The Chicken Rice Man

Not all cases of pain in the lower abdomen are due to appendicitis. This is one such story.
Chicken rice. For those not from Malaysia or Singapore, chicken rice is a yummy meal of rice cooked in chicken stock & garlic, steamed or roast chicken, served with sliced cucumber, soup, chilli & ginger sauce.
Chicken rice.
For those not from Malaysia or Singapore, chicken rice is a yummy meal of rice cooked in chicken stock & garlic, steamed or roast chicken, served with sliced cucumber, soup, chilli & ginger sauce.

Mr Lim used to sell chicken rice.

His shop was close to where I used to work.

“I know that place!” I exclaimed. His face lit up.

A stout man in his fifties, he had a been to another hospital with abdominal pain and diarrhoea for 4 days. The pain first began in the upper part centrally, then moved to the lower right part of the abdomen. An ultrasound scan was reported to show acute appendicitis.

Surgical textbooks would have us believe this is a perfect description of pain due to appendicitis. He was markedly tender in the lower right quadrant and he had a fever.

Hmmmmm………

“We should do a CT scan of your tummy, just to make sure it’s really appendicitis.”
Experience had taught me things are not always what they seem to be.

A CT scan gives far clearer images of the abdomen than an ultrasound scan.

CT scans vs Ultrasound scans

CT scans or computerised tomography scans use X-Rays. Many X-ray images are taken rapidly from different directions.

A computer then combines all the images and reconstructs them as slices, rather like sliced bread.
Nowadays, CT scanners are very fast and accurate.

They do involve a little bit of exposure to X-rays (though not a high dose).

The other downside to CT scans is that they require an injection of intravenous contrast to get clear meaningful images. Some patients are allergic to iv contrast. In addition, iv contrast can also affect kidney function and care will have to be taken in patients with impaired kidney function.

Nevertheless, CT scans are well tolerated by the vast majority of patients and the invaluable information they yield often outweigh the downsides.

Ultrasound scans on the other hand use very high pitched sound waves to create the image. These sound waves are too high pitched for us to hear. The sound bounces off various tissues and are picked up by the ultrasound probe listening for echoes, rather like radar.

Ultrasound is good, fast, painless, cheap and safe.

It is the safest way to look at babies in the womb, for instance.

To have an ultrasound scan, the doctor has to cover the abdomen with jelly.

Ultrasound is great for finding out if a lump is made of tissue (solid) or fluid (cystic). Ultrasound can demonstrate blood flow in a simpler way than CT scans. They are also cheaper than CT scans.

However, ultrasound does not pass through air or bone. If there is bowel (containing air) in the way, that will block the ultrasound, limiting what can be seen. The same goes for bone. Ultrasound is generally not good at looking at the bowel.

The resolution of ultrasound depends on the frequency of the probe used. Higher frequencies give clearer images and more detail but have more limited penetration. Lower frequencies for deeper structures have lower resolution. This means deeper tissues are better imaged with a CT scan.

In summary, CT scans and ultrasound use very different technologies to create the image. They are best viewed as complimentary – some things are better seen on CT and others on ultrasound.
We doctors like to have the best of all possible worlds so that’s why we have both!

Sure enough, the CT showed the appendix to be enlarged and distended, as one would expect for appendicitis.

Except ……….. the wall of the appendix was not thickened or inflammed.
Nearby, there was plenty of inflammation, mostly centered on the large bowel next to the appendix.
Indeed, there was even a small pocket of air outside the bowel indicating perforation.

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Mr Lim’s CT scan showing inflammatory mass around right colon (white arrow)
Perforation!

Oh dear….

Mr Lim had a perforation of the large bowel, not appendicitis as initially suspected.
In the absence of trauma or injury, the most likely cause was Diverticular Disease.

Diverticular Disease – What is it?

A diverticulum is a small pouch or pocket in the wall of the bowel. In diverticular disease, there are many such pouches or diverticula. This is a benign condition and has no association with cancer. Many patients with diverticular disease have no symtoms and may not even be aware they have the condition unless they have a colonoscopy.

However, some patients develop complications which can sometimes be severe or life threatening (see below).

Diverticular disease is thought to result from constipation.

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The large bowel (colon) is a muscular tube made up of different layers. On the inside of the tube is the mucosa, a thin layer like tissue paper.

With prolonged constipation and straining, pressure builds up inside the bowel as it tries to propel the faeces onwards. Weak spots develop in the muscle wall causing small holes to form. The inside mucosa pouts out through these holes in the muscle to form little pockets or diverticula.

An important aspect of these diverticula is that they are very thin walled, lacking a muscle coat.

It is not hard to imagine these diverticula bursting when inflammed, leading to a perforation of the bowel.

