Acute diverticulitis

Acute

Diverticulitis

Wilma C. Diner, M.D.. and Howard J Barnhard,

M.D

HE PAST IO-15 YEARS have produced an overwhelming volume of literature on diverticular disease, especially that of the left colon. We shall present a survey of the important changing concepts of etiology, pathology, and therapy that have resulted in better understanding of this “disease of western civilization.” The newer more reliable roentgen findings that indicate diverticulitis will also be described, together with the findings in diverticulosis. Although most attention will be given to the left colon, the rest of the gastrointestinal tract will also be considered, with emphasis on the roentgen aspects that differ from those in the left colon.

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CLINICAL

FEATURES

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PROGNOSIS

Diverticular disease has increased in the developed western countries during this century and has remained rare in rural societies. The low-residue diet resulting from refined flour and cereals,22*38emotional stressX autonomic nerve lesions-32j,‘j and hormonal factors6” have all been implicated. It is a disease of the middle-aged and elderly, with approximately equal sex incidence!’ Lower abdominal cramping, intermittent constipation and diarrhea, left lower quadrant tenderness, and sometimes severe pain are typical of diverticulosis. Acute episodes of diverticulitis include the above features with fever, leukocytosis, signs of sepsis, and sometimes peritoneal irritation. Urinary symptoms, such as dysuria, are common and fistula into the bladder causes pneumaturia and pyuria. In patients on steroid therapy or those with underlying debilitating disease, perforation and fistula are more frequent and cause greater morbidity and mortality. Many patients with scattered diverticula never have symptoms or complications. Those who do have acute inflammation tend to recover from individual episodes only to suffer from recurrent ones. A second episode can be expected in about a third, with surgery usually becoming necessary. In one study, the immediate risk to life during the first hospital admission was 3”,,;4i morbidity and mortality rates are higher with successive recurrences. Progression tends to occur within an already involved area, usually the sigmoid, rather than to extend to other areas. The sigmoid is not only most commonly involved, but most frequently requires surgical intervention. There is no evidence that diverticulitis predisposes to the development ot carcinoma. The two diseases occur in similar populations in terms of age. nationality, and diet, so it is not surprising to find them together on occasion, Diverticulosis is now recognized as the most common cause of massive lower gastrointestinal tract hemorrhage, occurring in about 5”,, of all patients with

University of Arkansas Medical Cenrer, Wilma C. Diner, M.D.: Professor q/ Radiology. Department q/ Radio/q\,. Rock, Ark. Howard J. Barnhard, M.D.: Projessor and Chairman. versily of Arkansas Medical Cenrer. Little Rock, Ark. 72,701 (* I973 Seminars

by Grune & Stratton, in Roentgenology,

Lii:/v Lnt-

inc.

Vol VIII. No. 4 (October).

1973

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diverticulosis. The incidence of lesser degrees of hemorrhage is probably IS’;,-207,.59’2*47 The bleeding usually ceasesspontaneously, although one author believes that barium enema may actually stop the hemorrhage.’ Patients who bleed usually have no fever, leukocytosis, or other clinical evidence of inflammation, but are often hypertensive and arteriosclerotic. Intermittent minor bleeding, significant weight loss, and obstruction should alert one to the possibility of carcinoma. PATHOPHYSIOLOGY

Localized areas of high pressure normally occur between interhaustral contraction rings, particularly in the sigmoid40 (Fig. I). The high pressure as well as increased motility arise in response to meals, emotions, drugs (especially morphine and Prostigmin), in the irritable colon syndrome, and in known diverticular disease.8With prolonged high pressure, the mucosa is forced through the wall at vulnerable points, usually where blood vessels penetrate circular muscle and weaken the wa1l.3 Diverticula are thus formed in varying numbers, oriented in two lines between the one mesenteric and two antimesenteric taeniae. Fewer smaller diverticula of different configurations protrude between the two antimesenteric taeniae.3127 Goulard and Hampton should be credited with the inception of important new insights and changing concepts of diverticular disease.2” They examined surgical specimens from patients diagnosed as having diverticulitis roentgeno-

Fig. 1. considered diverticula.

