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Diverticulosis and Diverticulitis: A Clinical Study of the Complications
DIVERTICULOSIS AND DIVERTICULITIS: A CLINICAL STUDY OF THE COMPLICATIONS
KIRBY A. MARTIN, M.D., F.A.C.P.* AND CHARLES G. AOSIT, JR., M.D.t THE purpose of this clinic is to present some data on diverticulosis of the gastrointestinal tract and to comment on the complications and treatment of diverticula of the colon-diverticulitis, hemorrhage, perforation and intestinal obstruction. LOCATION, PREVALENCE AND AGE
Diverticula may be found in any part of the intestinal tract, only occasionally in the esophagus, stomach and small intestines, more frequently in the duodenum and very commonly in the colon, especially in its distal half. They may be congenital (Meckel's) but usually are acquired; if the latter, they are frequently multiple. Diverticula have been known to the anatomists as a rare finding for centuries, but the first description of them as an entity was that of Sommering in 1794 and Chuvelhier in 1849. Virchow in 1853 was the first to define them clinically. It was not until 1898, however, that a case of perforated diverticulitis with resulting left-sided peritonitis was reported by Graser. Lewald in 1914 is credited with the first roentgenologic diagnosis, but the prevalence of diverticula was not fully appreciated until the opaque motor meal x-ray technic became a common diagnostic procedure. Their importance as a clinical entity is still in a process of evolution. X-ray and postmortem examinations of the intestinal tract have shown diverticula to be uncommon before the age of 35 and increasingly frequent after 45 years. The incidence is usually stated to be higher in the male than in the female, also more common in the obese. They are frequently seen proximal to a partial obstruction. Numerous authors have stated that they are found in about 5 per cent of persons subjected to x-ray examination for any cause. Kocour 1 studied the incidence of diverticulosis in 7000 consecutive autopsies, and gives the percentage in each age decade. His figures show the condition to increase markedly in frequency after the age of 40, apd to become relatively stationary after the sixtieth year. Of the patients over 40 years of age, 3.58 per cent showed diverticulosis From the Department of Medicine, Cornell University Medical College and the New York Hospital, New York City. * Instructor in Medicine, Cornell University Medical College; Assistant Attending Physician, New York Hospital. t Assistant Attending Physician, Outpatient Department, St. Luke's Hospital. 6)9
640
KIRBY A. MARTIN, CHARLES G. ADS IT,
In.
and 0.15 per cent showed some complications which had caused the death of th~ patient. Contrary to most observations, his data show the incidence of diverticulosis in the female to be 33 per cent higher than in the male. Diverticula, when once formed, persist. Only occasionally do they produce symptoms. The patient whose colon is x-rayed usually has some symptoms to justify the procedure and then the failure to show diverticula does not necessarily disprove their presence. They may fail to fill at times, as does an appendix. It would thus follow that consecutive autopsies in a large series, in which special attention was paid to this condition, would be more likely to represent the true incidence of the disease than conclusions based upon clinical findings. It is interesting that Kocour found the incidence of gallbladder disease in persons over 40 years of age to be double in those also having diverticulosis. PATHOGENESIS
Anatomicaly, diverticula are blind sacs with small bases branching from the gastrointestinal tract. The pathogenesis is still incompletely understood. There is a common belief that the herniations occur at the point of entrance of a blood vessel into the wall of the bowel. To support this thesis, diverticula are frequently seen to develop in two parallel rows on either side of the mesocolon. Fansler2 disagreed with this concept and stated that it is unusual to find a blood vessel adjacent to the neck of a diverticulum, especially in the colon. It is his opinion that diverticula develop in the haustrations or sacculations of the colon, in the wall of which only one layer of muscle (circular) is found. In these haustrations, the susceptibility of the muscular wall to stretching and thinning is increased, especially in the descending colon and sigmoid where the intestinal tension is greatest. This stretching and thinning in older individuals he believes may result in herniation and formation of diverticula. In agreement with this is the experience of not infrequently finding diverticula on any or all sides of the colon. The wall of the diverticulum is therefore formed from mucous, submucous and peritoneal coats, and at times acquires a fatty coat. DIVERTICULITIS
Diverticulosis which precedes diverticulitis is present, as previously stated, in about 5 per cent of persons subjected to x-ray examination of the colon for any cause. Diverticulitis develops in about 12 to 15 per cent, according to Graham. 3 In other words, diverticula cause no symptoms in most instances. They are, however, potential sources of danger in producing localized stasis, inflammation and ulceration of the sac, with possible perforation. The sigmoid and descending colon are the most common areas to meet with these complications.
641
DIVERTICULOSIS AND DIVERTICULITIS
DIVERTICULA OF THE SIGMOID AND DESCENDING COLON
Further discussion in this clinic will be limited to the consideration of symptoms, diagnosis and treatment in the complications of divertic'ulosis found in the sigmoid and descending colon. The statistical data to be presented were obtained by reviewing the material in the record room of the New York Hospital. The selected case records were taken from our private files. The opinions expressed obviously are wider than the analysis of the material would permit. TABLE I.-DATA CONCERNING DIVERTICULITIS AT NEW YORK HOSPITAL,
1933
TO
1944* ---~~-----'"-~--
------
Total admissions to New York Hospital ..................... . 177,718 201 Cases of diverticulitis ........................................ . 0.001 Percentage of admission ..................................... . Sex ..................................... 105 males, 96 females Duration of symptoms................. 2 hours to 54 years Associated with: Carcinoma of large bowel ................................... . 5 Other carcinoma .............................................. 14 Cholecystitis and cholelithiasis ............................... 22 Gastric ulcer ................................................. 5 Duodenal ulcer ............................................... 4 ~ru~~~ .................................................. . 63 Diarrhea ..................................................... . 26 Constipation and diarrhea .................................... . 4 Hemorrhaget ................................................ . 17 Perforation .................................................. . 25 Fistula ....................................................... . 11 Perirectal abscesses .......................................... . 3 Confused with: Carcinoma of sigmoid ...................................... . 19 Appendicitis ................................................. . 7 Renal colic ............ . ................................... . 2 Deaths ........................................................... 32 Perforation ............................................ . 5 Hemorrhage .................................................. 1 Other ......................................................... 26 Cases of Meckel's diverticulum .................................... 28 Females ....................................................... 17 Males...... . ................................................ 11
* We are indebted to Mrs. Joan Haskett-Smith, volunteer worker at the New York Hospital, for her painstaking assistance in collecting these data from the reeord room. t Diverticulitis with hemorrhage (excluding Meckel's)-17; of these, 10 perforated; one twice. One died of massive hemorrhage.
