Diseases of the
COLON r Vol. 18
RECTUM
October, 1975
No. 7
Symposium C o l o n i c D i v e r t i c u l a r Disease* Moderator:
DONALD M. GALLAGHER, M.D. San Francisco, California
Panelists: NElL S. PAINTER, M.D., .JOlly HODGSON, ~'I.D., MURRAY PHEILS, F.R.A.C.S., ALEJANBRO F. CASTRO, M.D.,
Miller's Bran
in M a n a g e m e n t
NElL S. PAINTER, IXl.S.t
A barium-enema study of a patient with diverticulosis shows dramatic differences from the normal colon which are so obvious that, today, any student has no difficulty in recognizing the disease. Only 70 years ago, this "new" disease was unknown. Colonic diverticula had been described as curiosities, but clinicians were unaware of them and did not see diverticulitis. W h y has this disease appeared on the clinical scene? T h e pathogenesis of colonic diverticula involves segmentation of the colon (Fig. 1). Cineradiography coupled with intraluminal pressure recording has shown that the colon can segment sufficiently to occlude its own lumen so that it functions as a series of "little bladders." In these bladders very high localized pressures that drive the mttcosa through the "trabeculated" colonic muscle may be produced. 4, 5, 12
DR. GALLAGHER
T h e first discussion topic is the role of bran in the treatment of diverticular disease. This will be given by Neil S. Painter of London, England, an attthority on this subject. Mr. Painter. MR. PAINTER
Mr. Chairman, ladies and gentlemen, this talk deals with diverticular disease and the use of miller's bran, and not divertlculitis as stated in the program. * Symposium presented at the joint meeting of the Section of Proctology, Royal Society of Medicine, the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, and the American Society of Colon and Rectal Surgeons, Washington, D.C., May 22 to 25, 1974. t ' r h e Manor House Hospital, Golders Green, N.W. 11 7HX, London, England. For reprints of the symposium please write to authors of individual articles.
549 Dis. Col. & Rect. October 1975
Volume I8 Number 7
,'~50
PAINTER
Dis. Col. & Reet. October 1975
The disease is now the commonest affliction of the colon in the nations of the western world.7, s, 10 When the prevalence of diverticulosis around the world is considered, its incidence varies from nil in the rural comnmnities of Africa and Asia to about a third of those more than 60 years old in Europe, Australia, and North America. 10 This is not a racial phenomenon as, although the disease is rare or absent in rural Africans, it is just as common in black Americans as in their white compatriots, and affects the West Indians living in Britain. T h e disease is appearing in the cities of Africa and Asia among that part of the population who are adopting the eating habits of the industrialized world. Similarly, the disease has appeared only recently in Japan, but is extremely common in Americans of Japanese stock who were reared in Hawaii or in the continental United States. s, to, n This "new" disease cannot be due to a
T h e recognition of the segmentation mechanism of pressure production explains only how these herniations of the colonic mucosa occur, but does not shed light on the etiology of the condition. Fortunately, clues as to the causation of diverticular disease can be gleaned from the history of the disease and from study of its geographic prevalence. Colonic diverticula were considered only an interesting curiosity until Graser 3 in 1899 pointed out that infection of these mucosal sacs might lead to perforation and peritonitis. In the next ten years he was proved right. By 1917, Telling and Gruner I4 were able to catalog all the complications of the disease that we know only too well today and, by 1925, Spriggs and Marxer 13 could describe the radiologic appearances of the various stages of the disease. There is little doubt that diverticulitis suddenly became what Sir John Bland-Suttont called a "newly discovered bane of the elders."
