|Year : 2015 | Volume
| Issue : 1 | Page : 18-21
Diverticular disease of the colon in Calabar, Nigeria: A case report and review of the African literature
Grace B Inah1, Gbenga A Kajogbola2, Rowland Ndoma-Egba3
1 Department of Radiology, University of Calabar, Calabar, Nigeria
2 ASI UKPO Diagnostics Medical Centre, Calabar, Nigeria
3 Department of Surgery, University of Calabar, Calabar, Nigeria
|Date of Acceptance||21-Mar-2015|
|Date of Web Publication||20-Jul-2015|
Grace B Inah
Department of Radiology, University of Calabar, Calabar
Source of Support: None, Conflict of Interest: None
Diverticular disease of the colon, though common in the western world, was thought to be rare in sub-Saharan Africa. Studies have however shown that it may not be uncommon in Nigeria. This is a case report of a 61-year-old male patient who presented with rectal bleeding in Calabar, South-South Nigeria. Clinical examination revealed mild pallor and blood stained hard stool in the rectum. Barium enema showed multiple diverticular along the whole colon but sparing the rectum. Diagnosis of diverticular disease of the colon was made. Diverticular disease may be more widespread in Nigeria than previously thought and should be considered an important differential diagnosis in rectal bleeding.
Keywords: Diverticular disease, Nigerian adult, rectal bleeding
|How to cite this article:|
Inah GB, Kajogbola GA, Ndoma-Egba R. Diverticular disease of the colon in Calabar, Nigeria: A case report and review of the African literature. Niger J Surg Sci 2015;25:18-21
|How to cite this URL:|
Inah GB, Kajogbola GA, Ndoma-Egba R. Diverticular disease of the colon in Calabar, Nigeria: A case report and review of the African literature. Niger J Surg Sci [serial online] 2015 [cited 2021 Oct 18];25:18-21. Available from: https://www.njssjournal.org/text.asp?2015/25/1/18/161220
| Introduction|| |
Diverticular disease of the colon refers to small out-pouchings from the colonic lumen due to mucosal herniation through weakened areas in the muscle layer at the point of entry of blood vessels that supply the colon.  It is an acquired adult disease typically found in developed countries and thought to be rare among the black population. , The cause is not known though it has been reported to occur due to persistently raised intra-colonic pressure and is associated with constipation.  It is also known to be associated with a low residue diet.  It has been reported that it is a 20 th century problem and has been associated with processed food and food refinement in industrialized countries. , Data show a substantial rise in colonic diverticula within the past few decades with prevalence increasing with age, from <10% in people younger than 40 years to 50-66% in patients older than 80 years in the developed countries. ,,
Though the diverticular disease was considered uncommon in African and Asian countries, recent studies, however, show a rise in its prevalence in the African population. ,,
Only very few cases have been reported in three centers in Nigeria-Ibadan  and Ife  in the south-west, and Port-Harcourt  in the South-South region of Nigeria. Apart from the 1998 report in three siblings who were earlier domiciled in the industrialized world but reported in the South-South,  no case has since been reported there.
In the majority of cases, there was no clinical suspicion before the radiological diagnosis. It may well be that cases of the diverticular disease are being missed in the country due to low index of suspicion.
We report here a case of diverticular disease in a 61-year-old man who has lived all his life in South-South Nigeria and presented at the out-patient department (OPD) of the University of Calabar Teaching Hospital with rectal bleeding and was referred to the Radiology Department for barium enema studies. We also review the literature for this "rare" condition in Nigeria.
| Case Report|| |
A 61-year-old Nigerian male and retired civil servant presented at the OPD of the University of Calabar Teaching Hospital, Calabar, Nigeria with a 3-month history of passage of bloody stool without mucus and 1-week history of pain at both iliac fossae. The pain started insidiously at the left lumbar region, and had no aggravating or relieving factors. The stool contained frank blood, was well formed but did not contain mucus. There was no past medical history of fever, rigors or peptic ulcer disease. He had sought medical advice initially at a private hospital before he was referred to the Teaching Hospital. He is of the Efik ethnic group. There was no associated history of weight loss. He was slightly pale, anicteric, afebrile with normal respiration, pulse and blood pressure. Rectal examination revealed blood stained hard stool in the rectum but no masses. The full blood count was Hb 11.0 g/dl and white blood cells - 72,000/mm 3 (granulocytes - 55%; lymphocytes 30%; monocytes 15%). The scout film of the abdomen revealed no abnormalities except multiple osteophytes in the lumbar vertebrae [Figure 1]. Radiographs following the barium enema examination showed: Multiple diverticula affecting the ascending, transverse, descending, and sigmoid sections of the colon, sparing the rectum [Figure 2] and a normal presacral space [Figure 3]. A diagnosis of diverticular disease of the colon and lumbar spondylosis was made. The management of the patient by the clinician included high fiber diet and antibiotics. Colonoscopy was recommended for the patient who failed to comply for various logistic reasons. He was seen again at follow-up were he gave the explanation for not being able to do so, but symptoms had improved on the prescribed management.
|Figure 1: Scout film of the abdomen showing osteophytes of the lumbar vertebrae|
Click here to view
|Figure 2: Barium enema showing multiple out-pouchings of the entire colon sparing the rectum|
Click here to view
|Figure 3: Barium enema showing out-pouchings at the descending and sigmoid colon. The presacral space is preserved|
Click here to view
In general, management of the diverticular disease is related to Hinchey staging of its severity. It is modified as follows:
Stage 0: Simple diverticulitis and severe hemorrhage. Resuscitate with whole blood, intravenous fluids, and antibiotics. Hemorrhage settles spontaneously. Inflammation usually resolves.