Segmentation. responsible

This formation of multiple for localized foci of high

pockets pressure,

by interhaustral predisposing

to

contraction rings is the formation of

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logically and were unable to correlate the roentgen criteria with actual pathologic findings of /nflammation. It has since been repeatedly demonstrated that about a third of specimens of sigmoid colon removed because of a clinical or roentgen diagnosis of diverticulitis will show absolutely no inflammation.” These srgmoids usually reveal varying degrees of shortening, thickening, or true hypertrophy of the taenia coli and of the circular muscle.3,‘4 The circular muscle changes (myochosis)‘7 are probably the result of long-standing elevated pressure and hyperactivity.4” The muscle thickening produces transverse folding ot mucosa (Fig. 2), which shows roentgenographically an exaggerated mucosal fold pattern and saw-toothed or serrated margin of the bowel (Fig. 6). is the aggregation of many diverticular “Simple massed diverticulosis” pouches in a limited area without muscle change, usually involving most of the left colon. The mere presence of many diverticula, each with mucosal lining protruding through the wall, accounts for loss of caliber of the bowel lumen without implicating muscle shortening or thickening. The painless diarrhea form of irritable colon syndrome may predispose to this type of diverticulosis.“* 24 The diverticula and muscular hypertrophy of “spastic colon diverticulosis” follows the painful irritable colon syndrome with its excess motor activity and increased intrasigmoid pressure.” Diverticula are said to develop in patients

Fig. 2. thickening

Diverticulosis. and shortening.

The exaggerated The small polyp

transverse mucosel folds is an incidental finding.

are

produced

by

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with irritable colon syndrome about twice as frequently as the 10%-12x incidence of diverticula in all colon studies.2’ Whenever inflammatory change is present in tissue specimens, evidence of micro- or macroperforation at the tip or side wall of one or occasionally more diverticula can be demonstrated. 33Macroperforation produces localized abscessesbetween pelvic organs or within folds of mesentery. Sometimes there is free perforation into the peritoneal cavity. More commonly, microperforation exists, and focal areas of inflammation and abscess formation are seen within pericolic fat at the tip of the pouch around the site of perforation (Fig. 3). In time, these lesions resolve by fibrosis and shrinkage to the point where one may not be able to recognize the site of perforation. Fistulas may track along the bowel wall, into an abscess, into the gutter or abdominal wall, or into nearby organs, most frequently the bladder. They have been reported to extend into virtually every surrounding structure, even into a hip joint damaged by disease many years earlier.14 After massive hemorrhage, meticulous examination is necessary to locate the eroded blood vessel, usually at the mouth of the pouch. A thrombus may protrude into the colonic lumen from the involved diverticulum.54 Large tortuous or arteriosclerotic vessels are usually implicated.37 Such a vessel may pulsate against a fecal mass within the diverticulum, eroding the wall.48 Inflammation is a negligible factor in most such specimens. ROENTGEN

FINDINGS

IN DIVERTICULOSIS

Diverticula may be demonstrated in varying numbers, sometimes throughout the entire colon. Those in the sigmoid usually predominate, and it may be the

Fig. 3. Perforated diverticulum. Microscopic in the serosal fat around the tip of the pouch.

section

shows

the perforation

with

a microabscess

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Fig. 4. Simple massed diverticulosis. Many diverticula with heaped-up mucosa but little or no evidence of muscular thickening.

only area involved. Large numbers of diverticula clustered in one zone, usually the sigmoid, with luminal narrowing simply due to their presence alone, constitute simple massed diverticula” (Fig. 4). The corrugated, concertina-like, dove-tailed palisading of the folds with serrated or saw-toothed marginal pattern, luminal narrowing, and focal tenderness reflect shortening and thickening of musculature rather than inflammation (Figs. 5 and 6). When unilateral. the

Fig. 5. Diverticulosis with typiccl appearance of mucosal folds and ridging due to muscular hypertrophy and shortening. Diverticula of varying shapes protrude from the apex of grooves between prominent trensverre muscle bundles.