PRESSURE TRACE FIG. I, Segmentation and pressure production. T h e top diagram shows a longitudinal section of normal colon with its r~ 2 lumen open. Any movement of the wall will meet with resistance as its contents are free to move and so no significant change of pressure will be registered by recording leads. T h e center diagram shows the middle segment, partly isolated from its fellows by contraction rings. Any f u r t h e r contraction of the wall of this segment will be op~-cn 2 ~ .... posed by its contents, which can escape only through the narrowed colon on either side of this segment. Consequently, a wave of pressure will be reSegment contracting corded by lead 2, and this preslumen open. sure will be localized to this segment alone. T h e bottom diagram shows the middle segment isolated from its fellows by ex1 treme segmentation that has temporarily occluded the colonic ,~rl lumen. Contraction of this segment on its trapped contents will produce a very high pressure localized to this segment. Segment contracting W h e n segmented, the colon does not act as an open tube but as lumen occluded. a series of "little bladders" whose outflow is obstructed in both directions. Hence, colonic and vesical diverticula owe their origins to a similar mechanism. (Reprinted with permission from Painter NS.5)
LEAD:- I
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Volume 18 Number 7
MILLER'S
BRAN
IN MANAGEMENT
551
Fie. 2. Role of segmentation in the physiology of the sigmoid colon and its relationship to the pathogenesis of dicerticula. Longitudinal sections of human colon are shown diagrammatically. The top section shows a segment defined by contraction rings, A and B, on either side; these rings obstruct the segment's outflow so that if the segment contracts further, its contents will offer resistance to its walls, as it contents cannot move into the adjoining segments easily. Hence, in this segment, pressure that will be localized to this segment will be produced and will not affect the neighboring segments, which may harbor different pressures. The second section shows contraction ring A remaining contracted while contraction ring B relaxes. If the segment bounded by A and B harbored a pressure higher than that in its neighbors (as in the top section) then relaxatiou of B would allow the contents of this segment to move to the right as indicated by the arrow. This is the mechanism by which the transportation of colonic contents is usually initiated, and it involves colonic segmentation. The third section shows how segmentation may halt material that is passing through the colon. Material moving from C towards B and A may be slowed by partial occlusion of the colonic lumen by contraction ring B and finally halted by contraction ring A, which has almost occluded the colonic lumen. Pressure results from this activity and is associated with segmentation. When segmentation takes place, the intersegmental contraction rings act as a series of barnes. Inflammation of the colon results in loss of function, and these rings do not contract properly and diarrhea results; for instance, the colon in active ulcerative colitis remains open like a drain and shows no haustration. The bottom section shows the relationship be-
tween segmentation and diverticulosis. T h e segmented colon acts as a series of "little bladders" whose outflow is obstructed at both ends. The colonic muscle is thicker between the segments where the contraction rings occur. It is between these rings that the segmental wall is weakest, and it is here that the mucosa is forced through the colonic wall by the pulsion force that results from segmentation. (Reproduced with permission from Painter NS.5)
s u d d e n w i d e s p r e a d c h a n g e in w h o l e p o p u l a t i o n s , so i t m u s t b e t h e r e s u l t of a c h a n g e i n t h e c o l o n ' s e n v i r o n m e n t , a n d t h i s is determined largely by diet. What has changed in the diet in the United Kingdom in the last c e n t u r y ? S i n c e 1870, o u r fat c o n s u m p t i o n h a s inc r e a s e d b y a b o u t 50 p e r c e n t , o u r s u g a r consumption has doubled, but our consumpt i o n of c e r e a l fiber h a s d i m i n i s h e d to a b o u t a t e n t h . T h e r e are t w o r e a s o n s for this. First, t h e i m p r o v e m e n t s i n r a i l a n d sea t r a n s p o r t a n d t h e a d v e n t of r e f r i g e r a t i o n m a d e a l t e r n a t i v e foods a v a i l a b l e o u t o f season, so e v e n t h e p o o r b e g a n to e a t less b r e a d , a n d , second, t h e i n t r o d u c t i o n of r o l l e r - m i l l i n g r e d u c e d t h e fiber c o n t e n t of o u r f l o u r still f u r t h e r . P r e v i o u s l y , s t o n e grinding coupled with sieving had removed m u c h of t h e b r a n f r o m o u r b r e a d , b u t m o r e efficient m i l l i n g p r o d u c e d even whiter
