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Differential diagnosis of diverticulitis and carcinoma of the sigmoid colon
Differential Diagnosis of Diverticulitis Carcinoma of the Sigmoid Colon DONALD L. MORTON, M.D.* AND
LEON GOLDMAN, M.D.,
From tbe Department of Surgery, University of California School of Medicine, San Francisco, California.
Sun Francisco,
and
CuliJornia
diseases are common in the same age groups and may coexist. The frequency of diverticuIa steadily increases with advancing age; Welch and his associates [rz] reported that by the age of eighty-five, 66 per cent of patients who had barium enemas were found to have diverticuIosis and 33 per cent had diverticulitis. The number of eIderIy people in the United States is rapidly increasing, and by 1975 it is estimated that there VviII be more than 2 I $72,000 peopIe sixty&e years old or oIder as compared to I 5,294,000 in I 959 [I?]. We can expect that as the number of eIderIy peopIe in our popuIation increases, so wiI1 the incidence of diverticula, and patients with coexistent carcinoma and diverticulitis or diverticuIosis wiI1 be seen even more frequently. Thus, the problem in diagnosis reaIIy becomes: is this lesion carcinoma, diverticuIitis, or both.
HE difficuIties in differentiating diverticulitis from carcinoma of the sigmoid coIon have been appreciated since the turn of the century, as evidenced by the reports of GIaser [r] in 1898 and Moynihan [2] in 1906. Since then, despite modern advances in surgica1 diagnosis and many pubhshed studies [?-a] this is stiI1 one of the most difficuIt diagnostic problems the surgeon encounters. These two diseases are not thought to be reIated etioIogicaIIy or pathoIogicaIly, yet they produce such a simiIar clinical picture that it is often difficult to differentiate between them. Both occur in the same age group, invoIve the same segment of colon, and often produce identical symptoms of changes in bowe1 habit, pain in the abdominal quadrant, recta1 bleeding and a paIpabIe mass. Sigmoidoscopy and barium enema wiI1 help to establish the diagnosis in many cases, but frequently the hndings are equivocal. Pemberton, BIack and Maino [9] report that in 25 per cent of their cases of diverticuIitis it was not possibIe to excIude carcinoma. A preoperative diagnosis of carcinoma was made in 18 per cent of the cases of diverticulitis reviewed by Welch, Allen and DonaIdson [IO]. The surgeon was unabIe to make the correct diagnosis at the operating tabIe, even after isoIation of the involved segment of bowe1, in as many as 21 per cent of the cases reported by Waugh and Wait [II]. The problem of diagnosis is further compIicated by the simultaneous occurrence of carcinoma with diverticuIitis and diverticuIosis. The presence of diverticulosis or diverticulitis does not in any way ruIe out carcinoma; both
T
CLINICAL MATERIAL The charts of a11 patients with diverticulitis or carcinoma of the sigmoid colon who were admitted to the medica and surgica1 services of the University of CaIifornia Hospitals from January 1945 to JuIy 1959 were reviewed. The diagnosis of carcinoma was confirmed by microscopic examination in a11 patients. The diagnosis of diverticulitis was established by pathoIogic examination of the surgical specimen in the patients who received operative treatment. The cIinica1 and barium enema tindings, confirmed by foIIow-up study, estabIished the diagnosis in the patients treated by medica means. Our findings are summarized in TabIes I and II. To our surprise associated benign or malignant tumors were found in 19 per cent of the 141 patients with diverticulitis seen during this
* Present address: National Cancer Institute, Bethesda, Maryland.
55
American
Journal OJ Surgery.
Volume 103, Jonuary
1962
Morton TABLE I INCIDENCE OF CARCINOMAAND BENIGN POLYPS
ASSOCIATED
WITH SIGMOID
and GoIdman TABLE
AND
MALIGNANT
DIVERTICULITIS
OF
INCIDENCE
THE
OF
ASSOCIATED
COLON
II
DIVERTICULOSIS
AND
WITH
CARCINOMA
SIGMOID
COLON
DIVERTICULITIS OF
THE
-
I
Disease
DiverticuIitis alone.. .. Benign polyps and diverticuIitis. MaIignant poIyps and diverticuIitis. Carcinoma and diverticulitis.. Total..
.
_.
114
IS 5
II
3 5
7
/___,___ .I 141 1
8
20
z 3 *
10
8
O20
of the
40
so
60
70
27
15
7
4
180
100
---
TotaI.........................
frequent occurrence of the two diseases in the same age groups makes their coexistence common, as the present study shows. The ratio of maIes to females in the carcinoma group ( I. I g maIes to every femaIe) did not differ significantIy from that in the diverticuIitis group (I .og maIes to every femaIe). TABLE SIGNS
AND
III SYMPTOMS
-
I73 1Patients with Carcinoma (%)
CIinicaI Feature
History of previous acute attacks. Duration of ihness Iess than om month....................... Weight loss.. . Dull constant pain in the Iowe] r part of the abdomen.. .. Cramping intermittent pain in the Iower part of the abdomen. Constipation alone.. . . Diarrhea aIone.. AIternating constipation and diarrhea......................... Rectal bIeeding.. Fever greater than 37.5”~. Tenderness of the abdomen. PaIpabIe mass.. . Signs of obstruction. , FistuIa formation. . Hemoglobin Iess than 12 gm. % Leukocytosis (more than IZ,OO(> white blood ceIIs/cu. mm.).
80
5
I34 IPatients with Diverticulitis (%)
52 51 28
5
37
43 38 24
31 35 34
13 75 II 35 27 II 4 37
9 35 (r8)* 33 59 22 5 9 IO
I3
25
-
AGE FIG.
81
.
:I
30
146
of the
IOO
CARCINOMA OF SIGMOID CARClNOMh WITH DIVERTICULA DIVERTICUUTIS OF SIG~ID
P M
%
Cases
Carcinoma of sigmoid. Diverticulosis and carcinoma sigmoid . DiverticuIitis and carcinoma sigmoid
81
period. Eight per cent of the patients had associated carcinoma or histologically malignant poIyps and I I per cent had associated adenomatous poIyps. Carcinoma of the sigmoid coIon was found in 180 cases, Ig per cent of which were associated with diverticuIa, either as diverticulosis (15 per cent) or diverticuIitis (4 per cent). It wiIl be noted that the seven cases of coexistent diverticuIitis and carcinoma are incIuded in both tabIes. Figure I shows that the age distribution of our patients with carcinoma of the sigmoid coIon and diverticuIitis was the same. It was not surprising, therefore, to find that the thirty-four cases of coexistent carcinoma and diverticuIa of the sigmoid coIon had a curve of distribution quite similar to that of carcinoma and diverticuIitis alone. DiverticuIosis and diverticuIitis have been reported not to predispose to carcinoma [ro,r4]. However, the _
No. of
Disease
* Percentage of patients with bIeeding not associated with poIyps or hemorrhoids.
I.