042
KIRBY A. i\IARTlN, CHARLES G. ADS IT, TABLE
.lIt.
2.-sl'l'I<: OF TilE DIVERTICULA, ACCORDING TO AGE Diverticula
Age
------- ----,------------1
Meckel's
Colon
Total
------------ - - - - - - - -
0-10 11 - 20
21 - 30
31 - 4{) 41 - 50 51 - 60
17 4
2 3
2
61 - 70 71 -
17 1 12 24
4 3
15 26
54 58
54 58
24
24
TABLE 3.-MECKEL'S DIVERTICULUM AT THE NEW YORK HOSPITAL OVER TWELVE YEARS
(Total Admissions 177,718)
No. Total cases ............................. 28 Total deaths .......................... 2* Cases operated on ..................... 14 Postoperative deaths .................. 0
Per Cent 7.14 50.00
o
* One stillborn, one newborn; no operations. TABLE 4.-DIVERTICULITIS REQUIRING OPERATION
Total cases operated on ................ Perforation ............................ Hemorrhage ........................... Diverticulosis and carcinoma ........... Deaths ................................ Deaths excluding carcinoma ............
No.
Per Cent
51 25 17 4 12 9
49.0 33.3 7.8 23.5 17.6
-------------------------------- ------
Cases explored for possible carcinoma .. 13 Carcinoma found ..................... 4 Deaths from carcinoma ................ 3 Deaths excluding carcinoma ........... 0
25.5 7.8 5.9
o
SYMPTOMS AND DIAGNOSIS
The symptoms vary greatly, from a single slight acute attack, recurring episodes or chronic inflammatory reaction, to acute or chronic perforation with localized peritonitis and abscess formation or general peritonitis. A fistula occasionally develops between the sigmoid and the vagina or the urinary bladder, the latter manifesting itself by the urine containing gas and fecal material. Local manifestations, if present, are usually in the left lower quad-
DIVERTICULOSIS AND DIVERTICULITIS
643
rant of the abdomen, but may be in the midline or to the right side, depending upon the position of the sigmoid and its tensinn; a spastic sigmoid may produce back pressure in the cecum and appendix, and the latter may be blamed for the symptoms. Pain on pressure over the sigmoid, muscle guard, spasm and flatulence are common. The symptoms usually give little information as to the extent of the lesion unless a tumor mass is felt. In other instances a dull intermittent or constant cramplike diffuse pain in the abdomen frequently associated with tenesmus is common, or the symptoms may be entirely rectal. A significant sign is the temporary relief that may follow a warm saline epema, a bowel movement or the passing of flatus. Fever and leukocytosis may be present. Diarrhea and constipation are equally common. Rectal bleeding does occur, but is rare except in Meckel's diverticulum; it may follow the passing of diverticular concretions, but blood in the stool indicates carcinoma until disproved. The clinical picture associated with diverticulitis can simulate almost any other abdominal disease. The importance of making a proper diagnosis is therefore obvious; operation is rarely advised in diverticulitis. Furthermore, the postoperative mortality was 20 per cent, with a residual mortality of 29 per cent in Babcock's4 series. In our series it was 23.5 per cent. X-ray study is indispensable in this work and if used to its fullest extent, fruitless surgical procedures can be avoided. DIFFERENTIAL DIAGNOSIS
In most cases it is easy to distinguish carcinoma from diverticulitis, difficult in a few, and almost impossible in an occasional case. In this latter group, exploratory laparotomy may be necessary. The operator frequently encounters a hard, irregular, fixed mass involving the sigmoid or descending colon and the diagnosis may remain uncertain pending the microscopic study. Carcinoma, like diverticulosis, is most commonly found in the sigmoid and descending colon, although the association of the two is so rare that there is no reason to believe that diverticulosis is a precursor of cancer. Proctoscopic examination is indicated. It is not uncommon to find a carcinoma of the rectum producing the symptoms, although the radiographs may be negative save for the presence of diverticula or perhaps diverticulitis of the sigmoid. Blood, pus and excess mucus with a foul odor coming from some point .higher than the rectum usually means carcinoma, but occasionally an intramural abscess in peridiverticulitis will give a similar picture if the abscess is draining into the gut. In all such cases a complete gastrointestinal study is indicated. Radiographic study is a valuable adjunct in the diagnosis of diverticulitis; in most cases it is all that is necessary. In complicated cases, however, the responsibility for the differential diagnosis is great. Still,
644
KIRBY A. MARTIN, CHARLES G. ADSIT,
JR.
the balance of evidence is in the interpretation of the radiographic findings, but the clinician who marshals all the clinical data in a given case will err less frequently. In acute uncomplicated cases the inflamed, edematous walls present a bizarre sawtooth outline giving such a characteristic radiograph, during a barium enema, that it is not likely to be confused, even though no diverticula are Seen (Case Ill). But diagnosis is more difficult in acute exacerbation of a chronic diverticulitis, a subacute or chronic peridiverticulitis which has produced a thick wall and a constricted lumen of the gut with cone-shaped ends (Case VII, A). There is usually a distortion of the pattern of the mucosal folds and a marked deformity of the 'bowel lumen (Case V). Air contrast enema and spot films of mucosal pattern are usually helpful in such cases. Still more complicated are those that develop intramural abscesses, losing part of the mucosal pattern (Case VII, B). Diverticula with long necks are common in such cases, and if they should fall at either end of the constriction, they may produce an overhanging edge like that seen in carcinoma. The two conditions do coexist occasionally and the prescnce of diverticula proximal or distal to the constricted area does no~· exclude carcinoma, as illustrated in -Case IX. The presence of diverticula does not help much in the differential diagnosis, but their absence does if proper delayed x-ray films are made following an opaque motor meal. However, the presence of diverticula in the constricting mass is important because they rarely if ever occur in carcinoma (Schatzki5 ) (Case VIII). TREATMENT
The treatment is medical in all but those few caSes in which serious complications mayor do occur. The predominant symptom in the average uncomplicated case is spasm of smooth muscle, the result of inflammation in the diverticula. The duration or intensity of the symptoms is such that only an occasional patient consults his physician. In more severe cases the following treatment is usually effective: Rest in bed, heat to abdomen, smooth diet, sedative, antispasmodic and inducing bowel moment with the least possible irritation. Phenobarbital gm. 0.032 CY:! grain), three times a day, or tincture of belladonna 1.9 cc. (30 drops) single or combined (we have never been impressed with the virtues of the latter). Mineral oil is beneficial during the acute phases, at the expense of a possible avitaminosis. Codeine 0.06 gm. (1 grain) or paregoric 4 cc. (1 dratn) may be indicated. Warm saline or oil enemas usually give comfort. Barium sulfate in 28.4-gm. (1 ounce) doses, given in a water suspension two or three times a week is beneficial. The barium supposedly displaces the irritating, fermenting intestinal content, reducing the inflammation and edema. The improvementof symptoms that so frequently follows x-ray study of the colon amply confirms this statement. .
