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Massive hemorrhage from diverticulosis of the colon
Massive
Hemorrhage from Diverticulosis of the Colon GARVER L. JENSEN,
M.D.,
Oakland, CaliJornia diverticuIa has been discussed by several authors [2,?,5-71. It is generaIIy stated that the is an out-pocketacquired “ faIse” diverticuIum ing of the mucosa through the muscular Iayers occurring most frequentIy in the taeniae near the mesenteric border and usuahy at the point where nutrient vesseIs penetrate the bowel waI1. Thus it often Iies in cIose proximity to sizable bIood channeIs. Further evidence is suppIied by Noer [I], who injected colon specimens with liquid latex and was able to demonstrate unusual vascuIarity in the walls of diverticula. It is obvious that hemorrhage cannot occur through the intact mucosa and that some degree of inflammation or erosion must be present. However, the area of inhammation in a bIeeding diverticulum may be so Iocahzed that none of the usua1 symptoms of diverticuIitis are produced and the typica spasm and saw-toothed appearance on x-ray examination are absent. Young and Howarth [6] beIieve that hemorrhage usuaIIy foIIows erosion and uIceration of a diverticulum which has become inverted. As might be expected, severe bIeeding in diverticulosis occurs most often in patients exhibiting a significant degree of arteriosclerosis with hypertension. It is diffrcuIt to appraise the incidence of massive bIeeding from diverticular disease. Quinn and Ochsner [7] pubIished a review of the experience at Charity Hospital. Over a ten-year period seventy-six patients were admitted for complications of diverticulitis or diverticuIosis. Thirty-seven or 48.7 per cent of these were hospitaIized primarily because of hemorrhage, and in twenty-three of these thirty-seven the bleeding was judged to be reaIIy massive. Welch, AIIen and Donaldson [8] reviewed 582 cases of diverticuIar disease and found five cases in which hemorrhage was the major indication for surgery. In 1955 Noer
HE management of undiagnosed gross bleeding from the coIon can present a perpIexing probIem. In recent years there has been increased interest in diverticuIar disease as a source of massive meIena. WhiIe many other Iesions of the large bowe1, including carcinoma, polyps, ulcerative colitis and the common recta1 Iesions, frequentIy produce recognizabIe gross blood in the stoo1, massive hemorrhage from these sources is very unusual. It has Iong been recognized that bleeding occurs in diverticuhtis; its occurrence is indicated in various series at from 3 to 47 per cent, most authors reporting from IO to 30 per cent incidence [I]. This bleeding is usuahy smaII in amount but in a certain proportion of cases, estimated at about 4 per cent [2], it is of suff~cient severity to require transfusions. That apparentIy uncomphcated diverticmosis can produce massive hemorrhage is a concept which has received attention onIy in the past few years. In contrast to earher teaching portraymg coIonic diverticuIa as anatomica curiosities producing no symptoms unIess a manifest inIIammatory process supervenes, it can now be stated that diverticulosis is the principa1 source of massive hemorrhage from the Iarge bowe1 [2-41. While it is obvious that far advanced carcinoma can erode a sizable blood vesse1, and there are a number of cases reported in which a fistulous tract from perforated diverticuIitis has penetrated a Iarge artery or vein, in these cases the diagnosis is usuahy fairIy evident and the indicated course of treatment is reasonably cIear. The rea1 probIem arises in the patient presenting profuse recta1 hemorrhage with no previous history or symptoms to suggest gastrointestinal disease. This paper concerns onIy massive hemorrhage from apparentIy uncompIicated diverticulosis. The anatomical basis for hemorrhage from
T
813
American Journal of Surgery, Volume yg, May, 1938
