Annotations
Diverticular
disease
and varicose
veins
Diverticular disease is the commonest disease of the large intestine in Britain and North America. It is estimated to be present in at least a third of the population over 40 years of age and two-thirds of the population at 80 years. Varicose veins are the commonest venous disorder, affecting some 15 per cent of the adult population. In contrast, diverticular disease is almost unknown and varicose veins are rare in developing countries. Burkitt’, 2 has pointed out that varicose veins and diverticular disease have a very similar geographical distribution, the incidence varying directly with the degree of economic development of the country. He has also stated that, since all the effects of any cause tended to be associated with one another, a recognized association between two or more diseases suggested an etiological factor common to both or all. Consequently, such diseases not only have a similar geographical distribution but tend to occur together in individual patients more frequently than would be expected from the prevalence of each in the community. In view of the demonstrated geographical relation between diverticular disease and varicose veins, we decided to determine whether the two conditions tended to be associated in individual patients. A varicose vein was defined as dilated, tortuous vein and five groups of patients were examined for the presence of varicose veins. Group
I.
Group
II.
Group
III.
Group
IV.
Group
V.
One hundred patients randomly selected who attended as outpatients for non-venous disorders. Eighty-three patients with a normal barium enema. Sixty patients with diverticular disease demonstrated on barium enema. Fifty patients, all of whom had undergone surgery for diverticular disease. Three hundred-thirty patients, consisting of three age and sex matched controls for each patient in Groups III and IV.
The prevalence Table I.
of varicose
Table I. Prevalence
veins in the five groups
of varicose
Group I. II. III. IV. V.
274
Conrad Latto, M.B., F.R.C.S. Royal Berkshire Hospital Reading, England
Varicose veins
REFERENCES 1.
60
16 (16%) 40 (48%) 44 (73%)
2.
50
37 (74%)
3.
330
110 (33%)
Randomly selected outpatients Normal barium enema Diverticular disease on barium enema Diverticular disease at operation
100
Matched controls and IV
III
in
veins Total
for groups
is given
The greater prevalence in patients with diverticular disease than in the age and sex matched controls was statistically significant (P < 0.091). The prevalence of varicose veins in the randomly selected outpatients correlates closely with the findings of others. The increased prevalence in patients with a normal barium enema suggests that the symptoms for which the investigation was requested may have been due to a prediverticular condition in some cases. Of the 110 patients with diverticular disease (Groups III and IV), in 90 the condition was limited to the pelvic colon, in 17 it involved the descending and pelvic colon, and in three the entire colon was affected but there appeared to be no correlation between the severity of the diverticular disease and the extent of the varicose veins. Our findings support the hypothesis put forward by Cleave3. a that diverticular disease and varicose veins are different manifestations of a common causal factor. Painter’s work-’ has led to wide acceptance that diverticular disease is caused by raised pressures in the lumen of the colon resulting from the fecal arrest consequent on a lowresidue diet-the characteristic diet of modem Western civilization. Cleave”. ’ postulates that the relation between fecal arrest and varicose veins is due to pressure exerted by a loaded pelvic colon or a loaded prolapsed cecum on the iliac veins. Burkitt’. t fully supports Cleave’- ’ in his incrimination of a low-residue diet as the primary cause, but suggests a different mechanism. He believes that it is due to raised intra-abdominal pressure resulting from straining at stool. This raised pressure, which is known to be transmitted down the leg veins after the valves become incompetent, appears to cause the initial valve failure. Vena caval pressures of up to 300 to 400 mm. Hg have been recorded with straining. These explanations are consistent with epidemiological and other evidence, whereas conventionally accepted theories as to the primary cause of varicose veins, such as heredity, pregnancy, constrictive clothing, and man’s lack of adaptation to the erect posture, are untenable and quite inconsistent with epidemiological evidence. It is of interest that 35 per cent of our patients with diverticular disease had previously undergone appendectomy and 11 per cent had had cholecystectomy.
83
4.
Burkitt, D. P.: Varicose veins, deep vein thrombosis, and haemorrhoids: epidemiology and suggested aetiology, Br. Med. J. 2:556, 1972. Burkitt, D. P.: Relationship as a clue to causation, Lancet 2:1237, 1970. Cleave, T. L., Campbell, G. C., and Painter, N. S.: Diabetes, coronary thrombosis and the saccharine disease, ed. 2, Bristol, 1969, John Wright & Sons, Ltd. Cleave, T. L.: On the causation of varicose veins, Bristol, 1960, John Wright & Sons, Ltd.
