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Coping with DiverticulitisPeter Cartwright has 17 years’ experience of working for patient andself-help associations, including as Assistant Director of the NationalAssociation for Colitis and Crohn’s Disease. He is a former Trustee of theBladder and Bowel Foundation, the main UK charity providing information and support to people with diverticular disease. Peter has anMSc in Microbiology, a BSc in Biomedicine and an MA in Sociology, andis the author of Coping Successfully with Ulcerative Colitis (Sheldon Press)and Probiotic Allies: How to maximise the health benefits of your microflora(Prentice Publishing). Peter is married with two grown-up children and twograndchildren.

Overcoming Common Problems SeriesSelected titlesA full list of titles is available from Sheldon Press,36 Causton Street, London SW1P 4ST and on our website Insomnia: Without really tryingDr Tim CantopherBirth Over 35Sheila KitzingerBreast Cancer: Your treatment choicesDr Terry PriestmanThe Chronic Fatigue Healing DietChristine Craggs-HintonChronic Fatigue Syndrome: Whatyou need to know about CFS/MEDr Megan A. ArrollThe Chronic Pain Diet BookNeville ShoneCider VinegarMargaret HillsCoeliac Disease: What you needto knowAlex GazzolaCoping Successfully with ChronicIllness: Your healing planNeville ShoneCoping Successfully with Your IrritableBowelRosemary NicolCoping with a Mental Health Crisis:Seven steps to healingCatherine G. LucasCoping with Asthma in AdultsMark GreenerCoping with BlushingProfessor Robert J. EdelmannCoping with Bronchitis and EmphysemaDr Tom SmithCoping with ChemotherapyDr Terry PriestmanCoping with Coeliac Disease: Strategiesto change your diet and lifeKaren BrodyCoping with Difficult FamiliesDr Jane McGregor and Tim McGregorCoping with DiverticulitisPeter CartwrightCoping Successfully with Hiatus HerniaDr Tom SmithCoping with DyspraxiaJill EckersleyCoping Successfully with PainNeville ShoneCoping with Early-onset DementiaJill EckersleyCoping Successfully with Panic AttacksShirley TrickettCoping with EndometriosisJill Eckersley and Dr Zara AzizCoping Successfully with ProstateCancerDr Tom SmithCoping with EpilepsyDr Pamela Crawford and Fiona MarshallCoping Successfully with ShynessMargaret Oakes, Professor Robert Borand Dr Carina EriksenCoping Successfully with UlcerativeColitisPeter CartwrightCoping Successfully with Varicose VeinsChristine Craggs-HintonCoping with GoutChristine Craggs-HintonCoping with GuiltDr Windy DrydenCoping with Headaches and MigraineAlison FrithCoping with Heartburn and RefluxDr Tom Smith

