Hello everybody and welcome back to my VLOG. This week I'm going to cover
something called diverticular disease and I'm doing it for a patient of mine.
And this is a patient who was recently diagnosed and has lots of things going
on now after the initial time that she was diagnosed and it made me realise
that it's a largely ignored disease in GP land until we actually come across it!
And I needed to know more so that's what I'm doing today, and hopefully then
you'll know more! So the place we need to start is; What is diverticular disease?
Well diverticular disease and diverticulitis are two related
conditions that happen in the colon or the large bowel. So diverticula, which is
where the disease name comes from, is, if you consider this is your large bowel (a
lot bigger than that obviously), let's say that's a tube and small pouches develop.
Poking outwards form the bowel. And those pouches, once present, give you the
diagnosis of diverticular disease. They are little pockets of bowel. So
diverticulitis is inflammation of those pockets and it's this inflammation that
causes pain and lots of the other symptoms that people get with a flare of
diverticulitis (one of those words again). So you most often find
these pockets or pouches in the descending colon. So that's the big bit
of colon on the left side of your body from just under your ribs down to your
anus, where the poo comes out! So that's your descending colon. So who
gets the diverticular disease? Well it increases with age, that's for sure, and
it's quite rare in people under 40. But having said that, if you do get diverticular
disease in younger patients, it runs a more virulent course and there are there's a
much higher risk of complications. Interestingly, it's rare
in rural Africa and Asia and it's most common in the USA, Europe and Australia.
And 50% of people by the age of 50 have got diverticular disease, and 70% by
the age of 80. So you can see as age goes up so does the prevalence of having it.
75 percent of those people however, so three in four, don't have any symptoms
at all and would never know that they actually had diverticula in their bowel.
25% have at least one episode of diverticulitis (the inflammation). So what
are the risks for developing diverticular disease? Well obviously
we've already said being over 50 or advancing age. Constipation is the main
risk and we'll talk about that. Smoking, being overweight or obese (especially in
younger people). Using NSAIDs; so that's ibuprofen, diclofenac, naproxen.
Paracetamol and having a low fibre diet and obviously it's the low
fibre diet that leads to constipation quite often. And genetics; you're more
likely to have diverticular disease if your mother or father had it.
So what are the symptoms? Well for most people, as I've said, there are
no symptoms - so that's the good news about it. So in diverticular disease, so
when you've just got the pockets, not inflammation, you can have pain down on
the lower left side of your tummy which comes and goes and it gets worse during
or after eating. Feeling bloated. Having mucus in your poo. Constipation or
diarrhoea or a combination of both, (switching between) and tenderness when
you press down in that lower left area. And that was the thing I didn't realise -
that even in between bouts of diverticulitis, just having the pockets
for some patients is enough to cause that tenderness. And then diverticulitis,
which is inflammation of those pockets; so then you have more severe and
constant pain. Usually, as I said, it's in that left lower side of the tummy.
But interestingly, in Asian patients, it can appear on the right side of the tummy. A
change in your bowel habit. So if you're normally constipated you might get
diarrhoea and vice versa. Having a fever (38 degrees). Being
generally unwell. Tired, nausea, vomiting, loss of appetite. Having
a palpable mass; so when you feel the tummy you can feel a lump. And having
blood in your poo. So as you can see, diverticulitis just ramps up the
symptoms that become more serious. So how does one get diagnosed with
diverticular disease or diverticulitis? So generally these patients initially
present to their GP. And the GP will do a thorough history and examination. And
they'll try and make sure that we're not dealing with another disease, so make sure
we're not dealing with irritable bowel syndrome, ceoliac, crohn's disease, ischemic colitis or bowel cancer.
When the GP examines you, you might be tender down in the left hand side of your tummy.
There might be a mass that they can feel, they will need to put a finger inside
your bottom (where the poo comes out) and that might be a tender examination. If
they did bloods they should normally be normal in diverticular disease but not
in diverticulitis where you will show signs of infection. They might send
you for what's called a barium enema, where you have a special substance put
inside your rectum (into your last bit of your colon) and then an x-ray has a look
at it and it goes into the pockets and can show you the pockets. And it can
therefore identify pockets and where they are but it doesn't tell you whether
or not there's any relevance of that to you clinically. You can have a
colonoscopy which is a camera, again up the backside, which can be more diagnostic
and tell you about clinical relevance. So what are the complications of having
diverticular disease? So you can develop abscesses,
like boils, but inside your abdomen and these can be really serious they can
lead to peritonitis; so poison inside your stomach essentially or not your stomach your abdomen. abdomen the area where all of your
And this can lead to sepsis and ultimately that can actually cause death.
