text:
Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Monday, September 10, 2007
Ken's Colon
Poor Ken Griffey, Jr. Seems like his body keeps letting him down, one thing after another. I was there at the beginning of his career in Seattle, and he was a joy to watch. Now [I began this post a few months ago] he's been having trouble with diverticulitis for the past several months. Guy his age? He's gonna need it out one of these days.
Among the design flaws of the human body (the hemorrhoidal veins and pilonidal dimples are also on the list) is the fact that the blood supply to the colon travels on the outer surface, feeding the inner lining (the mucosa) by sending little branches diving through the muscle layer to get there. Each hole-for-an-artery in the muscle represents a weak spot through which the mucosa can pooch outward, forming a pocket known as a diverticulum. In some people, it happens.
In the US, more than a third -- maybe half -- of people over fifty have at least a few diverticula. Most never know it. For some, it becomes a problem. Unusual in someone his age, Ken Griffey's diverticulitis is likely, according to the odds, to be a recurring problem. Instead of the occasional pocket here and there, I'm guessing his colon shows the typical sawtooth pattern of extensive diverticulosis. (Terminology time: having diverticula is called "diverticulosis, not in and of itself always a problem. Having an infected diverticulum is "diverticulitis. A problem.)
The problems diverticula can cause are in two categories: bleeding, and infection. Because, by developmental definition, each diverticulum abuts an artery, it's easy to understand why inflammation or irritation in one can cause erosion into and bleeding from the vessel. Similarly, infection of a little pocket containing hardened stool isn't hard to figure, either. ("Inspissated" is the medical term for some substance that gets dried out and hardened, and it happens to be among my favorites of words learned in medical school. All those sweet and steamy sibilants, stippled by a percussive "p" and a tensile "t." Inspissated. Great word. And "bezoar." Already wrote about that, but feel like saying it again. Bezoar.)
Surgery for diverticular disease involves navigating numerous grey-zones, and a few of crystal clarity. Seeing someone exsanguinate is a sure signal to swing the scalpel. Bleeding from a diverticulum can be steady and severe. But even when the need to operate is obvious, the target may not be; so the extent of the operation can be in doubt, going in. Less likely nowadays, with better imaging and shorter delays in obtaining it, going to the OR with uncertainty as to which part of the colon contains the bleeder wasn't rare only a few years back. And the nature of diverticular bleeding is that it can stop and start randomly. The stopping, perversely, seems to like to happen just as the patient enters the imaging suite. So, short of unrelenting bleeding, there's a certain degree to which deciding when and if to operate is a crap-shoot. (Pun intended? You decide.)
By far the most common site for diverticula, and for bleeding there-from, is the sigmoid colon. (This probably has to do with pressure generated in having a bowel movement, and is why constipation and diverticulosis have an association; and why high fiber intake is really good for people who have it.) There are times when you find yourself in the patient's belly with a less than clear idea of where the bleeding is coming from: a negative or equivocal imaging study; no time to have gotten one. Then what? It might depend on how localized or extensive that person's diverticula are.
You might resect the sigmoid if it has the dense concentration that one often sees; maybe even send it right to the lab to see if the pathologist can identify the culprit pocket. Some people advocate dividing the colon at about its half-way point, and seeing if blood keeps flowing from the upper half. Having been impressed with how well-tolerated is the removal of most of the colon (as long as there's a decent amount of rectum -- which never has diverticula -- left), I've not been reluctant, when the chips were down, to do a sub-total colon resection.
With diverticulitis, there are lots of decisions as well. It takes a residency and then some to understand the issues and the choices. Some easy (perforation with peritonitis; fistula -- these need surgery for sure, even if the perfect one might be a matter of opinion), some not (mild attacks, repeatedly -- how many, how severe, is enough.) Timing of surgery, and what exactly to do, are decisions into which judgment and experience are at play. For example, after a severe attack which subsides, it's nice to wait several weeks for things to cool down before operating; but recurrent attacks might occur in the interim. The ideal is to be able to do a one-stage operation -- meaning take out the bad part and sew the ends together.
When forced to operate in the middle of a flare-up, it may or may not be necessary to make a temporary colostomy. That's crystal ball stuff. In the really old days, it was three stages: diverting colostomy, followed by resection, followed by a final operation to put everything back together. One of the signs that even surgeons respond -- if reluctantly -- to evidence is that a three-stager almost never is done any more, and many one-stage operations are now considered safe when, not long ago, two would have been the obvious choice.
I should add this: surgery for diverticular disease is gratifying. It's rare to have further problems after having the diseased area removed, and the comparatively small section that's typically taken out leads to no side effects at all. So it's a pretty happy group of patients. It is that for which we surgeons shoot.
84 comments:
- rlbates said...
Nice post Dr Sid! I'm going to send it to my Mom who had a partial colon resection due to diverticulitis (perforation, but no colostomy--thankfully). She is doing great these days. Thanks.
- Sid Schwab said...
A reader asked me, in an email, to clarify about the precariousness of the blood supply to the colon. I'll answer here, so others can read it. As opposed to the richly endowed small bowel, the colon's blood supply is, in some areas, less generous. It's fine for normal use: it's mainly when operating that one has to take particular care. Any bowel operation necessarily interferes with circulation to the area removed; with colon, one has to take care that if a significant vessel is removed, the remaining circulation to the bowel where it's sewn back together is adequate. That's true no matter where you operate, of course; it's just that certain areas of the colon require close attention. Or else the area of connection (anastomosis) can leak, or scar down and become obstructive.
My husband has diverticulosis. Most of the time it's not an issue, but we have discovered the hard way that cashews, uncooked green peppers, and large amounts of cantaloupe are Right Out. It makes sense that the cashews would do it, but he can eat vast amounts of pecans or peanuts without trouble.
People's insides are strange. - 9/10/2007 9:00 PM
- beajerry said...
Remember Doug and Wendy Whiner?
(SNL moment) - 9/11/2007 6:52 AM
- Klari said...
It's such a cool word (bezoar) that's it's been, unsurprisingly, harrypotterised.
I just read your blog post about bezoars, i tremendously enjoyed that part: "word sequence cautery, suction (...) how gross!". - 9/11/2007 10:47 AM
- RoseAG said...
Can they tell you if you've got them when they do a colonoscopy?
- Sid Schwab said...
Rose: Yes, they can be seen on colonoscopy. Remember, they are very common, and in most people who have them, they cause little or no trouble. I told my patients who had diverticula with minimal or no symptoms to take plenty of fiber to avoid constipation; no need to do more unless there are specific symptoms. (That's what I told my patients: readers here need to hear from their own doctors, and not take my advice for this or ANYTHING!)
- mscriver said...
So how does all this relate to Gardner's Syndrome, the tendency to have polyps that can develop into trouble? I lost a step-daughter who had the genetic proclivity. They told her children not to get a genetic analysis because if they have it, too, it might damage both their health insurance and their job prospects.
Prairie Mary - 9/12/2007 9:03 PM
- Sid Schwab said...
PM: there's no relation between Gardner's syndrome and diverticular disease. The former is a genetic trait -- a consequence of an abnormal gene -- and the latter is, as I put it, a design flaw to which everyone is potentially subject, partly preventable by having plenty of fiber in the diet and avoiding constipation.
The genetic testing thing is complicated, all right. - 9/13/2007 8:45 AM
- Tom said...
A recent barium enema showed that my diverticulosis was not confined but extended throughout the colon. How unusual is this? Does this raise any additional concerns.
I was recently hospitalized with diverticulitis that responded to antibiotics - 11/14/2007 3:19 PM
- Sid Schwab said...
It's not rare that there are diverticula throughout. It depends on how extensive. It's still most common that the problems occur in the sigmoid colon, so often if surgery is necessary, that's the part that's removed (assuming it's known that that's where the problems have been) and the rest are left alone. But surgery isn't always necessary; especially after only one episode that responds easily to antibiotics; it's not possible for me to say much more from this far away.
- Melissa Simpson said...
My husband is a 34 year old otherwise healthy and fit male who has suffered from what he calls mild diverticulitis for the about a year now. Stared out as two severe bouts of diarrhea (could be unrelated), and then an attack of diverticulitis about three months later. He calls it mild because the pain isn't all that great, and each time it happens it responds well to antibiotic treatment.
He's now had five attacks over the past 8 months. If this stuff responds well to antibiotics, is surgery advisable? I realize you can't provide a medical diagnosis over the Internet; I'm more interested in your general opinion.
He's not a big fan of having parts removed (who is), so he'd like to avoid surgery. However, we're also pragmatic, and would also like to avoid taking antibiotics once a month for the rest of his life. There must be some sort of middle ground. - 2/02/2008 7:38 AM
- Sid Schwab said...
Melissa: it's a crystal-ball sort of thing. If he's doing everything he can to avoid them (which, mainly, means having plenty of fiber in his diet) and is having attacks at that rate, the odds are they will keep happening. The potential is there for things to get significantly worse. For an otherwise healthy person the risk of surgery is very low, and the chance of side effect from losing the sigmoid colon (assuming that's what the operation would be) is really small, and the chances of being relieved permanently (assuming the diverticula are mostly limited to that area) is high. I can't diagnose or recommend. I can just say most people like him sooner or later need surgery, and are glad they did, when they get to that point. If one indeed had a crystal ball, one would like to do surgery before complications of the disease occurred, if one could see they would.
- Chucky said...
Hartman's procedure??
I have a question I hope you could give me some feedback on or tell me whether you ever heard of this happening.