August, 1975, Vol. 90, No. 2
Annotations
5.
6.
Painter, N. S.: The aetiology of diverticulosis of the colon with special reference to the action of certain drugs on the behaviour of the colon, Ann. R. Coll. Surg. Engl. 34:98, 1964. Painter, N. S.: Pressures in the colon related to diverticular disease, Proc. R. Sot. Med. 63(Suppl.):144, 1970.
Myocardial
7. 8.
Painter, N. S.: Irritable or irritated bowel, Br. Med. J. 2:46, 1972. Latto, C., Wilkinson, R. W., and Gilmore, 0. J. A.: Diverticular disease and varicose veins, Lancet 1:1089, 1973.
infarction
Do we really know when when it is produced!
an infarct
is prevented?
We do know
George E. Burch, M. D. Tulane University School of Medicine and Charity Hospital New Orleans, La.
Comparative yield stress testing
of ECG leads in multistage
Exercise testing for detection of coronary artery disease is based chiefly on production of deviation of the S-T segment of the electrocardiogram (ECG). Selection of the ECG lead or combination of leads which detects this phenomenon with greatest accuracy is, therefore, of the highest order of importance: the subject, however, has been curiously neglected. Blackburn and Katigbak’ demonstrated early in the history of the method, in a study of 100 patients, that Lead V, recorded alone would detect 89 per cent of available information in terms of S-T deviation: 11 per cent would be detected only if other leads were recorded (chiefly Leads, II, aV,, and V,,). Mason and co-workers,’ in a study of 56 patients, found that 19 patients were “positive” in one lead only and that of these 19 patients, seventeen were positive in leads other than Lead V, (four in inferior leads, two in Lead V,, four in V,, and seven in Lead V,). These findings have been substantially ignored by many subsequent investigators in the field who have confined their observations to a single bipolar lead with a positive electrode at the V, position:‘-“’ Since a loss of 10 to 30 per cent in sensitivity must diminish the usefulness of stress testing significantly, it seemed appropriate to analyze a large number of stress tests with the goal of determining definitively the most sensitive combination of leads for detection of S-T deviation. Multi-stage stress tests (4,197) were divided into two groups. Group A, nine leads recorded (Leads I, II, III, aV,,, aV,,, aVp, V,, V,, and V,). In this group, 411 tests were graded as positive (1 millimeter S-T depression flat or downsloping for 0.08 second). In 59 tests (14.5 per cent), S-T depression was noted exclusively in leads other than Lead V, as follows: 28 (8.5 per
American Heart Journal
cent) S-T depression in Leads II, III, and aV,: 7 (1.9 per cent) S-T depression only in Lead V,: 7 (1.9 per cent) S-T depression in Leads II, III, aVF, and V,. Group B, full conventional leads recorded: 947 studies: 147 positive. Thirty-eight (21 per cent) S-T depression exclusively in leads other than Lead V, Twenty-three (12.84 per cent) S-T depression only in Leads II, III, and aV,.: 3 (1.6 per cent) S-T depression in Leads II, III, aVp, and V,;: 5 (2.79 per cent) S-T depression in Lead V, only: 3 (1.67 per cent) S-T depression in Lead V, only: 1 (0.55 per cent) S-T depression in Lead V, only 1 (0.55 per cent) S-T depression in Lead 1: 2 (1.1 per cent) positive in Leads V,, V:,, and V, only. This analysis of 590 positive stress tests revealed that failure to record leads other than Lead V,, will introduce a negative error of magnitude 15 to 20 per cent in stress testing in specific terms of detection of S-T depression. The well-documented percentage of false-negative responses in patients with demonstrated coronary artery disease (about ?A per cent)” may be, in part, a result of this procedural deficiency. Brendan P. Phi&, M.D. Larry J. Buckeis, M.D. University of Arizona Medical Center Tucson, Arit. 85724 Acknowledgment is made (Fund No. 5-Sol-RR0567-05)
of National for this
Institutes study.
of Health
support
REFERENCES 1.
Blackbum, H., and Katigbak, graphic leads to take after 67:184,1964.
R.: What exercise?
electrocardio-
AM. HEARTJ.