56
Diverticulitis
and Carcinoma
of Sigmoid
CoIon TABLE
CLINICAL
FINDINGS
CLINICAL IV
Table III summarizes the signs and symptoms found in these two diseases. AI1 patients with carcinoma and uncomplicated diverticuIosis are included in these tables under carcinoma of the sigmoid colon. However, the seven cases of coexistent carcinoma and diverticulitis are not included in these tables since their cIinica1 features cannot be assigned reIiably to either disease. After revielving the history and clinica findings \ve found that there were no distinguishing pathognomic features of either disease in a given patient. Indeed, the incidence of constipation, diarrhea, abdomina1 tenderness, palpable mass, fistuIa and obstruction was so uniform in the two diseases that these findings were not of differentia1 diagnostic value. Certain features were found, however, that suggested one disease or the other often enough to be of value in diagnosis; they are summarized in Table IV and wiI1 be discussed separateIy. Most of these diagnostic findings are a reflection of differences in the basic pathologic process and natura1 history of the two diseases. Diverticulitis is a chronic disease which has a tendency toward recurrence; a history. of one or more previous attacks suggestive of dlverticulitis was obtained from 52 per cent of our patients, who often had a Iong history of recurrent episodes. One must, however, aIways be alert for the development of carcinoma in such patients; 5 per cent of the patients with carcinoma in this study also had a history of previous attacks. Changes in bowel habit occur very frequently in patients with either carcinoma or diverticulitis of the sigmoid colon, but the mode of onset and the severity of symptoms differ considerably in the two diseases. Diarrhea and constipation in patients with diverticulitis were often acute in onset and occurred simuItaneously with other symptoms, such as pain in the abdomen, tenderness, fever, nausea and vomiting. When the attack of diverticuIitis subsided, the bowel pattern often returned to normal. In contrast, the onset of a change in bowel habit in patients with carcinoma often did not coincide with the appearance of other s!-mptoms. Patients with carcinoma often had rectal bleeding (which they attributed to hemorrhoids) or a tendency toward constipation, often with a gradual decrease in the
FEATURES
IV
OF DIFFERENTIAL
CARCINOMA
AKD
SIGMOID
History of prvvious attacks On~f2t (,r illness
Rare
DIAGNOSTIC
DI”ERT,C”LlTlS
OF
VALbE
THE
COLON
(9 I’; )
Gradual onset; only 5 “; hospitnlizcd during first month
or symptoms
Type of pain in the lower part c,r the abdomen Dull and con-
stant
1 I Rare
(5 ’ ; )
Common
Cramping and intermittent bleeding
Rectal
(43 ‘;,)
Very frequent, (750;); tended be persistent scanty
Common
(3-‘,)
Common
(31 ‘,)
tc but
very frequent
Anemia Fever and tosis
(67 c ; 1 Common (37 ‘;) Uncommon
leukocy-
size of the stools foIIowed by alternating diarrhea or pain in the Iower part of the abdomen. These changes characteristicaIly were very slow in onset, gradually progressed and bowel habits did not return to normal. These differences in onset of symptoms in patients with either diverticuIitis or carcinoma were also reflected in how Iong the symptoms were present before the patient was hospitalized. Fifty-one per cent of the patients with cliverticulitis were hospitaIized during the first month of symptoms. The patient with diverticulitis is often quite ill and consults a physician early in his iIIness, but the SIOW, miId onset of symptoms in carcinoma causes 0nIy 5 per cent of patients to consuIt a physician and to be hospitaIized during their first month of symptoms. Pain was experienced frequently b>- patients with either disease. The location of the pain varied considerably in both diverticulitis and carcinoma, but most often it was felt across the lower part of the abdomen or was localized to the Iower Ieft quadrant. The character and 57
Morton
and
duration of pain differed in the two diseases. Pain in the Iower part of the abdomen in patients with carcinoma was usuaIIy due to partia1 obstruction of the bowe1. The pain was cramping, intermittent and was often reIieved by passing gas or feces. Cramping pain of the Iower abdominal quadrants was present in 43 per cent of our patients with carcinoma. Diverticulitis often produced cramping pain identica1 to that described by patients with carcinoma, but it aIso caused another type of pain rareIy found in carcinoma. Thirty-seven per cent of the patients with diverticuIitis described pain in the lower portion of the abdomen of a duI1 but steady and unremitting character but this type of pain occurred in onIy 5 per cent of the patients with carcinoma. The duI1, constant pain found in diverticulitis may be expIained by constant irritation of nerve endings in the bowe1 or mesentery from the inffammatory reaction which occurs in this disease. As Iong as the inflammatory process persists the pain continues and is therefore constant. If enough spasm of the surrounding bowe1 waI1 or fibrosis resulting from chronic diverticuIitis occurs to produce obstruction of the Iumen of the bowel, a cramping type of pain may result. Thus, cramping, intermittent, pain of the Iower abdomina1 quadrants was found in both diseases, but a duI1 constant pain was very suggestive of diverticuIitis. Recta1 bIeeding often occurs in patients with carcinoma of the sigmoid colon and in patients with diverticulitis. A history of passing gross bIood from the rectum was obtained from 75 per cent of patients with carcinoma of the sigmoid coIon. Most often, the blood passed by patients with carcinoma was bright red and scanty, and bleeding occurred persistentIy at daiIy or weekIy intervaIs. Recta1 bIeeding occurred in 35 per cent of our patients with diverticuIitis. The rea1 probIem was to determine how much of this bIeeding was caused by diverticulitis alone and how often it was caused by an associated lesion. Eighteen patients with benign or malignant poIyps and five patients with hemorrhoids had recta1 bIeeding coexistent with diverticulitis. UnfortunateIy, we could not prove that bIeeding was caused by a coexistent Iesion and not by diverticulitis, but the fact that eighteen of the twenty patients with diverticulitis who had coexistent adenomatous poIyps also had recta1 bIeeding strongly suggests that the
GoIdman poIyps caused the recta1 bIeeding. Others have noted how commonIy adenomatous poIyps are associated with bIeeding in diverticuIitis [15,16]. It is dangerous to attribute recta1 bIeeding to diverticuIitis aIone unti1 careful examinations have demonstrated that both the upper gastrointestina1 tract and coIon are free of a11 other lesions. Even then, resection of the invoIved coIon may revea1 polyps not visible by sigmoidoscopy, barium enema or pneumocoIonic examination. UndoubtedIy, bIeeding can occur in patients with diverticuIitis aIone. If patients with diverticulitis who had associated Iesions which couId have been the source of recta1 bIeeding are eIiminated from our series, there remain twenty-four cases (18 per cent) in which there was no other apparent expIanation for the recta1 bIeeding. Mobeley, Dockerty and Waugh [r7] report that the source of this bleeding is most often an uIceration in the affected coIonic waI1 or within one of the diverticuIa. In our study, rectal bIeeding in patients with diverticuIitis aIone was usuaIIy smaI1 to moderate and was often associated with other symptoms of diverticuIitis. The bIeeding was usuahy transient; it did not occur persistentIy at daiIy or weekly intervaIs as so often happened in carcinoma or adenomatous bIeeding from poIyps. Five patients experienced bleeding massive enough to produce signs of shock. The bIeeding began suddenIy and was the chief compIaint in a11 five. Rectal bIeeding is much more suggestive of carcinoma of the sigmoid coIon than it is of diverticuIitis aIone, unIess there are coexistent Iesions such as polyps, hemorrhoids or malignant tumors that could be the source of bIeeding. Fever occurred about three times more often in patients with diverticulitis (33 per cent) than in patients with carcinoma of the sigmoid colon (I I per cent). Leukocytosis (more than 12,000 white bIood celIs/cu. mm.) was found about twice as often in patients with diverticuIitis (25 per cent) as in patients with carcinoma (13 per cent). Anemia (Iess than 12 gm. per cent of hemogIobin) occurred nearIy four times as often in patients with carcinoma (37 per cent) as in diverticuIitis (IO per cent). Weight Ioss occurred more than twice as frequentIy in patients with carcinoma (67 per cent) as in those with diverticulitis (28 per cent). We do not recommend extended medica therapy when there is a reasonabIe question of
58
DiverticuIitis
and
Carcinoma
of Sigmoid
CoIon
TABLE v ROENTGENOGRAPHIC FIh-DINGS*
carcinoma, but the response to medical treatment varies considerabIy in these two diseases. Patients with uncomplicated diverticulitis usuaIIy improved rapidIy after medica therapy consisting of low residue diet, stoo1 softeners, antispasrnodics and antibiotics. The patients with carcinoma CharacteristicalIy responded sIowly or not at a11 to such a regimen.