I am a 43 yr. old male and thought I was healthy and fit until I began suffering increasingly chronic contipation (from 1-2x per yr. to 4-5) that seemed to be lasting longer and longer and responding less and less to OTC procducts like Ducolax. I'll try to make this as succinct as possible. Anyway, in mid july of this yr. I had a severe bout of constipation that would not respond to OTC products and I went to a after hours emergency clinic where I received x-rays that the Dr. found to reveal a partial blockage of the descending colon. She gave me some anti-spasmodics for IBS, oral Toradol, pain meds and recommended a Mg+ solution and Milk of Magnesia. Well the pain let up a little but the constipation persisted despite these interventions and enemas.
The next day the pain was so great (pretty much localized to the lower left abdominal quadrant) I had to go to the ER. I had a CT that confused the radiologist as well as the general surgeon and ultimately had to have a emergency explorative abdominal surgery. The general surgeon found a severe acute diverticulitis with an anastomosing infection and did a Hartmans procedure with an end colostomy. The Dr. plans to reverese the procedure in a couple of months. NB - unfortunately it was a open procedure and not laproscopic.
Since I was d/c'd from the hospital the ostomy site has been very painful and heavy feeling. A couple of weeks after being home the L. lateral border of the ostomy began to get very hard and indurated and there was severe pain when my bowels would move. This progressed until the ostomy would not move any more and I began to feel the same pain that I initially went into the ER with.
I went back to ER and they found an increased signal near the ostomy, I was running a fever in the low 100's and my WBC's were elevated to over 15K. I was admitted and received Cipro IV for 4 days until the ostomy began to work again and my fever and blood work normalized. My Surgeon said that he had never seen this before and figured that it was an iatrogenic infection.
Since then, the same thing happened again, back to the ER where I was given oral Cipro for 10 days and it cleared up again.
That being finished, the same thing is happening again and when I try to push on the swollen part there is some is one part on the lower medial aspect of the ostomy that oozes or squirts what looks like a mix or pus, stool and blood. It is not very viscous and when pressed it literally squrits out of one little area about the size of pencil lead. With this I am running a low grade fever, getting chills, my inguanil lymph nodes are swollen and tender on the L and the ostomy feels heavy and painful again.
So, I am curious if you ever heard of this. My surgeon has been pretty passive about this and I'm wondering if you think it is cause for concern??
It seems like there must be a preforation somewhere that is leaking into the muscle/fascial layer or something since its so recurrent. I don' t like the idea of being on antibiotics long term and I am concerned about abdominal infections once the procedure is reversed.
I would appreciate any insight or thoughts you may have regarding this and would be happy to answer any further questions you may have.
Thank you in advance. - 9/14/2008 11:52 AM
- Sid Schwab said...
chucky: it's hard for me to be specific, because I don't know the situation well enough. I agree that high among the possibilities is that there's a fistula from near the stoma; or inadequately drained infection. Possible options include open exploration of the area, or a contrast study (injecting soluble contrast medium into the stoma and taking an xray, or possibly looking in with a scope. Chronic antibiotic use without knowing more about what's going on seems unlikely to be sufficient.
A couple of general and non-useful comments: without knowing what your initial xray in the ER looked like, I can't really say; but giving powerful laxatives when there appeared to be a partial colon blockage was, shall we say, gutsy. And don't feel bad about open vs laparoscopic surgery in this situation. I'd call it the right call, once again acknowledging I don't know the details. I do think your surgeon needs to be very directly involved in the current stoma problems you are having.
I also find it interesting that he said he'd never seen anything like that before; it makes me wonder what kind of training/experience he's had. That's pretty snarky of me, I realize: but if you're not getting satisfaction, another surgical opinion wouldn't hurt. - 9/14/2008 2:06 PM
- Chucky said...
thank you for the reply and insight, I appreciate. Your book sounds like an interesting and entertaining read.
I had a foot of my colon removed last Sept. due to recurring diverticulitis. Done via lap . Three months later I had hardness and pain around the naval area and a low grade fever. CT showed inflammation consistent with diverticulitis. I still don't believe it was diverticulitis because I still have hardness a lot. I can move it around. I don't even have constipation at the time. I was wondering if it could be an internal hernia??? If it is or not is there a reason for me to be concern??
- Sid Schwab said...
anonymous: it could be hernia, infection, or other things. If it's still there, it should be checked by your surgeon.
It comes and goes. NO reason that I can figure out.
- Scungi said...
I know this post is rather old, but I am enlightened about your blog.
I am a 30 year old male, that was reently hospitalized twice (13 days in total) in the past three weeks for diverticulitis. The diverticulum that is causing the discomfort is in the descending colon, and surgery was advoided both times with abx, but unsure if it was a second flare up so recent or not responding to the orginal abx (flagyl and levoquin) and was precesribed Augmentin (Zoson (sic)) in the hospital after.
My plan of treatment now is hopefully for it to settles down, and have a colonoscopy to see exactly whats going on (surgeon suspects it could be related to Crohns or colititus due to strong family history, and young age, as well as diverticulum location).
That being said, surgery appears imminent, due to the fact I have been experience this undiagnosed for 10+ years, but the idea of having my descending colon as well as my sigmoid colon removed (though sigmoid not affected)but best to do preventitively? As well as a better resection to the anus? My surgeon is well researched and well versed, but out of curiousity with the limited details, your thoughts? - 5/05/2009 12:21 PM
- Sid Schwab said...
Scungi: I was just thinking about this post, because Ken Griffey Jr is out again with diverticulitis.
I really can't offer much without knowing the exact details of location and diagnosis, the latter of which ought to be clarified by the colonoscopy. Exactly how much colon to remove, and where to hook it up will be determined, I'd say, by those findings. As a general rule, people who've had up to half of their colon removed will likely have entirely normal bowel function; and in most cases, even taking more than that can lead to little significant change in bowel habits.
There are anatomic considerations, too, regardless of the underlying disease: the blood supply to the remaining colon can dictate the need to take more, or less, depending on location. - 5/05/2009 1:18 PM
- Scungi said...
That is how I found out about this blog post of yours due to the fact Ken Jr. is out with it, and my brother mentioned we had it in common.
The way the surgeon laid it out to me was to reconnect to the anus is better because the connection is much more like to be stable and less of a possibility of a reoccurance, especailly since it occurs more often in the sigmoid colon. That was my layman's terms described by me, I am sure it was better described by him at the time.
Like I said though the GI guy does not think Crohns or colititis is contributing based on the CT scan, I have a colonoscopy schedule hopefully to sort it all out.
Any familiarity with left testicular pain in your practice associated with diverticulitis? It seemed to be a shock to most of the residents, not so much the attendings or the surgeons, but it was excruciating pain, often get it with general "tough"gas as well. I do have a verococele (sic) there but small, not big enough to worry about states the consult urologist who saw me while admitted, and does not believe my pain is from the vercocele either.
Thanks for your quick response on a old post, describe everything to tee, and helps me describe it to friends and co-workers trying to figure out what was wrong with me. - 5/05/2009 7:39 PM
- Sid Schwab said...
Testicular pain is not rare with diverticulitis, depending on where the inflammation is in the colon, since the neurovascular structures to the left testis run behind the colon, in part.
Your surgeon might have meant "rectum," as opposed to "anus" (more properly, "anal canal.")There's a potential functional difference, as well as complexity of the operation, when hooking to anus (harder, more potential for control or sexual issues) as opposed to rectum (easier, unlikely to have other issues.) When the diagnosis is diverticulitis, as opposed to Crohn's or ulcerative colitis, it's pretty unlikely to need to go all the way down to the anus. - 5/05/2009 8:10 PM
- Scungi said...
You are right with the rectum, been so overwhelmed with the whole ordeal lately, I am getting everything confused.
Keeping my fingers crossed I do not get another flare up as well before the colonoscopy.
But again, thanks for the education and the great pictures that go with it, I feel like printing out your blog to hand out to everyone at work, so they understand what happened to me.
Thanks again - 5/05/2009 8:17 PM
- -Steve said...
Well, not sure if you are still checking this at all, had another flare up in 11/01........ended up scheduling surgery for 01/29. Two weeks prior again another flare up, took ABX early to try to hold it off, didn't really work but still went ahead with the surgery.
Removed a good portion of my transverse and descending colon (again only 30), and reconnected from transverse basically at the sigmoid. Everything is working out fine, but the Dr. stated was very inflamed and an abscess was clearly present.
Just trying to get back into eating and having regular BM's, but nervous about reoccurrence especially in the sigmoid.
Thanks for your blog, it has been helpful and informative - 2/15/2010 10:06 PM
- -Steve said...
-Steve and Scungi, same person, two different emails account, sorry for the confusion
- Sid Schwab said...
Sounds like it was time, Steve. Hope all goes well.
- Unknown said...
Hi Dr Sid...tomorrow will be 2 weeks from by colon resection. I had been in the hospital on antibiotics due to diverticulitis for a week as well. I was released 4 days after surgery and the surgeon removed about 16inches of my colon and I did not need a colostomy. My appointment with my surgeon is next week. I had been running a low fever of between 98.8 and 102.0 between January and the surgery two weeks ago. My temp is still running about 99.2-99.8. My main concern is that my normal temp prior to January 2010 was always about 97.5, rarely higher. Bowel movements have not returned to normal yet, but I have had problems in that areas for 5-8 years (diahrea and constipation. Do you have any thoughts at all on what is still causing the 99+ temps (I do break out in sweats at least once a night). I am 68 years old. Thank you so much.
Nancy - 7/11/2010 1:43 PM
- Sid Schwab said...
Nancy: having low-grade fevers after major abdominal surgery is not rare, and may just reflect a combination of various factors involved in healing. But it could also be due to infection, either in the incision or inside somewhere. So it's best to inform your surgeon. I can't really say any more from this far away.