Jensen [I] reviewed forty-one cases of massive hemorrhage from eighteen papers pubhshed since 1942 and added two cases from his own experience, both of which required surgery. It is evident that whiIe statisticahy not common, massive meIena from diverticular disease does occur frequentIy enough to deserve consideration. A major probIem in the diagnosis of hemorrhage from diverticuIosis Iies in the fact that it can be reached onIy by excIuding other Iesions which couId cause bIeeding. Since it is impossibIe to demonstrate a bIeeding divertic&m by any direct test or examination, one must arrive at a presumptive diagnosis by process of eIimination. Ochsner [7] has proposed the folIowing criteria: (I) passage of gross recta1 bIood, bright or maroon in coIor; (2) evidence of diverticuIa on barium enema; (3) absence of other intrinsic lesions on recta1 and proctoscopic examinations; and (4) norma stomach and smaI1 bowe1 on gastrointestina1 examination, It may, of course, be impossibIe to perform a11 of these examinations on a patient who has Iost a Iarge amount of bIood from acute hemorrhage. Surgical exploration as a method of diagnosis is highIy unsatisfactory. Laparotomy during active bIeeding typicaIIy reveaIs onIy a coIon hIled with bIood in which muItipIe diverticuIa are present. Colotomy. with operative endoscopy is of IittIe value m IocaIizing the bIeeding point. The problem of detecting the site of bIeeding in a coIon fiIIed with bIood can be appreciated when one realizes that the mucosal erosion responsibIe for the hemorrhage is generally so smaI1 that it escapes detection even on the resected specimen or at necropsy examination [2,3,7,9]. In view of the difhcuIties invoIved in Iocalization of the bIeeding diverticuIum at surgery, we may we11 inquire into the prognosis in nonoperated patients. The majority of patients will respond to conservative management and a cessation of bIeeding may usuaIIy be expected to foIIow a program of rest, sedation, transfusions and intestina1 antiseptics. Moreover, many of these patients remain we11 indehniteIy without further hemorrhage. CertainIy conservative treatment shouId be empIoyed initiaIIy in a11 cases of hemorrhage of the Iarge bowel. However, most surgeons of wide experience agree that an occasiona patient wiI1 continue to bleed and that the possibiIity of exsanguinat-
ing hemorrhage from this source, whiIe not great, is real. In the patient whose bleeding cannot be controhed by conservative management with repeated transfusions, surgica1 intervention is mandatory. At Iaparotomy the first objective is to make a definite diagnosis, if possibIe. The entire coIon shouId be examined carefuIIy for evidence of tumor, poIyp or inhammatory process. When no abnormaIity other than diverticuIosis is noted the surgeon is faced with a diffrcuIt decision. If the diverticuIa are limited to a portion of the colon, the invoIved segment should be resected. If, however, the entire large bowe1 is involved and no IocaIization of the bIeeding site is possibIe, the probIem is great. In this circumstance four possible courses are open: (I) cIosure of the abdomen and dependence on conservative (2) tota extirpation of the abdomimeasures; na1 coIon; (3) bIind resection of the most invoIved segment (usuaIIy the sigmoid) ; and (4) formation of one or more Iocalizing coIostomies, or precoIostomies as advocated by Peters [J]. To do nothing in the face of continuing liemorrhage is obviousIy unsatisfactory. TotaI colectomy with an unprepared bowel in a poor risk patient who has Iost a Iot of bIood is a formidabIe procedure and may not be practica1. GeneraIIy the sigmoid region exhibits the most extensive diverticuIosis and on the basis of probability is most likely to be the source of bIeeding [y]. Resection of this segment may be expected to remove the bleeding point in most but certainIy not a11 cases. The aIternate method, that of making coIostomies, provides for diversion of the fecal stream and makes possibIe the introduction of intestina1 antiseptics and topica coaguIants. This course of action is open to the criticism that no direct attack is made upon the source of the hemorrhage. If hemorrhage does continue, however, the presence of coIostomies may aid in IocaIization and permit a more conservative resection at a Iater operation. It is apparent that no cIear course is open to the surgeon faced with emergency surgery in a problem of this kind. When the situation is somewhat Iess urgent, further diagnostic study is possibIe and a more IeisureIy evaIuation can be made. If, because of recurrent bIeeding or because malignant disease cannot be ruled out, surgery is decided upon, elective resection of the involved colon may be accomplished after adequate bowel Since inff ammatory reaction is preparation.