275
Diverticular
disease
and varicose
veins
Diverticular disease is the commonest disease of the large intestine in Britain and North America. It is estimated to be present in at least a third of the population over 40 years of age and two-thirds of the population at 80 years. Varicose veins are the commonest venous disorder, affecting some 15 per cent of the adult population. In contrast, diverticular disease is almost unknown and varicose veins are rare in developing countries. Burkitt’, 2 has pointed out that varicose veins and diverticular disease have a very similar geographical distribution, the incidence varying directly with the degree of economic development of the country. He has also stated that, since all the effects of any cause tended to be associated with one another, a recognized association between two or more diseases suggested an etiological factor common to both or all. Consequently, such diseases not only have a similar geographical distribution but tend to occur together in individual patients more frequently than would be expected from the prevalence of each in the community. In view of the demonstrated geographical relation between diverticular disease and varicose veins, we decided to determine whether the two conditions tended to be associated in individual patients. A varicose vein was defined as dilated, tortuous vein and five groups of patients were examined for the presence of varicose veins. Group
I.
Group
II.
Group
III.
Group
IV.
Group
V.
One hundred patients randomly selected who attended as outpatients for non-venous disorders. Eighty-three patients with a normal barium enema. Sixty patients with diverticular disease demonstrated on barium enema. Fifty patients, all of whom had undergone surgery for diverticular disease. Three hundred-thirty patients, consisting of three age and sex matched controls for each patient in Groups III and IV.
The prevalence Table I.
of varicose
Table I. Prevalence
veins in the five groups
of varicose
Group I. II. III. IV. V.
274
Conrad Latto, M.B., F.R.C.S. Royal Berkshire Hospital Reading, England
Varicose veins
REFERENCES 1.
60
16 (16%) 40 (48%) 44 (73%)
2.
50
37 (74%)
3.
330
110 (33%)
Randomly selected outpatients Normal barium enema Diverticular disease on barium enema Diverticular disease at operation
100
Matched controls and IV
III
in
veins Total
for groups
is given
The greater prevalence in patients with diverticular disease than in the age and sex matched controls was statistically significant (P < 0.091). The prevalence of varicose veins in the randomly selected outpatients correlates closely with the findings of others. The increased prevalence in patients with a normal barium enema suggests that the symptoms for which the investigation was requested may have been due to a prediverticular condition in some cases. Of the 110 patients with diverticular disease (Groups III and IV), in 90 the condition was limited to the pelvic colon, in 17 it involved the descending and pelvic colon, and in three the entire colon was affected but there appeared to be no correlation between the severity of the diverticular disease and the extent of the varicose veins. Our findings support the hypothesis put forward by Cleave3. a that diverticular disease and varicose veins are different manifestations of a common causal factor. Painter’s work-’ has led to wide acceptance that diverticular disease is caused by raised pressures in the lumen of the colon resulting from the fecal arrest consequent on a lowresidue diet-the characteristic diet of modem Western civilization. Cleave”. ’ postulates that the relation between fecal arrest and varicose veins is due to pressure exerted by a loaded pelvic colon or a loaded prolapsed cecum on the iliac veins. Burkitt’. t fully supports Cleave’- ’ in his incrimination of a low-residue diet as the primary cause, but suggests a different mechanism. He believes that it is due to raised intra-abdominal pressure resulting from straining at stool. This raised pressure, which is known to be transmitted down the leg veins after the valves become incompetent, appears to cause the initial valve failure. Vena caval pressures of up to 300 to 400 mm. Hg have been recorded with straining. These explanations are consistent with epidemiological and other evidence, whereas conventionally accepted theories as to the primary cause of varicose veins, such as heredity, pregnancy, constrictive clothing, and man’s lack of adaptation to the erect posture, are untenable and quite inconsistent with epidemiological evidence. It is of interest that 35 per cent of our patients with diverticular disease had previously undergone appendectomy and 11 per cent had had cholecystectomy.
83
4.
Burkitt, D. P.: Varicose veins, deep vein thrombosis, and haemorrhoids: epidemiology and suggested aetiology, Br. Med. J. 2:556, 1972. Burkitt, D. P.: Relationship as a clue to causation, Lancet 2:1237, 1970. Cleave, T. L., Campbell, G. C., and Painter, N. S.: Diabetes, coronary thrombosis and the saccharine disease, ed. 2, Bristol, 1969, John Wright & Sons, Ltd. Cleave, T. L.: On the causation of varicose veins, Bristol, 1960, John Wright & Sons, Ltd.