Stage 1a and 1b: The management at this stage is principally conservative in the emergency situation. Here, with resuscitation using intravenous fluids, nil per oral, antibiotics and resting the bowels, the acute inflammatory phase soon settles down.
Stage 2: Pericolic abscess and pelvic abscess are present. Laparoscopic drainage, intravenous fluids and antibiotics are administered.
Stage 3 and 4: Purulent or fecal peritonitis are present. For this stage, resuscitation with intravenous fluid, antibiotics and surgical exploration are required. Hartman's procedure is preferred. With the availability of better equipment including laparoscopic surgery, the one-stage procedure is becoming the norm. The extent of resection is controversial because of the fear of recurrence. Current opinion suggests that where the sigmoid colon is involved, resection should extend to the upper rectum.
Follow-up by colonoscopy is necessary to continuously exclude the presence of malignancy in view of the symptoms. It is also important to see the patients regularly to evaluate the progress of the disease and hence make a decision about possible prophylactic resection and anastomosis.
| Discussion|| |
Diverticulosis has been labeled a disease of western civilization because of its striking geographic clustering. , The disorder is said to be rare in rural Africa and Asia, with the highest prevalence seen in the United State of America, Europe, and Australia. , In the western world, diverticular disease has been noted to be a disease of adults and is found in two-thirds of autopsy population in those over 80 years. 
In the past, it was reported that the diverticular disease was unknown in the African, but more recent reports show that the disease is on the rise in the African population.  Madiba and Mokoena  reported 20 cases in a period of 5 years in South African blacks, while Kiguli-Malwadde and Kasozi  reported 31 cases in 5 years in Uganda. Baako  reported 37 cases over 3 years in Ghana.
Only very few cases of diverticular disease have been reported in three centers in Nigeria. Ogunbiyi  reported 11 cases from 603 barium enema examinations performed at University College Hospital, Ibadan. Ihekwaba  also reported 15 cases of colonic diverticular disease managed in the same hospital over the same period. Alatise et al.  presented 40 cases of the disease managed over 5 years at Ife in Nigeria. These were all in the southwestern region of Nigeria. Omojola and Mangete  reported diverticular disease of the colon in three Nigerian siblings in Port-Harcourt, South-South Nigeria. The current case is the first report in Calabar, Nigeria since the 1988 report on three siblings in Port-Harcourt. All these cases were seen in the adult population as in western reports. ,,
The reasons proffered for the rising incidence in the black population include, amongst others, changing dietary pattern. Western diet, characterized by processed low residue diet is said to predispose to the disease.  The Nigerian society is in a transitional phase with more persons adopting the western lifestyle and western diet. This may explain the emerging trend of diverticular disease in Nigeria. In addition, availability of diagnostic facilities and competence may also explain the emerging reports. It is important to note that in virtually all the cases reported in Nigeria, there was no clinical suspicion before radiological diagnosis. ,, In the western world, diverticular disease is a more common cause of lower gastro-intestinal bleeding than malignancies of the gut and practitioners have higher index of suspicion. 
The most common presentation among African patients is rectal bleeding as shown in our index case. ,, In a study in the USA, diverticular disease was found to be the commonest cause of lower GIT bleeding. 
The anatomical location of the diverticular disease in Asian population tends to be right sided in contrast to American, European and Australian series, which show a left sided preponderance.  Most African studies showed the preponderance of the disease on the right colon as in the Asian population. ,,, Other studies showed the disease involving the entire colon. ,,
Genetic factors have also been implicated in its etiology in Africa. Omojola and Mangete  in Port-Harcourt, reported a case series of three siblings, all having the diverticular disease, who previously lived in the industrialized world. Schlotthauer  also, reported seven cases of the diverticular disease in a family of nine siblings presenting between 49 and 70 years of age.
The diagnostic modalities for investigating the disease include barium enema, colonoscopy and computerized tomography (CT).  Current evidence shows that compared with Barium enema, only about half of the colonic diverticular can be detected by colonoscopy.  Colonoscopy is usually used to diagnose colonic diverticular bleeding. Identification of bleeding site of colonic diverticula on colonoscopy enables endoscopic treatment with clips, epinephrine injection, heat probing ligation. These modalities can circumvent complications such as hemorrhagic shock and re-bleeding.
By contrast, Barium enema can clearly detect colonic diverticula because barium fills the entire colon in diverticulosis.
