sid Schwab said...

anonymous: it could be hernia, infection, or other things. If it's still there, it should be checked by your surgeon.

Anonymous said...

It comes and goes. NO reason that I can figure out.

Scungi said...

I know this post is rather old, but I am enlightened about your blog.

I am a 30 year old male, that was reently hospitalized twice (13 days in total) in the past three weeks for diverticulitis. The diverticulum that is causing the discomfort is in the descending colon, and surgery was advoided both times with abx, but unsure if it was a second flare up so recent or not responding to the orginal abx (flagyl and levoquin) and was precesribed Augmentin (Zoson (sic)) in the hospital after.

My plan of treatment now is hopefully for it to settles down, and have a colonoscopy to see exactly whats going on (surgeon suspects it could be related to Crohns or colititus due to strong family history, and young age, as well as diverticulum location).

That being said, surgery appears imminent, due to the fact I have been experience this undiagnosed for 10+ years, but the idea of having my descending colon as well as my sigmoid colon removed (though sigmoid not affected)but best to do preventitively? As well as a better resection to the anus? My surgeon is well researched and well versed, but out of curiousity with the limited details, your thoughts?

Sid Schwab said...

Scungi: I was just thinking about this post, because Ken Griffey Jr is out again with diverticulitis.

I really can't offer much without knowing the exact details of location and diagnosis, the latter of which ought to be clarified by the colonoscopy. Exactly how much colon to remove, and where to hook it up will be determined, I'd say, by those findings. As a general rule, people who've had up to half of their colon removed will likely have entirely normal bowel function; and in most cases, even taking more than that can lead to little significant change in bowel habits.

There are anatomic considerations, too, regardless of the underlying disease: the blood supply to the remaining colon can dictate the need to take more, or less, depending on location.

Scungi said...

That is how I found out about this blog post of yours due to the fact Ken Jr. is out with it, and my brother mentioned we had it in common.

The way the surgeon laid it out to me was to reconnect to the anus is better because the connection is much more like to be stable and less of a possibility of a reoccurance, especailly since it occurs more often in the sigmoid colon. That was my layman's terms described by me, I am sure it was better described by him at the time.

Like I said though the GI guy does not think Crohns or colititis is contributing based on the CT scan, I have a colonoscopy schedule hopefully to sort it all out.

Any familiarity with left testicular pain in your practice associated with diverticulitis? It seemed to be a shock to most of the residents, not so much the attendings or the surgeons, but it was excruciating pain, often get it with general "tough"gas as well. I do have a verococele (sic) there but small, not big enough to worry about states the consult urologist who saw me while admitted, and does not believe my pain is from the vercocele either.

Thanks for your quick response on a old post, describe everything to tee, and helps me describe it to friends and co-workers trying to figure out what was wrong with me.

Sid Schwab said...

Testicular pain is not rare with diverticulitis, depending on where the inflammation is in the colon, since the neurovascular structures to the left testis run behind the colon, in part.

Your surgeon might have meant "rectum," as opposed to "anus" (more properly, "anal canal.")There's a potential functional difference, as well as complexity of the operation, when hooking to anus (harder, more potential for control or sexual issues) as opposed to rectum (easier, unlikely to have other issues.) When the diagnosis is diverticulitis, as opposed to Crohn's or ulcerative colitis, it's pretty unlikely to need to go all the way down to the anus.

Scungi said...

You are right with the rectum, been so overwhelmed with the whole ordeal lately, I am getting everything confused.

Keeping my fingers crossed I do not get another flare up as well before the colonoscopy.

But again, thanks for the education and the great pictures that go with it, I feel like printing out your blog to hand out to everyone at work, so they understand what happened to me.

Thanks again

-Steve said...

Well, not sure if you are still checking this at all, had another flare up in 11/01........ended up scheduling surgery for 01/29. Two weeks prior again another flare up, took ABX early to try to hold it off, didn't really work but still went ahead with the surgery.