DIVERTICULOSIS AND DIVERTICULITIS
645
Obstruction develops slowly as a· rule, and is rarely complete. It may be the first symptom. The treatment is secondary to the diver. ticulitis. We encountered this only eight times in our series. Acute perforation has been rare in our experience. It has been stated to occur about one half as often as perforation from carcinoma. We had eight cases. Acute perforation from a diverticulum in the colon, like acute perforation from any cause, calls for immediate operative . closure. These patients usually do well.
Fig. 125.-(Case I.)
Slow perforation. Perforation from a diverticulum or an intramural abscess is more common than acute perforation and, unlike an appendix, is likely to produce few symptoms for long periods of time, due to a slow but complete walling-off process. The sulfonamides have not been impressive, in our experience, in the uncomplicated cases or in those that perforate and form abscesses or fistulous tracts. Likewise in our limited experience, penicillin was beneficial only in secondary complications (Case VII, B). This group likewise is managed surgically. The exploratory laparotomy, as well as the postmortem findings, in these cases usually
646
KIRBY A. MARTIN, CHARLES G. ADS IT,
JR.
shows a widespread mesentery and lymph gland inflammatory involvement. This, in addition to abscess and sinus tracts, makes resection of the affected segment of the gut a hazardous task. CASE REPORTS
I Clinical: Woman, 53. Loss of 15 pounds of weight. No intestinal symptoms. Normal bowel function. Film (Fig. 125): 24-hour barium motor meal. Diagnosis: Diverticulosis of colon. Accessory: Osteogenesis i~perfecta; has had fourteen fractures. CASE
"~
Fig. 126.-(Case 11.) 11 Clinical: Man, 55. Vague abdominal distress for ten years, worse in past three months. Film (Fig; 126): 24-hour barium motor meal. In transverse Golon note "pseudodiverticula." Barium enema films showed no evidence of organic disease. Diagnosis: Duodenal ulcer, right renal calculi. Spastic colon. CASE
III Clinical: 'Man, 51. Acute abdominal pain; typical "left side appendicitis." Six years later, no further symptoms. Film (Fig. 127): Barium enema (film reversed). Note spasm in sigmoid; spikes set at varying angles to the lumen. No diverticula seen in sigmoid, one noted in transverse colon. On delayed films two small diverticula were seen in sigmoid. Diagnosis: Typical of acute, early diverticulitis. CASE
DIVERTICULOSIS AND DIVERTICULITIS CASE
647
IV
Clinical: Man, 51. No intestinal symptoms until ten hours before. Onset with acute left lower abdominal distress and a sudden desire to defecate and pass flatus. Diarrhea lasted three hours, followed by frequent periods of straining and tenesmus but passing only small amounts of mucus and bright red blood. Proctoscopic: From some point above the rectosigmoid area mucus and -bright red blood came into view; otherwise the examination was negative.
Fig. 127.-(Case Ill.) Film (Fig. 128): Barium enema. Note spasm in sigmoid with spikes set at various angles to the bowel lumen. (Postevacuant film showed four small diverticula.) Diagnosis: Acute diverticulitis of sigmoid with ' hemorrhage. Result: Symptoms subsided. V Clinical: Man, 55. Many attacks of left lower abdominal distress; none in acute phase,until now. Film (Fig. 129): Postevacuation barium enema, plus air injection. Note "spiral stair" effect from deep folds of mucosa. Diverticula are at apices of these folds. Diagnosis: Acute phase of chronic diverticulitis.
CASE
648
KIRBY A. MARTIN, CHARLES G. ADS IT, JR.
Fig. 128.-(Case IV.)
Fig. 129.-(Case V.) CASE VI, A Clinical: Man, 55. Generally constipated. During past ten years repeated attacks of diarrhea and lower abdominal distress. Now, temperature 100° F'i pulse
DIVERTICULOSIS AND DIVERTICULITIS
649
95, white blood cells 11,000, pain in left lower quadrant. Desire to defecate and pass flatus; slight muscle guard. Palpable mass in left lower quadrant.
A
B Fig. 130.- (Case VI.) Film (Fig. 130, A): Barium enema. Narrowing of the sigmoid lumen with a symmetrical arrangement of diverticula with long necks, "accordion type." Diagnosis: Acute exacerbation of a chronic diverticulitis, peridiverticulitis.
650
KIRBY A. MARTIN, CHARLES G. ADS IT,
In.
VI, B Same case four years later, following operation for acute perforation at the proximal end of narrowing. Patient had been asymptomatic for' nine months.
CASE
B Fig. 131.-(Case VII.) Film (Fig. 130, B): Barium enema. Funnel-shaped shadows at base of some diver-
ticula, probably fecalith.
Comment: Prognosis is poor, resection advised.