Diverticulitis
Carcinoma
Spastic boweI_with wide transversely arranged foIds; saw-tooth defect Cone-shaped ends to constricted areas
BoweI adjacent to tumor is usuaIIy normal
SharpIy defined margins of Iesion, often with overhanging edges: sheIf-like defect Long segments of invoIved Short segments of invoIved bowe1 bowel of mucosa1 Preservation of the mu- Destruction foIds cosa1 foIds Change in size of the con- Tendency toward incrcasing obstruction between stricted area between esaminations examinations The absence of diverThe presence of divcrticuIa ticuIai_ Flexibility at cone-shaped TypicaI deformity is freends as seen by a changquentIy a convex fiIIing ing Iumen during a singIe defect examination Obstruction without de- Obstruction with evidence monstrable tumor of tumor
DIAGNOSIS
Sigmoidoscopy shouId be performed on a11 patients. This examination may reveal signs suggestive of div-erticuIitis, such as edema and spasm with anguIation or fixation of the bowe1 waI1 but, unfortunately, carcinoma with inllammatorv changes can produce an identical picture. b’e found that sigmoidoscopy was of significant value in patients with carcinoma onIy \vhen biopsy of the carcinomatous Iesion could be obtained (38 per cent of our patients). The barium enema is the most important single diagnostic too1 in the differential diagnosis of carcinoma of the sigmoid colon and diverticulitis. The criteria upon which their differentiation is based have been we11 summarized by Rowe and KoIImar [7] in TabIe v. However, the presence of diverticuIa shouId not be taken as a reliabIe sign of diverticulitis, since 19 per cent of our patients with carcinoma aIso had diverticulosis. The x-ray findings were characteristic enough to be diagnostic in 92 per cent of patients with carcinoma aIone and in 82 per cent of patients with diverticulitis. However, in only 34 per cent of patients with coexistent carcinoma and diverticuIosis or diverticulitis was the diagnosis correct. Differentiation was not possible in 32 per cent of the cases and in another 34 per cent the diagnosis was incorrectJy interpreted as diverticuIitis alone. This emphasizes the grave danger that the presence of incidenta diverticula may Iead the radiologist or surgeon into a mistaken diagnosis of benign diverticulitis while he overlooks the associated carcinoma. Operations were performed on 145 patients with carcinoma of the sigmoid coIon aIone, twenty-five patients with carcinoma and uncomplicated diverticulosis and seventy-one patients with diverticulitis. It was often impossibIe to make the correct diagnosis even at the operating table. In 27 per cent of our cases of diverticuIitis and 20 per cent of the cases of carcinoma with diverticulosis, the
“F rom: Rowe, R. J. and KoIImar, G. H. IT]. t DiverticuIa were present in ro per cent of our patients with carcinoma.
surgeon did not know with which disease he was deaIing unti1 the invoIved bowel had been resected. The diagnostic accuracy at operation was not much greater than the accuracy of diagnosis by clinical means, especiahy in cases compIicated by a pelvis “frozen” with inffammatory reaction. Yet there is no doubt that a different type of operation should be performed for carcinoma than for diverticulitis. ’ COMMENTS
AIthough we found no distinguishing pathognomic feature of either disease, a carefu1 study of the cases revealed certain characteristics which were suggestive enough of each disease to be of differentia1 diagnostic vaIue. (Table v.) These findings should be carefuhy reviewed and correIated with the sigmoidoscopic and barium enema examinations in order to make the greatest number of correct diagnoses. In some patients it wil1 be impossibIe to make a certain diagnosis. Most of these patients wiI1 have compIications which in themselves are indications for surgery, such as obstruction, perforation, abscess and fistula formation or mas59
Morton
and
sive hemorrhage. In a few patients without comphcations, however, the presumptive diagnosis wiI1 be diverticulitis but carcinoma cannot be excIuded. These patients shouId be pIaced on a regimen of medica therapy consisting of a Iow residue diet, stoo1 softeners, antibiotics and antispasmodics in the hope that inffammation wiI1 subside. After the patient has been on this regimen for two weeks, the barium enema and sigmoidoscopic examination should be repeated. Operation is indicated at this time for any of the foIlowing reasons: (I) Poor response to medica therapy; (2) persistent recta1 bIeeding or paIpabIe mass; (3) equivoca1 barium enema. A more aggressive attitude toward the surgical treatment of diverticulitis is justified for severa reasons. Modern advances in surgery of the colon, such as the greater use of antibiotics and improved technics of anesthesia and fluid and eIectroIyte therapy, have greatIy reduced the operative risk [8,9,11,12]. In addition, carcinoma, malignant and adenomatous poIyps frequentIy coexist with diverticuhtis. A poor prognosis is usuaIIy associated with coexistent diverticulitis and carcinoma, or carcinoma associated with inflammatory changes where there is a deIay in diagnosis and proper treatment [6]. Most patients with diverticuIitis wil1 have repeated attacks (42 per cent in the present study and 67 per cent of the cases reported by Greene [18]) and in many complications will develop requiring later surgica1 treatment. FoIIow-up studies have shown that removal of the sigmoid coIon is an effective treatment for diverticulitis and usuaIIy prevents recurrent attacks [10,12]. It is much better to err on the side of earIier and more frequent surgery if there is any question whatever that carcinoma is present. Once the patient had been brought to Iaparotomy it was possible to make the diagnosis from the operative lindings in 98 per cent of our patients having carcinoma alone without diverticuIosis and/or perforation with surrounding inflammatory reaction. When the surgeon encounters such compIications as obstruction, abscess or IistuIa formation and finds the peIvis “frozen” in a dense inffammatory mass, al1 means of differentiation may fail. EnIarged mesenteric or para-aortic Iymph nodes may show only inflammatory hyperplasia resulting from diverticuIitis and not metaMuItipIe biopsy specimens static carcinoma.