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Fig. 6. Spastic colon diverticulosis. palisading of folds, and spike-, square-, terpreted es diverticulitis.

Severe muscular and club-shaped

thickening divert&da.

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with irregular narrowing, This should not be misin-

marginal changes may be caused by incompletely formed antimesenteric intertaenial diverticula.27 Zones of narrowing may be short, but are more often at least several centimeters long, and tend to have tapered changeable margins. The mucosal pattern remains intact within the affected area, although this may be difficult to determine when the narrowing is severe. 49The narrowing may be pronounced enough to produce complete obstruction to the retrograde flow of barium. Propantheline bromide (30 mg) administered intramuscularly 5 min before the barium is introduced may relax a spastic constricted area.15 Also, water-soluble contrast media may pass such an obstruction sufficiently to outline it. Massive hemorrhage from diverticula indicates erosion of a blood vessel. Mesenteric arteriography may demonstrate extravasation of contrast material at the bleeding site, a great help when resection becomes necessary for the control of intractable hemorrhage.55 Angiography should be performed before emergency or elective colectomy or arbitrary sigmoid resection because the bleeding point has been demonstrated to be in the right colon in a significant number of such patients.6 ROENTGEN

FINDINGS

IN DIVERTICULITIS

When acute diverticulitis is suspected clinically, there should be an initial period of observation. Plain abdominal and chest films should be taken to rule out perforation, obstruction, or other disease processes in the chest or abdomen. The abdominal film may reveal an inflammatory mass, sometimes separating small bowel loops from the sigmoid or bladder shadow. Abnormal

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gas shadows within a soft tissue density may represent gas in an abscess. Giant sigmoid diverticula are rare but characteristically present as a large, round, usually movable, gas-filled shadow in the upper abdomen, corresponding to a palpable mass. 26 Although this lesion may not fill with barium on contrast examination, it is always associated with diverticular disease and may perforate. A urinary fistula may be revealed by the presence of gas in the bladder. Barium enema is the essential diagnostic study. There is, however, some disagreement as to when it should be done. We believe it is safe if the patient is stable, not in shock, and free intraperitoneal gas and pus have been fairly well excluded. If free perforation is first noted at the time of the barium enema, it probably preexisted (possibly occurring during preparation) or at least would have happened spontaneously shortly thereafter.16 Whenever the study is to be performed, preparation should be omitted or limited to a gentle cleansing enema. If significant roentgen findings are found in the sigmoid, the examination should stop there. No additives should be used in the enema mixture. Some examiners prefer air contrast enema, but we do not think it is necessary. The demonstration of definitive roentgen signs of inflammatory disease requires careful technique. The patient should be asked to report any pain or discomfort during the procedure so that spot films may be exposed at appropriate sites. Gentle palpation may also detect local points of tenderness. These foci may rcveal one or more of the signs of perforated diverticulum. When frank diverticulitis is present, some or all of the previously described findings of diverticulosis will be seen, along with the changes indicative of inflammation and its complications. The criteria for the diagnosis of acute divertic:ulitis have changed in recent years. Lumen narrowing, serrated or sawtooth pattern of the margins, and incompletely tilled or spiked diverticula are no longer valid evidence of inflammation?0*33~34 These findings appear to be secondary to geometric effects of the herniated pouches themselves, or to the shortening and thickening of the muscularis. The new diagnostic criteria of acute diverticulitis are based on perforation of one or more diverticula. Therefore, the radiographic manifestations must include at least a mass indenting or encircling the bowel, with or without a col.lection of extraluminal barium, frank abscess, or fistulous tract.33 The most reliable finding is perforation.36 The diverticular pouch may appear collapsed and the amount of barium extending extraluminally may be only a tiny fleck or a streak;33 but any contrast material identified outside the diverticulum means that a perforation exists. Sometimes barium extravasation does not occur until after evacuation. An uncommon but characteristic finding is a longitudinal submucosal or subserosal fistulous tract parallel to the bowel with multiple luminal communications at the tips of the diverticula.si~59 Loc.al inflammation or small abscess formation around the perforation produces an eccentric mound or marginal filling defect indenting the lumen of the colon. It usually must be viewed in profile to be recognized and is the most common finding36 (Figs. 7 and 8). Again, complete obstruction to retrograde barium Row may exist, with or without evidence of obstruction from above, and propantheline bromide or water soluble media may be helpful. Small bowel study may reveal areas of in-

