It would be a supreme irony of history if Castro died of complications of surgery because he was too proud to wear a colostomy bag. LINK

Presumably this is a family blogsite, but the thought of it brings to mind all sorts of jokes that are loved by thirteen year old boys but not yet ready for prime time.

Actually, his problem has been a state secret in Cuba (which says a lot about that country). There has been a debate if he has had cancer of the stomach or bowel. From this latest report, it seems like maybe his problem was perforated bowel from diverticulitis.

If this report is true, the good news is that he doesn’t have cancer. The bad news is that complicated diverticulitis is almost as bad as having cancer.

OKay. Let me translate. What is diverticulitis.

Well, you have two intestines in your abdomen. One is like a garden hose (the small intestine). The second one is shorter, goes around in a circle like a canvas irrigation hose. Think of it as the leg of a pantyhose or leotard and you have about the right diameter. It doesn’t really absorb food as much as absorbs fluid (water etc) so when you go to the bathroom you produce solid waste.

Now in countries where there is a lot of fiber in the diet, it can push the load quite nicely (Think shoveling soft fluffy snow versus hard icy snow. There’s more to shovel but it’s lighter and easier to move). But in the West, and in places where they eat white rice, there isn’t a lot of waste to go through. This sounds nice but it means hardness or constipation.

So to push it along the large bowel has to squeeze hard. But there is a problem. The lining needs blood, and so there are tiny holes for the blood vessels to go thru, making the wall weak in these areas. And after fifty years of hard pushing, the holes get larger and an outpouching is produced. For example, get a baloon and squeeze. Notice that part of the baloon will “baloon out” thru your fingers? Well, in some parts of the body this is called a hernia, but in the intestines it is called a “diverticulum”. Thirty to fifty percent of Americans have some, and most cause no problems.

Gory photo here.

But in some people, they get inflamed or infected. Most cases are treated with an antibiotic and a light diet, more serious cases with antibiotics and IV fluid in the hospital. But serious cases can actually burst, leaving BM and germs to enter into the peritoneal cavity. Think burst appendix. Luckily, most cases are low in the left side and the body’s defenses wall off the leakage so you don’t die, but you are left with a problem…a large abcess.

The treatment of such cases is drainage of the pus pocket, removal (if possible) of the bad bowel, and then upstream diversion of fecal material.

Translation: You know how when you have a wound you have to keep it clean? Well, think of what would happen if you rubbed it several days with dirt…and that’s what happens if you allow the excrement to continue to flow by.

Usually it seals quickly and you can get away with sewing the intestine back together if the person is healthy and the infection is not bad, but in an older person or someone with health problems, it’s risky.

So you attach the intestine together, but upstream you take a loop and pull it out a separate hole to drain the excrement upstream, to keep it from going by the weaker area. You drain out a hole into a plastic bag that is glued to your side. This is embarassing, but many people cope with it fine. Usually after a couple months, you just close the hole and voila, hello bathroom, normal BM.

It sounds like Castro refused this, so they did the riskier surgery, and since he was old and didn’t heal well, his anastamosis leaked (the wound where they sewed the intestine together got infected and developed a new abcess and may have even pulled apart).

Bummer.

The big secret in all of this is that when you are sick, you don’t eat, and you don’t heal as well. They can give protein through a vein, but it’s tricky. So what we see, alas, in the elderly is a person who gets weaker and weaker and prone to infection both in the wound (skin of the abdomen and inside the abdomen) and in other places (Kidneys and lung).

The irony is that it is going to take a long time until Castro recovers, and there is a possibility that he will start going downhill in what we docs see in the old and frail and people with severe medical problems: One problem after another, with other systems starting to fail.

However, for anyone reading this article, remember: Most cases are of people healthier than Cigar smoking Castro. I have not had any patients die of diverticulitis, although I have had many who had rocky courses with their disease.

Wikipedia article is HERE

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Nancy Reyes is a retired physician living in the Philippines. Her website is Finest Kind Clinic and Fishmarket

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