Goldman may show onIy an inflammatory reaction aIthough carcinoma is hidden deepIy in the inflammatory mass. This is the situation in which the presumptive diagnosis based upon cIinica1 findings is of such great importance, as has been noted by CoIcock and Sass [?I. The decision as to what course to foIlow in the management of the patient depends to a Iarge degree upon the preoperative diagnosis of the surgeon. If carcinoma cannot be excluded primary resection necessitates en bloc resection of the inhammatory mass and construction of a safe anastomosis between Ioops of uninfl amed bowel. When this is not safeIy accomplished a proximal temporary coIostomy is carried out and the patient pIaced on antibiotics whiIe the infIammatory reaction is alIowed to subside. The involved bowel is then resected at a Iater date. EarIy, repeated barium enema and sigmoidoscopic examination, whiIe the inflammatory reaction is subsiding, may revea1 the correct diagnosis when initia1 examinations were unsatisfactory because of obstruction or inhammatory reaction. CytoIogic examination of rectal washings after irrigation of the distal colostomy Ioop may establish a diagnosis of unsuspected carcinoma [r9,20]. Prompt cIinica1 improvement with a decrease in the size of the inflammatory mass or a gain in weight after proxima1 coIostomy are often cIues that suggest diverticuIitis. However, it is advisabIe to proceed with caution because carcinoma with surrounding inflammatory reaction may show the same response to coIostomy. Carcinoma is strongIy suggested by a persistent mass or by recta1 bIeeding following colostomy [IO]. If any of these features which are suggestive of carcinoma appear or if the barium enema remains equivoca1 it is not safe to wait several months for the inflammatory process to subside compIeteIy. Such patients should undergo resection within a few weeks despite the increased operative risk. When resection is performed in such patients it shouId be a radica1 en bloc procedure as wouId be used for carcinoma. SUMMARY I. The charts of 173 patients with carcinoma, 134 with diverticulitis, and seven with coexistent diverticulitis and carcinoma of the sigmoid coIon admitted to the University of CaIifornia Hospitals during the fourteen and a haIf year period from January 1945 to July 1959 were reviewed in an attempt to lind
60
Diverticulitis
and Carcinoma
4. S.IORTOK, J. J., JR. DiverticuIitis
and carcinoma of the sigmoid. Surgery, 32: 765. 1952. 5. PONKA, .I. L., BRUSH, B. E. and Fox, J. D. DifFerc&l1 diagnosis of carcinoma of the sigmoid and diverticulitis. J. A. M. A., I 72: 5 I 5. 1960. diverticulitis and carci6. I
information that wouId be heIpfu1 in the differential diagnosis of these two diseases. 2. Nineteen per cent of patients with diverticulitis had associated carcinoma or benign or malignant polyps and 19 per cent of patients with carcinoma had associated diverticuIa of the coIon. 3. The age distribution of patients with carcinoma alone, diverticuhtis alone, and coexistent carcinoma with diverticula were similar. 4. We found no distinguishing pathognomic feature of either disease in a given patient but certain signs or symptoms were found to be more suggestive of one disease than the other. 5. Patients with an acute onset of symptoms, previous acute attacks suggestive of diverticulitis, constant, dull pain in the lower part of the abdomen, fever and Ieukocytosis (more than 12,000 white bIood ceIIs/cu. mm.) were more Iikely to have diverticulitis. 6. Patients who had gradua1 onset of symptoms, recta1 bleeding, weight Ioss and anemia were more likely to have carcinoma. 7. Recta1 bleeding occurred in 35 per cent of patients with diverticulitis, although 17 per cent of these patients had a coexistent lesion, such as polyps, which couId have been the source of bleeding. 8. The roentgenographic diagnosis by barium enema was correct in 92 per cent of patients with carcinoma alone, 82 per cent of patients with diverticulitis aIone but in only 34 per cent of patients with carcinoma coexistent with diverticulosis or diverticulitis. 9. EarIy surgica1 therapy is advised whenever there is any question of carcinoma.
noma of the colon; comprehensive study on survival. Arch. Surg., 73: 823, 1956. G. H. DivrrticuIitis of 7. ROWE, R. J. and KoLL~~~,
the coIon complicated
by carcinoma.
Internat.
Abstr. Surg., 94: I, 1952. 8. STARKLOPI:, G. B. and BINDBEUTAL, D. DivcrticuIitis or carcinoma of the coIon? Am. Sur,geon, 19: 5% 1953. 9. PEMBERTOE. J. DE J., BLACK, B. RI. and
MAINO.
C. R. Prbgress in ;he surgical management of diverticulitis of the sigmoid colon. Surg. Gynec. (9” Obst., 85: j23, 1947.
IO. WELCH, C, E. DiverticuIosis
and diverticulitis.
DlV,
P. 1, 1958. 11.
12.
J. M. and WALT, A. J. An appraisal of one stage anterior resection in diverticulitis of the sigmoid colon. Surg. Gynec. F Ohst., 104: 690,
WAUGH,
‘957. WELCH, C. E., ALLEN, A. W. and DONALDSON, G. A. An appraisa1 of resection of the colon for diverticulitis of the sigmoid. Ann. SW-~., 138:
332, 1953. 13. Bureau of the Census: Statistica Abstract of the United States, 1960, pp. 6-7, 267. Washington, D. C., 1960. U. S. Government Printing OffIce. ‘4. PONKA, J. L., Fox, J. D. and BRUSH, B. E. Coexisting carcinoma and divertic& of the colon. .4rcb. SWL 79: 373. ‘959. 15. BELL, I-I. G. BIeeding in recurrent low grade diverticulitis of the sigmoid. South. h4. J., 46: 453, 1953. 16. DE COSSE, J. J. and AMENDOLA, F. H. The significance of bIceding in diverticulitis of the sigmoid coIon. Ann. Surg., 145: 540, 1957. J. E., DOCKEKTY, M. B. and M’AUGH, 17. MOBLEI., J. ,\I. BIeeding in colonic diverticulitis. Am. J. SW., 94: 44, 1957. 18. GREENE., W. W. DiverticuIitis of the colon; radicaI vs. conservative treatment. Am. J. Sur,q., 94: 282, ‘957. 19. KNOERNSCHILD, H. E., CAMEROS, A. B. and ZOLLIKGER, R. IV. MiIiipore filtration of coIonic washings in malignant lesions of the Iargr bowe1. Am. J. Surg., IOI: 20, 1961. 20. WISSEMAN, C. L., JR., LEMON, H. M. and LAWRENCE, K. B. Cytologic diagnosis of cancer of the descending colon and rectum. Surg. Gynec. ?Y Obst., 89: 24, 1949.
REFERENCES
GLASER, E. Entzundliche
Stenose des Dickdarmes bcdingt durch Perforation multipIer falscher Divertikei. Zen~ralhl. Cbir., 26: 140, 1898. 2. MOYKIHAN, G. B. Mimicry of matignant disease of large intestine. Bit. M. J., 2: 1817, rgo6. 3. COLCOCK, B. P. and SASS, R. E. Diverticulitis and carcinoma of the sigmoid; differentia1 diagnosis. Surg. Gynec. CC+ Obst., gg: 627, 1954. I.
of Sigmoid CoIon
61
LEON GOLDMAN, M.D.,
From tbe Department of Surgery, University of California School of Medicine, San Francisco, California.