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Fig. 7. Diverticulitis. An inflarnmatory mass indents the inferior aspect of the sigmoid (arrow). The smudgy bubbles of gas superior to the involved sigmoid segment probably lie within an abscess.

flammation of small intestine where these loops lie adjacent or adherent to inflamed colon.30 To recapitulate, the diagnosis of diverticulitis should not be made without evidence of the perforation: (1) extraluminal barium or gas, either with a small

Fig. 8. Diverticulitis. An inflammatory mass deforms the sigmoid (arrows) in the region of multiple diverticula. The intact mucosal pattern speaks against carcinoma.

b, “:

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perforation, abscess (Fig. 9), fistula or sinus (Fig. IO), or free air in the peritoneal cavity, and/or (2) a mass impinging on or constricting the lumen of the bowel (Fig. 1 I). While current concepts make the spectrum of diverticular disease more readily understood, the radiologist may not always make a correct assessment of the situation.3h.42 That is, he may not be able to decide between perforation (diverticulitis) and diverticular disease with its muscular accompaniment. This problem exists because the barium often does not escape from the lumen, the mass may be missed, or the findings are simply too subtle to be appreciated. DIFFERENTIAL

DIAGNOSIS

Carcirronza (the most important entity to be ditrerentiated) usually shows a completely rigid fixed narrowing with abrupt shelflike ends and loss of mucosa or ulceration. Sometimes differentiation is impossible.” In such cases, surgical treatment is usually necessary. Significant bleeding and weight loss favor carcinoma, although massive hemorrhage is more apt to be due to erosion of a vessel in diverticulosis. Crohn’s &Tease (granulomatous colitis) shows cobblestone mucosal pattern. ulceration, and fistulas.5” Occasionally, the longitudinal tvpe of fistula parallels the bowel wall, lying between the muscularis and pericolic fat, where it communicates with intramural abscess crypts. The conviction that longitudinal fistulas are pathognomonic of Crohn’s disease, particularly if IO cm or more

Fig. 9. Diverticulitis with perforation and abscess. The irregular pooling of barium along the inferior margin of the proximal sigmoid is within a small abscess. Muscular changes are moderate but only a few diverticula are visualized. The gas lies in an adjacent loop of small bowel.

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Fig. 10. Diverticulitis multiple fistulas extending and below the sigmiid.

with above

long,29 is not shared by all authors.* Crohn’s disease is prone to involve more than just the sigmoid, including the small intestine. The two diseases sometimes occur together, the diverticular pouches disappearing as the inflammatory disease progresses. Ischemic areas or infarction produce a smooth, concentric stricture, or thick rigid folds (“thumb printing”), and a flattened border with large asymmetrical pseudodiverticula on the opposite side. This lesion develops and changes rapidly over a period of 4-6 wk. Scleroderma is associated with large-mouthed, square-shaped antimesenteric sacculations. Endometriosis and metastatic disease can produce an asymmetric bowel wall defect resembling small inflammatory mass or abscess, without the associated changes of diverticular disease. Metastatic carcinoma may encircle the bowel and constrict it, leaving the mucosal pattern intact, and may closely mimic diverticular disease. Irritable colon syndrome is said to cause the colon to fill rapidly because of the small lumen. Pain on filling occurs and sigmoid and descending colon spasm may be observed fluroscopically. Occasionally, massive contraction or complete local block will require propantheline bromide for relief in order to complete the examination. The haustral markings may be lost. Evacuation may be incomplete. Poor mucosal coating and linear folds on the postevacuation film are said to be characteristic.24 *Dr. Richard Marshak stated in a recent postgraduate course on gastrointestinal that he now believes such long fistulas can occur in diverticulitis, but still feels that or longer they are more likely to be associated with granulomatous colitis.2s

radiology if 10 cm

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SIGMOID DIVERTICULAR SEGMENTATION