DiverticuIosis
of CoIon
generally minimal or absent, resection and anastomosis may be performed safeIy in one stage. The folIowing previously unreported case is presented because of severa unusual features which are thought to be of interest. CASE
REPORT
A. L., a forty-three year oId white man, was admitted to the hospital on December 7, 1951. He had had no gastrointestina1 symptoms prior to the day of admission and except for an appendectomy two years previously his past niedical history was entireIy negative. At 3:oo A.M. he was awakened by a sudden urge to defecate and passed a large amount of red blood. He experienced mild nausea but did not vomit and there was no abdominal pain. After passing two more large bloody stooIs he compIained of weakness and faintness and was hospitalized. On admission there was no evidence of active bleeding and his bIood pressure was 130/90 mm. Hg. General examination was negative and anoscopic examination reveaIed no bIood in the distaI rectum. HemogIobin on admission was 13.6 gm. per cent with a red bIood cell count of 4,020,000 per cu. mm. and a white bIood ceI1 count of 15,500 per cu. mm. About twenty hours after his initia1 episode the patient again began to bleed per rectum, passing 2 to 3 pints of bright blood and cIots. an estimated The pulse became rapid and to combat shock bIood transfusions were started. Sigmoidoscopy was attempted but no Iesion was found, and active flow of bIood was observed to be coming from a level above the range of visibiIity. After a transfusion of 1,500 cc. of bIood the patient was stabilized but he continued to pass an occasional bloody stool for the next forty-eight hours and the hemogIobin dropped to 9.4 gm. per cent. Barium enema examination was performed after the bIeeding stopped and reveaIed onIy diverticuIosis confined to the region of the hepatic IIexure. (Fig. I.) Upper gastrointestina1 series showed no pathologic condition and sigmoidoscopy repeated after preparation again revealed no Iesion. The patient was discharged from the hospita1 to return for further studies at a Iater date, but on December 17th, ten days after his initia1 admission, he again began to pass bIood per rectum. He was rehospitalized for observation but no transfusions were required on this admission. Barium enema examination was repeated and again showed onIy the IocaIized diverticuIosis. On January r8th, after passing another blood stoo1, the patient was admitted for eIective surgery after bowe1 preparation. ExpIoration failed to revea1 any pathoIogic condition other than the diverticulosis. Careful examination of the entire Iarge bowel shoved onIy the diverticula of
FIG. I. Barium enema x-ray limited to the proximal coIon.
showing
diverticuIosis
the cecum and ascending colon, some of which contained inspissated fecal matter. Right hemicolectomy was performed with primary end-to-end iIiotransverse colostomy. The patient made an uneventful recovery and has remained well with no further hemorrhage for a period of five years. Examination of the specimen revealed numerous diverticula of the ascending colon, one of which, Iocated 8 cm. from the distal end, showed diffuse hemorrhage with typica ecchymotic discoloration. (Fig. 2.) Microscopic examination showed a typica faIse diverticulum with uIceration of the mucosa and evidence of acute submucosa1 hemorrhage. (Fig. 3.) COMMENTS
While this case presents the typica onset and course of moderateIy profuse hemorrhage from a diverticutum, the patient was somewhat younger than the usual person exhibiting we11 deveIoped diverticuIosis. AIso, he showed no evidence of the arterioscIerosis and hypertension usuaIIy found in patients bIeeding from this condition. Moreover, the diverticuIa were confined to the proxima1 coIon which is unusua1. Finally, contrary to the genera1 ruIe, we were abIe to demonstrate the actuaI bIeeding point in the specimen (something which has been possibIe in onIy two reported cases [ r,6]), thus confirming the diagnosis. The decision to operate in this case was made on the basis of recur815
Jensen
FIG. 2. Photograph showing ecchymotic
of the diverticurum from which discoIoration of the mucosa.
FIG. 3. Photomicrograph of the bIeeding hemorrhage and erosion of the mucosa.
rent hemorrhage Iocalized disease.
in a good risk patient
with
diverticulum
hemorrhage
occurred,
showing submucosal
those cases which wiI1 not respond to medica measures. As has been suggested, one shouId be guided by some poIicy comparabIe to that which has been generaIIy accepted for massive bIeeding from the upper gastrointestina1 tract [2].