Sun Francisco,
and
CuliJornia
diseases are common in the same age groups and may coexist. The frequency of diverticuIa steadily increases with advancing age; Welch and his associates [rz] reported that by the age of eighty-five, 66 per cent of patients who had barium enemas were found to have diverticuIosis and 33 per cent had diverticulitis. The number of eIderIy people in the United States is rapidly increasing, and by 1975 it is estimated that there VviII be more than 2 I $72,000 peopIe sixty&e years old or oIder as compared to I 5,294,000 in I 959 [I?]. We can expect that as the number of eIderIy peopIe in our popuIation increases, so wiI1 the incidence of diverticula, and patients with coexistent carcinoma and diverticulitis or diverticuIosis wiI1 be seen even more frequently. Thus, the problem in diagnosis reaIIy becomes: is this lesion carcinoma, diverticuIitis, or both.
HE difficuIties in differentiating diverticulitis from carcinoma of the sigmoid coIon have been appreciated since the turn of the century, as evidenced by the reports of GIaser [r] in 1898 and Moynihan [2] in 1906. Since then, despite modern advances in surgica1 diagnosis and many pubhshed studies [?-a] this is stiI1 one of the most difficuIt diagnostic problems the surgeon encounters. These two diseases are not thought to be reIated etioIogicaIIy or pathoIogicaIly, yet they produce such a simiIar clinical picture that it is often difficult to differentiate between them. Both occur in the same age group, invoIve the same segment of colon, and often produce identical symptoms of changes in bowe1 habit, pain in the abdominal quadrant, recta1 bleeding and a paIpabIe mass. Sigmoidoscopy and barium enema wiI1 help to establish the diagnosis in many cases, but frequently the hndings are equivocal. Pemberton, BIack and Maino [9] report that in 25 per cent of their cases of diverticuIitis it was not possibIe to excIude carcinoma. A preoperative diagnosis of carcinoma was made in 18 per cent of the cases of diverticulitis reviewed by Welch, Allen and DonaIdson [IO]. The surgeon was unabIe to make the correct diagnosis at the operating tabIe, even after isoIation of the involved segment of bowe1, in as many as 21 per cent of the cases reported by Waugh and Wait [II]. The problem of diagnosis is further compIicated by the simultaneous occurrence of carcinoma with diverticuIitis and diverticuIosis. The presence of diverticulosis or diverticulitis does not in any way ruIe out carcinoma; both
T
CLINICAL MATERIAL The charts of a11 patients with diverticulitis or carcinoma of the sigmoid colon who were admitted to the medica and surgica1 services of the University of CaIifornia Hospitals from January 1945 to JuIy 1959 were reviewed. The diagnosis of carcinoma was confirmed by microscopic examination in a11 patients. The diagnosis of diverticulitis was established by pathoIogic examination of the surgical specimen in the patients who received operative treatment. The cIinica1 and barium enema tindings, confirmed by foIIow-up study, estabIished the diagnosis in the patients treated by medica means. Our findings are summarized in TabIes I and II. To our surprise associated benign or malignant tumors were found in 19 per cent of the 141 patients with diverticulitis seen during this
* Present address: National Cancer Institute, Bethesda, Maryland.
55
American
Journal OJ Surgery.
Volume 103, Jonuary
1962
Morton TABLE I INCIDENCE OF CARCINOMAAND BENIGN POLYPS
ASSOCIATED
WITH SIGMOID
and GoIdman TABLE
AND
MALIGNANT
DIVERTICULITIS
OF
INCIDENCE
THE
OF
ASSOCIATED
COLON
II
DIVERTICULOSIS
AND
WITH
CARCINOMA
SIGMOID
COLON
DIVERTICULITIS OF
THE
-
I
Disease
DiverticuIitis alone.. .. Benign polyps and diverticuIitis. MaIignant poIyps and diverticuIitis. Carcinoma and diverticulitis.. Total..
.
_.
114
IS 5
II
3 5
7
/___,___ .I 141 1
8
20
z 3 *
10
8
O20
of the
40
so
60
70
27
15
7
4
180
100
---
TotaI.........................
frequent occurrence of the two diseases in the same age groups makes their coexistence common, as the present study shows. The ratio of maIes to females in the carcinoma group ( I. I g maIes to every femaIe) did not differ significantIy from that in the diverticuIitis group (I .og maIes to every femaIe). TABLE SIGNS
AND
III SYMPTOMS
-
I73 1Patients with Carcinoma (%)
CIinicaI Feature
History of previous acute attacks. Duration of ihness Iess than om month....................... Weight loss.. . Dull constant pain in the Iowe] r part of the abdomen.. .. Cramping intermittent pain in the Iower part of the abdomen. Constipation alone.. . . Diarrhea aIone.. AIternating constipation and diarrhea......................... Rectal bIeeding.. Fever greater than 37.5”~. Tenderness of the abdomen. PaIpabIe mass.. . Signs of obstruction. , FistuIa formation. . Hemoglobin Iess than 12 gm. % Leukocytosis (more than IZ,OO(> white blood ceIIs/cu. mm.).
80
5
I34 IPatients with Diverticulitis (%)
52 51 28
5
37
43 38 24
31 35 34
13 75 II 35 27 II 4 37
9 35 (r8)* 33 59 22 5 9 IO
I3
25
-
AGE FIG.
81
.
:I
30
146
of the
IOO
CARCINOMA OF SIGMOID CARClNOMh WITH DIVERTICULA DIVERTICUUTIS OF SIG~ID
P M
%
Cases
Carcinoma of sigmoid. Diverticulosis and carcinoma sigmoid . DiverticuIitis and carcinoma sigmoid
81
period. Eight per cent of the patients had associated carcinoma or histologically malignant poIyps and I I per cent had associated adenomatous poIyps. Carcinoma of the sigmoid coIon was found in 180 cases, Ig per cent of which were associated with diverticuIa, either as diverticulosis (15 per cent) or diverticuIitis (4 per cent). It wiIl be noted that the seven cases of coexistent diverticuIitis and carcinoma are incIuded in both tabIes. Figure I shows that the age distribution of our patients with carcinoma of the sigmoid coIon and diverticuIitis was the same. It was not surprising, therefore, to find that the thirty-four cases of coexistent carcinoma and diverticuIa of the sigmoid coIon had a curve of distribution quite similar to that of carcinoma and diverticuIitis alone. DiverticuIosis and diverticuIitis have been reported not to predispose to carcinoma [ro,r4]. However, the _
No. of
Disease
* Percentage of patients with bIeeding not associated with poIyps or hemorrhoids.
I.