As we know, perforation of your bowel; so one of the pockets can actually burst
which then makes a hole in your colon and that's actually what leads to the
peritonitis. Poo seaps out of the colon into the space in your tummy. A fistula;
so a fistula is a connection between different body parts that there
shouldn't normally be. And it allows poo to travel into areas where it shouldn't
be. A bowel obstruction - so your bowel gets totally blocked, so you can no longer
move anything along it and that's a life threatening complication. Or Haemorrhage;
they can bleed and you can lose lots of blood. So as you can see there are some
serious complications. So what further investigations might happen when it's
suspected that you have diverticular disease or diverticulitis? Well a chest x-ray,
(which might sound odd as we're talking about something lower down) could show
air underneath your diaphragm from a perforation and that's called a pneumo
peritoneum. That would be a very serious finding and obviously that would only be
done in an acute setting where you've been admitted because of complications.
An x-ray of your tummy may show small or large bowel dilatation. So your
bowel is bigger than it should be which may also show an obstruction because air
is getting trapped. That could also indicate an abscess or show an abscess.
You can have a CT scan with some dye to show contrast which would easily and
most likely diagnose an abscess. For fistula's, the best way to investigate
those is by a cystoscopy which is where a camera goes into your bladder and up
through the different tubes there, a cystography, contrast x-rays, or dye
put in - contrast with dye/methylene blue. And then if you've got a haemorrhage, a
flexible sigmoidoscopy. So again that's going into the bowel and having a
look at that last portion of bowel to see what's going on, where
you're bleeding from. So as you can see there are lots of different diagnostic
tools that a GP and the hospital would use between them to diagnose what's
going on, depending on exactly what's happening to you. So what is the
treatment if you don't have symptoms? So if you have uncomplicated disease or you
don't have any symptoms at all, the most important thing is that you have a high-fibre
diet so that, you keep the stool soft and you keep them moving. We need to warn
patients, even if they don't have symptoms or complications that there is a
risk of perforation if they use opioid medicine so codiene/dihydrocodeine; all of
those medications which are quite common. Or NSAIDs; ibuprofen/diclofenac/naproxen
It's best to avoid those and stick with paracetamol. There is some
evidence that calcium channel blockers, which are blood pressure tablets, are
associated with a reduction in perforation of the bowel and
complications but there isn't enough evidence yet for those to be used
routinely. And there's no need as I said for any pain relief apart from
paracetamol at that stage, and usually not even paracetamol because you're not
getting symptoms. But if you are getting symptoms from diverticular disease, a
high-fibre diet; bulk forming laxatives. Keeping your fluid intake high to make sure
that you're well hydrated. If you have blood loss sometimes you might need to
go into hospital to have a transfusion. Anti spasmodic medications can help
with pain, so to just make sure that the gut isn't contracting on itself and going
into spasm. And we don't recommend osmotic laxatives; so laxatives that attract water.
And as I said before paracetamol for pain relief.
If you have diverticulitis and that's been diagnosed by your GP and the decision
has been taken to be treated at home then initially you will have a broad-spectrum
antibiotic. So something that really does cover off more than one bacteria so that
could be for example co-amoxiclav or it could be a combination
of metronidazole and ciprofloxacin, if you have an allergy to penicillin.
Paracetamol for pain relief and at that point just clear liquids for your diet.
Take all solids out and no high fibre at this stage - just clear liquids. As your
symptoms improve you can gradually and gently start to reintroduce solid food
but carefully over two to three days so that the bowel gets used to it. There is
some evidence that Mesalazine is better at improving symptoms and bowel
habit and preventing recurrence of diverticulitis than antibiotics alone.