CONCLUSIONS
WhiIe exsanguinating hemorrhage from the large bowe1 is not common, massive bIeeding does occur from coIonic diverticuIa and wiI1 occasionaIIy proceed to a fata termination unIess there is surgica1 intervention. In view of the evident probIems invoIved in the operative treatment of this condition the initia1 program shouId be conservative in a11 cases. The diffIcuIty lies in recognizing before the patient becomes a prohibitive surgical risk,
SUMMARY
The consensus of thought regarding the formation of coIonic diverticuIa and the mechanism by which bIeeding occurs has been reviewed. The probIems invoIved in the surgical treatment of those cases in which hemorrhage has not been controIIed by conservative meas816
Diverticulosis ures has been discussed. A case showing unusuaI features has been presented.
some
REFERENCES I. NOER, R. J. Hemorrhage as a complication of Ann. Surg., 141: 674-684, ,955. diverticulitis. 2. KUNATH, C. A. Massive bleeding from diverticuIosis ofthe coIon. Am. J. Surg., gr : gr 1-917, 1956. 3. PETERS, H. E., JR. Massive hemorrhage from the Iower intestina1 tract. West. J. Surg., G~nec. Z* Obst., 64: 646-649, 1956. 4. RIVES, J. D. and EMMETT, R. 0. MeIena, a survey of 206 cases. Am. Surgeon, 20: 458-470. ,954. 5. HOAR, C. S. and BERNHARD,W. F. Colonic bleeding and diverticular disease of the &on. Surg., Gynec. fl Obsc., gg: 101-107, 1954. 6. YOUNG, J. M. and HOWARTH, M. B. Massive hemorrhage in diverticuIosis; possibIe explanation of cause with presentation of a case requiring surgica1 treatment. Ann. Surg., 140: 128-131, 1954. 7. QUINN, W.
C. and OCHSNER, A.
BIeeding
as a
of CoIon compIication of diverticuIosis or diverticulitis of the coIon. Am. Surgeon, rg: 397-402, 1953. 8. WELCH, C. E., ALLEN, A. W. and DONALDSON, G. A. An appraisa1 of resection of the colon for diverticuIitis of the sigmoid. Ann. Surg., 138: 332-343~ 1953. o. SCARBOROUGH. R. A. DiverticuIitis of the colon. Calijornia hied., 80: 445-448, 1954. IO. ALLEN, A. W. Surgery of diverticuIitis of the colon. Am. J. Surg., 86: 545-548, 1953. I I. CATE, W. R. Colectomy in the treatment of masAnn. sive melena secondary to diverticulosis. Surg., 137: 558-560, 1953. 12. FOSTER, R. L. and FISHER, R. F. CoIostomy as emergency treatment for massive meIena secondary to diverticuIitis. Am. Surgeon, 20: 734-738, 1954.
H. B. Large meIena of obscure origin. Ann. Surg., I 20: 582-597, 1944. 14. TURNBCLL, G. C. Massive hemorrhage from diverticuIa of the coIon: a report of twelve cases. Quart. Bull. Northwestern Univ. M. School, 22: ‘3.
STONE,
292, 1948.
Hemorrhage from Diverticulosis of the Colon GARVER L. JENSEN,
M.D.,
Oakland, CaliJornia diverticuIa has been discussed by several authors [2,?,5-71. It is generaIIy stated that the is an out-pocketacquired “ faIse” diverticuIum ing of the mucosa through the muscular Iayers occurring most frequentIy in the taeniae near the mesenteric border and usuahy at the point where nutrient vesseIs penetrate the bowel waI1. Thus it often Iies in cIose proximity to sizable bIood channeIs. Further evidence is suppIied by Noer [I], who injected colon specimens with liquid latex and was able to demonstrate unusual vascuIarity in the walls of diverticula. It is obvious that hemorrhage cannot occur through the intact mucosa and that some degree of inflammation or erosion must be present. However, the area of inhammation in a bIeeding diverticulum may be so Iocahzed that none of the usua1 symptoms of diverticuIitis are produced and the typica spasm and saw-toothed appearance on x-ray examination are absent. Young and Howarth [6] beIieve that hemorrhage usuaIIy foIIows erosion and uIceration of a diverticulum which has become inverted. As might be expected, severe bIeeding in diverticulosis occurs most often in patients exhibiting a significant degree of arteriosclerosis with hypertension. It is diffrcuIt to appraise the incidence of massive bIeeding from diverticular disease. Quinn and Ochsner [7] pubIished a review of the experience at Charity Hospital. Over a ten-year period seventy-six patients were admitted for complications of diverticulitis or diverticuIosis. Thirty-seven or 48.7 per cent of these were hospitaIized primarily because of hemorrhage, and in twenty-three of these thirty-seven the bleeding was judged to be reaIIy massive. Welch, AIIen and Donaldson [8] reviewed 582 cases of diverticuIar disease and found five cases in which hemorrhage was the major indication for surgery. In 1955 Noer