56
Diverticulitis
and Carcinoma
of Sigmoid
CoIon TABLE
CLINICAL
FINDINGS
CLINICAL IV
Table III summarizes the signs and symptoms found in these two diseases. AI1 patients with carcinoma and uncomplicated diverticuIosis are included in these tables under carcinoma of the sigmoid colon. However, the seven cases of coexistent carcinoma and diverticulitis are not included in these tables since their cIinica1 features cannot be assigned reIiably to either disease. After revielving the history and clinica findings \ve found that there were no distinguishing pathognomic features of either disease in a given patient. Indeed, the incidence of constipation, diarrhea, abdomina1 tenderness, palpable mass, fistuIa and obstruction was so uniform in the two diseases that these findings were not of differentia1 diagnostic value. Certain features were found, however, that suggested one disease or the other often enough to be of value in diagnosis; they are summarized in Table IV and wiI1 be discussed separateIy. Most of these diagnostic findings are a reflection of differences in the basic pathologic process and natura1 history of the two diseases. Diverticulitis is a chronic disease which has a tendency toward recurrence; a history. of one or more previous attacks suggestive of dlverticulitis was obtained from 52 per cent of our patients, who often had a Iong history of recurrent episodes. One must, however, aIways be alert for the development of carcinoma in such patients; 5 per cent of the patients with carcinoma in this study also had a history of previous attacks. Changes in bowel habit occur very frequently in patients with either carcinoma or diverticulitis of the sigmoid colon, but the mode of onset and the severity of symptoms differ considerably in the two diseases. Diarrhea and constipation in patients with diverticulitis were often acute in onset and occurred simuItaneously with other symptoms, such as pain in the abdomen, tenderness, fever, nausea and vomiting. When the attack of diverticuIitis subsided, the bowel pattern often returned to normal. In contrast, the onset of a change in bowel habit in patients with carcinoma often did not coincide with the appearance of other s!-mptoms. Patients with carcinoma often had rectal bleeding (which they attributed to hemorrhoids) or a tendency toward constipation, often with a gradual decrease in the
FEATURES
IV
OF DIFFERENTIAL
CARCINOMA
AKD
SIGMOID
History of prvvious attacks On~f2t (,r illness
Rare
DIAGNOSTIC
DI”ERT,C”LlTlS
OF
VALbE
THE
COLON
(9 I’; )
Gradual onset; only 5 “; hospitnlizcd during first month
or symptoms
Type of pain in the lower part c,r the abdomen Dull and con-
stant
1 I Rare
(5 ’ ; )
Common
Cramping and intermittent bleeding
Rectal
(43 ‘;,)
Very frequent, (750;); tended be persistent scanty
Common
(3-‘,)
Common
(31 ‘,)
tc but
very frequent
Anemia Fever and tosis
(67 c ; 1 Common (37 ‘;) Uncommon
leukocy-
size of the stools foIIowed by alternating diarrhea or pain in the Iower part of the abdomen. These changes characteristicaIly were very slow in onset, gradually progressed and bowel habits did not return to normal. These differences in onset of symptoms in patients with either diverticuIitis or carcinoma were also reflected in how Iong the symptoms were present before the patient was hospitalized. Fifty-one per cent of the patients with cliverticulitis were hospitaIized during the first month of symptoms. The patient with diverticulitis is often quite ill and consults a physician early in his iIIness, but the SIOW, miId onset of symptoms in carcinoma causes 0nIy 5 per cent of patients to consuIt a physician and to be hospitaIized during their first month of symptoms. Pain was experienced frequently b>- patients with either disease. The location of the pain varied considerably in both diverticulitis and carcinoma, but most often it was felt across the lower part of the abdomen or was localized to the Iower Ieft quadrant. The character and 57
Morton
and
duration of pain differed in the two diseases. Pain in the Iower part of the abdomen in patients with carcinoma was usuaIIy due to partia1 obstruction of the bowe1. The pain was cramping, intermittent and was often reIieved by passing gas or feces. Cramping pain of the Iower abdominal quadrants was present in 43 per cent of our patients with carcinoma. Diverticulitis often produced cramping pain identica1 to that described by patients with carcinoma, but it aIso caused another type of pain rareIy found in carcinoma. Thirty-seven per cent of the patients with diverticuIitis described pain in the lower portion of the abdomen of a duI1 but steady and unremitting character but this type of pain occurred in onIy 5 per cent of the patients with carcinoma. The duI1, constant pain found in diverticulitis may be expIained by constant irritation of nerve endings in the bowe1 or mesentery from the inffammatory reaction which occurs in this disease. As Iong as the inflammatory process persists the pain continues and is therefore constant. If enough spasm of the surrounding bowe1 waI1 or fibrosis resulting from chronic diverticuIitis occurs to produce obstruction of the Iumen of the bowel, a cramping type of pain may result. Thus, cramping, intermittent, pain of the Iower abdomina1 quadrants was found in both diseases, but a duI1 constant pain was very suggestive of diverticuIitis. Recta1 bIeeding often occurs in patients with carcinoma of the sigmoid colon and in patients with diverticulitis. A history of passing gross bIood from the rectum was obtained from 75 per cent of patients with carcinoma of the sigmoid coIon. Most often, the blood passed by patients with carcinoma was bright red and scanty, and bleeding occurred persistentIy at daiIy or weekIy intervaIs. Recta1 bIeeding occurred in 35 per cent of our patients with diverticuIitis. The rea1 probIem was to determine how much of this bIeeding was caused by diverticulitis alone and how often it was caused by an associated lesion. Eighteen patients with benign or malignant poIyps and five patients with hemorrhoids had recta1 bIeeding coexistent with diverticulitis. UnfortunateIy, we could not prove that bIeeding was caused by a coexistent Iesion and not by diverticulitis, but the fact that eighteen of the twenty patients with diverticulitis who had coexistent adenomatous poIyps also had recta1 bIeeding strongly suggests that the
GoIdman poIyps caused the recta1 bIeeding. Others have noted how commonIy adenomatous poIyps are associated with bIeeding in diverticuIitis [15,16]. It is dangerous to attribute recta1 bIeeding to diverticuIitis aIone unti1 careful examinations have demonstrated that both the upper gastrointestina1 tract and coIon are free of a11 other lesions. Even then, resection of the invoIved coIon may revea1 polyps not visible by sigmoidoscopy, barium enema or pneumocoIonic examination. UndoubtedIy, bIeeding can occur in patients with diverticuIitis aIone. If patients with diverticulitis who had associated Iesions which couId have been the source of recta1 bIeeding are eIiminated from our series, there remain twenty-four cases (18 per cent) in which there was no other apparent expIanation for the recta1 bIeeding. Mobeley, Dockerty and Waugh [r7] report that the source of this bleeding is most often an uIceration in the affected coIonic waI1 or within one of the diverticuIa. In our study, rectal bIeeding in patients with diverticuIitis aIone was usuaIIy smaI1 to moderate and was often associated with other symptoms of diverticuIitis. The bIeeding was usuahy transient; it did not occur persistentIy at daiIy or weekly intervaIs as so often happened in carcinoma or adenomatous bIeeding from poIyps. Five patients experienced bleeding massive enough to produce signs of shock. The bIeeding began suddenIy and was the chief compIaint in a11 five. Rectal bIeeding is much more suggestive of carcinoma of the sigmoid coIon than it is of diverticuIitis aIone, unIess there are coexistent Iesions such as polyps, hemorrhoids or malignant tumors that could be the source of bIeeding. Fever occurred about three times more often in patients with diverticulitis (33 per cent) than in patients with carcinoma of the sigmoid colon (I I per cent). Leukocytosis (more than 12,000 white bIood celIs/cu. mm.) was found about twice as often in patients with diverticuIitis (25 per cent) as in patients with carcinoma (13 per cent). Anemia (Iess than 12 gm. per cent of hemogIobin) occurred nearIy four times as often in patients with carcinoma (37 per cent) as in diverticuIitis (IO per cent). Weight Ioss occurred more than twice as frequentIy in patients with carcinoma (67 per cent) as in those with diverticulitis (28 per cent). We do not recommend extended medica therapy when there is a reasonabIe question of
58
DiverticuIitis
and
Carcinoma
of Sigmoid
CoIon
TABLE v ROENTGENOGRAPHIC FIh-DINGS*
carcinoma, but the response to medical treatment varies considerabIy in these two diseases. Patients with uncomplicated diverticulitis usuaIIy improved rapidIy after medica therapy consisting of low residue diet, stoo1 softeners, antispasrnodics and antibiotics. The patients with carcinoma CharacteristicalIy responded sIowly or not at a11 to such a regimen.