Appreciate the information you provide. My husband has had severe pain in his left testical/groin area for the past two weeks with some very low left back pain. Initially thought kidney stone - 2 CTs show a stone present in the left kidney, but drs say it is (1) not the cause of his pain & (2) stones are not 'positional'. He is only uncomfortable (entire left groin is tender) when lying flat. When he sits, the pain increases to intolerable levels and when he stands, it rapidly increases to severe - after 10-30 seconds upright he is in excruciating pain and must lie down. MRI shows some lumbar degeneration, but urologist, GP, back specialist & general surgeon say it is also not the cause of his pain. None have ever seen a presentation that is positional - lying flat = ache in back and tenderness in left groin region. Standing = severe pain in left testical which is relived by lying flat on his back. CT showed diverculosis but not diverculitis. Would the CT have revealed any colon problems or would a colonoscopy be useful? Would the CT have shown any potentially dangerous problems such as an abdominal aortic aneurysm? He has a follow-up with the general surgeon on Monday who seems to be committed to helping find the cause - although when the usual suspects are ruled out (spine, kidney stone, no hernia felt on manual exam), I know that diagnostics are not, as you say, crystal balls (pun intended - easy for me to say, I guess). I want to make sure that they explore or test for things that could be imminently life-threatening, even if those causes are not the most likely. I also want to get him in to see the proper type of specialist (hence the urologist when he described the pain as similar to a past kidney stone, the back doctor when the urologist & GP said 'might be back' ). He has an appointment with a neurologist on Thursday, and I could get him to a recommended urologist or vascular specialist if varicoceles or other vascular problem could be the issues - or gastro if a colonscopy would be useful - although, the prep for a colonscopy will be difficult for a guy who can't walk to the bathroom. I do respect the new general surgeon we saw yesterday - but obviously I have a more vested interest in my husband's life and pain than even the most dedicated physician who is responsible for hundreds of patients. I have sufficient education to evaluate what I read, but my degree and background is not medical - so I can only gather information, make observations and ask questions - I can't diagnose or treat him, as much as I wish I could. It has been a couple of months since your last comment on this thread, but if you are still reading these comments, I want to thank you for providing the information that you have, and for addressing some of the concerns that others have asked about. Responsibly, you never attempt to diagnose or make treatment judgments from afar, but I see where you have provided clarity and explanations to those seeking information. I am in a similar professional field and know that often in a practice, the treating physician (or advising attorney, counseling CPA, etc) is trying to treat/manage/handle the immediate situation presented and often does not have the time or the thought to provide additional background and information that a patient or client might need. Thank you for providing that service to others where you can.
- Sid Schwab said...
It sounds like a challenging problem. I think a CT would have shown such things as aneurysmal disease or diverticulitis, neither of which really fits well with his pattern of positional pain. Were a kidney stone the cause it's likely he'd have at least microscopic blood in his urine. A hernia that would cause that severe pain ought to be palpable when he's standing, although it's possible to have a form of "internal hernia," such as an obturator hernia, that could be difficult to diagnose. Still, pain that severe from a hernia that is so positional would be pretty unusual.
Depending on the nature and location of the pain (ie, if it sounds neuropathic) I'd still be keeping neuromuscular sources high on the list.
Sounds like it'll take persistence to figure it out. Good luck to you both. - 9/11/2010 9:00 AM
Due to prev centerline laporoscopic ventral hernia repair (massive) resulting from perf appendix/peritonitis surgery (burst while in hospital-they blew the diagnosis), I am wondering if this would definitely preclude any future surgery to correct my bothersome diverticlitis. I'm to the point now that if it wasn't for this 20x25cm pc of Proceed mesh in my belly, I'd schedule the surgery quickly. If the mesh is compromised, would that require another procedure to replace the entire pc of mesh? I am under medical care-good medical care-but am interested in your opinion. Also, with my advanced diverticular disease, would receiving a high contrast (barium?) enema be dangerous/risky when I have my next CT Scan? (in 3 days...) Any danger of impacting/clogging the diverticulae? I am under good medical care but am interested in you opinion! Thanks
- Sid Schwab said...
Michael Ronnau: The prior surgery, and preceding peritonitis, would not preclude future surgery for diverticulitis. It might make it harder. Or not, depending on time interval and your body's response, and how and exactly where the mesh was placed.
When it's necessary to cut through mesh, in most cases the cut can be closed with some sort of non-absorbable suture, such as nylon.
Contrast studies can be done with diverticular disease. Usually it's best to use a water soluble contrast medium rather than barium. - 9/18/2010 1:12 PM
- Unknown said...
Dr. Sid, could you please weigh in on yet another "mystery of the universe"?
I went to the ER this week with what I thought was a kidney stone in my left side just under my rib cage, but the CAT scan didn't show one and there was no blood in the urine. I have had a kidney stone before and this felt like one. This "attack" came on out of the blue and I got hit with an intense wave of nausea, but didn't vomit. The CAT scan did show diverticulosis in my intestine. Because of this and the possibility of diverticulitis the ER doc put me on Cipro. My doctor, an internist, checked me out further and we decided to watch things. I continued having left sided pain and took a limited amount of pain killers and Ibuprofen, continuing the Cipro. At day 3 1/2 I'd still not had a bowel movement, but hadn't eaten to much owing to nausea and general malaise. That evening though I took a laxative and had a painful bowel movement and felt much better.
The pain in my side by this time had decreased greatly, but toward the end of each day I'd be feeling kind of yucky with some pain (more of a soreness) in my side. The whole thing is still a mystery, but the greatest possibility to have emerged after closely looking at this thing is that I may have caused diverticulitis to have occurred by ingesting too many raw cashews. I had eaten about half a bag of them the day before the attack and eat a pound of them a week. I was wondering therefore if this seems plausible (also there is evidence that there is some toxicity in cashews even when the toxins are removed through steam extraction as is the case with the ones I buy) and if you have any experience or views in the regard. As of this writing I'm feeling better in the mornings and get yucky at bedtime and still on Cipro. I'm a fairly active 55 year old guy with excellent health who works outside all day. - 10/30/2010 8:25 AM
- Sid Schwab said...
Rick: I can't make any meaningful diagnosis from over here. The distinction between diverticulosis (meaning there are diverticula there, which is true of maybe a third or more of Americans over 50) and diverticulitis, meaning infection causing various symptoms, usually is based on typical signs of infection, such as fever and elevated white blood cell count, (and, often, signs of inflammation on CT scan or other imaging.)
As I've also said, I don't think there's evidence that specific foods cause diverticulitis, nuts or otherwise. The bag of cashews could have caused some sort of other stomach upset, however.
I hesitate to go further, since there's no way I can know what went on. The above are statements I consider to be true, but they are general statements; how they apply to you, I can't say. - 10/31/2010 1:41 PM
I happened on your blog and hope you will be able to still answer me.
I had terrible abdominal pain and the doctor sent me for a barium enema to find out if it was diverticulitis. Something I NEVER want to have to go through again. After reading most of your posts why did they do that procedure instead of a CT or something less traumatic?
I live in South Africa so I dont know if this is the normal way to check.
Why I was searching is that I am totally confused as to what I should or shouldnt eat. I have avoided nuts because I too had eaten a fair amount of cashews the day before the pain started.
I have gone to a dietician and tried sticking to a fibre diet but I still find my stomach very bloated all the time. Is this normal?
Now while searching I find differing information to what my dietician gave me!
My constipation problem only started after I had a bladder sling and then an operation for correction for a total vaginal prolapse.
Could these operations have interferred with my colon at all? As after the first one the bladder sling I would get terrible pain in my lower back and feel feverish before each passing of stools.
Thanks - 3/17/2011 4:32 AM
- Sid Schwab said...
Eve: I can't answer specifically, not knowing what was seen on the Xray. In general, for people with problems from diverticular disease, a high-fiber diet is the main dietary recommendation. The goal is to avoid constipation.
Being bloated is not normal, if by bloated you mean noticeable distention of your abdomen. If that's the case, it needs a diagnosis.
It's possible your surgery could have affected your colon in some way.
I know of and have corresponded with a surgeon in South Africa. Based on his blog, I'd say he's really good. His name is Neil Taverner. If you track him down and see him, tell him I sent you. - 3/17/2011 9:41 AM
- phil neason said...
Dr. Sid,
Just came across your blog and think it's great-
5 days ago wound up in the ER, lower abdominal pain, especially sharp over the appendix. CT showed " stranding prox sigmoid distal descending colon most likely for diverticulitis" . For two months before this I've had major constipation, "full" feeling and what feels like difficult breathing. Maybe pressure on my diapraghm? Only occurs with the constipation. I have psoriatic arthritis, could my systemic inflammation from that condition be playing a part here, particularly the breathing thing? Thanks for your blog-
Phil Neason - 9/05/2011 12:40 PM
- Sid Schwab said...
Glad you found the blog, phil neason, and thanks for the kind words.
I hate to offer diagnostic opinions here because there's no way I can know enough of what's going on. With diverticulitis the peritioneum over the area can become inflamed (that's what causes most of the pain), and that can inhibit breathing sometimes. Some inflammatory bowel conditions can be associated with arthritis, but I'm not sure it's the other way around with psoriatic arthritis.
Constipation can be both cause and effect with diverticular disease, as I've said in this post, and if that's what's causing the constipation you'll need a dietary plan to deal with it.
With those CT scan findings, I assume you've been referred to or are planning to see a gastroenterologist. S/he will be able to give you much better information. - 9/05/2011 1:12 PM
- phil neason said...
