Etiology and pathogenesis of diverticulosis coli: a new approach.

1988May
Med. Hypotheses
Med Hypotheses 1988 May;26(1):17-20

The paper describes a hypothesis as to the etiology and pathogenesis of diverticulosis coli. Colonic diverticulosis develops as a result of excessive straining at defecation due to habitual bowel emptying in a sitting posture, which is typical of Western man. The magnitude of straining during habitual bowel emptying in a sitting posture is at least three-fold more than in a squatting posture and upon urge. The latter defecation posture is typical of latrine pit users in underdeveloped nations. The bowels of Western man are subjected to lifelong excessive pressures which result in protrusions of mucosa through the bowel wall at points of least resistance. This hypothesis is consistent with recent findings of elastosis of the bowel wall muscles, the distribution of diverticula along the colon, as well as with epidemiological data on the emergence of diverticulosis coli as a medical problem and its geographic prevalence.

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1988May
Med. Hypotheses
Med Hypotheses 1988 May;26(1):17-20

The paper describes a hypothesis as to the etiology and pathogenesis of diverticulosis coli. Colonic diverticulosis develops as a result of excessive straining at defecation due to habitual bowel emptying in a sitting posture, which is typical of Western man. The magnitude of straining during habitual bowel emptying in a sitting posture is at least three-fold more than in a squatting posture and upon urge. The latter defecation posture is typical of latrine pit users in underdeveloped nations. The bowels of Western man are subjected to lifelong excessive pressures which result in protrusions of mucosa through the bowel wall at points of least resistance. This hypothesis is consistent with recent findings of elastosis of the bowel wall muscles, the distribution of diverticula along the colon, as well as with epidemiological data on the emergence of diverticulosis coli as a medical problem and its geographic prevalence.

1989Feb
Med. Hypotheses
Med Hypotheses 1989 Feb;28(2):71-3

Primary (simple) constipation is a consequence of habitual bowel elimination on common toilet seats. A considerable proportion of the population with normal bowel movement frequency has difficulty emptying their bowels, the principal cause of which is the obstructive nature of the recto-anal angle and its association with the sitting posture normally used in defecation. The only natural defecation posture for a human being is squatting. The alignment of the recto-anal angle associated with squatting permits smooth bowel elimination. This prevents excessive straining with the potential for resultant damage to the recto-anal region and, possibly, to the colon and other organs. There is no evidence that habitual bowel elimination at a given time each day contributes considerably to the final act of rectal emptying. The natural behavior to empty the bowels in response to a strong defecation reflex alleviates bowel emptying by means of the recto anal inhibitory reflex.

The aim of the study was to compare the straining forces applied when sitting or squatting during defecation. Twenty-eight apparently healthy volunteers (ages 17-66 years) with normal bowel function were asked to use a digital timer to record the net time needed for sensation of satisfactory emptying while defecating in three alternative positions: sitting on a standard-sized toilet seat (41-42 cm high), sitting on a lower toilet seat (31-32 cm high), and squatting. They were also asked to note their subjective impression of the intensity of the defecation effort. Six consecutive bowel movements were recorded in each position. Both the time needed for sensation of satisfactory bowel emptying and the degree of subjectively assessed straining in the squatting position were reduced sharply in all volunteers compared with both sitting positions (P < 0.0001). In conclusion, the present study confirmed that sensation of satisfactory bowel emptying in sitting defecation posture necessitates excessive expulsive effort compared to the squatting posture.

1976Dec
Postgrad Med
Postgrad Med 1976 Dec;60(6):76-81

Colonic diverticula result from herniation of the mucosa through weak spots in the muscular wall. Clinically manifested diverticulitis has been thought to have its pathologic basis in an abscessed diverticulum obstructed by a fecalith, but studies of resected sigmoids have failed to produce evidence to support this view. Instead, the outstanding lesion was found to be a perforation in the fundus of a diverticulum, with surrounding peridiverticular or pericolic inflammation. Another surprising finding in pathologic studies was that one out of three sigmoids resected for "diverticulitis" showed no inflammation in or around the diverticula, but the wall of the sigmoid was impressively thickened. This type of diverticulosis, which is frequently symptomatic, has been referred to as painful diverticular disease or spastic colon diverticulosis. Diverticula without muscle thickening are usually asymptomatic, and the condition is referred to as diverticulosis or simple massed diverticulosis. It is uncertain whether the two types have a similar pathogenesis. High intrasigmoid pressures, abnormalities of sigmoid musculature, low-fiber diet, and psychologic stress are thought to be important factors in the formation of diverticula.

2004Apr
J. Clin. Gastroenterol.
J Clin Gastroenterol 2004 May-Jun;38(5 Suppl 1):S11-6

Left-sided diverticulosis coli is a common condition in western communities, with 30% to 50% of adults over the age of 60 being affected. It predominantly involves the sigmoid colon. The diverticula (pseudodiverticula) are pockets of mucosa bounded by muscularis mucosae and invested with a thin layer of submucosa, that are forced out through weak points in the muscularis propria, the tips ending in the colonic subserosa. The weak points in the muscle coat are the sites of entry of the nutrient vessels of the colonic mucosa. Diverticulosis is attributed to increased colonic intraluminal pressure while straining at stool in individuals who eat low-fiber diets. Muscular hypertrophy, shortening of the bowel, and thickened mucosal folds due to mucosal redundancy are characteristic of this condition. Complications of diverticulosis include bleeding, diverticulitis, peridiverticular abscess, perforation, stricture, and fistula formation. However, most individuals with diverticulosis are asymptomatic, without evidence of complications. Mucosal changes in the diverticula in uncomplicated diverticulosis include an increased lymphoid infiltrate, development of lymphoglandular complexes, mucin depletion, mild cryptitis, architectural distortion, Paneth cell metaplasia, and ulceration. The mucosa of the remainder of the sigmoid colon (ie, the nondiverticular mucosa) is usually normal, but in about 1% of cases it has features that are indistinguishable from ulcerative colitis or from Crohn's disease (segmental colitis associated with diverticular disease, SCAD). Such cases pose a difficult diagnostic challenge as patients with SCAD respond to medical or surgical therapy for diverticular disease, whereas those with ulcerative colitis or Crohn's disease will develop other manifestations of their disease in time and require different treatment. In SCAD, the mucosal changes are confined to the area of diverticulosis; therefore, histologic evaluation of the rectum (which is unaffected by diverticulosis) and more proximal bowel can be helpful in the differential diagnosis.

Etiology and pathogenesis of diverticulosis coli: a new approach.
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