DIVERTICULOSIS AND DIVERTICULITIS
651
CASE VII, A Clinical: Woman, 63. Constipated; treated fifteen years for "colitis." Fi;rst symptom was acute, severe rectal pain. Temperature 104 F ., pulse 140, white blood cells 18,000. No abdominal. signs or symptoms. Rectal and vaginal examination negative save for general discomfort. Later, stool contained blood and pus. Film (Fig. 131, A): Barium enema. Filling defect in sigmoid colon, much spasm, partial intestinal obstruction. Note numerous diverticula with long necks at unusual distances from the central axis of the gut. Diagnosis: Diverticulitis, acute phase of a chronic peridiverticulitis, intramural abscess and question of perforation of a diverticulum with pelvic abscess; partial obstruction of colon. 0
CASE
VII, B
In same case two days later a sigmoid-vaginal fistula developed. Temperature subsided and general condition improved until a four year old osteomyelitis of leg became active. Sulfonamides had no apparent effect on abscess or osteomyelitis. One million units of -penicillin effected a quick subsidence of the osteomyelitis but had no demonstrable effect on the pelvic abscess. Film (Fig. 131, B): 36-hour barium motor meal plus barium enema. Note evidence of intramural abscesses and a fistulous tract to pelvic abscess i~dicated by arrows. Outcome: Resection of sigmoid colon three months following a colostomy. Patient died thirty-six days postoperatively of general peritonitis and sepsis. Surgical Pathology: Specimen removed at operation showed an 18-inch segment of colon, 12 inches of which were dense, firm and greatly thickened with many diverticula, intramural abscesses and intramural fistulas, some communicating with the lumen of the bowel and one to the external surface.
652
KIRBY A. MARTIN, CHARLES G. ADSIT, JR.
CASE VIII (Courtesy of Dr. Frederic Bancroft) Clinical: Woman, 80. Intermittent attacks of left lower quadrant pain for forty years. Lost 15 pounds in last seven months, abdominal distress worse. Diarrhea, with blood in stool. Palpable lllilSS in left lower quadrant. Film (Fig. 132): Fixed irregularity in outline of descending colon with eccentric lumen. Mucosal pattern destroyed. No diverticula seen in area of filling defect but are numerous distal to same. Note large soft tfssue shadow inqicated by arrows. Probably a cyst; had no relation to colon; was not explored. Diagnosis: Carcinoma of colon with partial colonic obstruction. Diverticulitis, chronic type. Operation: Resection of descending colon and sigmoid-anastomosis, colostomy closed. Pathology: Diagnosis-adenocarcinoma of colon; peridiverticulitis of colon. Result: Discharged home-bowel function normal.
Fig. 133.- (Case IX.) IX Clinical: Man, 53. Moderate constipation for several years, with many attacks of vague abdominal distress. Since past ten months has had tendency toward diarrhea; more recently has had blood in stool; no weight change. Film (Fig. 133): 36-hour motor meal, plus barium enema. Large constant filling defect in descending colon with partial colonic obstruction. Note numerous diverticula with long necks on medial side of filling defect and no diverticula lateral side, save one at upper border producing an overhanging ' edge; mucosal pattern destroyed. Diagnosis: Diverticulitis, peridiverticulitis of descending colon and sigmoid with colonic obstruction; question of carcinoma of descending colon. Operation: Resection and end-to-end anastomosis. Specimen showed a chronic peridiverticulitis with an ulcerating carcinoma on lateral wall. Result: Recovered.
CASE
DIVERTICULOSIS AND DIVERTICULITIS
653
COMMENT
In practice many cases of colonic disturbance are labeled and treated as "colitis" without proper examination and study. Most will prove to be functional, but an occasional one will have an organic lesion responsible for the symptoms. A significant point to suggest the latter is a change in the bowel rhythm, a change in the rate of flow (diarrhea or constipation) or a change in character of the content (increase or decrease of fluid, presence of blood, mucus or pus). Diagnosis is the first consideration. It is to be borne in mind that this study, for the most part, represents only the occasional case of diverticulitis in which the patient was sufficiently ill to be admitted to the hospital. The disease is very commonly met in ambulatory practice and.father infrequently in hospital practice. The severity of the symptoms gave no clue in most instances as to the stage of the disease process. This fact has a tendency· to lessen the percentage of severe complications to the total group. And, for the same reason, a large percentage responded well to medical treatment. Acute perforations, when they did occur, were frequently found in the absence of other complications, such as peridiverticulitis, and if recognized early, usually did well following operative closure of the perforation . . In the group in which peridiverticulitis was the predominant feature, partial colonic obstruction, slow perforation with abscess formation and fistula were common complications. Our data support the view that there has been no significant change in the mortality rate in this group in twenty-five years, despite the general progress in medical management in many other conditions. Peridiverticulitis and carcinoma are most commonly found in the descending and sigmoid colon. They also have in common the same age group. The treatment of diverticulitis is generally considered medical; carcinoma surgical. In several instances a preoperative positive diagnosis was impossible and a resection of the lesion was carried out. In Table 4 you will note that there were thirteen operations on such cases and only four carcinomas were found. If we exclude these four carcinomas the mortality drops to 0 against 22.9 in the group as a whole. The difference lies in the fact that infection as a complication was infrequent. The fault, therefore, would appear to lie in the continued failure to recognize those cases with impending danger as a separate group and institute proper surgical measures. This is a serious criticism of our diagnostic acumen, but improvement will follow if operation is offered early as a preventive of a too-often widespread infection and fatal outcome.
654
KIRBY A. MARTIN, CHARLES G. ADSIT,
.Tn.
SUMMARY
During the period between 1933 and 1944 there were 201 patients with acute diverticulitis admitted to the New York Hospital in a total admission of 177,718 patients, or 0.00112 per cent. There were 28 cases of Meckel's diverticulum, or 0.00016 per cent. Fourteen patients were operated on with no postoperative deaths. There were 51 cases operated on for some complication in relation to the diverticulitis with 12 deaths, or 23.5 per cent. Carcinoma was encountered in the presence of diverticulitis in 4 cases, or 7.8 per cent. Carcinoma 'was suspected and operation carried out on 13 cases (25.5 per cent), with 3 deaths, or 5.9 per cent. Excluding carcinoma, it was 0 against 23.5 per cent in the group as a whole. Peridiverticulitis, like carcinoma, occurs in the same age group and is most commonly found in the descending and sigmoid colon. The lesion formed is frequently confused with carcinoma and may lead to serious complications, followed by a high mortality rate. Data are presented to suggest how a differential diagnosis can be made and how the mortality rate can be lowered. BIBLIOGRAPHY
1. 2. 3. 4. 5.
Kocour, E. J.: Am. ]. Surg., 37:433, 1937. Fansler, W. A.: Tr. Am. Proctolog. Soc., 41:231, 1940. Graham, R. R.: Can ad. M. A. ]., 36:1 (Jan.) 1937. Babcock, W. W.: Rev. Gastroentero!., 8:72, 1941. Schatzki, R.: Radio!., 34:651, 1940.
