At Home with Dr Christian Jessen - 161

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Hard to digest

Diverticula A: Diverticular disease
Diverticula B: Diverticulum containing faeces

Mr Haq has expertise in revision
abdominal surgery in particular: incisional
hernia repair using the minimal access
approach; abdominal wall reconstruction;
and reversal surgery for stomas.
Diverticulosis is one of the most common
gastrointestinal conditions affecting the general
population in the western world. It is estimated
that over one million people are affected
by diverticular disease in the UK.
Approximately 50% of all people have
diverticula by the time they are 50 years of
age, and nearly 70% of all people have
diverticula by the time they are 80 years old.
Diverticular disease is rare in people younger
than 40 years, but is becoming more common.
Diverticulosis is a term that is used to
describe the presence of colonic diverticula,
a small sac-like outpouching of mucosal and
submucosal layers of the colonic (large bowel)
wall. It has been suggested that a low-fibre
diet plays a vital role in the development
of diverticulosis, and age-related changes in
the connective tissue of the colon may also
lead to increased colonic rigidity.

Low-fibre diets can reduce stool volume and
predispose individuals to develop constipation
that, in turn, leads to increased intraluminal
pressure and colonic wall tension, causing
the production of such outpouchings of the
colon alongside points of weakness along
the colon, in particular at the sigmoid colon.
While most people with colonic diverticulosis
remain asymptomatic, about 20% of those
will experience complications. The two most
common and well-recognised complications
are acute episodes of bleeding and
diverticulitis. Patients may also experience
chronic and vague gastrointestinal symptoms
including abdominal pain, bloating,
constipation and diarrhoea. Of the 15-20%
symptomatic patients, 75% of them will
have painful diverticular disease without
inflammation, 1-2% will require hospitalisation
and 0.5% will require surgery.
Acute diverticulitis is characterised by
inflammation, microperforation and abscess
formation; 25-33% of these patients
may have recurrent symptoms. In patients
who have gastrointestinal symptoms without
overt diverticulitis, low-grade inflammation,
gut dysfunction, visceral hypersensitivity and
colonic dysmotility have been identified as
potential contributing factors to symptoms.

Symptom control

Traditional therapy includes fibre, bowel rest,
antibiotics, pain control and even surgery for
selected cases. Advice about following a
high-fibre diet should be given; the diet should

'MOST PATIENTS WITH ACUTE DIVERTICULITIS
WILL RESPOND TO CONSERVATIVE
TREATMENT; 15-30% WILL NEED SURGERY'
'I HAVE A NEW LIFE THANKS TO MR HAQ'

Valerie Seaward, 72, retired, East Sussex, had surgery for diverticulosis
'I had been suffering with diverticular
disease for many years. The pain from
the disease eventually triggered a heart
problem, which in turn stopped me from
being able to have an operation for
the disease - it was a vicious circle.
However, I had four ablations to correct
the heart palpitations, after which Mr
Haq was able to do the diverticular
operation, where a part of my bowel
was removed via keyhole surgery.
'A friend recommended Mr Haq to
me, and I must say that everything about
the treatment I received was wonderful.
I had waited so many years to have the
operation. I was extremely ill and on

antibiotics, and I was only getting worse.
My life wasn't worth living, but I have
a new life now thanks to Mr Haq. I was
in hospital for 12 days, and I received a lot
of care and attention during my treatment.
'Mr Haq also has a special nurse who
phoned me every day for several days
after I came home to make sure I was
fine and to give me advice. I experienced
a lot of pain after the surgery, but if you
were to look at me now, you wouldn't
even be able to tell I'd had the procedure
- you can't see a thing!
'I'd certainly recommend Mr Haq to
others; he was very kind, very caring, and
he is an extremely skillful surgeon.'

contain whole grains, fruit and vegetables.
Adequate fluid intake is also very important.
Bulk-forming laxatives (such as ispaghula,
sterculia or methylcellulose) may be beneficial
to supplement the diet if a high-fibre diet is
not effective or acceptable, or if constipation
or diarrhoea occurs. Recent advances in the
medical treatment of diverticular disease
include the use of mesalamine - an antiinflammatory drug - rifaximin and probiotics
as the understanding of the disease evolves.

Surgery answers

Most patients admitted with acute diverticulitis
will respond to conservative treatment, but
15-30% will need surgery. The indications
for surgery in the emergency setting are:
*Purulent or faecal peritonitis
*Uncontrolled sepsis
*Fistula
*Obstruction
*Inability to exclude carcinoma
Free perforation with generalised peritonitis,
although uncommon, carries a high mortality
rate (up to 35%) and needs urgent surgical
intervention. Risk of recurrent symptoms after
an attack of acute diverticulitis is about one
in three. Recurrent attacks are less likely to
respond to medical treatment and have a high
mortality rate. Although often recommended,
recent evidence indicates that prophylactic
resection has little impact in preventing
subsequent complications, as most patients
who need urgent surgery have no history
of having diverticular disease.

In an emergency

For major surgery, a recent multicentre
randomised controlled trial (RCT) found
that a one-stage procedure (primary
anastomosis) significantly reduced rates
of post-operative peritonitis and emergency
re-operation compared with a two-stage
procedure. The latter is the formation of an
end colostomy with oversewing of the rectal
stump - the Hartmann's procedure, which
usually takes around three hours to perform.
Clear indications for elective surgery
for diverticular disease include complaints
of ongoing pain and repeated hospital
admissions, stenosis, fistulas, or recurrent
diverticular disease.

FOR MORE INFORMATION
Contact Mr Haq's secretary, Nicky Waring.
Email nicky@londonlaparoscopicsurgery.com
call 07584 437341 or fax 0871 661 6664.
Consulting sessions are available at London
Bridge Hospital, The Lister Hospital and
Renaissance Healthcare, 19 Harley Street.
North Downs House, Old Reigate Road,
Dorking, Surrey, RH4 1NT
At Home with Dr Christian Jessen

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