MULTIPLE DIVERTICULA OF THE COLON.

1067

Stages of Diverticulosis. previously described the following stages development of multiple diverticula of the The

MULTIPLE DIVERTICULA OF THE

We have in the colon.

COLON. BY EDMUND I. SPRIGGS, M.D., F.R.C.P.

LOND.,

AND

O. A. MARXER, RADIOGRAPHER, KUTHIN CASTLE.

(WITH

ILLUSTRATIVE PLATE.)

Introduction. IN the

of the observation and treatment of of the large a great number of instantaneous photographs of the affected part of the bowel and, in some cases, to watch the progress of the disease over a series of years. Many of these observations have been reported in former papers.l It is proposed in this account to set torth the radiographic features of the stages of diverticulosis in sumewhat more detail, and to summarise the clinical aspects, which have been more fully described course

208 cases of multiple diverticula intestine it has been possible to study

elsewhere.2

(1)The prediverticular Sfate.-This is illustrated

by the full large piece

SENIOR PHYSICIAN ;

3 4

The definition we suggest for diverticulitis and the sections on aetiology, prognosis, and treatment, also some of the illustrations, are ba.sed upon the remarks made, and the slides shown, by one of us in opening the recent discussion on diverticulitis at the Royal Society of Medicine.4 Multiple diverticula of the colon have been recognised for over a century by pathologists, but not till the last ten years, since the radiology of the bowel has grown more precise, has it become known how often they are present, and are the cause of disease. A summary of the history of the subject is given in a former paper in the Quarterly Journal o,f Medicine.2 References will there be found to various papers up to 1924, including the monographs of Bensaude, Caine, and Hillemand (1913) and of Telling and Gruner (1917), who givelarge bibliographies. Papers we have been able to consult which in the appeared from 1925 to 1927 are mentioned report on the above-mentioned discussion.4

page photograph, Fig. W, which shows a of the descending colon at this stage. The normal segmentation of the bowel is absent, being replaced by a ragged outline of little convex irregularities. These are best seen quite close to the arrow leading from the word " colon," but are evident along the whole course. This photograph (which we have published formerly but in a much smaller size) is a good one for showing what is meant by the prediverticular state, but it is seldom that so large an area of the bowel wall is involved. The prediverticular state is often seen along one side of the bowel only ; it may be seen in even part of one haustrum (Fig. A), the rest of the haustra and the

opposite aspects of the bowel wall showing healthy outlines. In nearly all cases small diverticula can be seen

in

some

part of the bowel at the

same

time

as

the

prediverticular state, or if the case is observed again at intervals they will be found to develop at that area. This stage precedes the formation of the pouches, and it is apparently associated with some weakening of the submucosa and of the muscular layers ; it is while the prediverticular state is in evidence that the minute hernias, which subsequently form diverticula, are pushed between muscle-fibres. (2) A stage of irritation is often seen to follow the This is shown on the lower prediverticular stage. border to the right in Figs. C and S. Since the prediverticular state was first described, some writers have mistakenly regarded that appearance a,s what was meant. The larger concertina-like appearance, however, is usually to be observed in a part of the bowel which has formerly been in the prediverticular

state.

The Developed Diverticula.—These (3) sizes and of may

are

of various

them, even large ones; contain all the coats, including muscle-fibres, as

shapes ;