Removed a good portion of my transverse and descending colon (again only 30), and reconnected from transverse basically at the sigmoid. Everything is working out fine, but the Dr. stated was very inflamed and an abscess was clearly present.

Just trying to get back into eating and having regular BM's, but nervous about reoccurrence especially in the sigmoid.

Thanks for your blog, it has been helpful and informative

-Steve said...

-Steve and Scungi, same person, two different emails account, sorry for the confusion

Sid Schwab said...

Sounds like it was time, Steve. Hope all goes well.

Nancy said...

Hi Dr Sid...tomorrow will be 2 weeks from by colon resection. I had been in the hospital on antibiotics due to diverticulitis for a week as well. I was released 4 days after surgery and the surgeon removed about 16inches of my colon and I did not need a colostomy. My appointment with my surgeon is next week. I had been running a low fever of between 98.8 and 102.0 between January and the surgery two weeks ago. My temp is still running about 99.2-99.8. My main concern is that my normal temp prior to January 2010 was always about 97.5, rarely higher. Bowel movements have not returned to normal yet, but I have had problems in that areas for 5-8 years (diahrea and constipation. Do you have any thoughts at all on what is still causing the 99+ temps (I do break out in sweats at least once a night). I am 68 years old. Thank you so much.

Sincerely,
Nancy

Sid Schwab said...

Nancy: having low-grade fevers after major abdominal surgery is not rare, and may just reflect a combination of various factors involved in healing. But it could also be due to infection, either in the incision or inside somewhere. So it's best to inform your surgeon. I can't really say any more from this far away.

Anonymous said...

Appreciate the information you provide. My husband has had severe pain in his left testical/groin area for the past two weeks with some very low left back pain. Initially thought kidney stone - 2 CTs show a stone present in the left kidney, but drs say it is (1) not the cause of his pain & (2) stones are not 'positional'. He is only uncomfortable (entire left groin is tender) when lying flat. When he sits, the pain increases to intolerable levels and when he stands, it rapidly increases to severe - after 10-30 seconds upright he is in excruciating pain and must lie down. MRI shows some lumbar degeneration, but urologist, GP, back specialist & general surgeon say it is also not the cause of his pain. None have ever seen a presentation that is positional - lying flat = ache in back and tenderness in left groin region. Standing = severe pain in left testical which is relived by lying flat on his back. CT showed diverculosis but not diverculitis. Would the CT have revealed any colon problems or would a colonoscopy be useful? Would the CT have shown any potentially dangerous problems such as an abdominal aortic aneurysm? He has a follow-up with the general surgeon on Monday who seems to be committed to helping find the cause - although when the usual suspects are ruled out (spine, kidney stone, no hernia felt on manual exam), I know that diagnostics are not, as you say, crystal balls (pun intended - easy for me to say, I guess). I want to make sure that they explore or test for things that could be imminently life-threatening, even if those causes are not the most likely. I also want to get him in to see the proper type of specialist (hence the urologist when he described the pain as similar to a past kidney stone, the back doctor when the urologist & GP said 'might be back' ). He has an appointment with a neurologist on Thursday, and I could get him to a recommended urologist or vascular specialist if varicoceles or other vascular problem could be the issues - or gastro if a colonscopy would be useful - although, the prep for a colonscopy will be difficult for a guy who can't walk to the bathroom. I do respect the new general surgeon we saw yesterday - but obviously I have a more vested interest in my husband's life and pain than even the most dedicated physician who is responsible for hundreds of patients. I have sufficient education to evaluate what I read, but my degree and background is not medical - so I can only gather information, make observations and ask questions - I can't diagnose or treat him, as much as I wish I could. It has been a couple of months since your last comment on this thread, but if you are still reading these comments, I want to thank you for providing the information that you have, and for addressing some of the concerns that others have asked about. Responsibly, you never attempt to diagnose or make treatment judgments from afar, but I see where you have provided clarity and explanations to those seeking information. I am in a similar professional field and know that often in a practice, the treating physician (or advising attorney, counseling CPA, etc) is trying to treat/manage/handle the immediate situation presented and often does not have the time or the thought to provide additional background and information that a patient or client might need. Thank you for providing that service to others where you can.