Diverticulitis
Carcinoma
Spastic boweI_with wide transversely arranged foIds; saw-tooth defect Cone-shaped ends to constricted areas
BoweI adjacent to tumor is usuaIIy normal
SharpIy defined margins of Iesion, often with overhanging edges: sheIf-like defect Long segments of invoIved Short segments of invoIved bowe1 bowel of mucosa1 Preservation of the mu- Destruction foIds cosa1 foIds Change in size of the con- Tendency toward incrcasing obstruction between stricted area between esaminations examinations The absence of diverThe presence of divcrticuIa ticuIai_ Flexibility at cone-shaped TypicaI deformity is freends as seen by a changquentIy a convex fiIIing ing Iumen during a singIe defect examination Obstruction without de- Obstruction with evidence monstrable tumor of tumor
DIAGNOSIS
Sigmoidoscopy shouId be performed on a11 patients. This examination may reveal signs suggestive of div-erticuIitis, such as edema and spasm with anguIation or fixation of the bowe1 waI1 but, unfortunately, carcinoma with inllammatorv changes can produce an identical picture. b’e found that sigmoidoscopy was of significant value in patients with carcinoma onIy \vhen biopsy of the carcinomatous Iesion could be obtained (38 per cent of our patients). The barium enema is the most important single diagnostic too1 in the differential diagnosis of carcinoma of the sigmoid colon and diverticulitis. The criteria upon which their differentiation is based have been we11 summarized by Rowe and KoIImar [7] in TabIe v. However, the presence of diverticuIa shouId not be taken as a reliabIe sign of diverticulitis, since 19 per cent of our patients with carcinoma aIso had diverticulosis. The x-ray findings were characteristic enough to be diagnostic in 92 per cent of patients with carcinoma aIone and in 82 per cent of patients with diverticulitis. However, in only 34 per cent of patients with coexistent carcinoma and diverticuIosis or diverticulitis was the diagnosis correct. Differentiation was not possible in 32 per cent of the cases and in another 34 per cent the diagnosis was incorrectJy interpreted as diverticuIitis alone. This emphasizes the grave danger that the presence of incidenta diverticula may Iead the radiologist or surgeon into a mistaken diagnosis of benign diverticulitis while he overlooks the associated carcinoma. Operations were performed on 145 patients with carcinoma of the sigmoid coIon aIone, twenty-five patients with carcinoma and uncomplicated diverticulosis and seventy-one patients with diverticulitis. It was often impossibIe to make the correct diagnosis even at the operating table. In 27 per cent of our cases of diverticuIitis and 20 per cent of the cases of carcinoma with diverticulosis, the
“F rom: Rowe, R. J. and KoIImar, G. H. IT]. t DiverticuIa were present in ro per cent of our patients with carcinoma.
surgeon did not know with which disease he was deaIing unti1 the invoIved bowel had been resected. The diagnostic accuracy at operation was not much greater than the accuracy of diagnosis by clinical means, especiahy in cases compIicated by a pelvis “frozen” with inffammatory reaction. Yet there is no doubt that a different type of operation should be performed for carcinoma than for diverticulitis. ’ COMMENTS
AIthough we found no distinguishing pathognomic feature of either disease, a carefu1 study of the cases revealed certain characteristics which were suggestive enough of each disease to be of differentia1 diagnostic vaIue. (Table v.) These findings should be carefuhy reviewed and correIated with the sigmoidoscopic and barium enema examinations in order to make the greatest number of correct diagnoses. In some patients it wil1 be impossibIe to make a certain diagnosis. Most of these patients wiI1 have compIications which in themselves are indications for surgery, such as obstruction, perforation, abscess and fistula formation or mas59
Morton
and
sive hemorrhage. In a few patients without comphcations, however, the presumptive diagnosis wiI1 be diverticulitis but carcinoma cannot be excIuded. These patients shouId be pIaced on a regimen of medica therapy consisting of a Iow residue diet, stoo1 softeners, antibiotics and antispasmodics in the hope that inffammation wiI1 subside. After the patient has been on this regimen for two weeks, the barium enema and sigmoidoscopic examination should be repeated. Operation is indicated at this time for any of the foIlowing reasons: (I) Poor response to medica therapy; (2) persistent recta1 bIeeding or paIpabIe mass; (3) equivoca1 barium enema. A more aggressive attitude toward the surgical treatment of diverticulitis is justified for severa reasons. Modern advances in surgery of the colon, such as the greater use of antibiotics and improved technics of anesthesia and fluid and eIectroIyte therapy, have greatIy reduced the operative risk [8,9,11,12]. In addition, carcinoma, malignant and adenomatous poIyps frequentIy coexist with diverticuhtis. A poor prognosis is usuaIIy associated with coexistent diverticulitis and carcinoma, or carcinoma associated with inflammatory changes where there is a deIay in diagnosis and proper treatment [6]. Most patients with diverticuIitis wil1 have repeated attacks (42 per cent in the present study and 67 per cent of the cases reported by Greene [18]) and in many complications will develop requiring later surgica1 treatment. FoIIow-up studies have shown that removal of the sigmoid coIon is an effective treatment for diverticulitis and usuaIIy prevents recurrent attacks [10,12]. It is much better to err on the side of earIier and more frequent surgery if there is any question whatever that carcinoma is present. Once the patient had been brought to Iaparotomy it was possible to make the diagnosis from the operative lindings in 98 per cent of our patients having carcinoma alone without diverticuIosis and/or perforation with surrounding inflammatory reaction. When the surgeon encounters such compIications as obstruction, abscess or IistuIa formation and finds the peIvis “frozen” in a dense inffammatory mass, al1 means of differentiation may fail. EnIarged mesenteric or para-aortic Iymph nodes may show only inflammatory hyperplasia resulting from diverticuIitis and not metaMuItipIe biopsy specimens static carcinoma.