Computed tomography is used for the diagnosis of extra-colonic abnormalities associated with complicated diverticular disease.  CT should be the initial study in acutely ill patients, especially when the clinical features are atypical for diverticulitis. Improvements in endoscopic technology have made it possible for gastroenterologists not only to diagnose sources of bleeding accurately but also achieve hemostasis at bleeding vessels, and adherent clots and other bleeding sites. , The diagnostic modality of choice is abdominal CT.  However, CT is limited in its use in developing countries due to nonavailability of the test and where available, prohibitive cost of the investigation. In Africa, where facilities are not readily available, a combination of barium enema and colonoscopy are recommended for diagnosis.
Our patient falls within the age range of patients elsewhere, presented with rectal bleeding and had the disease involving almost the entire colon like in other African studies.
| Conclusion|| |
Diverticular disease, though considered rare in Africans, is being reported more and more in the literature probably due to the increase of the adoption of the western lifestyle. It may well be that cases of diverticular disease of the colon are being missed in the country due to failure to report, low index of suspicion and dearth of diagnostic facilities. It is very important that clinicians practicing in Africa bear this in mind when they encounter patients with rectal bleeding, iliac fossa pain and change in bowel habit. Radiologist should also look for this disease in patients referred to them with these symptoms even when there is no clinical suspicion.
It is crucial that health education in Africa should encourage the population to continue with indigenous diets rich in fiber and discourage the adoption of western life-style hook, line and sinker.
| Acknowledgement|| |
We wish to thank Prof. E. E. Ekanem for critiquing the manuscript before submission for publication
| References|| |
Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004;363:631-9.
Floch MH, White JA. Management of diverticular disease is changing. World J Gastroenterol 2006;12:3225-8.
Parra-Blanco A. Colonic diverticular disease: Pathophysiology and clinical picture. Digestion 2006;73 Suppl 1:47-57.
Painter NS, Burkitt DP. Diverticular disease of the colon: A deficiency disease of Western civilization. Br Med J 1971;2:450-4.
Painter NS, Burkitt DP. Diverticular disease of the colon, a 20 th
century problem. Clin Gastroenterol 1975;4:3-21.
Parks TG. Natural history of diverticulitis disease of the colon. Clin Gastroenterol 1975;4:53-69.
Kiguli-Malwadde E, Kasozi H. Diverticular disease of the colon in Kampala, Uganda. Afr Health Sci 2002;2:29-32.
Madiba TE, Mokoena T. Pattern of diverticular disease among Africans. East Afr Med J 1994;71:644-6.
Ogunbiyi OA. Diverticular disease of the colon in Ibadan, Nigeria. Afr J Med Med Sci 1989;18:241-4.
Alatise OI, Arigbabu AO, Lawal OO, Adetiloye VA, Agbakwuru EA, Ndububa DA. Presentation, distribution pattern, and management of diverticular disease in a Nigerian tertiary hospital. Niger J Clin Pract 2013;16:226-31.
Omojola MF, Mangete E. Diverticula of the colon in three Nigerian siblings. Trop Geogr Med 1988;40:54-7.
Roberts PL, Veidenheimer MC. Current management of diverticulitis. Adv Surg 1994;27:189-208.
Reinus JF, Brandt LJ. Vascular ectasias and diverticulosis. Common causes of lower intestinal bleeding. Gastroenterol Clin North Am 1994;23:1-20.
Loyal D, Christopher's Textbook of Surgery. Philadelphia: W.B. Saunders; 1968. p. 718-20.
Baako BN. Diverticular disease of the colon in Accra, Ghana. Br J Surg 2001;88:1595.
Ihekwaba FN. Diverticular disease of the colon in black Africa. J R Coll Surg Edinb 1992;37:107-9.
Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: A population-based study. Am J Gastroenterol 1997;92:419-24.
Segal I, Leibowitz B. The distributional pattern of diverticular disease. Dis Colon Rectum 1989;32:227-9.
Rajendra S, Ho JJ. Colonic diverticular disease in a multiracial Asian patient population has an ethnic predilection. Eur J Gastroenterol Hepatol 2005;17:871-5.
Mokoena T, Madiba TE. Haemorrhage - The main presenting feature of diverticular disease of the colon in blacks. S Afr Med J 1994;84:83-5.
Schlotthauer HL. Familial diverticulosis of the colon; report of seven cases in one family of nine persons. Ann Surg 1946;124:497-502.
Niikura R, Nagata N, Shimbo T, Akiyama J, Uemura N. Colonoscopy can miss diverticula of the left colon identified by barium enema. World J Gastroenterol 2013;19:2362-7.
Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: Results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999;13:430-6.
Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988;95:1569-74.
Jensen DM, Machicado GA. Management of severe lower gastrointestinal bleeding. In: Barkin JS, O'Phelan CA, editors. Advanced Therapeutic Endoscopy. 2 nd
ed. New York: Raven Press; 1994. p. 201-8.
[Figure 1], [Figure 2], [Figure 3]