MIJSCULAR

1

HYPERTROPHY

SIMPLE

\

MASSED

DISEASE

j

,-;

\_

I

DIVERTICULOSIS

SEVERE SPASTIC DIVERTICULOSIS

PERFORATION

WITH

MASS

COLON

Fig. 11. Schematic representation of the development of diverticular disease of the sigmoid. Micro- or macroperforation with extraluminal gas or barium and/or inflammatory mass or abscess are necessary for a diagnosis of diverticulitis.

CURRENT

THERAPY

In contrast to previous recommendations of a low-residue diet, current therapy is based on the theory that abnormally high intracolonic pressure and motility patterns are due to low-residue diets,z3,40and that adding bulk to the stool will prevent them. Painter et al. claim 8.5S/,of 70 patients hospitalized one or more times were relieved of symptoms on a bran diet.39 Laxatives should be avoided. Morphine should not be used to relieve pain because it increases intraluminal pressure. Demerol does not produce this effect, so it is a good substitute. Control of emotional factors contributing to the high intracolonic pressures may be helpful.* A patient with clinical signs of acute inflammation and micro- or macroperforation should be treated with rest, fluids, and antibiotics until the acute inflammation has subsided. Frank abscess, fistula, perforation, or peritonitis are managed surgically with either primary resection or diverting colostomy followed later by resection, anastomosis, and colostomy closure. The newest approach, Reilly’s longitudinal sigmoid myotomy, is based on current theories of the role of pressure and muscle changes. He has reported

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satisfactory results with few complications in over 70 patients followed approximately 7 yr. 46 The operation is usually performed for symptomatic diverticulosis that fails to respond to other forms of therapy, or during quiescent periods between episodes of diverticulitis. Others have also reported good clinical results with this operation, as well as evidence of its effect in lowering intrasigmoid pressure and improving the roentgen appearance.“*53Both resection and myotomy must extend downward past the rectosigmoid junction to be certain of relief of abnormal pressure. Some surgeons still believe that all diverticula-bearing areas of the colon should be removed in massive hemorrhage, regardless of the current bleeding site. Recent authors suggest that determination of the bleeding site by angiography is essential to the decision concerning the extent of the surgical procedure.6 DIVERTICUIAR

DISEASE

IN OTHER AREAS

Rectum Diverticula of the rectum are rare, representing about 2% of all colonic diverticula. They are large, generally solitary, and usually congenital in type, containing all layers of the wall. They often coexist with colonic diverticula elsewhere. We found few reports of diverticulitis, probably because of their large openings and ability to contract and empty. When perforation occurs, it tends to be less serious because of its extraperitoneal location, below the pelvic peritoneal reflection.19 This event is usually mistaken for carcinoma on roentgen studies. Anal diverticula have been reported. They occasionally become inflamed and form a fistula.18 Cecum Acquired diverticulosis of the cecum is commonly associated with scattered diverticula in the left colon, and sometimes in the terminal ileum. Congenital diverticula, more common than the acquired ones, are usually solitary and are frequently located near the ileocecal valve. Diverticulitis can complicate either type. The patients are generally younger than those presenting with left colon disease. The incidence of cecal diverticulitis is higher among Orientals and possibly Polynesians than Caucasians.7v44 There is no concrete evidence that increased intraluminal pressure and muscle thickening play important etiologic roles as in the sigmoid. Generally, only one diverticulum is involved. A localized process is more common than free perforation. Chronic penetration with granuloma formation also occurs. Most pathologic reports show that obstruction of the diverticula and purulent and gangrenous changes are present at the time of surgery. Cecal diverticulitis is usually clinically misdiagnosed as acute appendicitis, so colon contrast studies are rarely done, The clinical picture tends, however, to be somewhat more indolent, and melena and diarrhea should suggest it over appendicitis. 58Nausea and vomiting are more common in appendicitis. At operation, the inflammatory mass may suggest carcinoma, a fact that has resulted in many overly extensive surgical procedures. This can be avoided by