Coping with Life after StrokeDr Mareeni RaymondDr Dawn’s Guide to Sexual HealthDr Dawn HarperCoping with Liver DiseaseMark GreenerDr Dawn’s Guide to Toddler HealthDr Dawn HarperCoping with Memory ProblemsDr Sallie BaxendaleDr Dawn’s Guide to Weight and DiabetesDr Dawn HarperCoping with Obsessive CompulsiveDisorderProfessor Kevin Gournay, Rachel Piperand Professor Paul RogersDr Dawn’s Guide to Women’s HealthDr Dawn HarperCoping with Pet LossRobin GreyCoping with Phobias and PanicProfessor Kevin GournayDr Dawn’s Guide to Your Baby’s First YearDr Dawn HarperThe Empathy Trap: Understandingantisocial personalitiesDr Jane McGregor and Tim McGregorCoping with SchizophreniaProfessor Kevin Gournay and Debbie RobsonEpilepsy: Complementary and alternativetreatmentsDr Sallie BaxendaleCoping with Stomach UlcersDr Tom SmithFibromyalgia: Your treatment guideChristine Craggs-HintonCoping with the Psychological Effectsof CancerProfessor Robert Bor, Dr Carina Eriksenand Ceilidh StapelkampThe Fibromyalgia Healing DietChristine Craggs-HintonCoping with the Psychological Effectsof IllnessDr Fran Smith, Dr Carina Eriksenand Professor Robert BorCoping with Thyroid DiseaseMark GreenerDepression: Why it happens and how toovercome itDr Paul HauckDepression and Anxiety the Drug-Free WayMark GreenerDepressive Illness: The curse of the strongDr Tim CantopherThe Diabetes Healing DietMark Greener and Christine Craggs-HintonDr Dawn’s Guide to Brain HealthDr Dawn HarperDr Dawn’s Guide to Digestive HealthDr Dawn HarperDr Dawn’s Guide to Healthy Eatingfor DiabetesDr Dawn HarperHay Fever: How to beat itDr Paul CarsonHelping Elderly RelativesJill EckersleyHold Your Head up HighDr Paul HauckThe Holistic Health HandbookMark GreenerHow to Accept YourselfDr Windy DrydenHow to Be Your Own Best FriendDr Paul HauckHow to Beat Worry and StressDr David DelvinHow to Eat Well When You Have CancerJane FreemanHow to Start a Conversation andMake FriendsDon GaborHow to Stop WorryingDr Frank TallisDr Dawn’s Guide to Healthy Eating for IBSDr Dawn HarperInvisible Illness: Coping withmisunderstood conditionsDr Megan A. Arroll and ProfessorChristine P. DanceyDr Dawn’s Guide to Heart HealthDr Dawn HarperThe Irritable Bowel Diet BookRosemary Nicol

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Overcoming Common ProblemsCoping with DiverticulitisSecond editionPETER CARTWRIGHT

First published in Great Britain in 2007Sheldon Press36 Causton StreetLondon SW1P seven timesSecond edition published 2016Copyright Peter Cartwright 2007, 2016All rights reserved. No part of this book may be reproduced ortransmitted in any form or by any means, electronic or mechanical,including photocopying, recording, or by any information storage andretrieval system, without permission in writing from the publisher.The author and publisher have made every effort to ensure that theexternal website and email addresses included in this book are correct andup to date at the time of going to press. The author and publisher are notresponsible for the content, quality or continuing accessibility of the sites.British Library Cataloguing-in-Publication DataA catalogue record for this book is available from the British LibraryISBN 978–1–84709–437–7eBook ISBN 978–1–84709–438–4Typeset by Fakenham Prepress Solutions, Fakenham, Norfolk NR21 8NNFirst printed and bound in Great Britain by Ashford Colour PressSubsequently digitally printed in Great BritaineBook by Fakenham Prepress Solutions, Fakenham, Norfolk NR21 8NNProduced on paper from sustainable forests

ContentsForewordixAcknowledgementsxiNote to the readerxiiIntroduction – the basics of diverticulitis11 What causes diverticular disease?132 Diagnosis and tests283 Symptoms and treatments404 Diet535 Living with diverticular disease686 Surgery777 Living with a stoma908 Special circumstances1019 Future developments108Useful addresses120Further reading122Index123vii

ForewordIn Western countries, the prevalence of diverticular diseaseincreased during the last century. Diverticular disease is currentlyone of the five most costly gastrointestinal disorders affectingthe US population. This has widespread implications, as it isnow one of the commonest surgical conditions encounteredin the Western world. This increase probably reflects both anincrease in detection and an ageing population.Thirty years ago, the proportion dying from diverticulardisease was decreasing. However, during the last 20 years annualage-standardized rates of hospital admission and surgical intervention have increased by 15 per cent, from 20.1 per 100,000 to23.2 per 100,000, while inpatient and population mortality ratesremain unchanged. This increasing burden of disease demandsrobust, evidence-based management guidelines. Without suchdata, implementing management to a growing group of peoplewould be costly for both health care providers and patients alike.This can be a disease that can change one’s life, and as such it isunderstandable why those with it want more information.Such information can be difficult to find and the medicalliterature is confusing and contradictory in places. As ourknowledge and understanding of diverticular disease and itscomplications improves, the concepts related to managementcontinue to change. Much of the published literature is outof date due to better diagnostic tools, and newer therapeuticopinions.This book presents the general consensus view of the literature as regards conservative and surgical management ofdiverticular disease. The aim has been to provide patients withinformation in a factual and detailed manner, yet in plainEnglish that allows them to participate in the management ofix

