Lack of care and fibre a lethal combination
Bloody diarrhoea was a common occurrence for Henry Wong, 53.
He had suffered from a type of inflammatory bowel disease called ulcerative colitis for a decade. However, despite the cramping, abdominal discomfort and diarrhoea associated with the disease, Wong resisted taking proper care of his health. He was much too busy managing his factory in China.
Although several medications were available to help control the inflammation in the colon, Wong (real name withheld for patient confidentiality reasons) chose to use only oral steroids to manage his condition.
He failed to keep a close watch over his diet. While ulcerative colitis patients are advised to avoid foods very high in fibre, such as bran, beans, nuts and seeds, he took it as licence to avoid fruits and vegetables altogether and indulged in a diet high in meat and low in fibre.
One morning, the sight of his diarrhoea shocked Wong badly. Instead of the bright red blood that was he was accustomed to seeing in his stool, he saw a black, tarry mess.
He hurried to the Hong Kong Sanatorium & Hospital to see his doctor, Dr Annie Chan On-on, director of the Gastroenterology & Hepatology Centre.
When stool turns black, it usually means that the blood in the stool has been in the gastrointestinal (GI) tract for some time.
As ulcerative colitis affects the large intestine and rectum, bleeding caused by this condition often results in fresh-looking blood, because the blood does not stay in the body for long before it is expelled with the stool.
Chan first thought that the bleeding was occurring somewhere higher up in the GI tract. She ordered a gastroscopy for Wong.
A thin, fibre-optic instrument was inserted via Wong's mouth and throat into his stomach and duodenum (the first part of the small intestine). Chan found no sign of trouble there.
But Wong continued to purge and was getting weaker. Barely hours after his admission into hospital, he started to feel weak and dizzy. His systolic blood pressure plunged from 120mmHg to 80mmHg.
Tests showed that the internal bleeding was severe - he had already lost a third of his body's blood. Instead of 15 grams of haemoglobin per decilitre of blood, Wong's reading hovered around 10g/dl.
Chan gave him a blood transfusion immediately, but she also needed to locate the site of bleeding right away.
She used a red blood cell nuclear scan to track down the site of the bleeding. A small amount of radioisotope, a radioactive substance, was injected into Wong to tag his red blood cells. A scan then told Chan how the cells were behaving inside Wong's body.
Blood was leaking into his caecum, a pouch located where the small intestine, large intestine and appendix meet. Because it is far away from the anus, the blood would have darkened while it travelled down the full length of the large intestine and out of the body.
While Chan now knew the location of the bleeding, she did not know why. A colonoscopy was done using an endoscope - a thin, flexible tube with a camera on the end - and Chan was able to have a clear view of Wong's large intestine. Inside, she found numerous pouches in the wall of Wong's ascending colon and caecum.
These pouches are called diverticula. Although not proven, the cause of diverticulosis (the condition of having diverticula) is widely thought to be linked to a low-fibre diet.
The condition is more common in Western societies, where processed foods and low-fibre diets are commonplace. About 10 per cent of Americans over 40 years of age suffer from it.
Low-fibre diets often cause constipation, and straining to eliminate stool can cause weak spots in the colon to bulge out, thereby creating the diverticula. However, no one knows what actually causes these pouches to form.
In Wong's case, several of the diverticula were actively bleeding - blood vessels in the weakened walls of the pouches had burst and were leaking copious amounts of blood.
Using the endoscope, Chan injected adrenaline directly into the bleeding sites to cause the blood vessels to constrict and to close. The bleeding promptly stopped.
Wong was very lucky that the bleeding in the diverticula had been arrested in time. Chan says that the rate of blood loss could have been fatal.
Other complications are also possible. The diverticula can become inflamed in a condition called diverticulitis, resulting in fever, chills, abdominal pain and nausea. A large enough diverticulum can burst and perforate the intestinal wall. The diverticula can also become infected as bacteria collect in the pouches, which can potentially lead to the development of abscesses that would need to be drained by a doctor. Perforated diverticula could also leak pus into the abdominal cavity.
The damage caused by infection can also cause tissue to stick together abnormally, or even result in partial or total blockage of the intestines. Faeces can even become trapped in the pouches and become impacted.
This wake-up call made Wong realise that he needed to better manage his underlying condition, and he was finally willing to make the necessary changes to his medication and diet.
Chan gave him a topical medicine in an enema form that he had to administer daily to control the ulcerative colitis in the left side of his colon, and he remained on a low dose of steroids. With his newfound compliance, Wong's condition improved, and the bouts of bloody diarrhoea diminished.