Wow, thanks Dr. Sid for such a quick response-
Yes I have a follow-up colonoscopy on Nov.7 with a Gastro guy highly recommended by a close friend who had two nasty bouts with the disease then a resection. I will mention the arthritis info to him of course. Thanks again for your comments-
Phil Neason - 9/05/2011 1:26 PM
Dr. Sid,
11 days since my diverticulitis attack, was doing fine, with no pain since the initial attack, had some fatigue/breathing issues (which I wrote you 5 days ago), but recovered well, energy is back, feel good yesterday and today. I finished 11 days of flagyl and levaquin, 500mg each, once par day.
My concern is that after no pain but feeling miserable for 9 days, yesterday I felt great but had mild discomfort immediately prior to my only BM. I had taken Miralax and Citruscel 4days ago as my doctor told me if I was feeling constipated to act on it that way. I stopped the Citruscel yesterday morning. Today I feel great but had bad cramping prior to, during and immediately after my only BM. About 5 mins total. Started firm, then soft, then pudding. No blood. Am I regressing? Appreciate your take on this, thanks-Phil Neason - 9/11/2011 5:05 PM
- Sid Schwab said...
Usual disclaimer, regarding my inability to be accurate from far away.
I can say in general that symptoms you describe can persist for many days, a few weeks, since even when signs of infection have subsided, residual inflammation and swelling, thickening of the bowel, can take a while to resolve. So absent fever, increasing pain, symptoms such as yours don't necessarily suggest regression.
Your treating doctors are better able to assess and advise, yada yada... - 9/11/2011 5:47 PM
Wow again, your quick responses put restless minds at ease... I've read that's the case, and if it was a weekday would have called my GE. I will monitor pain, fever, etc. If anything occurs I'll call him. Thanks again. Phil Neason
- Diana said...
Love it! Thank you for your smart, informative piece and generous answers to the Diverticulitis Dilemma.
I am going in for the resection surgery next week and am soooo looking forward to not having this pain and nastiness hanging over me.
My question to you is, why the heck is there so little information out there for what people should be eating when they get an attack and afterward as they heal? It has taken me hours and hours - cumulative days of research online and talking to nutritionists and dietitians to get a good idea of what I should eat and drink. Sadly it seems the GI docs and surgeons are least informed (bad for business?).
A second question if I may, after reading on other sites people's experiences with Diverticulitis (young, old, fat, thin, exercisers, vegans...), could there be some truth to the theory that antibiotic use without restoring the good bacteria (via Probiotics and such) in the gut be a big contributing factor? Thoughts please?
Thank you again for the clear explanation with a side of humor. Much appreciated!
Diana - 11/01/2011 6:22 PM
- Sid Schwab said...
Diana, I'm glad the blog continues to be useful. I'm betting you'll be really glad you had the operation.
As to dietary questions: one problem is probably related to the fact that it's taken a complete about-face in the past several years, from avoiding fiber and seeds and nuts, etc, to realizing the only important thing is fiber, with the aim of avoiding constipation and the need to strain. It should be your goal after surgery, too.
As to a possible role of probiotics: I have no opinion, meaning I've not seen anything that confirms it. I think the etiology of diverticula is multi-factoral; but it seems the most important factor might be chronic straining at stool. Problems are less common in people with high fiber and vegetarian diets. Why some with diverticula have little or no symptoms, and others get diverticulitis is mysterious, far as I know; but, to repeat and repeat, it seems less frequent in those who maintain good bowel function.
I always told patients I saw who'd not had what I considered clear indications for surgery that they should maintain enough fiber intake to avoid constipation and straining; other than that, no specific avoidance such as seeds, etc. - 11/01/2011 7:05 PM
- phil neason said...
Dr. Sid,
I first wrote in September, following an acute diverticulitis attack. My follow-up colonoscopy was yesterday, and in the pack of post-exam materials ( I don't remember much of my conversation with my GE, I was still foggy) his notes say "Multiple large and small-mouthed diverticula were found throughout the entire colon. The colonoscopy was technically difficult and complex due to the multiple diverticula, significant looping and a generally tortuous colon." I can guess what this means, but it doesn't sound good. What is my prognosis going forward, are there surgical options with diverticula on the right and left sides? I'm a little worried. Thanks for your guidance-
Phil Neason - 11/08/2011 4:41 PM
- Sid Schwab said...
Really, you'll need to talk it over with your gastroenterologist in a non-drugged state. Tortuosity, per se, may not mean much. It's just the way some colons are; an anatomic variation.
The surgical question begins not with the extent to which there are diverticula throughout the colon; it has more to do, in general, with the number and/or severity of episodes of diverticulitis a person has had.
Once it's decided that surgery is the right course -- often anything but a black and white decision -- then the extent of the operation must be figured. It's not rare to have diverticula throughout the colon; it doesn't mean the whole colon needs to go. Depends on where the infections have occurred, whether there are concentrations of diverticula on one place (usually the sigmoid colon).
For the record, and not suggesting it'd be the right operation because I have no way of knowing, a sub-total colectomy, where all but the last several inches are removed, is remarkably well-tolerated by most people; some have "normal" bowel movements, many have a few easily managed bowel movements a day. Only a small minority have problems with diarrhea that can't be managed. - 11/08/2011 7:08 PM
- phil neason said...
Dr. Sid,
Thanks once again for a very quick and easy- to-understand response. I was worried that there might not be any surgical options, if the frequency and severity of attacks continues.. It wouldn't be so much the attacks themselves, or the pain, which although bad I'm able to tough out, but the collateral damage, i.e. my extensive travel for work (the last attack began 2 hours into a 5 hour plane flight), international travel, etc. It fills me with trepidation of course. Will I be hospitalized in a foreign country, or even out of state due to bad timing, things like that. Knowing there might be some other options should it get really bad gives my mind a little peace. For that, I thank you-
Phil Neason - 11/08/2011 8:20 PM
I've been told that the infected colon could contain parasites. Is this an accurate statement?
- Sid Schwab said...
All colons contain parasites, by strict definition. It sure as hell sells a lot of bogus colon cleanses, though.
- Diana said...
Hiya! A wrote to you a few months ago re: impending resection surgery. I thank you for your great response and thought I would post a follow up report.
I am now six weeks post surgery. I feel pretty darn good and can eat anything now. I did lose 35 pounds from August to November which puts me happily back in the svelt column :o) I will stay svelt thank you.
I had been hospitalized twice for DIverticulitis with a known abscess and put on Augmentin and rest for the six weeks prior to surgery to calm the bowels. I was one sick puppy. I had had 4 CT scans with contrast in the two months leading up to surgery - which did not show the grapefruit sized, leaking abscess attached to my bladder - surprise! Surgeon said he was totally surprised to see that and all the scar tissue everywhere. My OBGYN was on call since there appeared to be a cyst on my ovary and my surgeon thought it might need to be removed (it was). So I ended up with the Da Vinci and three surgeons working on me. 5-1/2 hours, seven holes and no bags! Doc thinks that abscess has been brewing for maybe three years. Doc took out 8 inches of Sigmoid and the first ring of muscles in the rectum. Turns out those muscles gets tighter with age ('bout the only thing!) and would have caused more diverticula in the future.
I am 48 years young, feel some discomfort still but can tell I am healthier now than I have been in a very long time.
Thank you for your very informative blog (I am a big fan of other one as well). You are right, I am so very glad I had the surgery.
Can you shed light on why the almighty CT scans missed something so large? The head of radiology had even reviewed at least two of the scans. - 12/25/2011 1:21 PM
- Sid Schwab said...
Diana: sounds like really good news, and there's no surprise that you'd feel so much better after all that.
As to why it didn't show up: CT scan can be unpredictable in how well it shows soft tissue abnormalities; and sometimes it's hard to tell bowel from other stuff around it; the abscess may or may not have been in full flower when your scans were done.
In any case, it's good that it's all out of there, and I'd guess there's more feeling good to come as more healing occurs.
Thanks for the followup. - 12/25/2011 6:06 PM
Dr. Sid, I have had a few attacks of diverticulitis and antibiotics usually take care of it. Cipro is almost always prescribed..an antibiotic that I refuse to take due to the dangerousness of it. Most antibiotics make me very ill. Can you recommend one other than a fluoroquinlone?
Thank you! Lori - 12/31/2013 9:01 PM
- Sid Schwab said...
I'm sorry, Lori, but I don't want to get into specific therapeutic recommendations on this blog. I can never know enough about an individual from so far away.
- Unknown said...
I've had my sigmoid resection about 11 years ago. I recently started having bouts with diverticulitis again, currently on Flagyl and Cipro. If worse case, another surgery is performed will the do another resection or do a total colon removal? My pain is in the same area as my initial before surgery.
- Sid Schwab said...
BRC: I'd say it'd be unlikely they'd recommend removing the entire colon unless it was full of diverticula throughout.
- Jean said...
Sent a message earlier but likely did not post correctly. I emailed you today. If it wasn't received I will try again.
- Jean said...
I'm sure it didn't work as this time I see the statement your comment will be visible after approval - same person who emailed you this morning.
- Sid Schwab said...
So far, so good, Jean.
Hi Sid,
I'm a 47 yr old male. About a year and a 1/2 ago I had terrible lower abdominal pain - It started with night sweats. Then bloody gas diarrhea with no pain. This bloody gas diarrhea suddenly stopped after about 4 weeks. Then a week later I began to have extremely extremely foul smelling BM's that were loose and I had constant lower pelvic pain and gas that would not seem to come out along with left side pain. I could not eat and lost 20+ pounds. This lasted for weeks until I saw a doctor who thought it was probably diverticulitis and gave me Flagyl. The Flagyl worked right away and I got better really quickly.
