Brobson Lutz, MDIt started slowly but within 24 hours I could hardly walk. I was in excruciating pain,” says Madelyn Bagneris, a manager of an Entergy electric company business unit who was in Touro Infirmary earlier this year.
Bagneris qualifies as a long-term diverticulitis survivor. Her first attack occurred in 1993. She had some abdominal pain and was in a hospital a few days after receiving antibiotics. Until Hurricane Katrina, things were quiet on her intestinal front. After Katrina her life, just like so many others who live here, fell apart.
Bagneris evacuated her mother from Lafon Nursing Home just before the storm. Her recently renovated Gentilly home flooded. She and 17 other family members camped out with her sister in Baton Rouge for two weeks before moving her mother to a new nursing home in Texas. Her brother, who had leukemia, died of pneumonia in Texas.
Two months after the levees failed, Bagneris was in Ochsner Hospital in Jefferson with another attack of acute diverticulitis. Like the first, it responded to antibiotics.
Entergy then temporally relocated her to Jackson, Miss., for 10 months. By August 2006, she was back home living out of her second story. Last May her entire house was ready. About this time she was admitted to Touro and her days of longanimity were ending – two bad bouts of diverticulitis in two years.
“It was worse than my prior kidney surgery and hernia surgery combined. It was worse than childbirth. At least then you know it’s going to end. I didn’t know what I had. My prior attacks of diverticulitis were short and went away. It was never like the 10 scale pain I had last May.”
Some definitions are in order. Diverticula are tiny bulges of intestinal lining that protrude through the intestinal wall. They hang outside the colon like multiple small appendices. Large ones reach the size of a small thumb and their numbers increase with age. The normal surge of intestinal contents slows to a more stagnant flow in these intestinal appendages.
The mere presence of diverticula without symptoms is called diverticulosis. Just like inflammation of an appendix is called appendicitis, inflammation of one or more diverticular pouches is termed diverticulitis.
On admission to Touro Infirmary, Bagneris had exquisite abdominal tenderness and decreased bowel sounds – non-specific findings that can be attributed to a variety of abdominal problems.
Dr. Ed Staudinger examined Bagneris and ordered a CT scan that clinched the diagnosis. It showed classic findings of acute diverticulitis confined to a localized section of her colon. She received around-the-clock antibiotics but her abdominal symptoms didn’t improve. She had definite indications for surgery – multiple prior attacks and a current bout responding slowly to intravenous antibiotics.
Using a small camera inserted into her abdomen, Staudinger used “keyhole” surgical techniques to remove a six-inch segment of her large intestine. After cutting out the diseased segment, he stapled the two disease-free ends together. Compared to open surgery, laparoscopic surgery allows for faster return to normal gastrointestinal function. Postoperatively, the smaller incisions hurt less.
In the pathology laboratory Dr. John Oliver carefully examined the six-inch piece of colon and made a few fresh cuts to obtain tissue for microscopic examination. The cause of Bagneris’ pain was obvious under his microscope. There was a nasty looking ulcer barely visible to the eye in one of her diverticula. The surrounding tissue was very inflamed and extended to a layer of fat surrounding her colon wall.
There were no malignant cells anywhere. All her pain was due to the intense inflammation traced to this tiny ulcer in Bagneris’ colon wall. The area around this ulcer was scarred and damaged from prior bouts of acute diverticulitis through the years.
For years conventional medical wisdom linked diverticular disease to insufficient dietary fiber, nuts and seeds in the diet and emotional stress.
The Western humanoid diet over the last century has decreased in fiber. Indigestible fiber from grains, fruit and vegetables provide important bulk that decreases constipation. Constipation causes increased straining to produce a bowel movement. Supposedly this increased pressure causes out-pockets to spring from the weaker segments of the intestinal wall. These weak spots bulge out and become diverticula. If one of these diverticular becomes inflamed or infected, the result is diverticulitis.
Most of the time minor symptoms of diverticulitis resolve with no treatment. There may be a bout of constipation followed by a couple of days of diarrhea and some mild abdominal cramping and nausea. The discomfort is usually more on the left side, the opposite side from the typical pain of acute appendicitis. Onset of chills, fever, vomiting or rectal bleeding signal more urgent concerns.
Part of the lore surrounding diverticular disease is to avoid certain foods – nuts, corn, popcorn and other seeds. Recent studies have debunked these recommendations. In one large study following almost 50,000 men over several years, researches found no associations between diverticular disease and consumption of nuts, corn, or popcorn. (Actually men eating more popcorn and nuts had a decreased risk of diverticulitis.)
For years physicians have believed that there’s a link between stress and diverticulitis. Since Katrina, New Orleanians have had no shortage of stress.
Dr. Jay Turkewitz, a local neurologist and health care advocate, is one of these believers. “There is an absolute epidemic of diverticulitis which is worse since Katrina. I know. I had surgery for diverticulitis myself just a few months ago and I’m certain that it was driven by stress. I know of seven or eight other cases. Surgery for diverticulitis was not nearly as common before Katrina.”
His observational data are subject to continued debate.
“There is absolutely no proven connection between stress and diverticulitis,” says Dr. Chesley Hines, an gastroenterologist at Ochsner. Hines acknowledges a collective increase in community stress since Katrina but he doesn’t believe the incidence of diverticulitis in patients he sees has risen.
Dr. Herbert Meyer, an Uptown gastroenterologist and former partner of Hines, disagrees with Hines.
“Stress may not be the definitive cause of diverticulitis but it will certainly magnify the symptoms and exacerbate the condition. Anecdotally, I’m seeing more patients with diverticulitis in my office, in the hospital and needing surgery over the past two years compared to before the storm,” says Meyer.
As with stress, the true value of fiber remains unproven even though strong epidemiological studies show that once a population decreases dietary fiber intake, its prevalence of diverticular disease soars.
The diagnosis: Most folks age 50 and over have at least a few diverticula. Regardless of the cause, only a small portion of these folks will ever need medical care for acute diverticulitis. Diverticular Disease: What You Should Know
What is diverticular disease? Diverticular disease is caused by pouches called diverticula that form in the wall of the large intestine. People with diverticulosis have pouches in the colon that may not cause any problems. Diverticulitis is when the pouches are red, hot, swollen and painful.
Who gets this disease and why? This disease affects men and women and is common in older people. Many doctors think it’s caused by not eating enough fiber.
How can my doctor tell if I have this disease? Several tests can show if you have this disease. These include barium enema, colonoscopy and CT scanning. In colonoscopy, a camera attached to a thin tube is passed through the rectum to look at the bowel. Often, the disease is found when tests are ordered for a different problem.
What can I expect if I have this disease? Most people with diverticula never have symptoms. About one in every four people with this disease develops diverticulitis or diverticular bleeding. Diverticulitis can cause sores, blockages, openings in the bowel wall or infection.
Source: American Academy of Family Physicians online at www.familydoctor.org.