Diverticular disease is one of the most common disorders among elderly people in western societies; early in the twentieth century it was believed to be extremely rare and a pathological curiosity. Burkitt and Painter, from as early as 1965, have written much on the subject, in which they called diverticular disease a 'twentieth century problem' and a disease of western societies. In contrast, diverticular disease appears to be rarer in developing countries. The prevalence of diverticular disease appears to increase with age and in western societies the reported frequency of diverticular disease occurs in different age ranges of the population; by the age of 50 years about 33% will exhibit signs of the disease, at 70 years 50% will exhibit signs of the disease and by 80 years 66% can expect to show signs of the disease. Fewer than 20% of patients will go on to develop complications, but these complications may be perforation, fistulae, peritonitis, strictures, bowel obstruction and haemorrhage.
The hypothesis about dietary fibre, or lack of it, has been perpetuated by many writers in human and animal studies (Brodribb and Humphreys, 1976; Findlay et al., 1974; Leakey et al., 1985; Manousos et al., 1985), many believing the disease to be the consequence of a low-fibre diet, as eaten in the western world. In searching the literature, with continuous regularity there are suggestions that fibre in the diet is beneficial in health promotion and disease management. Nurses are ideally placed to help patients understand issues of their disease management and effective promotion of health, but need to be aware of the guidelines and definitions of fibre intake.
We outline the history of diverticular disease and align this with the anatomy and physiology of the bowel, particularly looking at the function of the colon. The disease is then viewed from the uncomplicated cases and how best to look after the patient, to complicated disease, which includes three major complications: diverticulitis, haemorrhage and bowel obstruction. Surgery and its potential outcomes are discussed and a complete chapter on stoma care is included. We are both experienced stoma care nurse specialists in our own right, and Chapter 8 on stoma care can be used as a stand-alone section for the care of the patient with a colostomy, the rehabilitation process, the correct type of appliance to use and care in the community.
For many, having a colostomy, often undertaken as an emergency procedure, can be devastating and Chapter 8 endeavours to help the practitioner to think in a wider-ranging way and to consider the patient's culture, socioeconomic situation, beliefs, religion and any practices that may relate to his or her ill-health. Without understanding the culture in which the patient has grown up, the practitioner will have difficulty in understanding the reaction to the disease and illness, particularly when a stoma is formed.
Chapter 9 looks at literature from many countries around the world, both developed and developing, to compare the incidence of diverticular disease. Histologically, right-sided diverticular disease was the predominant pattern in far eastern countries, contrasting sharply with predominantly left-sided disease in the sigmoid colon in western countries.
As practitioners, most of us feel that we know enough about healthy eating and fibre in the diet because we have been advising people about it for many years, but fibre is an unexpectedly complex food fraction and a new fibre-oriented vocabulary is emerging that can confuse and misinform people. Chapter 11 helps to update current thinking, advising the practitioner of the new terminology of non-starch polysaccharides (NSPs) that are part of dietary fibre intake and the introduction of the dietary reference values and the Englyst measurement method (Department of Health, 1991).
Evidence-based medicine and evidence-based health care, aligned with research, can help both the promotion of good nursing practice and the understanding of failures in practice, with the aim of rectifying the situation. Nurses have an obligation to keep up with current literature in their field, read it critically and make balanced judgements about the quality and relevance of the work in relation to their practice.
Chapter 12 looks at alternative therapies and what may help and be of benefit to a patient with uncomplicated diverticular disease from Ayurvedic medicine to yoga. In Chapter 13 we look at consensus development in the diagnosis and development of diverticular disease. Importantly, in this chapter the surgical management is reviewed with regard to lowering morbidity, mortality and stoma formation, and who should be operating on patients to enable the patient to have the best possible outcome.
A glossary is included and a list of agencies that can help and support the patient who has a diagnosis of diverticular disease and his or her family.
Patricia K Black Christine H Hyde 2004
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