KIRBY A. MARTIN, M.D., F.A.C.P.* AND CHARLES G. AOSIT, JR., M.D.t THE purpose of this clinic is to present some data on diverticulosis of the gastrointestinal tract and to comment on the complications and treatment of diverticula of the colon-diverticulitis, hemorrhage, perforation and intestinal obstruction. LOCATION, PREVALENCE AND AGE
Diverticula may be found in any part of the intestinal tract, only occasionally in the esophagus, stomach and small intestines, more frequently in the duodenum and very commonly in the colon, especially in its distal half. They may be congenital (Meckel's) but usually are acquired; if the latter, they are frequently multiple. Diverticula have been known to the anatomists as a rare finding for centuries, but the first description of them as an entity was that of Sommering in 1794 and Chuvelhier in 1849. Virchow in 1853 was the first to define them clinically. It was not until 1898, however, that a case of perforated diverticulitis with resulting left-sided peritonitis was reported by Graser. Lewald in 1914 is credited with the first roentgenologic diagnosis, but the prevalence of diverticula was not fully appreciated until the opaque motor meal x-ray technic became a common diagnostic procedure. Their importance as a clinical entity is still in a process of evolution. X-ray and postmortem examinations of the intestinal tract have shown diverticula to be uncommon before the age of 35 and increasingly frequent after 45 years. The incidence is usually stated to be higher in the male than in the female, also more common in the obese. They are frequently seen proximal to a partial obstruction. Numerous authors have stated that they are found in about 5 per cent of persons subjected to x-ray examination for any cause. Kocour 1 studied the incidence of diverticulosis in 7000 consecutive autopsies, and gives the percentage in each age decade. His figures show the condition to increase markedly in frequency after the age of 40, apd to become relatively stationary after the sixtieth year. Of the patients over 40 years of age, 3.58 per cent showed diverticulosis From the Department of Medicine, Cornell University Medical College and the New York Hospital, New York City. * Instructor in Medicine, Cornell University Medical College; Assistant Attending Physician, New York Hospital. t Assistant Attending Physician, Outpatient Department, St. Luke's Hospital. 6)9
640
KIRBY A. MARTIN, CHARLES G. ADS IT,
In.
and 0.15 per cent showed some complications which had caused the death of th~ patient. Contrary to most observations, his data show the incidence of diverticulosis in the female to be 33 per cent higher than in the male. Diverticula, when once formed, persist. Only occasionally do they produce symptoms. The patient whose colon is x-rayed usually has some symptoms to justify the procedure and then the failure to show diverticula does not necessarily disprove their presence. They may fail to fill at times, as does an appendix. It would thus follow that consecutive autopsies in a large series, in which special attention was paid to this condition, would be more likely to represent the true incidence of the disease than conclusions based upon clinical findings. It is interesting that Kocour found the incidence of gallbladder disease in persons over 40 years of age to be double in those also having diverticulosis. PATHOGENESIS
Anatomicaly, diverticula are blind sacs with small bases branching from the gastrointestinal tract. The pathogenesis is still incompletely understood. There is a common belief that the herniations occur at the point of entrance of a blood vessel into the wall of the bowel. To support this thesis, diverticula are frequently seen to develop in two parallel rows on either side of the mesocolon. Fansler2 disagreed with this concept and stated that it is unusual to find a blood vessel adjacent to the neck of a diverticulum, especially in the colon. It is his opinion that diverticula develop in the haustrations or sacculations of the colon, in the wall of which only one layer of muscle (circular) is found. In these haustrations, the susceptibility of the muscular wall to stretching and thinning is increased, especially in the descending colon and sigmoid where the intestinal tension is greatest. This stretching and thinning in older individuals he believes may result in herniation and formation of diverticula. In agreement with this is the experience of not infrequently finding diverticula on any or all sides of the colon. The wall of the diverticulum is therefore formed from mucous, submucous and peritoneal coats, and at times acquires a fatty coat. DIVERTICULITIS
Diverticulosis which precedes diverticulitis is present, as previously stated, in about 5 per cent of persons subjected to x-ray examination of the colon for any cause. Diverticulitis develops in about 12 to 15 per cent, according to Graham. 3 In other words, diverticula cause no symptoms in most instances. They are, however, potential sources of danger in producing localized stasis, inflammation and ulceration of the sac, with possible perforation. The sigmoid and descending colon are the most common areas to meet with these complications.
641
DIVERTICULOSIS AND DIVERTICULITIS
DIVERTICULA OF THE SIGMOID AND DESCENDING COLON
Further discussion in this clinic will be limited to the consideration of symptoms, diagnosis and treatment in the complications of divertic'ulosis found in the sigmoid and descending colon. The statistical data to be presented were obtained by reviewing the material in the record room of the New York Hospital. The selected case records were taken from our private files. The opinions expressed obviously are wider than the analysis of the material would permit. TABLE I.-DATA CONCERNING DIVERTICULITIS AT NEW YORK HOSPITAL,
1933
TO
1944* ---~~-----'"-~--
------
Total admissions to New York Hospital ..................... . 177,718 201 Cases of diverticulitis ........................................ . 0.001 Percentage of admission ..................................... . Sex ..................................... 105 males, 96 females Duration of symptoms................. 2 hours to 54 years Associated with: Carcinoma of large bowel ................................... . 5 Other carcinoma .............................................. 14 Cholecystitis and cholelithiasis ............................... 22 Gastric ulcer ................................................. 5 Duodenal ulcer ............................................... 4 ~ru~~~ .................................................. . 63 Diarrhea ..................................................... . 26 Constipation and diarrhea .................................... . 4 Hemorrhaget ................................................ . 17 Perforation .................................................. . 25 Fistula ....................................................... . 11 Perirectal abscesses .......................................... . 3 Confused with: Carcinoma of sigmoid ...................................... . 19 Appendicitis ................................................. . 7 Renal colic ............ . ................................... . 2 Deaths ........................................................... 32 Perforation ............................................ . 5 Hemorrhage .................................................. 1 Other ......................................................... 26 Cases of Meckel's diverticulum .................................... 28 Females ....................................................... 17 Males...... . ................................................ 11
* We are indebted to Mrs. Joan Haskett-Smith, volunteer worker at the New York Hospital, for her painstaking assistance in collecting these data from the reeord room. t Diverticulitis with hemorrhage (excluding Meckel's)-17; of these, 10 perforated; one twice. One died of massive hemorrhage.