bread. These changes occurred between 1870 a n d 1880, a n d if t h e y were r e s p o n s i b l e for t h e a p p e a r a n c e of d i v e r t i c u l o s i s t h e disease ( w h i c h t a k e s a b o u t 40 years to d e v e l o p ) w o u l d h a v e b e e n e x p e c t e d to h a v e b e c o m e c o m m o n e r b y 1920. T h i s is p r e c i s e l y what happened. The decrease in cereal fiber consumption was t h e g r e a t e s t c h a n g e t h a t o c c u r r e d i n t h e d i e t of t h e i n d u s t r i a l i z e d n a t i o n s of t h e w e s t e r n w o r l d , a n d i t is this f r a c t i o n of our food that reaches the colon least c h a n g e d b y d i g e s t i o n . B u r k i t t e t al. z s t u d i e d t h e t r a n s i t t i m e s a n d d a i l y stool w e i g h t s of various ethnic groups in Europe, Africa, and Asia. T h e r u r a l A f r i c a n h a s b o w e l m o v e ments three times a day without straining and will pass a stool o n d e m a n d , o f t e n w i t h i n t e n m i n u t e s . H e o f t e n passes m o r e t h a n 400 g of soft s t o o l d a i l y a n d h a s a t r a n s i t t i m e of a b o u t 35 h o u r s . By c o n t r a s t ,
C
~ 9
PAINTER
D i s . Col. & R e e f . O c t o b e r 1975
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COLON r Vol. 18
RECTUM
October, 1975
No. 7
Symposium C o l o n i c D i v e r t i c u l a r Disease* Moderator:
DONALD M. GALLAGHER, M.D. San Francisco, California
Panelists: NElL S. PAINTER, M.D., .JOlly HODGSON, ~'I.D., MURRAY PHEILS, F.R.A.C.S., ALEJANBRO F. CASTRO, M.D.,
Miller's Bran
in M a n a g e m e n t
NElL S. PAINTER, IXl.S.t
A barium-enema study of a patient with diverticulosis shows dramatic differences from the normal colon which are so obvious that, today, any student has no difficulty in recognizing the disease. Only 70 years ago, this "new" disease was unknown. Colonic diverticula had been described as curiosities, but clinicians were unaware of them and did not see diverticulitis. W h y has this disease appeared on the clinical scene? T h e pathogenesis of colonic diverticula involves segmentation of the colon (Fig. 1). Cineradiography coupled with intraluminal pressure recording has shown that the colon can segment sufficiently to occlude its own lumen so that it functions as a series of "little bladders." In these bladders very high localized pressures that drive the mttcosa through the "trabeculated" colonic muscle may be produced. 4, 5, 12
DR. GALLAGHER
T h e first discussion topic is the role of bran in the treatment of diverticular disease. This will be given by Neil S. Painter of London, England, an attthority on this subject. Mr. Painter. MR. PAINTER
Mr. Chairman, ladies and gentlemen, this talk deals with diverticular disease and the use of miller's bran, and not divertlculitis as stated in the program. * Symposium presented at the joint meeting of the Section of Proctology, Royal Society of Medicine, the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, and the American Society of Colon and Rectal Surgeons, Washington, D.C., May 22 to 25, 1974. t ' r h e Manor House Hospital, Golders Green, N.W. 11 7HX, London, England. For reprints of the symposium please write to authors of individual articles.
549 Dis. Col. & Rect. October 1975
Volume I8 Number 7
,'~50
PAINTER
Dis. Col. & Reet. October 1975
The disease is now the commonest affliction of the colon in the nations of the western world.7, s, 10 When the prevalence of diverticulosis around the world is considered, its incidence varies from nil in the rural comnmnities of Africa and Asia to about a third of those more than 60 years old in Europe, Australia, and North America. 10 This is not a racial phenomenon as, although the disease is rare or absent in rural Africans, it is just as common in black Americans as in their white compatriots, and affects the West Indians living in Britain. T h e disease is appearing in the cities of Africa and Asia among that part of the population who are adopting the eating habits of the industrialized world. Similarly, the disease has appeared only recently in Japan, but is extremely common in Americans of Japanese stock who were reared in Hawaii or in the continental United States. s, to, n This "new" disease cannot be due to a
T h e recognition of the segmentation mechanism of pressure production explains only how these herniations of the colonic mucosa occur, but does not shed light on the etiology of the condition. Fortunately, clues as to the causation of diverticular disease can be gleaned from the history of the disease and from study of its geographic prevalence. Colonic diverticula were considered only an interesting curiosity until Graser 3 in 1899 pointed out that infection of these mucosal sacs might lead to perforation and peritonitis. In the next ten years he was proved right. By 1917, Telling and Gruner I4 were able to catalog all the complications of the disease that we know only too well today and, by 1925, Spriggs and Marxer 13 could describe the radiologic appearances of the various stages of the disease. There is little doubt that diverticulitis suddenly became what Sir John Bland-Suttont called a "newly discovered bane of the elders."