Sid Schwab said...

It sounds like a challenging problem. I think a CT would have shown such things as aneurysmal disease or diverticulitis, neither of which really fits well with his pattern of positional pain. Were a kidney stone the cause it's likely he'd have at least microscopic blood in his urine. A hernia that would cause that severe pain ought to be palpable when he's standing, although it's possible to have a form of "internal hernia," such as an obturator hernia, that could be difficult to diagnose. Still, pain that severe from a hernia that is so positional would be pretty unusual.

Depending on the nature and location of the pain (ie, if it sounds neuropathic) I'd still be keeping neuromuscular sources high on the list.

Sounds like it'll take persistence to figure it out. Good luck to you both.

Michael Ronnau said...

Due to prev centerline laporoscopic ventral hernia repair (massive) resulting from perf appendix/peritonitis surgery (burst while in hospital-they blew the diagnosis), I am wondering if this would definitely preclude any future surgery to correct my bothersome diverticlitis. I'm to the point now that if it wasn't for this 20x25cm pc of Proceed mesh in my belly, I'd schedule the surgery quickly. If the mesh is compromised, would that require another procedure to replace the entire pc of mesh? I am under medical care-good medical care-but am interested in your opinion. Also, with my advanced diverticular disease, would receiving a high contrast (barium?) enema be dangerous/risky when I have my next CT Scan? (in 3 days...) Any danger of impacting/clogging the diverticulae? I am under good medical care but am interested in you opinion! Thanks

Sid Schwab said...

Michael Ronnau: The prior surgery, and preceding peritonitis, would not preclude future surgery for diverticulitis. It might make it harder. Or not, depending on time interval and your body's response, and how and exactly where the mesh was placed.

When it's necessary to cut through mesh, in most cases the cut can be closed with some sort of non-absorbable suture, such as nylon.

Contrast studies can be done with diverticular disease. Usually it's best to use a water soluble contrast medium rather than barium.

Rick said...

Dr. Sid, could you please weigh in on yet another "mystery of the universe"?

I went to the ER this week with what I thought was a kidney stone in my left side just under my rib cage, but the CAT scan didn't show one and there was no blood in the urine. I have had a kidney stone before and this felt like one. This "attack" came on out of the blue and I got hit with an intense wave of nausea, but didn't vomit. The CAT scan did show diverticulosis in my intestine. Because of this and the possibility of diverticulitis the ER doc put me on Cipro. My doctor, an internist, checked me out further and we decided to watch things. I continued having left sided pain and took a limited amount of pain killers and Ibuprofen, continuing the Cipro. At day 3 1/2 I'd still not had a bowel movement, but hadn't eaten to much owing to nausea and general malaise. That evening though I took a laxative and had a painful bowel movement and felt much better.
The pain in my side by this time had decreased greatly, but toward the end of each day I'd be feeling kind of yucky with some pain (more of a soreness) in my side. The whole thing is still a mystery, but the greatest possibility to have emerged after closely looking at this thing is that I may have caused diverticulitis to have occurred by ingesting too many raw cashews. I had eaten about half a bag of them the day before the attack and eat a pound of them a week. I was wondering therefore if this seems plausible (also there is evidence that there is some toxicity in cashews even when the toxins are removed through steam extraction as is the case with the ones I buy) and if you have any experience or views in the regard. As of this writing I'm feeling better in the mornings and get yucky at bedtime and still on Cipro. I'm a fairly active 55 year old guy with excellent health who works outside all day.

Sid Schwab said...

Rick: I can't make any meaningful diagnosis from over here. The distinction between diverticulosis (meaning there are diverticula there, which is true of maybe a third or more of Americans over 50) and diverticulitis, meaning infection causing various symptoms, usually is based on typical signs of infection, such as fever and elevated white blood cell count, (and, often, signs of inflammation on CT scan or other imaging.)