I was never tested to see what it actually was but I added fiber to my diet, ate more veggies, got exercise and have been well over a year.
Over time I forgot about the whole incident - dropped the fiber, and began to eat more like I used to, stopped going to the gym, drank beer again, gained weight etc. - back to the old me - feeling fine and living the good life.
However, 6 weeks ago I started to get night sweats again - then 3 weeks ago I have had some more lower pelvic pain and left side pain - similar to a year and 1/2 ago along with the bad gas cramps - then a bad UTI started along with gas and poop in the urine and I am and remain a bit swollen in the left pelvis area just above the penis (I think this is where the fistula must be as I feel the gas move there).
The doctor gave me CIPRO for 3 weeks which took away all the pain and the UTI. I feel fine now except for the gas and poop in urine. My doctor sent me for a CT scan and it confirmed a Colovesical fistula and now I've been referred to a surgeon (in 2 months as I'm in Canada and have to wait in line).
I asked the doctor what caused the fistula - he said nothing on the CT scan gives any clue as to the cause.
I am wonder what your opinion might be - do you think infection or Diverticulosis or a cancer caused this fistula? I assume if Cancer the antibiotics would not have been so effective however.
Your opinion would be much appreciated,
- Sid Schwab said...
NKM, from what you describe it's almost surely due to diverticulitis; but, of course, based on the story alone I can't say with certainty that it's not due to cancer.
I've touted the Canadian system many times, but two months seems a bit long. In the meantime it's probably best to get back in the fiber groove to make your stools as non-liquid as possible. The good news is that, barring another flare-up, by the time you see the surgeon things ought to be calmed down enough inside to go ahead with the surgery.
In re-reading this post (it's been a while!) I note I mentioned fistulae in general, but didn't mention the not-rare complication of colovesical fistula specifically. Should have. But you seem to have discovered it on your own. The good news is that the surgery is only a little bit of a bigger deal than the routine sigmoid colectomy; usually, anyway. In my experience, once the colon and bladder are separated the colectomy part proceeds more or less as usual, and closing the hole in the bladder tends not to be a big deal. - 9/25/2015 2:36 PM
Thank you Sid for your response. Makes me feel a lot better about this while thing.
I wonder why they didn't detect any diverticulitis or any other cause on the CT? My thought is that by the time they did it the infection was gone - but I don't know why they did not see the pouches - perhaps they are hard to find on a CT.
- Unknown said...
Hi Sid,
I am searching for a particular diet over the internet for my diverticulitis disease and unable to find the rigth diet for it, can you please check this diverticulitispainfreefoods by Mike Hohlweg and let me know if it something that i should use, thanks, Mark - 1/30/2016 2:44 AM
- Sid Schwab said...
I don't know if yours is a spam message or not, Mark; but since you provided no link to whatever it is you're referring to, I'm posting your question. The bottom line is that the only recommendation for diet for diverticular disease is a high-fiber diet. The old recommendations to avoid various foods haven't held up; nor are there, far as I know, any specific recommended foods. I'd be skeptical of "diet" that recommends them, other than those that provide adequate fiber. The main thing is to avoid constipation, which generates higher pressures in the colon. So high fiber it is.
Hi Dr Sid,
I am hoping you are still able to receive/respond to comments here. This is an outstandingly well-written and documented article - thank you for taking the time to share this with us.
I have two questions I am hopeful you might be able to help with (given all caveats with distance)
- I am scheduled to have a lap sigmoid resection in just over a week due to almost constant recurrent diverticulitis attacks, but I am again today in lower left quadrant pain and it seems like at the very start of a flare up ... can they operate if I am having a flare up? Would the surgery need to be postponed, and does it increase the complications or even risk of a stoma?
- I am very embarassed to ask this, but I can't find any information anywhere ... after the sigmoid resection is complete and completely healed, is it still possible to have receptive anal intercourse? As its diverticulitis I assume the rectum remains intact? I am very worried about this.
Many, many thanks,
Starling - 5/15/2016 6:49 PM
- Sid Schwab said...
Starling, whether they proceed or not will depend on how severe the attack is. I think you should contact your surgeon's office right away about it. They may want to see you, maybe start you on antibiotics. Assuming things don't heat up too much, it's likely they could proceed and unlikely they'd need to do a colostomy. (Usual caveats, yadda yadda...)
And after normal recovery there should be no impact on sexual activity of any sort. It would only be in the unlikely event (for a routine sigmoid resection) of the anastomosis (putting the ends back together) being done very low in the pelvis that it could, temporarily, affect receptive anal intercourse. - 5/15/2016 8:01 PM
Thank you so much for your input! I am heading to the surgeon's office today.
- Starling - 5/18/2016 1:03 PM
My brother suffered for years with bouts of diverticulitis, he just passed away December 1, 2016, he was 58 years young. A few weeks before his passing he was having pain on his left side, debilitating enough that he had to lie down when the episodes came. I don't know why he didn't go see his doctor, but hindsight is 20/20.
The morning of his death he was running a fever, vomiting and collapsed at home. On the way to the hospital he blacked out. At the hospital he had a 105 degree fever and they could not stabilize him and his blood pressure was very low. The hospital said he died from Septic shock.
My question is, have you encountered a scenario like this in your practice? Could the pain he was having possibly come from an infected pocket in his colon from years of having diverticulitis, leaking into his abdomen, giving him the sharp pain eventually leading to the Septic shock? Ignoring it for not sure exactly how long, I'm wondering if it's possible, infection and bowel was leaking into his abdomen and then would cease to be as painful as it was absorbed into his abdominal cavity. He also had chronic diarrhea.
His family decided not to have an autopsy. I would appreciate any insight you have in this matter. You have a great blog and have helped many people with your answers. Thank you - 12/15/2016 9:37 AM
- Sid Schwab said...
Sorry to hear of your brother, Diane. Re-reading my post here I see I gave short shrift to the subject of perforation and peritonitis other to have mentioned it as a clear-cut indication for emergency surgery.
The answer to your question is, yes, absolutely. I encountered many cases of perforated diverticulitis with sepsis and although I don't think any of them died, it's entirely possible, depending on timing of intervention, the patient's presenting condition, and response to the surgery, antibiotics, and other supportive measures.
Whereas I obviously can't say whether perforated diverticulitis is the cause of your brother's sepsis and death, it fits. - 12/15/2016 11:54 AM
Thank you Dr. Schwab, I appreciate your insight and response.
- Unknown said...
Dr Schwab, happy to have found your post! Thanks for all the insight.
My husband, 33yo, had emergency appendectomy dec 11 and the surgeon said the appendix looked unhappy at the distal end and obviously removed it; he also fixed an umbilical hernia.
20 days later we ended up in the ED again, this time with a cellulitis of the surgical site and perhaps a mild case of shingles. That part remains questionable. The CT we were told was normal, some inflammation at the surgical site but nothing unexpected. He was given a two week course of augmentin and valtrex for shingles.
All seemed well for the past week until Wednesday he started complaining of what he felt was bladder pain. CT revealed sigmoid diverticulitis and he is now admitted and on IV Zosin. The lower midline abdominal pain is slightly and slowly improving but now he has testicular pain. No fever, CBC is within normal, urine clean. He does have a history of prostatitis about 5 years ago. The surgeon who did the appy did mention on his initial CT that his prostate is large for his age.
I know I read in a previous comment you said the nerve tracts are common in this area. My question is, does this bladder pain and testicular pain line up with the diverticulitis diagnosis? Also, I would have thought him being on augmentin at home for the cellulitis would have prevented or simultaneously treated the diverticulitis, I am confused on this? Any insight would be appreciated. - 1/14/2017 6:34 PM
- Sid Schwab said...
Bladder and testicular pain can result from diverticulitis, as they can from prostatitis. Augmentin can be used to treat diverticulitis, but it's probably not the first choice.
In most cases of prostatitis, there'd be some white cells in the urine and the prostate would be tender on exam.
In most cases of appendicitis the entire worm is angry. The tip can get angry if it's touching an another area of inflammation, such as diverticulitis. Pathology reports might make the distinction.
I say these things as general propositions, not with the intention of diagnosing your husband's situation, which I absolutely can't do from so far away. Happily, it sounds like he's on the mend. Your questions are good ones, and you should feel entitled to ask the docs taking care of him. - 1/14/2017 6:55 PM
- Unknown said...
I can't thank you enough and I very much appreciate the insite. They told him this morning they would send him home on augmentin tomorrow !? And he spoke up so they said flagyl and cipro.. finding myself frustrated... as I'm sure many people do in these situations. When you mention pathology, are you referring to the appendix report? I never thought to ask about those results...
- Sid Schwab said...
The pathology report might show whether the appendix showed typical appendicitis, or if the "angriness" at the tip was from being adjacent to an area of inflammation.
- Unknown said...
Hi Dr Scwhab my husband has been discharged for a few days now and the combo flagyl and cipro seem to be taking their toll on him. Do you usually tell patients to stick it out? He is feeling flulike, foggy, nausea, diarrhea... of course we have a call into the doc but just curious on your thoughts. Also his right abd pain is returning which he has felt on and off since the before appendectom... describes it as same pain we initially went to ER for 5 weeks ago. Any thoughts? Thanks so much for your time!!!
- Sid Schwab said...
I'm sorry, Ms Beale, but my aim here is to provide general information; I really don't want to get into specific advice or opinions when I can't know anywhere near as much as his doctors. I understand how frustrating these things can be, and I sympathize. But I don't want to go further than I already have.
I could write for a week, and I am not sure I would have covered all the details, but I will attempt to keep it short.