Indeed, it can even be a hazard while doing a colonoscopy as it is possible to cause a perforation with the scope. Fortunately, this does not happen often.

It is for this reason I am always very careful when performing a colonoscopy on patients with diverticular disease.

Sometimes, one can treat small perforations due to diverticular disease with intravenous antibiotics. The perforation is sealed off by fat and the infection slowly resolves.

Similar case showing perforation due to a faecolith (white arrow) and appendix (green arrow) Compare this case (open surgery) with Mr Lim's case (laparoscopic surgery)
Similar case showing perforation due to a faecolith (white arrow) and appendix (green arrow)
Compare this case (open surgery) with Mr Lim’s case (laparoscopic surgery)

 

However, I was worried about Mr Lim.

He had diabetes as well and diabetic patients generally have a lower resistance to infection such as one would get with a perforated large bowel diverticulum.

If the perforation got bigger instead of sealing off, he could get worse leading to an abscess.

Moreover, persistent infection would make his diabetes more difficult to control.

Better to get it properly sorted out.

That meant removing the affected part of the large bowel then joining it all up again.
A much bigger operation than appendicectomy.

a bigger operation… through the same small holes!

So we proceeded to bowel resection after carefully bringing his diabetes under control.

All done with keyhole (laparoscopic) surgery.

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Inflammed bowel mass due to perforated diverticulum – view from laparoscope The perforation is covered up by adherent fat.
Appendix seen at laparoscopy
Appendix seen at laparoscopy

Mr Lim made a great recovery and the results from the lab confirmed our suspicion of a perforated diverticulum.

Mr Lim, looking good after surgery.
Mr Lim, looking good after surgery.
Complications of Diverticular Disease

Most cases of diverticular disease do not cause any trouble and patients are often unaware they have thin condition unless they have a colonoscopy or CT scan. Some cases do go on to develop complications which can be severe.

The main complications are:

  1. Inflammation
    This occurs when a lump of faeces gets stuck inside a diverticulum. That diverticulum can get obstructed and inflammed. The inflammatory mass can look like cancer even though it is benign. The patient complains of fever and a tender hard mass in the abdomen.
  2. Bleeding
    The diverticulum often has a blood vessel running inside and inflammation can lead to bleeding. This bleeding can sometimes be severe, requiring emergency surgery. Diverticular disease is the commonest cause of massive fresh rectal bleeding.
  3. Perforation
    If the inflammation in the diverticulum progresses, it can lead to perforation, as in this case. Untreated, the leakage of faeces causes infection which can lead to septic shock. The body tries to wall off the leak and this can result in an abscess. The patient has a fever, tender mass and may experience a change in the bowel habit.

To learn more about diverticular disease, see my article in Health Information.

Angiogram (special X-ray of blood vessels) showing bleeding from diverticular disease of the right colon (arrow). This patient required emergency surgery to stop the bleeding.
Angiogram (special X-ray of blood vessels) showing bleeding from diverticular disease of the right colon (arrow).
This patient required emergency surgery to stop the bleeding.

Diverticular Disease

What Is It?

Diverticular disease is a condition where the large bowel wall develops small pouches. The bowel wall is like a muscular tube with a thin inside lining called the mucosa. The muscle in the wall contracts to squeeze and move the contents along. In diverticular disease, the muscle wall develops small holes, like weak spots. The inside lining or mucosa then bulges out. From the inside, this looks like the holes in Swiss cheese. Each one is a bit like a tiny cave or pocket. Sometimes there is just one diverticulum (singular) or there can be many diverticula (plural). It may affect only part of the large bowel or the entire large bowel (colon) could be affected.
In the West, the commonest site affected by diverticular disease is the sigmoid colon. However, in the East the right colon and caecum are more commonly affected.

View at colonoscopy showing diverticular disease

 

What is the cause?

Diverticular disease is related to constipation. Hard stools make the job of the large bowel more difficult. The muscle has to work much harder to push the contents along. Pressure builds up and eventually the muscle develops areas of weakness that become diverticula.

What trouble can diverticular disease cause?

Many patients with diverticular disease have no trouble or symptoms whatsoever. Problems arise usually because faeces gets lodged inside the diverticulum, obstructing the opening. The diverticulum becomes inflamed, rather like appendicitis. This is called diverticulitis. This can affect a whole segment of large bowel leading to a big inflamed mass. The patient complains of pain and a tender lump. This mass can cause bowel obstruction and surgery becomes necessary.
The inflamed diverticulum can also perforate, leading to a collection of pus or abscess next to the bowel. The patient becomes ill with severe abdominal pain and fever. Sometimes it can perforate into a nearby organ like the urinary bladder or vagina. An abnormal passage called a fistula is created and this can lead to leakage of faeces into the urine or vagina.