the fact that they can be observed to In a few instances even large pellets of faeces can be passed out of them from time to time if the necks are wide enough and not inflamed. Indeed, these masses appearing in the fæces have sometimes been called soft gall-stones. Others of the developed Stotistacs. (diverticula show very little muscle-fibre. The shadow Some stage of diverticulosis of the large intestine obtained with barium meal or enema differs according 1 was found in 10 per cent. of 1000 consecutive patients to the width of the neck of the pouch. If the neck is admitted to this hospital in whom an X ray examina-wide enough the barium may enter the whole of the tion of the alimentary canal was made, two men being 4diverticulum and fill it, as shown in some of those in affected to one woman. From this frequency it may -Fig. V (illustrative plate). If the neck is narrower the be assumed that it would also be found in some of barium 1 does not displace the former contents, but fills those complaining of symptoms not thought to concernonly the lower part of the pouch lying next to the neck, the alimentary canal, and who were not examined withgiving a crescentic shadow such as is also seen in barium. Further, since half the people with small Fig. V. These crescentic shadows are characteristic. diverticula of the colon suffer no inconvenience When the neck of the diverticulum is very narrow, therefrom, they are probably present in a not incon-material cannot get out and hardens in situ, forming siderable proportion of the general population over what is called a stercolith. A stercolith of long 50 years of age. : standing may cause a shadow which can be recognised Diverticulosis is nearly always found in the latter without a barium meal. half of life. The average age of 1000 patients was 45, (4) Diverticulitis.—At this stage inflammatory that of 100 diverticulous ones being 58. The condition processes arise about the necks of pouches, especially has been described in children, but is rare ; the of those containing stercoliths, and spread to the wall of the bowel, giving rise to a local colitis or pericolitis. youngest in our series was 25. The distribution of the diverticula in 166 consecuMethod. tive cases was as follows :to give clear pictures of The meal found opaque Whole colon .... 24 Pelvic colon ... 120 ., detail consists of 120 g. of barium sulphate suspended Cæcum 8 Descending colon.. 79 33 Ascending colon in 500 c.cm. of Horlick’s malted milk or buttermilk. 33 Transverse colun This appears to fill every crevice in the colon, and has often shown diverticula that had remained undetected 1Proc. Roy. Soc. Med., Surg. Sect., 1920, xiii., 65. with other suspensions. The enema consists of 2Quart. Jour. Med., 1925, xix., 1-34. 400-450 g. of barium sulphate made up to two pints 3Brit. Med. Jour., Jan. 23rd, 1926. with buttermilk, warmed to body temperature. The 4 Proc. Roy. Soc. Med., 1927, xx., 665. 5 Since our former papers were published a certain number meal enables certain points to be observed; the enema of patients has been admitted in whom the disease was already others. For example, the former, which mixes with or diagnosed, increasing the incidence by selection. suspected But that was not the case during the time from which the the secretions and is more like the natural ingesta, shows the distribution of the food and its rate of above-quoted series was taken. ..

..

Rectum Appendix hectuni

-

..

...

..

---------

6 4

-------

is shown contract.

some

by

1068 passage along the gut, especially before and after clefts or divisions between the haustra, but does not defæcation, any constrictions or spasm, and the enter them. A simple mucosal lesion of the bowel does not always position of the ingesta at times of pain or discomfort ; it may also fill stercolith-bearing diverticula better give radiological signs of its presence, but when the than the enema; whilst with the latter it can be submucuus and muscular layers are involved the seen how far the different parts distend normally or normal segmrentation of the colon is altered and the are constricted. In over 200 cases observed with both change is visible. meal and enema, in only two did the enema fail to The temporary absence of segmentation during

show diverticula. Both screening and radiography must be employed, the one guiding the other, all parts of the bowel being

movements id

called inhibition. detailed study of the development of diverticula each figure is, unless otherwise t stated. an exact tracing mass

In the following

more

from a photograph, and not a diagram. The blaci; the bariunt-filleel area is lumen of the bowel.

‘ B C ’A Xormat A = haustra below and MUnU patches of prediverticular state above. B = Areas of prediverticular state involving circumference of bowel and causing apparent

ring constriction. The same piece of bowel (as B) after treatment. No constriction. rregularities, the aftermath of prediverticular ntatc, also small pouches iti formation. In all these figures (A to U) the text should he consulted foi- the full description.

