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Diverticula of the rectum
Diverticula PAUL
M.
WALSTAD,
M.D. AND
of the A. R. SAHIBZADA,
From the Department of Surgery, Harlan Appalachian Regional Hospital, Harlan, Kentucky. Reprint requests should be sent to Dr. Walstud. Daniel Boone Clinic. Martins Fork Road, Harlan, Kentucky 40831.
OST
CASE
1968
Harlan,
Kentucky
Case II. The patient, a seventy-eight year old white woman, entered the Harlan Applachian Regional Hospital in August 1967 with the diagnosis of chronic cholecystitis because of episodes of right subcostal pains during the preceding thirty months. She gal-e no history of vomiting, jaundice, melena, or hematemesis. She was not trouhled with constipation, and rarely used laxatives. Roentgenologic studies revealed a nonfunctioning gallbladder as well as an esophageal hiatal hernia. Barium enema studies demonstrated, in addition to some leit colonic diverticula, a large rectal diverticulum about 7 cm. from the anus, with two medium sized diverticula directly across from it on the right lateral wall. (Fig. 3.) Proctosigmoidoscopic examination verified these observations. No evidence of bleeding, inflammation, tumor growth. or fecal impaction was found. After cholecystectom>- the patient has had periodic examinations of the rectal diverticula since August 196i. No complications from the diverticula have developed.
REPORTS
Case I. The patient, a seventy-six year old white man, entered the Harlan Appalachian Regional Hospital in March 1967 with a one day history of rectal bleeding and lower abdominal pains. Four years previously he had required pyloroplasty with vagotomy for a bleeding duodenal ulcer. During the interim he had had no further rectal bleeding or hematemesis. In the previous twelve years he had frequently taken mineral oil or castor oil as a remedy for chronic constipation. Because of continued rectal bleeding the patient had abdominal surgery for suspected recurrence of bleeding duodenal ulcer. At operation bleeding was found to be confined to the colonic area. In order to better localize the bleeding site transverse loop colostomy was performed. The postoperative barium enema studies demonstrated sigmoidal as well as rectal diverticula. (Fig. I .) A 3 by 5 cm. diverticulum, whose orifice was 2.5 cm. in diameter, arose from the left anterolateral aspect of the lower part of the rectum, about 5 cm. from the anal margin. Directly opposite on the right rectal wall another but smaller diverticulum was demonstrated. (Fig. 2.) When seen on proctosigmoidoscopic examination these diverticula showed no evidence of tumor, bleeding, or inflammation. During the past year repeated L’ol. 116, Deremher
M.D.,
examinations of the rectal diverticula have revealed no change in their appearance. Biopsy of one of the diverticula showed no evidence of malignancy, but did show a small area of ulceration with underlying chronic inflammatory cell infiltration. The colostomy has been closed with no further bleeding.
proctologists and radiologists agree that rectal diverticula are rarely found during examination of the lower intestinal tract [I,,?]. There are few reports in the literature regarding this condition, which in its manifestations may closely mimic rectal cancer [1,3,4]. The following reports concern four patients in whom rectal diverticula were detected during examinations being carried out for other conditions. In all these patients rectal diverticula coexisted with colonic diverticula.
M
Rectum
Case III. The patient, a sixty-two year old white woman, was referred to the Out-Patient Department of the Harlan Appalachian Regional Hospital in September 196i with a history of rectal bleeding for several days previously. She had been under treatment for a duodenal ulcer and hypertension. The patient did not complain of constipation or rectal pains. On general physical examination the only significant finding was that of tarry stools on rectal examination. No bleeding was seen at protosigmoidoscopy. Barium enema examination demonstrated sigmoidal diverticula as well as multiple rectal diverticula, which had been overlooked on proctosigmoidoscopy. (Fig. 4.) The rectal diverticula showed no evidence of bleeding, tumor, or abscess formation. The patient has had no further rectal bleeding six months after the present illness. 937
Walstad and Sahibzada
938
FIG. 1. CASE I. Diverticula of the rectum demonstrates two rectal direrticula. FIG. 2. CASE I. Spot projection the two rectal diverticula.
and colon.