HE management of undiagnosed gross bleeding from the coIon can present a perpIexing probIem. In recent years there has been increased interest in diverticuIar disease as a source of massive meIena. WhiIe many other Iesions of the large bowe1, including carcinoma, polyps, ulcerative colitis and the common recta1 Iesions, frequentIy produce recognizabIe gross blood in the stoo1, massive hemorrhage from these sources is very unusual. It has Iong been recognized that bleeding occurs in diverticuhtis; its occurrence is indicated in various series at from 3 to 47 per cent, most authors reporting from IO to 30 per cent incidence [I]. This bleeding is usuahy smaII in amount but in a certain proportion of cases, estimated at about 4 per cent [2], it is of suff~cient severity to require transfusions. That apparentIy uncomphcated diverticmosis can produce massive hemorrhage is a concept which has received attention onIy in the past few years. In contrast to earher teaching portraymg coIonic diverticuIa as anatomica curiosities producing no symptoms unIess a manifest inIIammatory process supervenes, it can now be stated that diverticulosis is the principa1 source of massive hemorrhage from the Iarge bowe1 [2-41. While it is obvious that far advanced carcinoma can erode a sizable blood vesse1, and there are a number of cases reported in which a fistulous tract from perforated diverticuIitis has penetrated a Iarge artery or vein, in these cases the diagnosis is usuahy fairIy evident and the indicated course of treatment is reasonably cIear. The rea1 probIem arises in the patient presenting profuse recta1 hemorrhage with no previous history or symptoms to suggest gastrointestinal disease. This paper concerns onIy massive hemorrhage from apparentIy uncompIicated diverticulosis. The anatomical basis for hemorrhage from
T
813
American Journal of Surgery, Volume yg, May, 1938
Jensen [I] reviewed forty-one cases of massive hemorrhage from eighteen papers pubhshed since 1942 and added two cases from his own experience, both of which required surgery. It is evident that whiIe statisticahy not common, massive meIena from diverticular disease does occur frequentIy enough to deserve consideration. A major probIem in the diagnosis of hemorrhage from diverticuIosis Iies in the fact that it can be reached onIy by excIuding other Iesions which couId cause bIeeding. Since it is impossibIe to demonstrate a bIeeding divertic&m by any direct test or examination, one must arrive at a presumptive diagnosis by process of eIimination. Ochsner [7] has proposed the folIowing criteria: (I) passage of gross recta1 bIood, bright or maroon in coIor; (2) evidence of diverticuIa on barium enema; (3) absence of other intrinsic lesions on recta1 and proctoscopic examinations; and (4) norma stomach and smaI1 bowe1 on gastrointestina1 examination, It may, of course, be impossibIe to perform a11 of these examinations on a patient who has Iost a Iarge amount of bIood from acute hemorrhage. Surgical exploration as a method of diagnosis is highIy unsatisfactory. Laparotomy during active bIeeding typicaIIy reveaIs onIy a coIon hIled with bIood in which muItipIe diverticuIa are present. Colotomy. with operative endoscopy is of IittIe value m IocaIizing the bIeeding point. The problem of detecting the site of bIeeding in a coIon fiIIed with bIood can be appreciated when one realizes that the mucosal erosion responsibIe for the hemorrhage is generally so smaI1 that it escapes detection even on the resected specimen or at necropsy examination [2,3,7,9]. In view of the difhcuIties invoIved in Iocalization of the bIeeding diverticuIum at surgery, we may we11 inquire into the prognosis in nonoperated patients. The majority of patients will respond to conservative management and a cessation of bIeeding may usuaIIy be expected to foIIow a program of rest, sedation, transfusions and intestina1 antiseptics. Moreover, many of these patients remain we11 indehniteIy without further hemorrhage. CertainIy conservative treatment shouId be empIoyed initiaIIy in a11 cases of hemorrhage of the Iarge bowel. However, most surgeons of wide experience agree that an occasiona patient wiI1 continue to bleed and that the possibiIity of exsanguinat-