042
KIRBY A. i\IARTlN, CHARLES G. ADS IT, TABLE
.lIt.
2.-sl'l'I<: OF TilE DIVERTICULA, ACCORDING TO AGE Diverticula
Age
------- ----,------------1
Meckel's
Colon
Total
------------ - - - - - - - -
0-10 11 - 20
21 - 30
31 - 4{) 41 - 50 51 - 60
17 4
2 3
2
61 - 70 71 -
17 1 12 24
4 3
15 26
54 58
54 58
24
24
TABLE 3.-MECKEL'S DIVERTICULUM AT THE NEW YORK HOSPITAL OVER TWELVE YEARS
(Total Admissions 177,718)
No. Total cases ............................. 28 Total deaths .......................... 2* Cases operated on ..................... 14 Postoperative deaths .................. 0
Per Cent 7.14 50.00
o
* One stillborn, one newborn; no operations. TABLE 4.-DIVERTICULITIS REQUIRING OPERATION
Total cases operated on ................ Perforation ............................ Hemorrhage ........................... Diverticulosis and carcinoma ........... Deaths ................................ Deaths excluding carcinoma ............
No.
Per Cent
51 25 17 4 12 9
49.0 33.3 7.8 23.5 17.6
-------------------------------- ------
Cases explored for possible carcinoma .. 13 Carcinoma found ..................... 4 Deaths from carcinoma ................ 3 Deaths excluding carcinoma ........... 0
25.5 7.8 5.9
o
SYMPTOMS AND DIAGNOSIS
The symptoms vary greatly, from a single slight acute attack, recurring episodes or chronic inflammatory reaction, to acute or chronic perforation with localized peritonitis and abscess formation or general peritonitis. A fistula occasionally develops between the sigmoid and the vagina or the urinary bladder, the latter manifesting itself by the urine containing gas and fecal material. Local manifestations, if present, are usually in the left lower quad-
DIVERTICULOSIS AND DIVERTICULITIS
643
rant of the abdomen, but may be in the midline or to the right side, depending upon the position of the sigmoid and its tensinn; a spastic sigmoid may produce back pressure in the cecum and appendix, and the latter may be blamed for the symptoms. Pain on pressure over the sigmoid, muscle guard, spasm and flatulence are common. The symptoms usually give little information as to the extent of the lesion unless a tumor mass is felt. In other instances a dull intermittent or constant cramplike diffuse pain in the abdomen frequently associated with tenesmus is common, or the symptoms may be entirely rectal. A significant sign is the temporary relief that may follow a warm saline epema, a bowel movement or the passing of flatus. Fever and leukocytosis may be present. Diarrhea and constipation are equally common. Rectal bleeding does occur, but is rare except in Meckel's diverticulum; it may follow the passing of diverticular concretions, but blood in the stool indicates carcinoma until disproved. The clinical picture associated with diverticulitis can simulate almost any other abdominal disease. The importance of making a proper diagnosis is therefore obvious; operation is rarely advised in diverticulitis. Furthermore, the postoperative mortality was 20 per cent, with a residual mortality of 29 per cent in Babcock's4 series. In our series it was 23.5 per cent. X-ray study is indispensable in this work and if used to its fullest extent, fruitless surgical procedures can be avoided. DIFFERENTIAL DIAGNOSIS
In most cases it is easy to distinguish carcinoma from diverticulitis, difficult in a few, and almost impossible in an occasional case. In this latter group, exploratory laparotomy may be necessary. The operator frequently encounters a hard, irregular, fixed mass involving the sigmoid or descending colon and the diagnosis may remain uncertain pending the microscopic study. Carcinoma, like diverticulosis, is most commonly found in the sigmoid and descending colon, although the association of the two is so rare that there is no reason to believe that diverticulosis is a precursor of cancer. Proctoscopic examination is indicated. It is not uncommon to find a carcinoma of the rectum producing the symptoms, although the radiographs may be negative save for the presence of diverticula or perhaps diverticulitis of the sigmoid. Blood, pus and excess mucus with a foul odor coming from some point .higher than the rectum usually means carcinoma, but occasionally an intramural abscess in peridiverticulitis will give a similar picture if the abscess is draining into the gut. In all such cases a complete gastrointestinal study is indicated. Radiographic study is a valuable adjunct in the diagnosis of diverticulitis; in most cases it is all that is necessary. In complicated cases, however, the responsibility for the differential diagnosis is great. Still,
644
KIRBY A. MARTIN, CHARLES G. ADSIT,
JR.
the balance of evidence is in the interpretation of the radiographic findings, but the clinician who marshals all the clinical data in a given case will err less frequently. In acute uncomplicated cases the inflamed, edematous walls present a bizarre sawtooth outline giving such a characteristic radiograph, during a barium enema, that it is not likely to be confused, even though no diverticula are Seen (Case Ill). But diagnosis is more difficult in acute exacerbation of a chronic diverticulitis, a subacute or chronic peridiverticulitis which has produced a thick wall and a constricted lumen of the gut with cone-shaped ends (Case VII, A). There is usually a distortion of the pattern of the mucosal folds and a marked deformity of the 'bowel lumen (Case V). Air contrast enema and spot films of mucosal pattern are usually helpful in such cases. Still more complicated are those that develop intramural abscesses, losing part of the mucosal pattern (Case VII, B). Diverticula with long necks are common in such cases, and if they should fall at either end of the constriction, they may produce an overhanging edge like that seen in carcinoma. The two conditions do coexist occasionally and the prescnce of diverticula proximal or distal to the constricted area does no~· exclude carcinoma, as illustrated in -Case IX. The presence of diverticula does not help much in the differential diagnosis, but their absence does if proper delayed x-ray films are made following an opaque motor meal. However, the presence of diverticula in the constricting mass is important because they rarely if ever occur in carcinoma (Schatzki5 ) (Case VIII). TREATMENT
The treatment is medical in all but those few caSes in which serious complications mayor do occur. The predominant symptom in the average uncomplicated case is spasm of smooth muscle, the result of inflammation in the diverticula. The duration or intensity of the symptoms is such that only an occasional patient consults his physician. In more severe cases the following treatment is usually effective: Rest in bed, heat to abdomen, smooth diet, sedative, antispasmodic and inducing bowel moment with the least possible irritation. Phenobarbital gm. 0.032 CY:! grain), three times a day, or tincture of belladonna 1.9 cc. (30 drops) single or combined (we have never been impressed with the virtues of the latter). Mineral oil is beneficial during the acute phases, at the expense of a possible avitaminosis. Codeine 0.06 gm. (1 grain) or paregoric 4 cc. (1 dratn) may be indicated. Warm saline or oil enemas usually give comfort. Barium sulfate in 28.4-gm. (1 ounce) doses, given in a water suspension two or three times a week is beneficial. The barium supposedly displaces the irritating, fermenting intestinal content, reducing the inflammation and edema. The improvementof symptoms that so frequently follows x-ray study of the colon amply confirms this statement. .