15 years ago, I was diagnosed with diverticulitis. This is after having my appendix removed, and finding out it was perfectly healthy, and many (10+) hospital stays where they went back and forth between possible Chron's or Colitis. I must say I was 26 years old when I heard diverticulitis for the first time. The next few years were the same, a few hospital stays / year with antibiotics and I was on my way. In 2005, I was hospitalized 13 times between April and August. At this point I had antibiotics at home through IV, as they were attempting to clear infection for a scheduled surgery to remove the infected portions of my colon which was to happen in september. On August 3, I collapsed at home and was taken for Emergency surgery. I had a sub total colectomy, and had an ileostomy. I recovered well, and had reversal surgey 9 months later.
It had been 10 years with 0 symptoms or limitations! I count my lucky stars every day as I nearly refused the reversal surgery. I may have had an ileostomy, but I was pain free and able to eat (no more feeding tubes)!!!
I am now 41, and this past November, I started signs. The same pain and symptoms started, and though I immediately reverted to a liquid diet, I had to return to the ER with a fever and unbareable pain. A CT scan confirmed diverticulitis. I was put on IV antibiotics and 5 days later was able to leave the hospital with antibiotics. I remained on a liquid diet (knowing the symptoms all too well) as I had not yet worked my way up to transition to a low residue diet, and the infection returned again after 3 days of completing my dosage of 10 days of Flagyl and Cypro. This repeated itself times 2 since November. I will see a surgeon again on Feb 2 and if I have been symptom free long enough, he will do a scope. My questions are this, from your perspective, should I continue waiting? I will say my very first surgery happened because of a perforation. After 3 weeks in ICU I recovered from peritonitis. I am afraid history is repeating itself with 3 serious flare ups in the last 60 days and 4 rounds of antibiotics. Should I just have everything removed? The surgeon mentioned in our only encounter that when he can do the scope, he can see what he is dealing with and see if he can take a little piece? Thoughts? And I know this isn't for immediate medical advice. I will see my surgeon in a couple of weeks. Last thing, my original surgeries happened in Canada, I am now in the US, just in case you wonder why I don't go back to my surgeon as he knows what he is dealing with.
Appreciate your thoughts. - 1/23/2017 7:55 PM
- Sid Schwab said...
As I wrote, the decision to operate, and when, can be difficult, especially when there's no obvious emergency. Not knowing how much and which part was removed before, how much and which parts are left, I'm unable to comment on the "everything removed" question; besides which my purpose in writing here is to provide information (and good stories!); I really can't make specific suggestions or recommendations.
For general information, I can say that diverticula don't involve the rectum; it's uncommon to remove the entire colon for diverticulitis, saving the rectum, but I've done it. Hooking the ileum to the rectum can avoid ileostomy and, especially for younger people, can result in more frequent than usual, but continent, bowel movements. - 1/24/2017 8:56 AM
- Ann Isker said...
Hi I'm a 52 yr old female had my first diverticulitis attack in Feb of 2015 w hemorrhaging which lasted all day until about 7 pm er visit antibiotics pain meds was ok for about a year within the last 9 months have had around 8 episodes of infection this last time the worst couldn't have a bowel movement despite taking mirilax and eating nothing but soup finally went a small amount few days later was on tolit 4 hours nothing in extreme pain 2 days later finally relief pain in lower left side went to dr who gave me flaygil and cipro took it all felt good few days less than a week later pain in my side again constipation despite eating mostly soup saw surgeon who decided surgery was best put in hospital on flaygil and cipro again ct again said no infection went home next day was in pain feeling very sick went back to er Sunday in pain that was more than a month ago as to initial pain scheduled for a colonoscopy Nov 7 surgery after I have been in constant excruciating pain since my infection began this time.no Pain meds due to causing constipation have tryed softeners eating not much analgesics don't help much constant pain after I BM it males it hurt worse am having pain on my right side now too feel nasty fever pain constant nothing seems to stop it not even bm I have a visit with the Dr for pre op colonoscopy for the 7 the my question is why am I having so much pain with no relief and why does it hurt after bm that are soft applying a heating pad made the pain almost unbearable called my clinic told to take miralax even though I said I'm not constipated or warm bath to ease pain none of it has worked what is your opinion as to what I should do I can see my surgeon on wed the 1 st should I wait until wed am confused because they didn't seem to get what I was saying about my pain am concerned about why so long and how much have had is some blood but not now.what is your take on it .
- Sid Schwab said...
Ms Isker: much as I'd like to help, I really can't offer much in your case. I'd need to be able to see your Xrays and other tests, and your records. Diverticular disease can cause bleeding, or infections with pain. Usually not both at the same time. It sounds like you've had both, but I hesitate to assume your problem is related to diverticulitis now, because I just don't have the information. If it's been confirmed that that's what's going on, and given the amount of trouble you're having, surgery seems high on the list of options. Your docs, and particularly your surgeon, are best able to address your concerns and answer your questions.
- Lady D said...
Hello Sir, your blog is a breathe of fresh air. After scouring the internet for answers, it's nice to find a forum addressing my specific concerns by a medical professional. I am a 61 year old African American female. On October 9, 2019, I was traveling across country and I went to ER with severe abdominal pain. I was admitted for three days and treated with antibiotics through IV. I was released with 12 days oral meds of Cipro and Flagyl. A CT scan revealed sigmoid diverticulitis with abscess formation no bleeding, no diarrhea, no fever with some constipation. On November 11th, I reported back to the ER again with severe abdominal pain and again admitted, treated with IV antibiotics Sent home this time Amox-Clav. Since then I have had two mild flare-ups that were treated at home with antibiotics. I have pledged to change my lifestyle with a fiber-rich diet and exercise, but have had a chance with these back to back flare ups. A colonoscopy consult is scheduled for February. I don't know if I should wait or try to seek medical attention elsewhere to try and get in sooner. My question to you is, in your opinion do you think surgery is enviable as a result of the continued flare ups or is it possible it will resolve itself.
Prior to these episodes, I have not had any kind of stomach issues expect when I was 17 I had a bowel obstruction (don't know all the details) this came from out of the blue after all these years. What a life changer one minute I'm traveling enjoying life and now this has stopped me in my tracks. Your response is greatly appreciated. Thank you so much. - 12/30/2019 11:42 AM
- Sid Schwab said...
I try to avoid making specific recommendations or provide specific opinions in particular circumstances. What I can say is that, in general, when a person has had two or more episodes of diverticulitis severe enough to require hospitalization, they fall into a category where surgery is high on the list of options, and in which "lifestyle changes" might not do the trick. I'd also tell them that, with the disease mainly limited to the sigmoid colon, where it's most common, surgical removal has a high likelihood of permanent cure and a very low risk of postoperative problems.
- Lady D said...
Thank you Dr. Sid. Would it be colon removal or something less evasive?
- Sid Schwab said...
It would be removal of that segment of colon, the sigmoid (for S-shaped) colon. When done between attacks, when the infection is simmered down, it's almost always possible to sew the ends together without a colostomy. And losing that amount of colon, which is around one-fifth of the total length, has no long-term effects; i.e., bowel function would be expected to be normal after healing.
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Searching for something specific? Our Sydney-based customer service experts are here to help!
Out with the old, in with the new! HelloCars will buy your old car and get you behind the wheel with a new car on subscription from just $119 per week.
HelloCars Subscription means no worries. Subscribe to drive with no long-term commitment and one affordable weekly payment. Never stress about the nuts and bolts of car ownership again!


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text: African-American man Barack Obama, 47, was given the least-desirable job in the entire country Tuesday when he was elected president of the United States of America. In his new high-stress, low-reward position, Obama will be charged with such tasks as completely overhauling the nation's broken-down economy, repairing the crumbling infrastructure, and generally having to please more than 300 million Americans and cater to their every whim on a daily basis. As part of his duties, the black man will have to spend four to eight years cleaning up the messes other people left behind. The job comes with such intense scrutiny and so certain a guarantee of failure that only one other person even bothered applying for it. Said scholar and activist Mark L. Denton, "It just goes to show you that, in this country, a black man still can't catch a break."


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Products are delivered by GLS, FedEx e Poste Italiane couriers.
A tracking service of the package is in place forthese forwarders. The courier delivers from Monday to Friday, both in the morning and the afternoon. The recipient may not request a specific day or time for the delivery. In the absence of the recipient, the courier will leave a notice at the recipient's address. Delivery will be attempted twice, after which the courier will attempt to contact the recipient. Bloomart will not be held responsible for any failure by the courier company to complete timely delivery. In the case of deliveries to receptions (signed for by the receptionist), Bloomart will not be held responsible for the package arriving at the final recipient. If a country is not on the country list, that means delivery is not currently available for that destination; however, since Bloomart is looking at extending the list of countries that we deliver to, we recommend you contact [email protected].
At the time of delivery, the Client shall be required to check:
- that the number of packages delivered corresponds to the number shown on the delivery note;
- that the packaging is intact, not damaged, or wet or spoiled, including with reference to the materials used for sealing (adhesive tape or metallic strapping).
Any damage to the packaging and/or to the product or any lack of correspondence in the number of packages or the details, must be notified immediately by indicating the nature of the problem on the delivery note for the product, which shall be returned to the carrier.
Any problems concerning the physical integrity, correspondence or completeness of the products received must be reported within 14 days of delivery, by contacting customer service at [email protected].
Shipping Costs
Shipping costs depend on the destination and the weight/volume of the package. You can see the shipment cost online at the end of the order process, before confirmation of the order. Your confirmation is equivalent to express acceptance of the entire order including the shipping cost as calculated.