But that's likely to be something which is instigated by a secondary care,
gastroenterologists, than just at your GP alone. If however you are so poorly with
diverticulitis (and this is always the judgment that GP has to make, because patients do get very sick and as we've
already seen the complications can be quite severe) you may need hospital
admission. If you're not able to keep your hydration up, not keep enough down,
if your pain is not managed by paracetamol alone. If you've got rectal bleeding, so
blood from your bottom, which needs a transfusion because it's so
severe or there's any signs that you've perforated (as I've said before the hole
in the bowel) or you're septic, you will need to go to hospital. If your GP suspects
that you have an abscess or a fistula you will need to go to hospital. And if
your symptoms are not getting better within 48 hours,
again it's off the hospital I'm afraid. If you're very frail or you've got other
diseases that make you a higher risk of complications, then again hospital is the
only way. Some people require surgery, so 15 to 30 percent of people who
are admitted because of sepsis, peritonitis, a fistula, an obstruction,
needs surgery. And sometimes there's questions over whether or not there is an
underlying cancer, and so those people will need surgery. Surgery is often used
for recurrence, but it's important to note that most
patients who end up having surgery don't even know they've got diverticular
disease and it's their first presentation. So how do you manage these
complications, which are quite vast? So if you have an abscess you'll need
antibiotics and complete bowel rest; so no food going into your bowel. And if it
isn't resolving with that treatment you have to have a CT guided drainage/
surgery initially. But if complicated you may need surgery to take away that part
of your bowel. If you've got a fistula (so this connection between body parts) if
it's going from your colon to your bladder you may need again surgery to
take that fistula away and close it. If it's going between your bowel
and your vagina you may need a vaginal repair and surgical resection.
If you have an obstruction; if it's the small bowel it may improve with bowel
rest and conservative treatment but if you've got a situation where the doctors
can't decide whether or not there might be an underlying cancer, and we can't exclude
that, then you will need surgery to have a look and you may need an endoscopic
balloon dilatation. So that's when special camera goes in and a balloon
goes into the area where you've got a narrowing and it's blown up to stretch
that narrowing. So that's called a stricture and that's when we would use
that. Sometimes, where the stricture or the narrowing of the bowel is, a stent
can be used to go in and again hold that part of the bowel open that was
previously closed. You do need to have some bowel preparation for that where
your bowel is emptied out. And you may need a resection of bowel. So it's complicated,
and this is where the gastroenterologist and surgeons take over, because obviously
this is well outside the scope of a GP surgery! But these are all
complications that need to be addressed quickly. And if you've got a haemorrhage,
as I've said, that looks like you might need a transfusion, you'll need
fluid and blood. You might need special drugs called
vasopressin to actually stop the bleeding. And sometimes you can have
angiography, where the tube goes in and actually has a look with a very fine
camera - similar to what they do for heart attacks - to actually see what's going on
and to get you ready for surgery to find that where the bleeding is. Sometimes we
can actually embolise the bleeding - so seal it off using
heat and if all of those things fail then you need surgery to stop that
haemorrhaging as well. So as you can see there are lots of really complicated
things that can go wrong with diverticular disease and then
diverticulitis. But it's only the minority of patients where this happens,
so don't be terrified. It's not going to happen to most people with diverticular
disease. So how do you prevent it? So dietary fibre is the key; as much
dietary fibre as you can actually get into you and tolerate, to prevent the
development of diverticular in the first place. But then once you've actually got
them to actually minimise the chances of complications or diverticulitis; exercise
does help prevent development but that's probably because exercise helps bowel
movements and to prevent constipation. Because the final points I have is to
just avoid constipation at all costs. So whats the long term outlook for
people with this disease? 75%, as I've said, never get symptoms so it's good.
Mortality and morbidity; so you know, problems that lead to disability or even
death are related to complications and only occur in 10 to 20 percent of
sufferers. And so don't forget that only twenty five percent of people actually
have symptoms, so that's a really small amount of people that get the
complications during their lifetime. Most complications are associated with the
initial attack of diverticulitis and after that it tends
to run a more benign course. So things tend to get better after that first
attack. So hopefully I've given you a snapshot
of what is a difficult disease and can be really really difficult for people to
manage but can be managed. So this is diverticular disease and diverticulitis.
I'm going to put some links up afterwards to some information from NICE
and some other support groups for people with these diseases, so that they can see
what other people do. And hopefully that will be a big help. But the
most important message from today is from a very young age avoid constipation.
And even if you get diagnosed with diverticular disease, carry on trying to
avoid constipation at all cost - that's the message. If you've got any
questions for me, please ask them, I'll always answer them and if you've got any
suggestions for future VLOGs, I'll always do them for you as well. So please feel
free to make those suggestions as well. So I hope that helped, take care, see you
soon and as ever thanks for watching!