What CAN I do about my severe stomach cramps?
I AM 30 and have got diverticulitis (inflammation of the gut) for the third time in four years.
However, this time there seems to be a problem. The antibiotics I was given worked, but I am getting severe cramping under my belly button — sharp pains come and go throughout the day. Ruben Rodriguez, via email.
DIVERTICULITIS is very unusual in a person of your age. I am not sure that I have ever seen it in a patient so young — it is rare enough in people in their 40s.
This is because diverticulitis develops over time and is a result of ageing of the large intestine. The culprit is usually diet — that is, a lack of fibre.
as the gut ages, it can form diverticula, small pouches in the intestinal wall, ranging from the size of an orange pip to a large grape. Most of us have a scattering of them by the time we reach late middle age, though some people have many.
Diverticula without symptoms are known as diverticulosis.
Problems occur if the contents of the gut become impacted in a diverticulum, which can trigger inflammation and infection, with symptoms of pain, fever and sometimes diarrhoea or rectal bleeding. This is known as diverticulitis. It can usually be treated with antibiotics.
Though diverticulitis can be diagnosed on the basis of the symptoms and examination of the abdomen, it can only be established conclusively by further investigation, such as a cT scan or a colonoscopy (where the lining of the colon would be examined using a tiny camera).
I’d be interested to know whether you had this kind of investigation or if your diagnosis was based on your symptoms and examination alone.
If it’s the latter then, given your age, questions must be asked about whether it is the correct diagnosis.
In my view, investigations are called for — imaging and possibly a colonoscopy if the scan didn’t provide further useful information and/or there were other symptoms (such as a change of bowel habit or rectal bleeding).
If investigations prove to be normal, the symptoms may be due to irritable bowel syndrome (IBS): the medical name for symptoms including stomach cramps, bloating, diarrhoea and/or constipation.
My view is that recurrent prescriptions of antibiotics are unwise without a proven diagnosis of diverticulitis. If there is any doubt, you should be referred to a gastroenterologist. I WAS given methotrexate for rheumatic arthritis in my knee.
While the knee responded well, within six months of taking the drug it had permanently scarred my lungs, reducing lung function — I now understand around one in 100 patients have this side-effect and that anyone prescribed methotrexate should be regularly tested for lung deterioration.
I feel the side-effects of this drug are not being highlighted along with the advantages.
John Cassie, Edinburgh. I aM sorry to hear you have been devastated by a serious side-effect of your treatment.
You are right — it is important that patients see the downside, as well as the upside, of drugs, and I am grateful to you for writing.
Methotrexate is a chemotherapy drug developed to treat cancer.
at much lower doses (7.5 mg to 25 mg once a week), it is used as a long-term therapy for rheumatic arthritis (or rheumatoid arthritis, where the immune system attacks the joints, causing inflammation) and the skin condition psoriasis (another disease where the immune system causes the damage).
Methotrexate is chemically related to folic acid, one of the B vitamins that plays a key role in the ability of cells to grow and divide. The drug works by replacing the folic acid molecule, inhibiting this ability.
This is particularly damaging to the cells that rapidly divide, such as bone marrow cells and cancer cells, causing them to die off.
But despite knowing how the drug works within cells, we don’t understand how it improves the inflammation and damage in rheumatoid arthritis.
The most common side-effects are rarely life-threatening. Most patients on long-term therapy will, at some stage, experience gastrointestinal problems (nausea, loose stools), soreness of the mouth (known as stomatitis), a rash, headache, fatigue, hair loss or slight fever.
The more severe adverse effects — which can occur in high or lowdose treatment — are potentially very serious: these include liver and lung damage.
The drug can also interfere with bone marrow production ( in turn, affecting the production of red and white blood cells, leading to severe anaemia and inability to combat infection) and raise the risk of lymphoma (cancer of the lymphatic system).
Lung damage is most likely to occur after weeks or months of lowdose methotrexate treatment. Most studies show this occurs in between 1 and 8 per cent of patients.
There are three types of complication: inflammation, infection and lymphoma affecting the lungs.
another side-effect is pulmonary fibrosis, or scarring of the lung, as you have experienced.
The risk factors for methotrexate lung damage include age (greater than 60) and diabetes. another risk factor may be pre- existing lung disease. Many of the side- effects, such as stomatitis, can be prevented by giving folic acid as a supplement to rescue normal cells from the methotrexate toxicity without altering its treatment benefit.
However, folic acid doesn’t reduce the risk of lung damage. This usually occurs in the first year of treatment, though studies have shown the side- effect may take years to occur.
The symptoms include fever, cough and breathlessness. These merit urgent investigation by X-ray or cT scanning, lung function tests and even biopsy.
Given that underlying lung fibrosis may be a risk factor for damage caused by methotrexate, most specialists organise a chest X-ray before prescribing it long-term.
ASfor whether patients should be regularly tested for lung deterioration, in fact, it has not been scientifically proven this does pick up any early damage.
Though, as you say, it does make good sense — possibly in establishing a baseline of the patient’s lung function before starting therapy, particularly as this might detect underlying lung disease not previously suspected.
The decision to treat a patient with methotrexate must balance the severity of the condition being treated with the potential for serious side- effects such as you have suffered.
If methotrexate is prescribed, there must be continued, repeated discussions at every opportunity of the potential for complications.
WRITE TO DR SCURR
TO CONTACT Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email drmartin@dailymail.co.uk — including contact details. Dr Scurr cannot enter into personal correspondence. His replies cannot apply to individual cases and should be taken in a general context. Always consult your own GP with any health worries.