Barium
film in left lateral decubitus
CASE IV. The patient, a seventy-three year old white man, was admitted to the Harlan Appalachian Regional Hospital in February 1968 for treatment of bronchopneumonia and pulmonary emphysema. He gave no history of constipation or rectal bleeding. During the course of treatment he had barium enema examination because of the development of abdominal distention and constipation. This examination revealed several small diverticula of the sigmoid and a solitary diverticulum of the rectum. There was no evidence of pathology involving the rectal diverticulum. With regard to the colon and rectum the patient has remained asymptomatic. COMMENTS
Incidence. Although sigmoidal diverticula are common, rectal diverticula are rare. The incidence of sigmoidal diverticula is 5 to 10 per cent [5,6]. The incidence of rectal diverticula has not been established. The incidence of sigmoidal diverticula at Harlan Appalachian Regional Hospital over the past twelve years has been about 4 per cent, and that of rectal diverticula approximately 0.08 per cent. These percentages are based on the discovery of 192 cases of colonic diverticula and four cases of rectal diverticula during 4,854 barium enema examinations by the Radiology Department of the Hospital. Thus 2 per cent of all diverticula were rectal. These last figures are in close agreement with
enema film
position
shows
those of Spriggs and Marxer [5]. In 1927 they reported four rectal diverticula in 166 cases of colonic diverticula, an incidence of 2.4 per cent. Several theories have been advanced to explain the low incidence of rectal diverticula [4,7]. The longitudinal muscle fibers of the tinea coli, by spreading out to ensheath the entire rectum, protect it from undue stress. Quite firm structures support and surround the rectum. In addition, the feces exert less internal pressure in the rectal area and are less active than in the colon. Etiology. The etiology of rectal diverticula is unknown [2,7]. Whereas appendices epiploicae exist in the colon and are influential in the formation of diverticula, they are absent from the rectum. Some suggested predisposing factors in the development of rectal diverticula include congenital anomalies, recurrent impactions exerting pressure and distention, traumas and infections with predisposition to weakening of the rectal wall, absence of supporting structures such as the coccyx, and relaxed rectovaginal septum. Age. Our four patients were in the age group that is usually associated with sigmoidal diverticula and not rectal diverticula. Several reports in the literature imply that rectal diverticula occur in younger patients [2,7]. The American
Journal
of Surgery
Diverticula
3
of Rectum
939
4
FIG. 3. CASE II. Spot projection film in left lateral dccubitus strates diverticula of the rectum and sigmoid colon.
position demon-
FIG. 4. CASE III. Barium enema film demonstrates the t\vo rectal divcrticula directly opposite each other as well as coexistinK colonic divrrticula.
Complications. In our four patients the rectal diverticula were not associated with complications such as abscess, bleeding, or malignancy, in contrast to most cases reported in the medical literature [I&4,7]. Once the diverticulum becomes inflamed from impacted feces or other irritants, there may be progression to abscess formation with eventual perforation. Fortunately the perforation occurs inferior to the peritoneal reflection, making the situation less dangerous than perforation of the colon in which spillage of infected contents into the abdominal cavity occurs. Occasionally an infected rectal diverticulum may be difficult to differentiate from malignancy [1,7]. Fistulas may also develop between the rectum and the adjacent organs [4]. Treatment. Since these four patients have remained asymptomatic and no complications have developed from the rectal diverticula, no surgery has been performed. Patients with asymptomatic diverticula should be periodically examined. They should maintain good bowel habits to avoid fecal impaction which may lead to ulceration and abscess formation. Those patients who are symptomatic and have complications require operation [2,7]. Complicating abscesses are drained in the standard fashion and fistulas are dealt with according to the presenting situation. Rarely abdominoVol. 116.
December
1468
perineal resection may be necessary. One must be alert to the possibility of coexisting carcinoma [I 1. SUMMARY
Rectal diverticula are rare. Four patients with asymptomatic rectal diverticula are presented. The development of complications indicates that surgical treatment is required. were Koentgenograms .Icknowledgment: taken and interpreted by Drs. Paul 0. Wells and Truman D. Simmons, Department of Radiology. REFERENCES
1. TWEUDELL, T. S. Diverticulitis of the rectum. Canud. 211._I. J., 70: 569, 1954. 2. WESTOS, S. D. and SCHLACHTER,I. S. Diverticulum of the rectum. Uis. Colon b Rectum, 2: 558, 1959. 3. U'ILSOX, L. B. Diverticula of the lower bowel; their development and relationship to carcinoma. Ann. Szq, 33: x3. 1911. 4. CIFFIN, H. Z. Diverticulitis of the rectum. Ann. Surg., .5:3:533, 1911. 5. SPRIGGS, E. I. and MARXER, 0. A. Multiple diverticula of the colon. Lnncet, 212: 1067, 1927. 6. LOCALIO, S. .\. and STAHL, W. M. Diverticular disease of the alimentary tract. I. The colon. Curr. Probl. Surg., p. 5. Chicago, 1967. Year Book Medical Publishers, Inc. 7. GAST, S. J. Diseases of the Rectum, Anus, and Colon, vol. 2. Philadelphia, 1923. W. B. Saunders co. 8. TELLING, W. H. M. Acquired diverticula of the sigmoid flexure. Lance!, 174: 843, 928, 1908.