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direct examination of the mucosa which, if uninvolved, should suggest another diagnosis. Further dissection will generally reveal the diverticulum and the inflammatory nature of the disease. Inflammatory changes usually remain localized, but may involve the adjacent small intestinal wall. On barium enema one may find circumferential narrowing, external fixation, and fistula formation, although these are less common findings than in the sigmoid. A typical appearance is that of an eccentric intramural indentation of the cecum, most often on the medial wall, produced by the inflammatory mass or abscess.* Transverse ridging and spicule formation of the mucosa pointing toward the indentation, compressed haustral pattern, and normal mucosal integrity are characteristic. Tenderness to deep palpation and complete filling of the appendix are helpful findings. Occasionally, smudges or bubbles of extraluminal gas can be seen? Appendiceal abscess is the most common entity to be differentiated from diverticulitis. On barium enema, the appendix usually fails to fill, and a defect may be seen at the tip of cecum rather than on the lateral wall or near the valve. Fecaliths are frequent in appendicitis and rare in diverticular disease. Granulomatous colitis produces typical mucosal changes. The ileum is usually involved. Carcinoma tends to be more rigid, with mucosal destruction. Metastatic mafignancy often presents multiple lesions with more rigidity and flattening. The mucosal folds spread apart rather than converge toward the mass. Tuberculosis characteristically shows intrinsic involvement of the terminal ileum and cecum. Amebiasis produces ulceration, large filling defect, and usually multicentric involvement of the colon. Nonspecific colon ulcer is currently believed to represent isolated diverticulitis.* Appendix

Appendiceal diverticula are rare. The patients tend to be younger than those with left colon involvement. Inflammation occasionally occurs, apart from appendicitis and unrelated to obstruction of the appendiceal lumen.1° The clinical manifestations are similar to those of appendicitis, although rectal bleeding56 and a more insidious vague history are more common. A pericecal inflammatory mass may be demonstrable on barium enema but definitive diagnosis would probably depend upon the unlikely event of a prior roentgen demonstration of appendiceal diverticulum. Small Intestine

Diverticula of the small intestine are predominantly the acquired pulsion type as in the left colon. Exceptions are Meckel’s diverticulum and an occasional congenital antimesenteric type in the jejunum or ileum. A recent study, in con*In accordance with a more recent do not arise from the antimesenteric and taenia libera. For this reason,

view of haustral anatomy and pathology, bona fide diverticuia row of haustral sacculations, between the taenia omentalis a localized inflammatory process involving this area alone

(laterally in the ascending and descending colon, and antero-inferiorly in the transverse colon) cannot be attributed to diverticulitis. If such involvement is due to diverticulitis, it also mvalves the other haustra and an extensive paracolic abscess must be presenL3’