DIVERTICULOSIS AND DIVERTICULITIS
645
Obstruction develops slowly as a· rule, and is rarely complete. It may be the first symptom. The treatment is secondary to the diver. ticulitis. We encountered this only eight times in our series. Acute perforation has been rare in our experience. It has been stated to occur about one half as often as perforation from carcinoma. We had eight cases. Acute perforation from a diverticulum in the colon, like acute perforation from any cause, calls for immediate operative . closure. These patients usually do well.
Fig. 125.-(Case I.)
Slow perforation. Perforation from a diverticulum or an intramural abscess is more common than acute perforation and, unlike an appendix, is likely to produce few symptoms for long periods of time, due to a slow but complete walling-off process. The sulfonamides have not been impressive, in our experience, in the uncomplicated cases or in those that perforate and form abscesses or fistulous tracts. Likewise in our limited experience, penicillin was beneficial only in secondary complications (Case VII, B). This group likewise is managed surgically. The exploratory laparotomy, as well as the postmortem findings, in these cases usually
646
KIRBY A. MARTIN, CHARLES G. ADS IT,
JR.
shows a widespread mesentery and lymph gland inflammatory involvement. This, in addition to abscess and sinus tracts, makes resection of the affected segment of the gut a hazardous task. CASE REPORTS
I Clinical: Woman, 53. Loss of 15 pounds of weight. No intestinal symptoms. Normal bowel function. Film (Fig. 125): 24-hour barium motor meal. Diagnosis: Diverticulosis of colon. Accessory: Osteogenesis i~perfecta; has had fourteen fractures. CASE
"~
Fig. 126.-(Case 11.) 11 Clinical: Man, 55. Vague abdominal distress for ten years, worse in past three months. Film (Fig; 126): 24-hour barium motor meal. In transverse Golon note "pseudodiverticula." Barium enema films showed no evidence of organic disease. Diagnosis: Duodenal ulcer, right renal calculi. Spastic colon. CASE
III Clinical: 'Man, 51. Acute abdominal pain; typical "left side appendicitis." Six years later, no further symptoms. Film (Fig. 127): Barium enema (film reversed). Note spasm in sigmoid; spikes set at varying angles to the lumen. No diverticula seen in sigmoid, one noted in transverse colon. On delayed films two small diverticula were seen in sigmoid. Diagnosis: Typical of acute, early diverticulitis. CASE
DIVERTICULOSIS AND DIVERTICULITIS CASE
647
IV
Clinical: Man, 51. No intestinal symptoms until ten hours before. Onset with acute left lower abdominal distress and a sudden desire to defecate and pass flatus. Diarrhea lasted three hours, followed by frequent periods of straining and tenesmus but passing only small amounts of mucus and bright red blood. Proctoscopic: From some point above the rectosigmoid area mucus and -bright red blood came into view; otherwise the examination was negative.
Fig. 127.-(Case Ill.) Film (Fig. 128): Barium enema. Note spasm in sigmoid with spikes set at various angles to the bowel lumen. (Postevacuant film showed four small diverticula.) Diagnosis: Acute diverticulitis of sigmoid with ' hemorrhage. Result: Symptoms subsided. V Clinical: Man, 55. Many attacks of left lower abdominal distress; none in acute phase,until now. Film (Fig. 129): Postevacuation barium enema, plus air injection. Note "spiral stair" effect from deep folds of mucosa. Diverticula are at apices of these folds. Diagnosis: Acute phase of chronic diverticulitis.
CASE
648
KIRBY A. MARTIN, CHARLES G. ADS IT, JR.
Fig. 128.-(Case IV.)
Fig. 129.-(Case V.) CASE VI, A Clinical: Man, 55. Generally constipated. During past ten years repeated attacks of diarrhea and lower abdominal distress. Now, temperature 100° F'i pulse
DIVERTICULOSIS AND DIVERTICULITIS
649
95, white blood cells 11,000, pain in left lower quadrant. Desire to defecate and pass flatus; slight muscle guard. Palpable mass in left lower quadrant.
A
B Fig. 130.- (Case VI.) Film (Fig. 130, A): Barium enema. Narrowing of the sigmoid lumen with a symmetrical arrangement of diverticula with long necks, "accordion type." Diagnosis: Acute exacerbation of a chronic diverticulitis, peridiverticulitis.
650
KIRBY A. MARTIN, CHARLES G. ADS IT,
In.
VI, B Same case four years later, following operation for acute perforation at the proximal end of narrowing. Patient had been asymptomatic for' nine months.
CASE
B Fig. 131.-(Case VII.) Film (Fig. 130, B): Barium enema. Funnel-shaped shadows at base of some diver-
ticula, probably fecalith.
Comment: Prognosis is poor, resection advised.
