Diverticular disease in Singapore

Diverticular disease is common in the west but rare in the east (Painter and Burkitt, 1969). The importance of high fibre has been discussed and is considered important in helping to prevent this condition. In the consumption of a low-fibre diet, not only is there the risk of developing diverticular disease, but there is also the possibility of a low-fibre diet being the precursor to appendicitis and colorectal cancer.

Appendicitis and colorectal cancer are common in Singapore and colorectal cancer is rising to become the main malignant neoplasm in the twenty-first century. Early studies in Singapore show that clinically diagnosed diverticular disease is relatively rare (Kyle et al., 1967).

Before 1986, 1014 consecutive large bowels from people aged 14 and over were examined postmortem. The whole of the bowel from anus to caecum was opened and cleaned and examined for diverticula. All positive cases were confirmed histologically. Ethnic grouping of the patients was into the three main areas of Chinese, Indian and Malay. It was noted that Chinese men had a larger proportion of diverticular disease (24%) than Malay (11.7%) or Indian (14.3%) men (Lee, 1986).

Right-sided diverticulosis was seen as the predominant pattern in all the postmortem age groups and was particularly prevalent before 40 years of age. This contrasts with findings in a western population of diverticulosis occurring predominantly on the left-side colon in the sigmoid area (Lee, 1986).

Further radiological investigation, done by Chia et al. (1991) using barium enemas as diagnosis, reviewed 524 studies. This study produced a 20% prevalence rate that is equal to western countries such as Sweden and the USA, and is higher than nearby Asian communities such as Thailand, Korea and Hong Kong. Again in Singapore, using a radiological medium, the feature of right-sided diverticulosis was demonstrated.

Studies from developing countries show that diverticular disease is uncommon and some communities will show a different anatomical variation as seen here. However, as a community becomes more developed and adopts a diet low in fibre, and high in saturated fat and meat, diverticular disease will be seen more often (Ellis, 1970; Painter and Burkitt, 1971). Over the last 20 years Singapore has progressed economically from being a developing country to the second richest in Asia and the twentieth in the whole world. With this has come the adoption of a low-fibre, refined diet as seen in the western world.

Chia et al. (1991), Vajrabukka et al. (1980) and Lee (1986) suggest that their data show that a predominantly Oriental population appear to develop right-sided diverticular disease, whereas a European population develop left-sided diverticulosis. Therefore, the anatomical site for diverticular disease is racial and genetic, although the prevalence is environmental and related to diet and low fibre. (See Table 9.1.)

Table 9.1 Diverticular disease in the Far East

Source

Singapore Lee (1986)

19.0

1014 66.3

Japan

Sugihara et al. (1984)

Barium 133

1839 68.6

Hong Kong Coode et al. (1985)

200 70.0

Thailand

Vajrabukka et al. (1980) Barium

289 66.7

Korea

Munakata et al. (1982)

Barium 0.3

3239 70.0

Adapted from Chia et al. (1991).

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