As I've also said, I don't think there's evidence that specific foods cause diverticulitis, nuts or otherwise. The bag of cashews could have caused some sort of other stomach upset, however.

I hesitate to go further, since there's no way I can know what went on. The above are statements I consider to be true, but they are general statements; how they apply to you, I can't say.

Eve said...

I happened on your blog and hope you will be able to still answer me.
I had terrible abdominal pain and the doctor sent me for a barium enema to find out if it was diverticulitis. Something I NEVER want to have to go through again. After reading most of your posts why did they do that procedure instead of a CT or something less traumatic?
I live in South Africa so I dont know if this is the normal way to check.
Why I was searching is that I am totally confused as to what I should or shouldnt eat. I have avoided nuts because I too had eaten a fair amount of cashews the day before the pain started.
I have gone to a dietician and tried sticking to a fibre diet but I still find my stomach very bloated all the time. Is this normal?
Now while searching I find differing information to what my dietician gave me!
My constipation problem only started after I had a bladder sling and then an operation for correction for a total vaginal prolapse.
Could these operations have interferred with my colon at all? As after the first one the bladder sling I would get terrible pain in my lower back and feel feverish before each passing of stools.
Thanks

Sid Schwab said...

Eve: I can't answer specifically, not knowing what was seen on the Xray. In general, for people with problems from diverticular disease, a high-fiber diet is the main dietary recommendation. The goal is to avoid constipation.

Being bloated is not normal, if by bloated you mean noticeable distention of your abdomen. If that's the case, it needs a diagnosis.

It's possible your surgery could have affected your colon in some way.

I know of and have corresponded with a surgeon in South Africa. Based on his blog, I'd say he's really good. His name is Neil Taverner. If you track him down and see him, tell him I sent you.

phil neason said...

Dr. Sid,
Just came across your blog and think it's great-
5 days ago wound up in the ER, lower abdominal pain, especially sharp over the appendix. CT showed " stranding prox sigmoid distal descending colon most likely for diverticulitis" . For two months before this I've had major constipation, "full" feeling and what feels like difficult breathing. Maybe pressure on my diapraghm? Only occurs with the constipation. I have psoriatic arthritis, could my systemic inflammation from that condition be playing a part here, particularly the breathing thing? Thanks for your blog-
Phil Neason

Sid Schwab said...

Glad you found the blog, phil neason, and thanks for the kind words.

I hate to offer diagnostic opinions here because there's no way I can know enough of what's going on. With diverticulitis the peritioneum over the area can become inflamed (that's what causes most of the pain), and that can inhibit breathing sometimes. Some inflammatory bowel conditions can be associated with arthritis, but I'm not sure it's the other way around with psoriatic arthritis.

Constipation can be both cause and effect with diverticular disease, as I've said in this post, and if that's what's causing the constipation you'll need a dietary plan to deal with it.

With those CT scan findings, I assume you've been referred to or are planning to see a gastroenterologist. S/he will be able to give you much better information.

phil neason said...

Wow, thanks Dr. Sid for such a quick response-
Yes I have a follow-up colonoscopy on Nov.7 with a Gastro guy highly recommended by a close friend who had two nasty bouts with the disease then a resection. I will mention the arthritis info to him of course. Thanks again for your comments-
Phil Neason

Phil Neason said...

Dr. Sid,
11 days since my diverticulitis attack, was doing fine, with no pain since the initial attack, had some fatigue/breathing issues (which I wrote you 5 days ago), but recovered well, energy is back, feel good yesterday and today. I finished 11 days of flagyl and levaquin, 500mg each, once par day.
My concern is that after no pain but feeling miserable for 9 days, yesterday I felt great but had mild discomfort immediately prior to my only BM. I had taken Miralax and Citruscel 4days ago as my doctor told me if I was feeling constipated to act on it that way. I stopped the Citruscel yesterday morning. Today I feel great but had bad cramping prior to, during and immediately after my only BM. About 5 mins total. Started firm, then soft, then pudding. No blood. Am I regressing? Appreciate your take on this, thanks-Phil Neason

Sid Schwab said...