DIVERTICULOSIS AND DIVERTICULITIS
651
CASE VII, A Clinical: Woman, 63. Constipated; treated fifteen years for "colitis." Fi;rst symptom was acute, severe rectal pain. Temperature 104 F ., pulse 140, white blood cells 18,000. No abdominal. signs or symptoms. Rectal and vaginal examination negative save for general discomfort. Later, stool contained blood and pus. Film (Fig. 131, A): Barium enema. Filling defect in sigmoid colon, much spasm, partial intestinal obstruction. Note numerous diverticula with long necks at unusual distances from the central axis of the gut. Diagnosis: Diverticulitis, acute phase of a chronic peridiverticulitis, intramural abscess and question of perforation of a diverticulum with pelvic abscess; partial obstruction of colon. 0
CASE
VII, B
In same case two days later a sigmoid-vaginal fistula developed. Temperature subsided and general condition improved until a four year old osteomyelitis of leg became active. Sulfonamides had no apparent effect on abscess or osteomyelitis. One million units of -penicillin effected a quick subsidence of the osteomyelitis but had no demonstrable effect on the pelvic abscess. Film (Fig. 131, B): 36-hour barium motor meal plus barium enema. Note evidence of intramural abscesses and a fistulous tract to pelvic abscess i~dicated by arrows. Outcome: Resection of sigmoid colon three months following a colostomy. Patient died thirty-six days postoperatively of general peritonitis and sepsis. Surgical Pathology: Specimen removed at operation showed an 18-inch segment of colon, 12 inches of which were dense, firm and greatly thickened with many diverticula, intramural abscesses and intramural fistulas, some communicating with the lumen of the bowel and one to the external surface.
652
KIRBY A. MARTIN, CHARLES G. ADSIT, JR.
CASE VIII (Courtesy of Dr. Frederic Bancroft) Clinical: Woman, 80. Intermittent attacks of left lower quadrant pain for forty years. Lost 15 pounds in last seven months, abdominal distress worse. Diarrhea, with blood in stool. Palpable lllilSS in left lower quadrant. Film (Fig. 132): Fixed irregularity in outline of descending colon with eccentric lumen. Mucosal pattern destroyed. No diverticula seen in area of filling defect but are numerous distal to same. Note large soft tfssue shadow inqicated by arrows. Probably a cyst; had no relation to colon; was not explored. Diagnosis: Carcinoma of colon with partial colonic obstruction. Diverticulitis, chronic type. Operation: Resection of descending colon and sigmoid-anastomosis, colostomy closed. Pathology: Diagnosis-adenocarcinoma of colon; peridiverticulitis of colon. Result: Discharged home-bowel function normal.
Fig. 133.- (Case IX.) IX Clinical: Man, 53. Moderate constipation for several years, with many attacks of vague abdominal distress. Since past ten months has had tendency toward diarrhea; more recently has had blood in stool; no weight change. Film (Fig. 133): 36-hour motor meal, plus barium enema. Large constant filling defect in descending colon with partial colonic obstruction. Note numerous diverticula with long necks on medial side of filling defect and no diverticula lateral side, save one at upper border producing an overhanging ' edge; mucosal pattern destroyed. Diagnosis: Diverticulitis, peridiverticulitis of descending colon and sigmoid with colonic obstruction; question of carcinoma of descending colon. Operation: Resection and end-to-end anastomosis. Specimen showed a chronic peridiverticulitis with an ulcerating carcinoma on lateral wall. Result: Recovered.
CASE
DIVERTICULOSIS AND DIVERTICULITIS
653
COMMENT
In practice many cases of colonic disturbance are labeled and treated as "colitis" without proper examination and study. Most will prove to be functional, but an occasional one will have an organic lesion responsible for the symptoms. A significant point to suggest the latter is a change in the bowel rhythm, a change in the rate of flow (diarrhea or constipation) or a change in character of the content (increase or decrease of fluid, presence of blood, mucus or pus). Diagnosis is the first consideration. It is to be borne in mind that this study, for the most part, represents only the occasional case of diverticulitis in which the patient was sufficiently ill to be admitted to the hospital. The disease is very commonly met in ambulatory practice and.father infrequently in hospital practice. The severity of the symptoms gave no clue in most instances as to the stage of the disease process. This fact has a tendency· to lessen the percentage of severe complications to the total group. And, for the same reason, a large percentage responded well to medical treatment. Acute perforations, when they did occur, were frequently found in the absence of other complications, such as peridiverticulitis, and if recognized early, usually did well following operative closure of the perforation . . In the group in which peridiverticulitis was the predominant feature, partial colonic obstruction, slow perforation with abscess formation and fistula were common complications. Our data support the view that there has been no significant change in the mortality rate in this group in twenty-five years, despite the general progress in medical management in many other conditions. Peridiverticulitis and carcinoma are most commonly found in the descending and sigmoid colon. They also have in common the same age group. The treatment of diverticulitis is generally considered medical; carcinoma surgical. In several instances a preoperative positive diagnosis was impossible and a resection of the lesion was carried out. In Table 4 you will note that there were thirteen operations on such cases and only four carcinomas were found. If we exclude these four carcinomas the mortality drops to 0 against 22.9 in the group as a whole. The difference lies in the fact that infection as a complication was infrequent. The fault, therefore, would appear to lie in the continued failure to recognize those cases with impending danger as a separate group and institute proper surgical measures. This is a serious criticism of our diagnostic acumen, but improvement will follow if operation is offered early as a preventive of a too-often widespread infection and fatal outcome.
654
KIRBY A. MARTIN, CHARLES G. ADSIT,
.Tn.
SUMMARY
During the period between 1933 and 1944 there were 201 patients with acute diverticulitis admitted to the New York Hospital in a total admission of 177,718 patients, or 0.00112 per cent. There were 28 cases of Meckel's diverticulum, or 0.00016 per cent. Fourteen patients were operated on with no postoperative deaths. There were 51 cases operated on for some complication in relation to the diverticulitis with 12 deaths, or 23.5 per cent. Carcinoma was encountered in the presence of diverticulitis in 4 cases, or 7.8 per cent. Carcinoma 'was suspected and operation carried out on 13 cases (25.5 per cent), with 3 deaths, or 5.9 per cent. Excluding carcinoma, it was 0 against 23.5 per cent in the group as a whole. Peridiverticulitis, like carcinoma, occurs in the same age group and is most commonly found in the descending and sigmoid colon. The lesion formed is frequently confused with carcinoma and may lead to serious complications, followed by a high mortality rate. Data are presented to suggest how a differential diagnosis can be made and how the mortality rate can be lowered. BIBLIOGRAPHY
1. 2. 3. 4. 5.
Kocour, E. J.: Am. ]. Surg., 37:433, 1937. Fansler, W. A.: Tr. Am. Proctolog. Soc., 41:231, 1940. Graham, R. R.: Can ad. M. A. ]., 36:1 (Jan.) 1937. Babcock, W. W.: Rev. Gastroentero!., 8:72, 1941. Schatzki, R.: Radio!., 34:651, 1940.