Delivery Times
Orders are dispatched 24 hours following receipt of your order, after which delivery times are 1-2 working days in Europe, and 3-5 working days for countries outside Europe. Delivery of your order may be delayed due to the product(s) being temporarily unavailable; failure by the courier company to complete timely delivery; unforeseen or uncontrollable circumstances; or due to public holidays.
In the case of payment by credit card or PayPal, your order may be delayed if the payment is not authorized or if there are insufficient funds. If you have not received your order after 8 working days (excluding Saturday and Sunday), please contact Customer Services at [email protected].
The lead times for delivery indicated by Bloomart are merely indicative and a delay to the same, or any delivery made with subsequent split consignments shall not entitle the Client to refuse the delivery or request compensation or indemnity.
Taxes and Duties
In the case of shipments to countries outside the European Union, goods may be subject to customs duties or taxes. Any additional taxes for customs clearance will be borne by the recipient. In the case of the goods not being delivered (due to, for example, the recipient having provided the wrong address and/or phone number, or the repeated absence of the recipient at the address provided), or if the goods are not accepted by the customer, the recipient will be charged a fee to cover the following expenses: shipment of the goods + return shipment of the goods + any customs fees for the return of the goods. The cost of the goods themselves will be reimbursed to the customer. Customs duties and taxes are charged when the goods arrive in the country of destination, and the cost varies depending on the country. For further information regarding duties and taxes, and providing for the clearance of goods, we recommend that you contact your local customs office.


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LINEN TROUSERS ISADORA, black
Solid color, soft linen trousers. The rubber waistband and drawstring ensure a comfortable fit. Linen trousers with two pockets, a wide cut and a tapered line go well with a shorter blouse or sweater.
An easy choice for summer day clothes!
Material: 100% LINEN
Linen that's gone through a special processed wash won't shrink in the wash and wrinkles up less. Linen is all natural, antibacterial and antistatic. Gets softer with every wash! The more it's worn, the more You it'll become! Linen is unique by the fabric characteristics--cools in the summer and warms in the winter. Feel and enjoy!
suurus |
size |
onesize |
vöö |
waist |
80-90 |
puus |
hips |
110 |
pikkus |
length |
108 |
Transport to Finland Itella Smartpost parcel terminal 9.90 eur
Return and exchange
The Seller must submit a withdrawal application within 14 days from the date of receipt of the goods for the exchange and return of the Products. The withdrawal application can be submitted as follows:
- A completed return / withdrawal form is sent with the returned Products to the Seller
- By sending an explicit e-mail in free from to email@example.com
- By submitting the completed return form on the website
Returns received by the Seller will only be accepted with the completed return form or application.
You can find the withdrawal form HERE
The return of the Product through a parcel terminal or courier is PAYABLE FOR THE CLIENT!
The Seller returns the purchase amount to the Customernot later than 14 daysafter receipt of the Product. Returns are made to the same account, from which Customer paid for the returned order.
Itella Smartpost parcel terminal Saku Selver
Recipient's telephone number +372 56 987 410
Company Linane Elustiil OÜ
By returning the Product with SmartPost, you can use the same code that you received the package.
Replaceable or refundable Products may not be damaged or with wearing marks, the Product must be in its original packaging and all original labels must be on the Product. In the event of a deterioration in the condition of the item to be returned, the Customer shall be liable for the reduction of the value resulting from the use of the item only if he / she has used the item in any other way than necessary in order to be convinced in the nature, characteristics and operation of the Product. In order to be convinced in the nature, characteristics and operation of the item, the Customer should handle and use the item only as if it would normally be allowed to do it in the shop.
The Customer is required to open the packaging of the Product with care, without damaging it. If the packaging cannot be opened without damaging it, the return of the Product in the original packaging is not required. The original packaging must be film-coated.
The Seller returns the purchase amount to the Customer not later than 14 days after receipt of the Product. Returns are made to the same account, from which Customer paid for the order.


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Root Canal Frequently Asked Questions
What is root canal treatment?
Root canal treatment is the removal of the nerve and blood vessels of a tooth for the purpose of trying to save the tooth from extraction. A simple analogy is removing the wick from a candle. The void where the wick was is cleaned and smoothed and then we place a rubber-type material into the cleaned out space to seal the canal.
What is the dental pulp?
The pulp is the soft tissue that contains nerves, blood vessels, and connective tissue. It lies within the tooth and extends from within the crown of the tooth (that portion of the tooth that is visible) to the tip of the root in the bone of the jaw.
What happens if the pulp gets injured?
When the pulp is diseased or injured and can't repair itself, it dies. The most common cause of pulp death is a cracked tooth or a deep cavity. Both of these problems can let germs (bacteria) enter the pulp. Germs can cause an infection inside of the tooth. Left without treatment, pus builds up at the root tip, in the jawbone, forming a "pus-pocket" called an abscess. An abscess can cause damage to the bone around the teeth.
Why does the pulp need to be removed?
When the infected pulp, which is made up of blood vessels and nerves, is not removed, pain and/or swelling can result. Some elements of the infection can injure your jaw bones and the resulting bacteria may enter your bloodstream. Without treatment, your tooth may have to be removed. In severe cases, you might need to be hospitalized due to an infection throughout your body.
What does treatment involve?
Treatment often involves from one to three visits. During treatment, the diseased pulp is removed. The pulp chamber and root canal(s) of the tooth are then cleaned and filled with a rubber-type material that seals the tooth so that no germs enter the tooth.
Here's how your tooth is saved through treatment:
First, an opening is made through the top of the tooth into the pulp chamber. The pulp is then removed. The root canal(s) is cleaned and smoothed. Medications may be put into the root canal(s) to help get rid of germs and prevent infection. If the treatment requires more than one visit, a temporary filling will be placed in the crown opening to protect the tooth between appointments or the tooth may be left open for a few days to drain. If a prescription is provided, please follow the directions as written. On the subsequent appointment, the temporary filling is removed and the pulp chamber and root canal(s) are cleaned and filled. However, if we advise you that your tooth requires a crown, you will need to return to our office for that procedure.


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We take pride in our customer interactions
Archive Accessories
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Our equipment is tested in some of the harshest environments possible, from Everest base camp to remote villages in the Congo. We're confident that if it works out there, it'll work whenever, wherever you need it. That said, we recommend checking the details of each product for durability ratings. For example, the Venture Power Banks are designed to withstand the elements, especially wet environments, as opposed to the Goal Zero Yeti Portable Power Stations that should be kept dry at all times. All of our solar panels are designed to be outside soaking up as much sun as possible, even if that means withstanding a storm (or several). Check the individual product user guides for more information, found here: (https://www.goalzero.com/user-guides/)
Solar generators use a Yeti Power Station and a solar panel to provide essential backup power. It's that simple. Two products that, combined, make up a solar generator. Our solar generators are portable, and they provide clean energy to recharge our devices or power our homes, RVs, vehicles, boats, and, on occasion, crock pots at that apres-ski tailgate.


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If revenge is a dish best served cold, in Washington it can also be served with a heaping side of irony.
The Supreme Court agreed Monday to Sen. Mitch McConnell's request to let Senate Republicans participate in the high-profile case Noel Canning v. National Labor Relations Board.
The question in that case is whether President Obama abused his recess appointment power in naming NLRB members. The president claims the Senate was in recess, which would make his appointments constitutional; Senate Republicans dispute Obama, saying the chamber wasn't in recess.
The court had initially given the lawyers for the administration and Noel Canning 60 minutes to make their case.
But McConnell, the Senate Republican leader, asked for time to present the Senate minority's position. The court granted that, adding 30 minutes for arguments. The administration will now get 45 minutes; Canning and Senate Republicans will split the same amount of time.
And the lawyer poised to make the Senate GOP's argument before the Supreme Court? Miguel Estrada, who argued the case for Senate Republicans in the lower court.
At the start of George W. Bush's administration, it was Democrats who filibustered Bush's nomination of Estrada to the D.C. Circuit. That filibuster contributed to the toxic spiral of filibusters that first caused Senate Republicans, then Democrats, to threaten using the "nuclear option" to weaken senators' ability to filibuster nominations until Democrats actually did it last month.
If the Obama administration and Senate Democrats wind up losing in the Supreme Court, the Estrada and nuclear-option back story could make the win for Republicans especially sweet.
Copyright 2021 NPR. To see more, visit https://www.npr.org.


text: Women's news from around Canada, and around the world. Check back here every day for the latest news about women's racing, events, people and places. Be sure to try out the Archives at the bottom of this page - now a searchable index. We are always looking for cycling news in your community, so drop us a line (firstname.lastname@example.com) - we'll be sure to credit you if we use it!


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EduMed srl Commitment to Data Privacy Protection
Protecting the security and privacy of your personal data is important to EduMed srl ; therefore, we conduct our business in compliance with applicable laws on data privacy protection and data security. We hope the policy outlined below will help you understand what data EduMed srl may collect, how EduMed srl uses and safeguards that data and with whom we may share it.
Personal data
Through our Web sites, EduMed srl will not collect any personal data about you (e.g. your name, address, telephone number or e-mail address), unless you voluntarily choose to provide us with it (e.g. by registration, survey), respectively, provide your consent, or unless otherwise permitted by applicable laws and regulations for the protection of your personal data.
Purpose of Use
When you do provide us with personal data, we usually use it to respond to your inquiry, process your order or provide you access to specific information or offers. Also, to support our customer relationship with you:
If you choose not to have your personal data used to support our customer relationship (especially direct marketing or market research), we will respect your choice. We do not sell or otherwise market your personal data to third parties, except to EduMed srl affiliates.
Purpose Limitation
EduMed srl will collect, use or disclose personal data supplied by you online only for the purposes disclosed to you, unless the disclosure:
EduMed srl does not collect any sensitive data pursuant to section 26 of Italian Legislative Decree 196/03.