Goldman may show onIy an inflammatory reaction aIthough carcinoma is hidden deepIy in the inflammatory mass. This is the situation in which the presumptive diagnosis based upon cIinica1 findings is of such great importance, as has been noted by CoIcock and Sass [?I. The decision as to what course to foIlow in the management of the patient depends to a Iarge degree upon the preoperative diagnosis of the surgeon. If carcinoma cannot be excluded primary resection necessitates en bloc resection of the inhammatory mass and construction of a safe anastomosis between Ioops of uninfl amed bowel. When this is not safeIy accomplished a proximal temporary coIostomy is carried out and the patient pIaced on antibiotics whiIe the infIammatory reaction is alIowed to subside. The involved bowel is then resected at a Iater date. EarIy, repeated barium enema and sigmoidoscopic examination, whiIe the inflammatory reaction is subsiding, may revea1 the correct diagnosis when initia1 examinations were unsatisfactory because of obstruction or inhammatory reaction. CytoIogic examination of rectal washings after irrigation of the distal colostomy Ioop may establish a diagnosis of unsuspected carcinoma [r9,20]. Prompt cIinica1 improvement with a decrease in the size of the inflammatory mass or a gain in weight after proxima1 coIostomy are often cIues that suggest diverticuIitis. However, it is advisabIe to proceed with caution because carcinoma with surrounding inflammatory reaction may show the same response to coIostomy. Carcinoma is strongIy suggested by a persistent mass or by recta1 bIeeding following colostomy [IO]. If any of these features which are suggestive of carcinoma appear or if the barium enema remains equivoca1 it is not safe to wait several months for the inflammatory process to subside compIeteIy. Such patients should undergo resection within a few weeks despite the increased operative risk. When resection is performed in such patients it shouId be a radica1 en bloc procedure as wouId be used for carcinoma. SUMMARY I. The charts of 173 patients with carcinoma, 134 with diverticulitis, and seven with coexistent diverticulitis and carcinoma of the sigmoid coIon admitted to the University of CaIifornia Hospitals during the fourteen and a haIf year period from January 1945 to July 1959 were reviewed in an attempt to lind
60
Diverticulitis
and Carcinoma
4. S.IORTOK, J. J., JR. DiverticuIitis
and carcinoma of the sigmoid. Surgery, 32: 765. 1952. 5. PONKA, .I. L., BRUSH, B. E. and Fox, J. D. DifFerc&l1 diagnosis of carcinoma of the sigmoid and diverticulitis. J. A. M. A., I 72: 5 I 5. 1960. diverticulitis and carci6. I
information that wouId be heIpfu1 in the differential diagnosis of these two diseases. 2. Nineteen per cent of patients with diverticulitis had associated carcinoma or benign or malignant polyps and 19 per cent of patients with carcinoma had associated diverticuIa of the coIon. 3. The age distribution of patients with carcinoma alone, diverticuhtis alone, and coexistent carcinoma with diverticula were similar. 4. We found no distinguishing pathognomic feature of either disease in a given patient but certain signs or symptoms were found to be more suggestive of one disease than the other. 5. Patients with an acute onset of symptoms, previous acute attacks suggestive of diverticulitis, constant, dull pain in the lower part of the abdomen, fever and Ieukocytosis (more than 12,000 white bIood ceIIs/cu. mm.) were more Iikely to have diverticulitis. 6. Patients who had gradua1 onset of symptoms, recta1 bleeding, weight Ioss and anemia were more likely to have carcinoma. 7. Recta1 bleeding occurred in 35 per cent of patients with diverticulitis, although 17 per cent of these patients had a coexistent lesion, such as polyps, which couId have been the source of bleeding. 8. The roentgenographic diagnosis by barium enema was correct in 92 per cent of patients with carcinoma alone, 82 per cent of patients with diverticulitis aIone but in only 34 per cent of patients with carcinoma coexistent with diverticulosis or diverticulitis. 9. EarIy surgica1 therapy is advised whenever there is any question of carcinoma.
noma of the colon; comprehensive study on survival. Arch. Surg., 73: 823, 1956. G. H. DivrrticuIitis of 7. ROWE, R. J. and KoLL~~~,
the coIon complicated
by carcinoma.
Internat.
Abstr. Surg., 94: I, 1952. 8. STARKLOPI:, G. B. and BINDBEUTAL, D. DivcrticuIitis or carcinoma of the coIon? Am. Sur,geon, 19: 5% 1953. 9. PEMBERTOE. J. DE J., BLACK, B. RI. and
MAINO.
C. R. Prbgress in ;he surgical management of diverticulitis of the sigmoid colon. Surg. Gynec. (9” Obst., 85: j23, 1947.
IO. WELCH, C, E. DiverticuIosis
and diverticulitis.
DlV,
P. 1, 1958. 11.
12.
J. M. and WALT, A. J. An appraisal of one stage anterior resection in diverticulitis of the sigmoid colon. Surg. Gynec. F Ohst., 104: 690,
WAUGH,
‘957. WELCH, C. E., ALLEN, A. W. and DONALDSON, G. A. An appraisa1 of resection of the colon for diverticulitis of the sigmoid. Ann. SW-~., 138:
332, 1953. 13. Bureau of the Census: Statistica Abstract of the United States, 1960, pp. 6-7, 267. Washington, D. C., 1960. U. S. Government Printing OffIce. ‘4. PONKA, J. L., Fox, J. D. and BRUSH, B. E. Coexisting carcinoma and divertic& of the colon. .4rcb. SWL 79: 373. ‘959. 15. BELL, I-I. G. BIeeding in recurrent low grade diverticulitis of the sigmoid. South. h4. J., 46: 453, 1953. 16. DE COSSE, J. J. and AMENDOLA, F. H. The significance of bIceding in diverticulitis of the sigmoid coIon. Ann. Surg., 145: 540, 1957. J. E., DOCKEKTY, M. B. and M’AUGH, 17. MOBLEI., J. ,\I. BIeeding in colonic diverticulitis. Am. J. SW., 94: 44, 1957. 18. GREENE., W. W. DiverticuIitis of the colon; radicaI vs. conservative treatment. Am. J. Sur,q., 94: 282, ‘957. 19. KNOERNSCHILD, H. E., CAMEROS, A. B. and ZOLLIKGER, R. IV. MiIiipore filtration of coIonic washings in malignant lesions of the Iargr bowe1. Am. J. Surg., IOI: 20, 1961. 20. WISSEMAN, C. L., JR., LEMON, H. M. and LAWRENCE, K. B. Cytologic diagnosis of cancer of the descending colon and rectum. Surg. Gynec. ?Y Obst., 89: 24, 1949.
REFERENCES
GLASER, E. Entzundliche
Stenose des Dickdarmes bcdingt durch Perforation multipIer falscher Divertikei. Zen~ralhl. Cbir., 26: 140, 1898. 2. MOYKIHAN, G. B. Mimicry of matignant disease of large intestine. Bit. M. J., 2: 1817, rgo6. 3. COLCOCK, B. P. and SASS, R. E. Diverticulitis and carcinoma of the sigmoid; differentia1 diagnosis. Surg. Gynec. CC+ Obst., gg: 627, 1954. I.
of Sigmoid CoIon
61