xForewordtheir problem. The management decisions are at times difficult,and the consequences significant, so patient participation isbeneficial for both patient and doctor. This book is a major stepin patient education and participation in the management oftheir disease.Professor Frank A. FrizelleProfessor of Colorectal SurgeryChristchurch School of Medicine and Health SciencesChristchurchNew Zealand

AcknowledgementsAlthough I take full responsibility for the content of this book,it is important to recognize the considerable help received froma wide range of knowledgeable people.For commenting on a draft text, I am grateful to the followingconsultant gastroenterologists: Professors Derek Jewell, DavidRampton, Jonathan Rhodes and Robin Spiller, and DoctorsNadeem Ahmad Afzal, Anton Emmanuel and Neil Stollman.Thanks also go to consultant surgeons Professor Neil Mortensenand Mr Geoffrey Hutchinson, consultant physician and psychotherapist Professor Nick Read and to specialist nurse LesleyBolster.The Diet chapter was the most difficult to prepare, andvaluable guidance was given by consultant gastroenterologistsProfessor John Cummings and Dr Martin Eastwood, nutritional sciences lecturer Dr Kevin Whelan, and private registereddietitian Elaine Gardner.Information and encouragement was also supplied by staffand members of the Bladder and Bowel Foundation and bymembers of the Colostomy Association.Finally, many thanks to my wife, Yvonne, for her unfailingencouragement.xi

Note to the readerThis is not a medical book and is not intended to replace advicefrom your doctor. Consult your pharmacist or doctor if youbelieve you have any of the symptoms described, and if youthink you might need medical help.xii

Introduction – the basicsof diverticulitisWhat is diverticulitis?The purpose of this book is to provide easy-to-understandinformation for people who have been diagnosed with diverticular disease (DD), and for their relatives and close friends.The information is intended to provide reassurance and tohelp the patient feel that he or she is in greater control of theirsituation.Diverticular disease refers to the appearance of small pouches(sacs), known as diverticula, that protrude outwards from thewall of the large intestine. Each diverticulum (singular of diverticula) consists of a small part of the inner lining of the intestinethat has been forced through the muscular layer of the intestineforming a small hernia (balloon). It is as if the normal intestinaltube had been squeezed and the pressure had made little protrusions of it to appear through any weak points. The number ofthese protrusions differs between individuals, and can be one ortwo, or as many as several hundred. They are usually the size ofsmall grapes (5–10 mm in diameter).In addition to the term diverticular disease, you may alsohear of diverticulosis and diverticulitis. What is the differencebetween these terms? The definitions used in this book are:llldiverticular disease: used to describe all forms of the presenceof diverticula;diverticulosis: the condition in which these small sacs appear,but cause no symptoms;symptomatic diverticulosis: the condition in which somesymptoms are experienced, but there is no infection of thesacs;1