August, 1975, Vol. 90, No. 2
Annotations
5.
6.
Painter, N. S.: The aetiology of diverticulosis of the colon with special reference to the action of certain drugs on the behaviour of the colon, Ann. R. Coll. Surg. Engl. 34:98, 1964. Painter, N. S.: Pressures in the colon related to diverticular disease, Proc. R. Sot. Med. 63(Suppl.):144, 1970.
Myocardial
7. 8.
Painter, N. S.: Irritable or irritated bowel, Br. Med. J. 2:46, 1972. Latto, C., Wilkinson, R. W., and Gilmore, 0. J. A.: Diverticular disease and varicose veins, Lancet 1:1089, 1973.
infarction
Do we really know when when it is produced!
an infarct
is prevented?
We do know
George E. Burch, M. D. Tulane University School of Medicine and Charity Hospital New Orleans, La.
Comparative yield stress testing
of ECG leads in multistage
Exercise testing for detection of coronary artery disease is based chiefly on production of deviation of the S-T segment of the electrocardiogram (ECG). Selection of the ECG lead or combination of leads which detects this phenomenon with greatest accuracy is, therefore, of the highest order of importance: the subject, however, has been curiously neglected. Blackburn and Katigbak’ demonstrated early in the history of the method, in a study of 100 patients, that Lead V, recorded alone would detect 89 per cent of available information in terms of S-T deviation: 11 per cent would be detected only if other leads were recorded (chiefly Leads, II, aV,, and V,,). Mason and co-workers,’ in a study of 56 patients, found that 19 patients were “positive” in one lead only and that of these 19 patients, seventeen were positive in leads other than Lead V, (four in inferior leads, two in Lead V,, four in V,, and seven in Lead V,). These findings have been substantially ignored by many subsequent investigators in the field who have confined their observations to a single bipolar lead with a positive electrode at the V, position:‘-“’ Since a loss of 10 to 30 per cent in sensitivity must diminish the usefulness of stress testing significantly, it seemed appropriate to analyze a large number of stress tests with the goal of determining definitively the most sensitive combination of leads for detection of S-T deviation. Multi-stage stress tests (4,197) were divided into two groups. Group A, nine leads recorded (Leads I, II, III, aV,,, aV,,, aVp, V,, V,, and V,). In this group, 411 tests were graded as positive (1 millimeter S-T depression flat or downsloping for 0.08 second). In 59 tests (14.5 per cent), S-T depression was noted exclusively in leads other than Lead V, as follows: 28 (8.5 per
American Heart Journal
cent) S-T depression in Leads II, III, and aV,: 7 (1.9 per cent) S-T depression only in Lead V,: 7 (1.9 per cent) S-T depression in Leads II, III, aVF, and V,. Group B, full conventional leads recorded: 947 studies: 147 positive. Thirty-eight (21 per cent) S-T depression exclusively in leads other than Lead V, Twenty-three (12.84 per cent) S-T depression only in Leads II, III, and aV,.: 3 (1.6 per cent) S-T depression in Leads II, III, aVp, and V,;: 5 (2.79 per cent) S-T depression in Lead V, only: 3 (1.67 per cent) S-T depression in Lead V, only: 1 (0.55 per cent) S-T depression in Lead V, only 1 (0.55 per cent) S-T depression in Lead 1: 2 (1.1 per cent) positive in Leads V,, V:,, and V, only. This analysis of 590 positive stress tests revealed that failure to record leads other than Lead V,, will introduce a negative error of magnitude 15 to 20 per cent in stress testing in specific terms of detection of S-T depression. The well-documented percentage of false-negative responses in patients with demonstrated coronary artery disease (about ?A per cent)” may be, in part, a result of this procedural deficiency. Brendan P. Phi&, M.D. Larry J. Buckeis, M.D. University of Arizona Medical Center Tucson, Arit. 85724 Acknowledgment is made (Fund No. 5-Sol-RR0567-05)
of National for this
Institutes study.
of Health
support
REFERENCES 1.
Blackbum, H., and Katigbak, graphic leads to take after 67:184,1964.
R.: What exercise?
electrocardio-
AM. HEARTJ.
275