Phil,

Usual disclaimer, regarding my inability to be accurate from far away.

I can say in general that symptoms you describe can persist for many days, a few weeks, since even when signs of infection have subsided, residual inflammation and swelling, thickening of the bowel, can take a while to resolve. So absent fever, increasing pain, symptoms such as yours don't necessarily suggest regression.

Your treating doctors are better able to assess and advise, yada yada...

Phil neason said...

Wow again, your quick responses put restless minds at ease... I've read that's the case, and if it was a weekday would have called my GE. I will monitor pain, fever, etc. If anything occurs I'll call him. Thanks again. Phil Neason

Diana said...

Love it! Thank you for your smart, informative piece and generous answers to the Diverticulitis Dilemma.

I am going in for the resection surgery next week and am soooo looking forward to not having this pain and nastiness hanging over me.

My question to you is, why the heck is there so little information out there for what people should be eating when they get an attack and afterward as they heal? It has taken me hours and hours - cumulative days of research online and talking to nutritionists and dietitians to get a good idea of what I should eat and drink. Sadly it seems the GI docs and surgeons are least informed (bad for business?).

A second question if I may, after reading on other sites people's experiences with Diverticulitis (young, old, fat, thin, exercisers, vegans...), could there be some truth to the theory that antibiotic use without restoring the good bacteria (via Probiotics and such) in the gut be a big contributing factor? Thoughts please?

Thank you again for the clear explanation with a side of humor. Much appreciated!

Diana

Sid Schwab said...

Diana, I'm glad the blog continues to be useful. I'm betting you'll be really glad you had the operation.

As to dietary questions: one problem is probably related to the fact that it's taken a complete about-face in the past several years, from avoiding fiber and seeds and nuts, etc, to realizing the only important thing is fiber, with the aim of avoiding constipation and the need to strain. It should be your goal after surgery, too.

As to a possible role of probiotics: I have no opinion, meaning I've not seen anything that confirms it. I think the etiology of diverticula is multi-factoral; but it seems the most important factor might be chronic straining at stool. Problems are less common in people with high fiber and vegetarian diets. Why some with diverticula have little or no symptoms, and others get diverticulitis is mysterious, far as I know; but, to repeat and repeat, it seems less frequent in those who maintain good bowel function.

I always told patients I saw who'd not had what I considered clear indications for surgery that they should maintain enough fiber intake to avoid constipation and straining; other than that, no specific avoidance such as seeds, etc.

phil neason said...

Dr. Sid,
I first wrote in September, following an acute diverticulitis attack. My follow-up colonoscopy was yesterday, and in the pack of post-exam materials ( I don't remember much of my conversation with my GE, I was still foggy) his notes say "Multiple large and small-mouthed diverticula were found throughout the entire colon. The colonoscopy was technically difficult and complex due to the multiple diverticula, significant looping and a generally tortuous colon." I can guess what this means, but it doesn't sound good. What is my prognosis going forward, are there surgical options with diverticula on the right and left sides? I'm a little worried. Thanks for your guidance-
Phil Neason

Sid Schwab said...

Really, you'll need to talk it over with your gastroenterologist in a non-drugged state. Tortuosity, per se, may not mean much. It's just the way some colons are; an anatomic variation.

The surgical question begins not with the extent to which there are diverticula throughout the colon; it has more to do, in general, with the number and/or severity of episodes of diverticulitis a person has had.

Once it's decided that surgery is the right course -- often anything but a black and white decision -- then the extent of the operation must be figured. It's not rare to have diverticula throughout the colon; it doesn't mean the whole colon needs to go. Depends on where the infections have occurred, whether there are concentrations of diverticula on one place (usually the sigmoid colon).