M.
WALSTAD,
M.D. AND
of the A. R. SAHIBZADA,
From the Department of Surgery, Harlan Appalachian Regional Hospital, Harlan, Kentucky. Reprint requests should be sent to Dr. Walstud. Daniel Boone Clinic. Martins Fork Road, Harlan, Kentucky 40831.
OST
CASE
1968
Harlan,
Kentucky
Case II. The patient, a seventy-eight year old white woman, entered the Harlan Applachian Regional Hospital in August 1967 with the diagnosis of chronic cholecystitis because of episodes of right subcostal pains during the preceding thirty months. She gal-e no history of vomiting, jaundice, melena, or hematemesis. She was not trouhled with constipation, and rarely used laxatives. Roentgenologic studies revealed a nonfunctioning gallbladder as well as an esophageal hiatal hernia. Barium enema studies demonstrated, in addition to some leit colonic diverticula, a large rectal diverticulum about 7 cm. from the anus, with two medium sized diverticula directly across from it on the right lateral wall. (Fig. 3.) Proctosigmoidoscopic examination verified these observations. No evidence of bleeding, inflammation, tumor growth. or fecal impaction was found. After cholecystectom>- the patient has had periodic examinations of the rectal diverticula since August 196i. No complications from the diverticula have developed.
REPORTS
Case I. The patient, a seventy-six year old white man, entered the Harlan Appalachian Regional Hospital in March 1967 with a one day history of rectal bleeding and lower abdominal pains. Four years previously he had required pyloroplasty with vagotomy for a bleeding duodenal ulcer. During the interim he had had no further rectal bleeding or hematemesis. In the previous twelve years he had frequently taken mineral oil or castor oil as a remedy for chronic constipation. Because of continued rectal bleeding the patient had abdominal surgery for suspected recurrence of bleeding duodenal ulcer. At operation bleeding was found to be confined to the colonic area. In order to better localize the bleeding site transverse loop colostomy was performed. The postoperative barium enema studies demonstrated sigmoidal as well as rectal diverticula. (Fig. I .) A 3 by 5 cm. diverticulum, whose orifice was 2.5 cm. in diameter, arose from the left anterolateral aspect of the lower part of the rectum, about 5 cm. from the anal margin. Directly opposite on the right rectal wall another but smaller diverticulum was demonstrated. (Fig. 2.) When seen on proctosigmoidoscopic examination these diverticula showed no evidence of tumor, bleeding, or inflammation. During the past year repeated L’ol. 116, Deremher
M.D.,
examinations of the rectal diverticula have revealed no change in their appearance. Biopsy of one of the diverticula showed no evidence of malignancy, but did show a small area of ulceration with underlying chronic inflammatory cell infiltration. The colostomy has been closed with no further bleeding.
proctologists and radiologists agree that rectal diverticula are rarely found during examination of the lower intestinal tract [I,,?]. There are few reports in the literature regarding this condition, which in its manifestations may closely mimic rectal cancer [1,3,4]. The following reports concern four patients in whom rectal diverticula were detected during examinations being carried out for other conditions. In all these patients rectal diverticula coexisted with colonic diverticula.
M
Rectum
Case III. The patient, a sixty-two year old white woman, was referred to the Out-Patient Department of the Harlan Appalachian Regional Hospital in September 196i with a history of rectal bleeding for several days previously. She had been under treatment for a duodenal ulcer and hypertension. The patient did not complain of constipation or rectal pains. On general physical examination the only significant finding was that of tarry stools on rectal examination. No bleeding was seen at protosigmoidoscopy. Barium enema examination demonstrated sigmoidal diverticula as well as multiple rectal diverticula, which had been overlooked on proctosigmoidoscopy. (Fig. 4.) The rectal diverticula showed no evidence of bleeding, tumor, or abscess formation. The patient has had no further rectal bleeding six months after the present illness. 937
Walstad and Sahibzada
938
FIG. 1. CASE I. Diverticula of the rectum demonstrates two rectal direrticula. FIG. 2. CASE I. Spot projection the two rectal diverticula.
and colon.