2lIntroduction – the basics of diverticulitisdiverticulitis: the inflammation of the sacs (caused by aninfection), involving abdominal tenderness and pain and aslight temperature, and from which other complications maydevelop.It is possible that your diagnosis may not tally with the definitionsabove. For example, you may be told that you have diverticulitis,but no infection is present. Sometimes health professionals usethe term diverticulitis because the word ‘disease’ in the termdiverticular disease might suggest to the general public that it iscontagious, which it is not. Doctors and nurses may think thatthe patient will find diverticulitis a more acceptable term.The majority of people with the protruding sacs have diverticulosis, with no signs or symptoms. For the minority withsymptoms, the most common are abdominal pain, change inbowel habits (constipation or diarrhoea) and bleeding from theback passage.Although diverticula can be found in any part of the intestine,they are commonly found in the large intestine, particularly inthe sigmoid part of the colon. To understand the significance ofthis, it is useful to consider the digestive tract and the role thatthe large intestine plays.The digestive tractThe digestive tract (also known as the intestine) is a tube thatruns through the body from the throat to the anus. Its purposeis to convert food particles into absorbable materials and energyfor the body, and to remove the unusable parts of food.Food provides the body with molecules so that it can growand replace worn-out cells and tissues. Food also providesenergy so that all the parts of the body can work. The difficulty with food, however, is that it cannot easily be takeninto the body. This is because, in addition to absorbing foodmolecules, the body also has to keep out harmful germs. The

Introduction – the basics of diverticulitis 3discrimination between food molecules and harmful germs ismade by specialist (epithelial) cells. These epithelial cells fittightly together forming a layer that lines the intestine and thatcontrols entry from the digestive tract into the body.The food that we eat consists mostly of carbohydrate, proteinand fat, and these molecules are all too large to pass throughthe epithelial barrier. These large molecules need to be brokendown (digested) so that they are small enough to pass throughthe epithelial layer and into the body.The process of digestion starts in the mouth (see Figure 1overleaf), where food is chewed into smaller pieces. Also inthe mouth, enzymes contained in saliva start the chemicalbreakdown of the large food molecules. From the mouth, thefood passes down a long tube (the oesophagus) into the stomach,which is where the digestive tract widens to form a bag. Here,the food is held while being churned by the stomach’s rhythmicmovements. Enzymes are secreted from the wall of the stomachand these break down the food molecules further. The contentsof the stomach become liquefied (known as chyme) and arereleased into the small intestine.The small intestine consists of three parts: the duodenum, thejejunum and the ileum. The duodenum is a short section of theintestine immediately after the stomach, into which more enzymesare secreted and where acid from the stomach is neutralized. Themain part of the small intestine, the jejunum and ileum, is wherethe digested food (chyme) is absorbed into the body. The smallintestine is about 6.5 m (22 feet) long, which allows enoughdistance for most of the digested food molecules to be absorbed.The final part of the digestive tract is the large intestine,which is where diverticula usually form. The large intestine isabout 1.5 m (4 feet) long, and is shorter than the small intestine.The names of the small and large intestines are due to the widthor bore of the tube. In other words, the large intestine has awider bore than the small intestine.

4Introduction – the basics of diverticulitisFigure 1 The digestive systemIf all the digested food has been absorbed through the smallintestine, what is the function of the large intestine? It used tobe thought that its only purpose was to reabsorb some of thewater (and salt) into the body, leading to the solidifying of thewaste into faeces. These faeces, being solid, are easier to hold inthe lower part of the large intestine until ready or convenient tobe released.More recently, however, the resident bacteria in the largeintestine have been recognized as important. There are trillions

Introduction – the basics of diverticulitis 5of bacteria living in the human large intestine. They feed on theparts of food not digested by the human enzymes, includingstarch and other complex carbohydrates. Some of the moleculesbroken down by the bacteria are absorbed into the bodythrough the wall of the large intestine rather than being usedby the bacteria. These molecules can provide up to 10 per centof our daily energy requirements.The large intestine consists of three parts: the caecum, thecolon and the rectum (see Figure 2). Diverticula may appearin any part of the colon, but in European and US populationsdiverticula arise mainly in the sigmoid colon. About 90 percent of patients have diverticula in this area, and 45–65 percent have diverticula only in this area and in no other part ofthe intestine. In contrast, within Asian populations diverticulaare found more widely along the colon, particularly on theascending (right-sided) colon.Transverse colonAscending colonDescending colon(left-sided)CaecumRectumSigmoid colonAnusFigure 2 The large intestine

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