A half-dozen people milled uncertainly around a woman on a stretcher. One of them asked, "A ver, quién la va a atender, que está mala."
(Who will see to her? She is in pain.) They scanned the harshly lighted emergency room for someone to trust. The spiky rhythms of their Argentine accents were unmistakable."Buenas noches,"
I said. "¿Cómo les puedo ayudar?"
(How may I help you?)
"This is my mother, Carmen Beneto," her daughter said, taking his hand. Beneto, although pale and obviously in pain, inclined her head with understated dignity.
"She has been sick for a week but only just let us know."
"It wasn't so bad. Until now," she said, smiling ruefully.
Jackie, the triage nurse, took her vital signs. "Temp's 102, pulse 130," she said, giving me her this-one-is-sick look.
We wheeled her into a slot.
"Where are you from?" I asked.
I examined her. Her lungs were clear: no obvious pneumonia. Her heart was normal. "I've never been. Beautiful?"
"Very," she replied with feeling.
I listened at her abdomenâ tapping the tip of my right middle finger against the last knuckle of the left. "How old are you?"
"Does this hurt?"
"Yes, I must admit it does," she replied, wincing to a very gentle tap.
"Where does it feel the worst?"
"Here, on the left, lower down."
"Well, it began, softly, on the plane."
"A week ago?"
"I'm afraid, yes. Sometimes it would retreat a little."
"Any nausea, vomiting?"
"No. I tried to keep eating well. I didn't want to worry anyone."
"What did you do today?"
"Today she walked across the Brooklyn Bridge," her daughter interjected.
By now I was convinced she had a belly full of pus caused by an infection of the intestinal wall. Incredulous, I asked, "The whole way?"
"It is captivating, " she said sheepishly.
"What do you do?" I inquired.
"I am a professor of Spanish literature at the University of Buenos Aires," she said.
"Did you know Jorge Luis Borges?" I asked teasingly.
"Of course." She smiled. "What conversations we had together."
"You knew Jorge Luis Borges? Who wrote about libraries that branch off to infinity? Where novels get rewritten in the particle of time it takes a firing-squad bullet to fly?"
"His library would beguile you for a lifetime. And now, my doctor, what diagnostic branches are you exploring?"
"By your exam and symptoms . . . there may be peritonitis."
"Ah," she said thoughtfully, as if presented with a rare ornithological specimen. "I imagine this is serious."
"Yes. It probably stems from a diverticulitis. In the colon."
"You are not sure?"
"Doctors should never be sure too soon. A CT scan will help."
No disease better proves that we are what we eat than diverticulitis. Virtually unheard of before 1900, the condition has emerged as one of the booby prizes of progress. A diverticulum (diverticula
is the plural) is a small pouch protruding from the colon—or any hollow organ—that shouldn't be there. Divertic-ulosis is the condition of having many of these pouches. And diverticulitis is what happens when the pouches get infected.
The rise of the disease in England around World War I has been attributed to changes in the way flour was made some 30 years earlier, when mills began removing two-thirds of the wheat's fiber during processing. Other evidence also supports a link to a lack of dietary fiber. Diverticulitis is nonexistent in rural sub-Saharan Africans, who eat a fiber-rich diet, yet it is common among the city dwellers of Johannesburg. Studies of rats have shown that those fed on a low-fiber diet have five times the incidence of diverticulosis as those fed a roughage-rich diet.
Draped around the abdomen like an inverted U, the colon's main job is to absorb water from liquid stool before it is expelled. How fiber helps keep it healthy is unclear. One possible explanation is that a high-bulk diet expands the colon, whereas a low-bulk diet narrows it. And a narrowed colon must generate higher pressures per square inch to move its contents along. Eventually that pressure may force the colon to bulge out at weak spots, where nourishing blood vessels penetrate the colon wall. Over time, these bulges enlarge into true blind sacs—diverticula. It is no coincidence that most (but not all) diverticula occur in the descending left colon, where forces are greatest.
By themselves, the little sacs are harmless. But the blood vessels alongside them can rupture and bleed. More dangerous still, bacteria-laden stool can leak through the intestinal wall onto the outer surfaces of the intestines, the peritoneum.
Not surprisingly, diverticulosis is most common among the elderly. But it can also occur in young people. I once examined a 24-year-old man complaining of two days' pain in the left lower quadrant of his abdomen. He had had no fever, nausea, vomiting, or diarrhea—in short, no symptoms of an intestinal disorder. I decided he had pulled an abdominal muscle and sent him home. The next day another doctor sent him to a surgeon, whoâ to my dismayâ found a large diverticular abscess.
Diverticulitis is deceptive and insidious. About a fifth of diverticulosis sufferers will, on occasion, complain of abdominal pain and a change in bowel function. The challenge for doctors is to identify those who harbor a true infection. The process begins when a weakened sac bursts, spilling feces into the abdominal cavity. Even then, fever and an elevated white blood cell count may be absent for days. Pain may be vague and hard to localize or arise deceptively on the right. Luckily, the body can often wall off the leaking bacteria and suppress infection. But if one ignores the early symptoms, and the spillage is either large or spreads quickly, the result can be a deep-seated abscess, peritonitis, or both.
Beneto," I said, holding up the film of her CT scan, "there appears to be an abscess. Here, where the left colon begins its descent to the rectum."
The professor and her daughter studied the white-on-black images. The circle with the moth-eaten interior—the diverticular abscess—was unmistakable. Gravely, she asked, "I suppose this will not resolve with antibiotics alone?"
I shook my head.
"Does that mean the artificial rectum? And the bag?"
"Very likely, I am afraid. But it will not be permanent. In several months the colon can be reconnected."
"There is no other way?"
I said nothing. She understood.
Less dire cases of diverticulitis can often be cured with oral antibiotics and a liquid diet, which relieves the pressures on the colon. Moreover, some abscesses can frequently be drained by using a CT scan to determine where to slip the needle through the skin or rectum. But for my stoic professor, it was too late. There was too much pus and too much inflammation. Peritonitis, even treated with latest-generation antibiotics, can kill a healthy 30-year-old. And although cutting out a segment of colon and reattaching the ends is technically easy, the repair could get badly infected and spill more bacteria-rich stool. The safest course is to perform a colostomy: Excise the infected portion of colon, then create an artificial exit for the upper colon that remains. The resulting portal looks a bit like a fish's mouth emerging from the water.
When the surgeons cut into Professora Beneto's abdomen, foul-smelling, greenish-yellow pus oozed out. To cleanse the infected area, they repeatedly poured saline into the abdominal cavity and suctioned it away. After draining the abscess, they removed about three feet of colon, then created the artificial opening. Throughout the operation, Professor Beneto's vital signs stayed rock-stable.
"Like a 20-year-old's," one of the surgeons told me later.
Four days later I visited the professor. She was sitting up, sipping fluids, surrounded by her family. She would not return to solid foods until well after her colon had healed.
"Ah, doctor," she said, lifting a hand in greeting, "What do you think Jorge Luis would remark on this business of seeing one's insides on the outside?"
"He would say beautiful bridges can indeed nurture the soul," I replied. "But he might add that the body sometimes needs to get itself to the doctor."
For an overview of diverticulitis, see http://merck.praxis.md/bpm/ bpmviewall.asp?page=CPM02GA363.