For the record, and not suggesting it'd be the right operation because I have no way of knowing, a sub-total colectomy, where all but the last several inches are removed, is remarkably well-tolerated by most people; some have "normal" bowel movements, many have a few easily managed bowel movements a day. Only a small minority have problems with diarrhea that can't be managed.

phil neason said...

Dr. Sid,
Thanks once again for a very quick and easy- to-understand response. I was worried that there might not be any surgical options, if the frequency and severity of attacks continues.. It wouldn't be so much the attacks themselves, or the pain, which although bad I'm able to tough out, but the collateral damage, i.e. my extensive travel for work (the last attack began 2 hours into a 5 hour plane flight), international travel, etc. It fills me with trepidation of course. Will I be hospitalized in a foreign country, or even out of state due to bad timing, things like that. Knowing there might be some other options should it get really bad gives my mind a little peace. For that, I thank you-
Phil Neason

Anonymous said...

I've been told that the infected colon could contain parasites. Is this an accurate statement?

Sid Schwab said...

All colons contain parasites, by strict definition. It sure as hell sells a lot of bogus colon cleanses, though.

Diana said...

Hiya! A wrote to you a few months ago re: impending resection surgery. I thank you for your great response and thought I would post a follow up report.

I am now six weeks post surgery. I feel pretty darn good and can eat anything now. I did lose 35 pounds from August to November which puts me happily back in the svelt column :o) I will stay svelt thank you.

I had been hospitalized twice for DIverticulitis with a known abscess and put on Augmentin and rest for the six weeks prior to surgery to calm the bowels. I was one sick puppy. I had had 4 CT scans with contrast in the two months leading up to surgery - which did not show the grapefruit sized, leaking abscess attached to my bladder - surprise! Surgeon said he was totally surprised to see that and all the scar tissue everywhere. My OBGYN was on call since there appeared to be a cyst on my ovary and my surgeon thought it might need to be removed (it was). So I ended up with the Da Vinci and three surgeons working on me. 5-1/2 hours, seven holes and no bags! Doc thinks that abscess has been brewing for maybe three years. Doc took out 8 inches of Sigmoid and the first ring of muscles in the rectum. Turns out those muscles gets tighter with age ('bout the only thing!) and would have caused more diverticula in the future.

I am 48 years young, feel some discomfort still but can tell I am healthier now than I have been in a very long time.

Thank you for your very informative blog (I am a big fan of other one as well). You are right, I am so very glad I had the surgery.

Can you shed light on why the almighty CT scans missed something so large? The head of radiology had even reviewed at least two of the scans.

Sid Schwab said...

Diana: sounds like really good news, and there's no surprise that you'd feel so much better after all that.

As to why it didn't show up: CT scan can be unpredictable in how well it shows soft tissue abnormalities; and sometimes it's hard to tell bowel from other stuff around it; the abscess may or may not have been in full flower when your scans were done.

In any case, it's good that it's all out of there, and I'd guess there's more feeling good to come as more healing occurs.

Thanks for the followup.

Anonymous said...

Dr. Sid, I have had a few attacks of diverticulitis and antibiotics usually take care of it. Cipro is almost always prescribed..an antibiotic that I refuse to take due to the dangerousness of it. Most antibiotics make me very ill. Can you recommend one other than a fluoroquinlone?
Thank you! Lori

Sid Schwab said...

I'm sorry, Lori, but I don't want to get into specific therapeutic recommendations on this blog. I can never know enough about an individual from so far away.

BRCinHozho said...

I've had my sigmoid resection about 11 years ago. I recently started having bouts with diverticulitis again, currently on Flagyl and Cipro. If worse case, another surgery is performed will the do another resection or do a total colon removal? My pain is in the same area as my initial before surgery.

Sid Schwab said...

BRC: I'd say it'd be unlikely they'd recommend removing the entire colon unless it was full of diverticula throughout.