The personal data controller is EduMed srl, with registered offices at Via della Badia, 18 25127 Brescia - Italy.
blog or Utilization Data
Through your use of teleblog services to access our Web site, your blog data (e.g. Internet protocol address) or utilization data (e.g. information on the beginning, end and extent of each access, and information on the teleblog services you accessed) are technically generated and could conceivably relate to personal data. To the extent that there is a compelling necessity, the collection, processing and use of your blog or utilization data will occur and will be performed in accordance with the applicable data privacy protection legal framework.
Non-Personal Data Collected Automatically
When you access our Web sites, we may automatically (i.e., not by registration) collect non-personal data (e.g. type of Internet browser and operating system used, domain name of the Web site from which you came, number of visits, average time spent on the site, pages viewed). We may use this data and share it with our worldwide affiliates to monitor the attractiveness of our Web sites and improve their performance or content.
"Cookies" - Information Stored Automatically on Your Computer
When you view one of our Web sites, we may store some data on your computer in the form of a "cookie" to automatically recognize your PC next time you visit. Cookies can help us in many ways, for example, by allowing us to tailor a Web site to better match your interests or to store your password to save you having to re-enter it each time. If you do not wish to receive cookies, please configure your Internet browser to erase all cookies from your computer's hard drive, block all cookies or to receive a warning before a cookie is stored.
EduMed srl will not knowingly collect personal data from children without insisting that they seek prior parental consent if required by applicable law. We will only use or disclose personal data about a child to the extent permitted by law, to seek parental consent pursuant to local law and regulations or to protect a child. The definition of "child" or "children" should take into account applicable laws as well as national and regional cultural customs.
To protect your personal data against accidental or unlawful destruction, loss or alteration and against unauthorized disclosure or access, EduMed srl uses technical and organizational security measures. Links to Other Web Sites EduMed srl Web sites contain links to other Web sites. EduMed srl is not responsible for the privacy practices or the content of other Web sites.
Links to other websites
You may find hyperlinks to other websites on the EduMed srl web pages. They are there to provide a better service to users. EduMed srl is not in any way responsible for the content of other websites users may access from its website. The existence of a hyperlink to another website does not therefore imply that EduMed srl endorses or accepts responsibility for the content of the linked website or the policy that website adopts as regards the processing of personal data and its use.
Questions and Comments
EduMed srl will respond to reasonable requests to review your personal data and to correct, amend or delete any inaccuracies. If you have any questions or comments about the EduMed srl Data Privacy Protection, please click on "Contact" and inform us about your request. As the Internet matures, so will our Data Privacy Protection Policy.
We will post changes to our Data Privacy Protection Policy on this page. Please check this page regularly to keep up-to-date.


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Catch & Dunk | |||||||||||||||
60 Basketball Games Basket Games 60 Basketball games for girls and guys to play online for free shooting and making hoops. Are you ready to play in NBA? Free fun games for boys girls kids teens child children teenagers interDidactica +7000 Free games online for cooking food, serve meals and drinks; dress up, fashion and makeover; Celebrities; Caring; ability, use your mental and physical skills; action, shooting and fighting; adventure, arcade and classic; puzzles and sudokus; car racing and driving; motorcycles, motobikes and quads; sports and competition; Halloween, Easter, Christmas and holidays; Mathematics; Music; Typing games to learn to type fast.Spelletjies | الألعاب | Jocs | Hry | |||||||||||||||


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Basic Account Info
- What can I do if I forget my password?
- How do I create a new account?
- Do I have to create an account?
- How do I change my account information?
What can I do if I forget my password?
That's no problem. If you forget your password, just tell us your email address, and we'll send it to you. Easy!
How do I create a new account?
Creating an account is simple. Our system will automatically ask for your contact information to set up an account when it is needed (when you place an order). If you'd like to create an account immediately go here: Create an Account
Do I have to create an account?
We know people don't like to create accounts on a website unless they have to. So, go ahead and browse through our products, read our resources, and enjoy. We won't ask for your contact information until you actually place an order, which we'll use to create your account. With an account, you will then be able to easily access all of your order information, including past orders and the status of existing ones.
How do I change my account information?
You can easily change your account information by going to your account page and editing your profile information. To get to your account page from anywhere on the website, simply click the Sign In or Account link at the top of the page.


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Returns & Exchanges
If you're looking to return your order, look no further, we're here to help!
Quick Links:
- Eligible Returns
- Returns Instructions
- Book Your Return
- Exchanges
- Store Credit
- Something's Wrong with My Order
Orange Sherbet offer free return shipping within 30 days of purchase. You can return your product for either a store credit or an exchange.
Please read through our returns policy below, then click on the link under 'Book Your Return' to begin the returns process.
Info for older returns store credits
Please note if you have a return credit code from prior to 7th of July 2021, you will still be eligible for the terms of our former returns policy. Please reach out to firstname.lastname@example.com for assistance with using your old returns store credit.
Eligible Returns
- Returns must be received within 30 days of date when the order was placed.
- All clothing must be in original, unwashed condition, with tags still attached.
- Clothing must be free from make-up, deodorant, and any other stains; perfume odours; and without excessive wear.
- We do not accept returns for items which pose a hygiene risk such as earrings, hats, etc.
- Items marked as 'Final Sale' are not eligible for exchange or return (excepted where the items are faulty under consumer law guidelines).
Any items that do not meet these requirements will be returned at the customers expense. Orange Sherbet reserves the right to refuse access to the returns portal if we believe items are not returned in the original condition as when they were shipped.
Return Instructions - Australian Customers
- Click on the below link "Login to start a return" and select the order from your order history
- Select the items from your order that you are wanting to return, and choose whether you would like a store credit or a size exchange.
- Download your return shipping label. You can either print it off at home or take your label to your local post office for printing.
- You can reuse the satchel that your order arrived in; however, please ensure that all old shipping labels are removed or covered prior to sending.
- Lodge your return at a post office or pop in a red post box.
- Please ensure your return is securely enclosed within a suitable satchel. Orange Sherbet is not responsible for items lost or damaged in transit to us.
Return Instructions - International Customers
Starting a return by signing-in is only for use within Australia. Please feel free to send your return to the below address and be sure to include your name and order number so we know who to contact once received. International return postage costs are the responsibility of the customer.
Orange Sherbet – Returns
2/21 Torres Crescent
Book Your Return
Click on the below link to begin your return. You will be redirected to our returns portal.
Login to start a return or exchange!If you prefer to start a return without signing-in to your account, you can do start a return with our returns portal here.
you are experiencing any issues with starting a return, please contact our returns department at firstname.lastname@example.com
If you found that the fit wasn't quite right on your item/s, you can use the returns portal to exchange for the size you would like. Simply follow the onscreen prompts to select your preferred size, and we will send out your replacement free of charge. Once your order is marked as 'in transit' by Australia Post, we will dispatch your exchange order, so you won't be without your perfect new outfit for long!
Please note that we are unable to hold sizes for exchange orders, so if the item runs out of stock in the time it takes for your return to reach us, you will be issued with a store credit to use on a future order.
We currently only have the ability to exchange for items that are the same style, but different size. If you would like to exchange for another style, please return your item/s for a store credit and use the gift card to purchase the new item/s you were wanting.
Large exchanges may be held for review before shipping.
Store Credit
Store credit's will be issued in the form of a gift card that is valid for 3 years. Once our team processes your return, you will be emailed a gift card to the value paid of the items returned.
Store credits are usually processed within 3 business days of receiving. If your gift card hasn't been issued to you within this period, please contact our returns teams and they will get back to you as quickly as possible.
Something's Wrong with My Order
In the rare event that you receive a faulty or incorrect item with your order, please reach out to our Returns Department at email@example.com or call 07 3283 5969.
Please take some photos of the issue, and have your order number ready, so we can assist you without delay. We will endeavour to find a solution for you as quickly as possible.
Can I return sale items?
Except items marked as 'Final Sale', all other discounted products are eligible for return or exchange. Final sale items are heavily discounted products reduced by 40% or more. However, if there is a major fault with your item, we will be more than happy to find a solution inline with Australian Consumer Law.
Do you offer refunds for returns?
We want you to be happy with your purchase; however, we are unable to offer refunds for change of mind, incorrect size selection, deciding you don't like the item, or you have no use for the item.
If you are unsure about the fit, features, or styling of any of our products, please reach out to our customer service team and they will be more than happy provide you with additional information to assist with your selection.
My order was pick up in store, can I still return my items?
Absolutely! You can either choose to return in store or via the online returns portal.
Can I return items from multiple orders?
The returns portal only allows you send items back from one order. However, you can reach out to our Returns Department, and they will assist you with returning items from multiple orders.
Is stock held for me once I request an exchange?
When requesting a size exchange via the return portal, stock is not reserved. However, once the tracking of your return is updated to 'in transit', your exchange will be released from our warehouse and on its way to you. To avoid missing out, we recommend sending your return back to us as soon as possible.
Can I exchange an exchange?
Unfortunately we can only provide one free exchange per order placed. If you need assistance with exchanges, our customer service team is here to help!
I didn't receive my return label?
Not a worry at all! Please reach out to our returns department and we can resend your return label if needed.
I used a discount on my order; how does this effect my return?
A discount code is applied evenly to all items within an order, which reduces the cost of each item respectively. When returning for a store credit, the gift voucher will be issued to value of each item after any discount codes have been applied.
What happens if I don't use my return label?
Your return label will expire after a certain period if it is not used. You will receive an email reminder to use your return label once it is nearing its expiry date.