ing hemorrhage from this source, whiIe not great, is real. In the patient whose bleeding cannot be controhed by conservative management with repeated transfusions, surgica1 intervention is mandatory. At Iaparotomy the first objective is to make a definite diagnosis, if possibIe. The entire coIon shouId be examined carefuIIy for evidence of tumor, poIyp or inhammatory process. When no abnormaIity other than diverticuIosis is noted the surgeon is faced with a diffrcuIt decision. If the diverticuIa are limited to a portion of the colon, the invoIved segment should be resected. If, however, the entire large bowe1 is involved and no IocaIization of the bIeeding site is possibIe, the probIem is great. In this circumstance four possible courses are open: (I) cIosure of the abdomen and dependence on conservative (2) tota extirpation of the abdomimeasures; na1 coIon; (3) bIind resection of the most invoIved segment (usuaIIy the sigmoid) ; and (4) formation of one or more Iocalizing coIostomies, or precoIostomies as advocated by Peters [J]. To do nothing in the face of continuing liemorrhage is obviousIy unsatisfactory. TotaI colectomy with an unprepared bowel in a poor risk patient who has Iost a Iot of bIood is a formidabIe procedure and may not be practica1. GeneraIIy the sigmoid region exhibits the most extensive diverticuIosis and on the basis of probability is most likely to be the source of bIeeding [y]. Resection of this segment may be expected to remove the bleeding point in most but certainIy not a11 cases. The aIternate method, that of making coIostomies, provides for diversion of the fecal stream and makes possibIe the introduction of intestina1 antiseptics and topica coaguIants. This course of action is open to the criticism that no direct attack is made upon the source of the hemorrhage. If hemorrhage does continue, however, the presence of coIostomies may aid in IocaIization and permit a more conservative resection at a Iater operation. It is apparent that no cIear course is open to the surgeon faced with emergency surgery in a problem of this kind. When the situation is somewhat Iess urgent, further diagnostic study is possibIe and a more IeisureIy evaIuation can be made. If, because of recurrent bIeeding or because malignant disease cannot be ruled out, surgery is decided upon, elective resection of the involved colon may be accomplished after adequate bowel Since inff ammatory reaction is preparation.
DiverticuIosis
of CoIon
generally minimal or absent, resection and anastomosis may be performed safeIy in one stage. The folIowing previously unreported case is presented because of severa unusual features which are thought to be of interest. CASE
REPORT
A. L., a forty-three year oId white man, was admitted to the hospital on December 7, 1951. He had had no gastrointestina1 symptoms prior to the day of admission and except for an appendectomy two years previously his past niedical history was entireIy negative. At 3:oo A.M. he was awakened by a sudden urge to defecate and passed a large amount of red blood. He experienced mild nausea but did not vomit and there was no abdominal pain. After passing two more large bloody stooIs he compIained of weakness and faintness and was hospitalized. On admission there was no evidence of active bleeding and his bIood pressure was 130/90 mm. Hg. General examination was negative and anoscopic examination reveaIed no bIood in the distaI rectum. HemogIobin on admission was 13.6 gm. per cent with a red bIood cell count of 4,020,000 per cu. mm. and a white bIood ceI1 count of 15,500 per cu. mm. About twenty hours after his initia1 episode the patient again began to bleed per rectum, passing 2 to 3 pints of bright blood and cIots. an estimated The pulse became rapid and to combat shock bIood transfusions were started. Sigmoidoscopy was attempted but no Iesion was found, and active flow of bIood was observed to be coming from a level above the range of visibiIity. After a transfusion of 1,500 cc. of bIood the patient was stabilized but he continued to pass an occasional bloody stool for the next forty-eight hours and the hemogIobin dropped to 9.4 gm. per cent. Barium enema examination was performed after the bIeeding stopped and reveaIed onIy diverticuIosis confined to the region of the hepatic IIexure. (Fig. I.) Upper gastrointestina1 series showed no pathologic condition and sigmoidoscopy repeated after preparation again revealed no Iesion. The patient was discharged from the hospita1 to return for further studies at a Iater date, but on December 17th, ten days after his initia1 admission, he again began to pass bIood per rectum. He was rehospitalized for observation but no transfusions were required on this admission. Barium enema examination was repeated and again showed onIy the IocaIized diverticuIosis. On January r8th, after passing another blood stoo1, the patient was admitted for eIective surgery after bowe1 preparation. ExpIoration failed to revea1 any pathoIogic condition other than the diverticulosis. Careful examination of the entire Iarge bowel shoved onIy the diverticula of
FIG. I. Barium enema x-ray limited to the proximal coIon.