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trast to earlier statistics, reported that careful small bowel examination revealed terminal ileal diverticula to be more common than in the jejunum.4) They are more common in Japanese than in Caucasians.23There is no real evidence of pressure phenomena playing an etiologic role. Inflammation and perforation of diverticula have been reported in all areas.” Roentgen findings of terminal ileal diverticulitis include edematous thickening of mucosal folds, narrowing or inflammatory mass formation, and perforation. Regional enteritis and tuberculosis should be considered in the differential diagnosis because the diverticula may not be visualized on a contrast study performed during the acute episode. They may fill after subsidence of acute inflammation. Bleeding occasionally occurs.32 Meckel’s Diverticulitis Inflammation in a Meckel’s diverticulum is probably its most common complication. However, it is usually only of histologic nature and clinically significant acute episodes are rare. They are caused by obstruction and occasionally perforate and lead to peritonitis. Such episodes are usually mistaken for appendicitis. Roentgen diagnosis depends on demonstrating the pouch itself, difficult because of overlying bowel loops. Visualization may be aided by continuing a small bowel examination until most of the barium has entered the colon.’ Contrast study may show edema of the adjacent ileal loops but is usually not done during an acute episode. The roentgen finding on plain films is a localized ileus without gas or fluid level in the cecum,” contrasting with appendicitis, in which a fluid level in the cecum is typical. One patient has been reported with Crohn’s diseaselimited to a Meckel’s diverticulum.” Duodenum Next to the colon, the second portion of the duodenum is the most common site of enteric diverticula (1%-2x of GI series). Diverticula are the false (pulsion) variety, usually protrude medially, and are generally buried in the pancreas. Duodenal diverticula may be single or multiple and vary from a few millimeters to several centimeters in diameter. They may contain food residue but are usually empty. The rarity of complications has been attributed to their wide mouth for easy drainage, supported position, and sterility of contents. In the absence of other causes of right upper quadrant inflammatory disease, if a duodenal diverticulum is present, locally tender, and retains barium for an extended period, a diagnosis of diverticulitis is probably justified. Secondary biliary and pancreatic symptoms are more likely to result from microperforation and peridiverticulitis than from the pressure of the pouch itself. If perforation occurs, it is usually retroperitoneal from diverticula lying on the posterolateral wall away from the pancreas?5 We have seen no report of diverticulitis in diverticula of the first portion of the duodenum. In the duodenum, diverticulitis, perforation, and even hemorrhage are rare and seldom diagnosed preoperatively, being confused with far more common conditions such as peptic ulcer disease and cholecystitis. However, the occa-

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sional instances of preoperative diagnosis have usually been by radiologic means. If a paraduodenal abscessdevelops, it can sometimes be recognized by displacement of duodenum and right kidney. Shackleton demonstrated leakage of Gastrografin from a perforated diverticular pouch that had resulted in retroperitoneal emphysema.s2 Fistulas occasionally result from perforation and abscess formation. These can involve the colon and even the aorta. Slow, long-standing bleeding or acute massive,hemorrhage can occur from these diverticula as from any other, and from the same mechanism. Sometimes aberrant vesselsin and around the pouch may be responsible. Occasionally, ectopic gastric or pancreatic tissue in a diverticulum may predispose it to bleeding. ACKNOWLEDGMENT Thanks are due to Dr. J. D. McConnell, Resident in Pathology, University of Arkansas Medical Center, and to Dr. H. J. White, Chief of Laboratory Services, Little Rock Veterans Administration Hospital for permission to use Figs. 2 and 3.

REFERENCES 1. Adams JT: Therapeutic barium enema for massive diverticular bleeding. Arch Surg 101: 457460, 1970 2. Anscombe AR, Keddie NC, Schofield PF: Solitary ulcers and diverticulitis of the caecum. Br J Surg 54:553-557, 1967 3. Arfwidsson S, Knock NG, Lehmann L, et al: Pathogenesis of multiple diverticula of the sigmoid colon in diverticular disease. Acta Chir Stand Suppl342: l-68, 1964 4. Beranbaum SL, Zausner J, Lane B: Diverticular disease of the right colon. Am J Roentgenol 115:334-348, 1972 5. Brown HW, Roy S: Hemorrhage in diverticulitis. Int Surg 49:135-142, 1968 6. Casarella WJ, Kanter IE, Seaman WB: Right-sided colonic diverticula as a cause of acute rectal hemorrhage. N Engl J Med 286: 450-453, 1972 7. Chang WYM: Colonic diverticulitis in Hawaii: a study of 414 cases. Hawaii Med J 24~442-445, 1965 8. Chaudhary NA, Truelove SC: Human colonic motility: a comparative study of normal subjects, patients with ulcerative colitis, and patients with irritable colon syndrome. Gastroenterology 4O:l, 1961 9. Corley KC: Roentgenologic aspects of Meckel’s diverticulum. Med Ann DC 38:592596, 1969 10. Deschenes L, Couture J, Garneau R: Diverticulitis of the appendix: report of sixtyone cases. Am J Surg 121:706-709, 1971 11. Dick ET: Sigmoidmyotomy in diverticular disease of the colon. Dis Colon Rectum 14:341 -346, 1971

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