Barium
film in left lateral decubitus
CASE IV. The patient, a seventy-three year old white man, was admitted to the Harlan Appalachian Regional Hospital in February 1968 for treatment of bronchopneumonia and pulmonary emphysema. He gave no history of constipation or rectal bleeding. During the course of treatment he had barium enema examination because of the development of abdominal distention and constipation. This examination revealed several small diverticula of the sigmoid and a solitary diverticulum of the rectum. There was no evidence of pathology involving the rectal diverticulum. With regard to the colon and rectum the patient has remained asymptomatic. COMMENTS
Incidence. Although sigmoidal diverticula are common, rectal diverticula are rare. The incidence of sigmoidal diverticula is 5 to 10 per cent [5,6]. The incidence of rectal diverticula has not been established. The incidence of sigmoidal diverticula at Harlan Appalachian Regional Hospital over the past twelve years has been about 4 per cent, and that of rectal diverticula approximately 0.08 per cent. These percentages are based on the discovery of 192 cases of colonic diverticula and four cases of rectal diverticula during 4,854 barium enema examinations by the Radiology Department of the Hospital. Thus 2 per cent of all diverticula were rectal. These last figures are in close agreement with
enema film
position
shows
those of Spriggs and Marxer [5]. In 1927 they reported four rectal diverticula in 166 cases of colonic diverticula, an incidence of 2.4 per cent. Several theories have been advanced to explain the low incidence of rectal diverticula [4,7]. The longitudinal muscle fibers of the tinea coli, by spreading out to ensheath the entire rectum, protect it from undue stress. Quite firm structures support and surround the rectum. In addition, the feces exert less internal pressure in the rectal area and are less active than in the colon. Etiology. The etiology of rectal diverticula is unknown [2,7]. Whereas appendices epiploicae exist in the colon and are influential in the formation of diverticula, they are absent from the rectum. Some suggested predisposing factors in the development of rectal diverticula include congenital anomalies, recurrent impactions exerting pressure and distention, traumas and infections with predisposition to weakening of the rectal wall, absence of supporting structures such as the coccyx, and relaxed rectovaginal septum. Age. Our four patients were in the age group that is usually associated with sigmoidal diverticula and not rectal diverticula. Several reports in the literature imply that rectal diverticula occur in younger patients [2,7]. The American
Journal
of Surgery
Diverticula
3
of Rectum
939
4
FIG. 3. CASE II. Spot projection film in left lateral dccubitus strates diverticula of the rectum and sigmoid colon.
position demon-
FIG. 4. CASE III. Barium enema film demonstrates the t\vo rectal divcrticula directly opposite each other as well as coexistinK colonic divrrticula.
Complications. In our four patients the rectal diverticula were not associated with complications such as abscess, bleeding, or malignancy, in contrast to most cases reported in the medical literature [I&4,7]. Once the diverticulum becomes inflamed from impacted feces or other irritants, there may be progression to abscess formation with eventual perforation. Fortunately the perforation occurs inferior to the peritoneal reflection, making the situation less dangerous than perforation of the colon in which spillage of infected contents into the abdominal cavity occurs. Occasionally an infected rectal diverticulum may be difficult to differentiate from malignancy [1,7]. Fistulas may also develop between the rectum and the adjacent organs [4]. Treatment. Since these four patients have remained asymptomatic and no complications have developed from the rectal diverticula, no surgery has been performed. Patients with asymptomatic diverticula should be periodically examined. They should maintain good bowel habits to avoid fecal impaction which may lead to ulceration and abscess formation. Those patients who are symptomatic and have complications require operation [2,7]. Complicating abscesses are drained in the standard fashion and fistulas are dealt with according to the presenting situation. Rarely abdominoVol. 116.
December
1468
perineal resection may be necessary. One must be alert to the possibility of coexisting carcinoma [I 1. SUMMARY
Rectal diverticula are rare. Four patients with asymptomatic rectal diverticula are presented. The development of complications indicates that surgical treatment is required. were Koentgenograms .Icknowledgment: taken and interpreted by Drs. Paul 0. Wells and Truman D. Simmons, Department of Radiology. REFERENCES
1. TWEUDELL, T. S. Diverticulitis of the rectum. Canud. 211._I. J., 70: 569, 1954. 2. WESTOS, S. D. and SCHLACHTER,I. S. Diverticulum of the rectum. Uis. Colon b Rectum, 2: 558, 1959. 3. U'ILSOX, L. B. Diverticula of the lower bowel; their development and relationship to carcinoma. Ann. Szq, 33: x3. 1911. 4. CIFFIN, H. Z. Diverticulitis of the rectum. Ann. Surg., .5:3:533, 1911. 5. SPRIGGS, E. I. and MARXER, 0. A. Multiple diverticula of the colon. Lnncet, 212: 1067, 1927. 6. LOCALIO, S. .\. and STAHL, W. M. Diverticular disease of the alimentary tract. I. The colon. Curr. Probl. Surg., p. 5. Chicago, 1967. Year Book Medical Publishers, Inc. 7. GAST, S. J. Diseases of the Rectum, Anus, and Colon, vol. 2. Philadelphia, 1923. W. B. Saunders co. 8. TELLING, W. H. M. Acquired diverticula of the sigmoid flexure. Lance!, 174: 843, 928, 1908.