showing
diverticuIosis
the cecum and ascending colon, some of which contained inspissated fecal matter. Right hemicolectomy was performed with primary end-to-end iIiotransverse colostomy. The patient made an uneventful recovery and has remained well with no further hemorrhage for a period of five years. Examination of the specimen revealed numerous diverticula of the ascending colon, one of which, Iocated 8 cm. from the distal end, showed diffuse hemorrhage with typica ecchymotic discoloration. (Fig. 2.) Microscopic examination showed a typica faIse diverticulum with uIceration of the mucosa and evidence of acute submucosa1 hemorrhage. (Fig. 3.) COMMENTS
While this case presents the typica onset and course of moderateIy profuse hemorrhage from a diverticutum, the patient was somewhat younger than the usual person exhibiting we11 deveIoped diverticuIosis. AIso, he showed no evidence of the arterioscIerosis and hypertension usuaIIy found in patients bIeeding from this condition. Moreover, the diverticuIa were confined to the proxima1 coIon which is unusua1. Finally, contrary to the genera1 ruIe, we were abIe to demonstrate the actuaI bIeeding point in the specimen (something which has been possibIe in onIy two reported cases [ r,6]), thus confirming the diagnosis. The decision to operate in this case was made on the basis of recur815
Jensen
FIG. 2. Photograph showing ecchymotic
of the diverticurum from which discoIoration of the mucosa.
FIG. 3. Photomicrograph of the bIeeding hemorrhage and erosion of the mucosa.
rent hemorrhage Iocalized disease.
in a good risk patient
with
diverticulum
hemorrhage
occurred,
showing submucosal
those cases which wiI1 not respond to medica measures. As has been suggested, one shouId be guided by some poIicy comparabIe to that which has been generaIIy accepted for massive bIeeding from the upper gastrointestina1 tract [2].
CONCLUSIONS
WhiIe exsanguinating hemorrhage from the large bowe1 is not common, massive bIeeding does occur from coIonic diverticuIa and wiI1 occasionaIIy proceed to a fata termination unIess there is surgica1 intervention. In view of the evident probIems invoIved in the operative treatment of this condition the initia1 program shouId be conservative in a11 cases. The diffIcuIty lies in recognizing before the patient becomes a prohibitive surgical risk,
SUMMARY
The consensus of thought regarding the formation of coIonic diverticuIa and the mechanism by which bIeeding occurs has been reviewed. The probIems invoIved in the surgical treatment of those cases in which hemorrhage has not been controIIed by conservative meas816
Diverticulosis ures has been discussed. A case showing unusuaI features has been presented.
some
REFERENCES I. NOER, R. J. Hemorrhage as a complication of Ann. Surg., 141: 674-684, ,955. diverticulitis. 2. KUNATH, C. A. Massive bleeding from diverticuIosis ofthe coIon. Am. J. Surg., gr : gr 1-917, 1956. 3. PETERS, H. E., JR. Massive hemorrhage from the Iower intestina1 tract. West. J. Surg., G~nec. Z* Obst., 64: 646-649, 1956. 4. RIVES, J. D. and EMMETT, R. 0. MeIena, a survey of 206 cases. Am. Surgeon, 20: 458-470. ,954. 5. HOAR, C. S. and BERNHARD,W. F. Colonic bleeding and diverticular disease of the &on. Surg., Gynec. fl Obsc., gg: 101-107, 1954. 6. YOUNG, J. M. and HOWARTH, M. B. Massive hemorrhage in diverticuIosis; possibIe explanation of cause with presentation of a case requiring surgica1 treatment. Ann. Surg., 140: 128-131, 1954. 7. QUINN, W.
C. and OCHSNER, A.
BIeeding
as a
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