Perforated diverticulum with inflammed mass
Perforated diverticulum with inflammed mass – white arrow. Note the normal appendix nearby – green arrow.

 

Sometimes, the inflamed diverticulum causes bleeding instead of perforation. Diverticular disease is the commonest cause of massive rectal bleeding. Thankfully, most of these cases stop bleeding by itself but if it continues to bleed, surgery may be needed.

A special X-Ray called an angiogram showing the vessels of the large bowel.

This 66 year old patient had severe bleeding from diverticular disease of the right colon. Note the puddle of dye (arrow) indicating the location of active bleeding.
This patient had to be rushed from the X-Ray department straight to the operating theatre as his blood pressure was low due to bleeding. His blood pressure recovered immediately the moment the vessel was ligated and the affected bowel removed, saving his life.

Can it cause cancer?

No.
However, if the diverticular disease is extensive, it can make it harder for your doctor to diagnose a small cancer hiding amongst the diverticula. Moreover, a diverticular mass can cause symptoms very similar to cancer like obstruction, rectal bleeding and an abdominal mass.

I’ve just been told I have diverticular disease. What should I do?

Nothing, if it is not causing any trouble.
If your diverticular disease is uncomplicated, you do not need surgery.
Just make sure you don’t get constipation.
Traditional medical advice is to eat lots of dietary fibre – all the usual stuff: fruits, vegetables, brown bread cereal etc. However, the benefit of fibre has been questioned recently. Avoid stimulant laxatives that increase pressure in the colon.
If your diverticular disease has led to bleeding, obstruction, perforation or a mass you will need to be admitted.
Obstruction or perforation requires emergency surgery. You may need to have a temporary colostomy (wear a bag, see my article on Colostomy).
Bleeding often settles eventually but requires medication and maybe blood transfusion. It is important to be observed on the ward as diverticular bleed can occasionally be a really, really BIG bleed!
A diverticular mass or diverticulitis without perforation can be treated with iv antibiotic injections. As Malaysians commonly get diverticulitis in the right colon (near the appendix) this can cause symptoms virtually identical to appendicitis. Nowadays, a CT scan should be able to tell the difference, thereby avoiding an unnecessary operation to look at a normal appendix. If the diverticulitis fails to settle on antibiotics or if there is perforation, surgery will be necessary.

Can the bowel be repaired?

In general, no. If there is no bleeding, obstruction or perforation the diverticular disease can be left alone. If surgery is required, the affected part of the large bowel is resected and removed. The bowel is then either joined back up or brought out as a colostomy.

How do I find out if I have diverticular disease?

We would need to look at your bowel. This could be a colonoscopy, CT scan, gastrografin enema study or at operation.
If there are many large diverticula, colonoscopy becomes more difficult and there is a small risk of bowel perforation.
Most of the time, we discover diverticular disease during colonoscopy for patients with bleeding or other symptoms.

Rectal Bleeding: Should You Be Worried?

Rectal Bleeding… Beware That Which Is Concealed!

Passing blood in the stools is a common problem. For some patients, the sight of blood in the toilet bowl is alarming but others simply blame it on piles and brush it off.

Rectal bleeding is always significant and requires further investigation and assessment by a specialist.

Why?

Well, though the commonest cause is probably piles (which are usually just troublesome rather than serious) rectal bleeding can also be due to other diseases in the large bowel.

Even if you DO have piles – (because piles are so common) it is possible for someone to have piles but be bleeding from Something Else in the large bowel.

And that Something Else could be serious….

 

Possible Causes of Rectal Bleeding
  • Anal fissure
  • Anal fistula
  • Diverticular disease
  • Colitis & Inflammatory bowel disease
  • Angiodysplasia
  • Polyps
  • Cancer

Notice the last two?

Polyps & Cancer.

You certainly do NOT want to miss picking up a hidden colon cancer, just because someone called it piles without checking out your bowel.

And as for polyps, there is quite a lot of evidence to link polyps to cancer.

So, if you have polyps, you wouldn’t want to be keeping those either.

As for the other things, Diverticular Disease can cause massive serious bleeding as well as perforation or obstruction but at the end of the day, it is totally benign and does not keep getting worse with time, like polyps and cancer.

 

What To Do If You Have Rectal Bleeding

So if you’re thinking: does rectal bleeding have anything to do with cancer?

First, don’t scare yourself unnecessarily. We won’t know until we conduct a thorough examination.

Make an appointment to see me.

I would probably advise a scope examination of the large bowel, called a colonoscopy.

If after the scope examination everything inside you is normal, we can then blame the bleeding on piles and be certain that we are not missing something potentially dangerous inside.

Then we can both breathe a sigh of relief!

 

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