PRESSURE TRACE FIG. I, Segmentation and pressure production. T h e top diagram shows a longitudinal section of normal colon with its r~ 2 lumen open. Any movement of the wall will meet with resistance as its contents are free to move and so no significant change of pressure will be registered by recording leads. T h e center diagram shows the middle segment, partly isolated from its fellows by contraction rings. Any f u r t h e r contraction of the wall of this segment will be op~-cn 2 ~ .... posed by its contents, which can escape only through the narrowed colon on either side of this segment. Consequently, a wave of pressure will be reSegment contracting corded by lead 2, and this preslumen open. sure will be localized to this segment alone. T h e bottom diagram shows the middle segment isolated from its fellows by ex1 treme segmentation that has temporarily occluded the colonic ,~rl lumen. Contraction of this segment on its trapped contents will produce a very high pressure localized to this segment. Segment contracting W h e n segmented, the colon does not act as an open tube but as lumen occluded. a series of "little bladders" whose outflow is obstructed in both directions. Hence, colonic and vesical diverticula owe their origins to a similar mechanism. (Reprinted with permission from Painter NS.5)
LEAD:- I
f4k\ ~ / ~ - "
f
t
3
Volume 18 Number 7
MILLER'S
BRAN
IN MANAGEMENT
551
Fie. 2. Role of segmentation in the physiology of the sigmoid colon and its relationship to the pathogenesis of dicerticula. Longitudinal sections of human colon are shown diagrammatically. The top section shows a segment defined by contraction rings, A and B, on either side; these rings obstruct the segment's outflow so that if the segment contracts further, its contents will offer resistance to its walls, as it contents cannot move into the adjoining segments easily. Hence, in this segment, pressure that will be localized to this segment will be produced and will not affect the neighboring segments, which may harbor different pressures. The second section shows contraction ring A remaining contracted while contraction ring B relaxes. If the segment bounded by A and B harbored a pressure higher than that in its neighbors (as in the top section) then relaxatiou of B would allow the contents of this segment to move to the right as indicated by the arrow. This is the mechanism by which the transportation of colonic contents is usually initiated, and it involves colonic segmentation. The third section shows how segmentation may halt material that is passing through the colon. Material moving from C towards B and A may be slowed by partial occlusion of the colonic lumen by contraction ring B and finally halted by contraction ring A, which has almost occluded the colonic lumen. Pressure results from this activity and is associated with segmentation. When segmentation takes place, the intersegmental contraction rings act as a series of barnes. Inflammation of the colon results in loss of function, and these rings do not contract properly and diarrhea results; for instance, the colon in active ulcerative colitis remains open like a drain and shows no haustration. The bottom section shows the relationship be-
tween segmentation and diverticulosis. T h e segmented colon acts as a series of "little bladders" whose outflow is obstructed at both ends. The colonic muscle is thicker between the segments where the contraction rings occur. It is between these rings that the segmental wall is weakest, and it is here that the mucosa is forced through the colonic wall by the pulsion force that results from segmentation. (Reproduced with permission from Painter NS.5)
s u d d e n w i d e s p r e a d c h a n g e in w h o l e p o p u l a t i o n s , so i t m u s t b e t h e r e s u l t of a c h a n g e i n t h e c o l o n ' s e n v i r o n m e n t , a n d t h i s is determined largely by diet. What has changed in the diet in the United Kingdom in the last c e n t u r y ? S i n c e 1870, o u r fat c o n s u m p t i o n h a s inc r e a s e d b y a b o u t 50 p e r c e n t , o u r s u g a r consumption has doubled, but our consumpt i o n of c e r e a l fiber h a s d i m i n i s h e d to a b o u t a t e n t h . T h e r e are t w o r e a s o n s for this. First, t h e i m p r o v e m e n t s i n r a i l a n d sea t r a n s p o r t a n d t h e a d v e n t of r e f r i g e r a t i o n m a d e a l t e r n a t i v e foods a v a i l a b l e o u t o f season, so e v e n t h e p o o r b e g a n to e a t less b r e a d , a n d , second, t h e i n t r o d u c t i o n of r o l l e r - m i l l i n g r e d u c e d t h e fiber c o n t e n t of o u r f l o u r still f u r t h e r . P r e v i o u s l y , s t o n e grinding coupled with sieving had removed m u c h of t h e b r a n f r o m o u r b r e a d , b u t m o r e efficient m i l l i n g p r o d u c e d even whiter
bread. These changes occurred between 1870 a n d 1880, a n d if t h e y were r e s p o n s i b l e for t h e a p p e a r a n c e of d i v e r t i c u l o s i s t h e disease ( w h i c h t a k e s a b o u t 40 years to d e v e l o p ) w o u l d h a v e b e e n e x p e c t e d to h a v e b e c o m e c o m m o n e r b y 1920. T h i s is p r e c i s e l y what happened. The decrease in cereal fiber consumption was t h e g r e a t e s t c h a n g e t h a t o c c u r r e d i n t h e d i e t of t h e i n d u s t r i a l i z e d n a t i o n s of t h e w e s t e r n w o r l d , a n d i t is this f r a c t i o n of our food that reaches the colon least c h a n g e d b y d i g e s t i o n . B u r k i t t e t al. z s t u d i e d t h e t r a n s i t t i m e s a n d d a i l y stool w e i g h t s of various ethnic groups in Europe, Africa, and Asia. T h e r u r a l A f r i c a n h a s b o w e l m o v e ments three times a day without straining and will pass a stool o n d e m a n d , o f t e n w i t h i n t e n m i n u t e s . H e o f t e n passes m o r e t h a n 400 g of soft s t o o l d a i l y a n d h a s a t r a n s i t t i m e of a b o u t 35 h o u r s . By c o n t r a s t ,
C
~ 9
PAINTER
D i s . Col. & R e e f . O c t o b e r 1975
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