Diverticular disease may cause only mild abdominal symptoms that are not of any real concern to the sufferer. Patients are reluctant to visit their GP for every minor ailment and the trend, today, is to look on the internet and fit symptoms to a disease or read a magazine's health pages. This leads to self-diagnosis and often self-medication; this can have a detrimental affect on the patient because he or she may incorrectly diagnose the symptoms and therefore take the incorrect medications. Other patients do not want to know what is wrong with them because, either they do not care or they think the symptoms too insignificant to warrant investigations; more worryingly, they are afraid that their symptoms are an indication of a life-threatening illness and delay seeking professional advice. This group of patients are the ones who may find themselves in the accident and emergency department (A&E) in a serious condition. Others will not have any consequences of ignoring their symptoms and will carry on with life in complete ignorance of diverticulosis.
Visiting the GP with vague abdominal symptoms may cause the patient anxiety, because the diagnosis may result in a serious condition. The GP has only an allotted time to see the patient, take the history, perform an examination and arrive at a diagnosis. Patients are not always good at describing their symptoms concisely and accurately when asked. Many patients are unable to name parts of their bodies when giving a history; tummy ache is usually a general description of abdominal pain without being specific to the actual location (Thompson and Patel, 1986). This can present the GP without a complete picture on which to base diagnosis and could result in the patient being referred to a rapid access clinic. These clinics have been set up to fast-track suspected colorectal cancer.
With the concept of the rapid access rectal bleeding clinic set up to diagnose colorectal cancer, investigations are colonoscopy, flexible sigmoidoscopy, air contrast CT pneumocolon or barium enema, all of which will diagnose diverticula if they are present in the colon.
In the asymptomatic patient who has attended the rapid access clinic with rectal bleeding or abdominal pain, with a preliminary diagnosis of suspected colorectal cancer, a finding of diverticular disease is a relief, until the relief of not having cancer recedes and the worry of diverticular disease impacts on the patient. These patients usually need reassurance because the term 'diverticular disease' sounds serious - an explanation of diverticular disease plus dietary advice to allay their fears.
Numerous patients with diverticular disease will be completely unaware that they have the disease. The symptoms are so mild that they do not cause any problems or produce symptoms. Most abdominal symptoms are often diagnosed as irritable bowel syndrome with no medical investigation being carried out. This diagnosis is often a self-diagnosed one rather than a medical one.
Investigating diverticular disease is twofold: the disease is frequently diagnosed as an incidental finding (Travis et al., 1993) while undergoing investigations to eliminate colorectal cancer or other colorectal diseases. The other means of getting a diagnosis is an emergency visit to A&E with symptoms of abdominal pain, haemorrhage or general malaise. These symptoms of diverticular disease will also require investigations to rule out any other colorectal pathology.
As in all consultations a detailed history is essential, especially with regard to the patient's bowel habit. It is necessary to ascertain the frequency of defecation, and the colour and consistency of the stools. Normal bowel habit varies from one to three times per day to once every 2-3 days; the way to determine bowel habit is to ask the patient what their bowel habit was before the current symptoms. The consistency and shape of stools are also important. To determine a diagnosis, as the stool may vary from hard pellets to watery stool, the following questions assist the doctor in the diagnosis (Bristol Stool Form Scale - Lewis and Heaton, 1997):
• Is the stool like thin string or thicker?
Rectal bleeding, usually associated with colorectal cancer, is one of the signs of diverticular disease and in the region of 17% of patients will experience rectal bleeding. Spontaneous cessation of rectal bleeding is common with diverticular disease. A minority will require hospitalization for their rectal bleeding because it can be profuse and constant; this symptom rarely requires surgical intervention (McConnell et al., 2003).
The patient who has symptoms of rectal bleeding needs to describe the type of bleeding:
• The colour of the blood: bright red, dark red or black?
• Is the blood seen on the toilet paper or in the toilet pan?
• Is there blood staining on their underwear?
Blood may not have been noticed; the patient may be colour blind or have coloured 'sanitizing agents' in the toilet. So other questions are required:
• Does the patient have pain?
• Does defecation relieve the pain?
• Does the patient complain of bloating?
• Is there a mucus discharge?
Abdominal examination is usually normal, although there may be tenderness in the left iliac fossa or descending colon. There will be a difference in the way investigations proceed from this point. Each establishment will have their own pathway for investigations from the 'one stop shop', 'nurse-led clinics' through to normal outpatient appointments. The authors' hospital operates a rapid access rectal bleeding clinic where patients are referred by their GP on the 2-week wait criterion. Patients are then seen in the outpatients department by the Consultant Colorectal Surgeon who will see them as described above, and perform digital rectal examination, rigid sigmoidoscopy and proctoscopy before referring the patient to the endoscopy or radiology department for investigations.
Radiological investigation will be a sigmoidoscopy, colonoscopy, barium enema or CT pneumocolon. All the investigations will show the diverticulum pockets if they are present.
When the diagnosis is confirmed, treatment for diverticulosis will be prescribed:
• Dietary advice
• Increase intake of water (2 litres each day)
• Analgesia if required
• Advice on bowel habit
• Health education.
There is additional advice on alternative therapies in Chapter 12. Patients need to decide for themselves the best treatment for their diverticulosis. Diet is very emotive and increasing fibre intake in some makes the symptoms worse. Through allowing the patient easy access to the colorectal nurse specialist by telephone contact, patients will learn how to control their symptoms so that they do not impose restrictions on their everyday activities. Regular outpatient appointments, once diagnosis is confirmed, will depend on local hospital policy. The author's hospital maintains contact with the patients through the colorectal nurse and this is found to be beneficial to all. Unnecessary outpatient appointments are reduced but contact is maintained. Patients appear to be pleased with this regimen. If there is a recurrence of their symptoms, help and advice are a phone call away. For the patient for whom surgery becomes the only option, the contact with the colorectal nurse is invaluable. The patient is more relaxed on admission because he or she will be fully informed of the outcomes of surgery, and the contact continues after discharge.
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