Diplomatic Pouches?

January 1, 2025 By Jonathan Sackier

You may have seen them at large, international airports, or strolling importantly around Washington, DC, all serious shoes and expressions, holding onto a world-weary leather case, a diplomatic pouch. I always wondered how a pouch could be “diplomatic”—does that mean it would not declare its presence and seek to be invisible?

Well, there are other pouches out there, and given the age demographic of aviators, around half of you reading this article have these pouches. I am speaking of diverticula, pouches in your colon, the large bowel, that may be diplomatic and silent…until they are not and behave like a crazed dictator!

The colon is a conduit that conveys food waste from the lower right quarter of the belly, up toward the ribs, turning left under the liver, crossing to the upper left then taking a sharp turn down toward the anus. It serves to remove water and does so by having a large absorptive surface area. Movement from start to finish is driven by coordinated muscular contractions called peristalsis and enabled by a continuous circular muscular tube that surrounds and squeezes the colon. Additionally, there are long muscle fibers divided into three taenia coli, bands that shorten the colon when they contract, helping to pulse food on its journey from your barbecue to create gainful employment for sewage plant workers. Between these bands, blood vessels enter the bowel wall providing nutrients so it can conduct its task and conduct poop on its way. These points of entry are weak spots, in areas that already lack a complete muscular coat. As the colon dives into the pelvis, the taenia coalesce and form the rectum, a straight tube whose added muscle mass serves to store feces prior to sending them on their way.

Western diets, low in both fiber and sufficient fluids, cause folks to have drier, smaller poop that is harder for the bowel to push down the line, requiring higher pressures to be generated. This in turn leads to little colon out-pouchings to develop right where blood vessels pierce the bowel wall between the long muscle bands. Because pressure is higher on the left side of the bowel, these diverticula are more common on that side, specifically an area called the sigmoid colon, the name referring to its “S” curves. Very often, diverticulosis, as a collection of diverticula is called, causes no symptoms. But it may start to declare its presence with a touch of bloating or vague discomfort most commonly to the left of the umbilicus. If that happens in the presence of a dodgy bowel habit, think diverticulosis. What do I mean by a “dodgy bowel habit”? Well, if you keep reading material in the bathroom because a bowel movement takes a long time, if you must make grunting noises and turn purple to poop, if you recognize tomato skins riding your flume log to the ocean two days after eating them…you have a dodgy bowel habit and are not eating enough fiber! Think about the word evacuation; if you are trying to exit a sinking boat or a burning car or plane, you want to get out fast. That is what a satisfying BM should be like, quick and effortless!

If you imagine a diplomatic pouch containing some inflammatory political material, you might be concerned as to what will transpire next. It is the same with diverticulosis. If the entry to a pouch gets blocked, contained mucus becomes infected and a bag of pus results, effectively resembling a boil inside your belly! This will induce a range of unpleasant symptoms, including cramping pain, vomiting, fever and chills, and severe abdominal tenderness. This episode of diverticulitis merits immediate medical attention with antibiotics and “bowel rest”—a fancy way of saying “no dinner for you, sonny!” If the inflammation does not resolve, a bad political situation can deteriorate further. For instance, the boil may burst, leaking infected pus into the abdominal cavity, or if the connection to the colon itself remains patent, fecal material can enter the cavity. Alternatively, an inflamed bowel may stick to a nearby organ and burrow into it, causing a fistula, an abnormal tunnel or connection that allows feces to enter the urinary system, vagina, or onto the skin or other bowel segments. Recalling that colonic weak spots occur where arteries and veins pierce the circular muscle, an adjacent, inflamed pouch can erode vessel walls and cause massive bleeding, which can flood out the anus, although it often stops spontaneously as blood pressure drops. Additionally, repeated episodes of inflammation can heal by scarring and lead to bowel narrowing, which can require more pressure to defecate and thereby induce further problems. Suffice it to say, diverticulitis is far from diplomatic and causes life-threatening complications.

If a doctor suspects you may be forming pouches, colonoscopy is the preferred means of diagnostic confirmation, where the operator will see numerous bowel wall gaps that lead into the pouches. While colonoscopy may not be the best experience of your life, it will be up there!

Sometimes emergency surgery is required to address perforation, bleeding, infection, blockage, or fistula. After two episodes of inflammatory diverticulitis, it may be sensible to consider an elective operation to remove the diseased bowel before something nasty happens, as the more episodes one has, the higher the likelihood of a serious problem sooner or later. A preemptive strike on a malevolent enemy if you like!

Diet and lifestyle changes can help prevent diverticulosis from developing, or limit flare-ups. In addition to a fiber-rich diet, reduce red meat intake, drink lots of water, do not smoke, limit alcohol consumption, and exercise regularly. Should surgery be required, it is best done electively, as surgeons can more likely remove the bad piece of bowel and join the ends together because if there is infection, fistula, inflamed or narrowed bowel, or recent blood loss, one may require a stoma where the bowel empties into a plastic bag affixed to the abdominal wall, sometimes for a number of weeks or months, but possibly permanently. Often, these operations can be performed under the guidance of a laparoscope, whereby small incisions are used, perhaps with robotic assistance. After the procedure, while there may be less bowel to absorb water, people usually make a full recovery. It reminds me of the English grammar teacher who needed this procedure and told me afterwards that she had a semicolon!

From an aviation perspective, if diagnosed with diverticulosis, report it to your AME at your next appointment. If an episode of diverticulitis renders you sick, self-ground, and if hospitalization or surgery is required, a lengthy spell away from the left seat may be required—remember, look after your health first!

While diverticulitis is no laughing matter, it is largely avoidable; over the years many surgeons have visited with me to see diverticulosis procedures as they hail from regions of the world where a high-fiber diet is the norm and the disease is absent. But when doctors get together we do like to find the humor in life situations, and if you want a giggle, check out Dave Barry’s article about colonoscopy, originally published in 2008 and updated here: https://www.miamiherald.com/living/liv-columns-blogs/dave-barry/article1928847.html. Meanwhile, skip the bacon and eggs and munch down on that granola if you don’t want to have a light at the end of your tunnel! Fly well!