Ci --=

brought into view

at

some

time with either meal

or

If this cannot be done the examination is so This applies especially to cases in far incomplet,e. which diverticulitis is suspected. The mere demonstration of residues showing the presence of diverticula must not be the height of the radiographer’s ambition. All possible data must be gathered to ensure a reliable judgment as to diagnosis, prognosis, and treatment. It is reported that diverticulitis may be present without radiographic demonstration of diverticula. This is not yet within our experience, but is, of course, possible, though unlikely if both meal and enema are used. In any case a localised diverticulitis, even sfter all pouches have been deformed beyond recognition, has the characteristic appearances described below. The normal bowel wall is generally engaged in a slow contraction or dilatation. This can be demonstrated by taking serial films at one second’s interval, with an enema.

instrument

cinema

like

camera,

a

Prediverticular State.—In the early prediverticular state, if only small patches are affected, the shape of the haustrum may bo alInost unaltered, provided the patch is not near an interhaustral cleft. If it i. a curtailment in depth and a displacement of the cleft result. Fi. A is a tracing from a stretch of sigmoid showing such a spread-out haus-

arrow

above tions denote the prediverticular state. The points to a minute hernia, or diverticulum. Owing to the diverticulosis the upper two haustra have come together, the cleft between them having almost disappeared. This shows how the irregular segmentation arises in a diverticulous bowel. On the opposite aspecof the bowel, the lower in this photograph, If the preboth haustra and clefts are regular. diverticular state involves large areas, haustration may become unrecognisable, and segmentation disappear. If only one side of the bowel is involved there will be interference with the diameter of the lumen ; when the whole circumference of the bowel is implicated, narrowing is considerable, and a ring constriction may be simulated. Fig. B shows such a piece of bowel. Part of the upper border was prediverticular. and another short stretch is involved in its whole circumference. Note

slow

designed

one of us. When such film is placed accurately one the upon another

by a

extent of the movement can be seen. A rigid piece of bowel wall, the seat of

shows no L tD G movement and can by this D = Small narrow-necked diverticultiiii retaining f.t’cal material. means be recognised. E = The same diverticulum four years later. When a lesion lies within F = Large stercolith-bearing diverticulum. The dotted line shows the position at phase 1 reach of the sigmoidoscope of a serial film, the continuous outline at phase 2—i.e., one .second later—demonstrating that instrument should be the movement of a. haustrum. G = Also from serial films showing the maximum contraction of this haustrum. employed. With suitable care its preparation and the consequent encroachment on the lumen as comuse should be painless, and no general needed. ; pared with the lumen in Fig. A. Devclopment of Diverticula.! Fig. C shows the same stretch of bowel after treatThe radiographic appearance of scalloping in the ment. There is now nu constriction. Small pouches normal colon is known as haustration, and any single are visible on both borders, shown by arrows. In the prediverticular state the circular musclescallop as a haustrum. The lower silhouette of Fig. A shows such a normal outline of a barium-filled bowel ; fihres are contracted,as is shown by the narrow the dotted line represents the peritoneal surface. The lumen, and the mucosa is thrown into narrow folds. It may be presumed that the longitudinal fibres are arrows on the left of the letter " A " indicate After the passing off of the prehaustra. : also involved. The deep indentations which almost bisect the ! diverticular state the haustra and the clefts between them tend to lose their symmetry. The appearance lumen of the colon determine the segmentation the two arrows on the right of the letter " A "). They suggests that muscle-fibres are damaged, being thinned are regular and symmetrical unless the bowel be bent in places, with corresponding bunching in others, as The contractions of the muscle-fibres. when all elastic band is cut or weakened in one place. at an angle. cause the segmentation, which affects all the layers of Judging by repeated observations at intervals of a year the bowel wall. The peritoneum may indicate the or more, any given haustrum tends to remain distorted

diverticulitis,

anaesthetic

the )

(see !

1069 same manner, and this haustral asymmetry and 6 of a serial film, from the descending colon of persist in an otherwise flexible diverticulous bowel. ’ Fig. V, superimposed, phase 1 being the continuous, See the and phase 6 the dotted line. The bowel wall is seen to This is the stage 2 mentioned above. irregular nondescript contractions deforming the be mobile, with its diverticula. The large diverticulum lower border of the bowel in C, the a.fterm..T,t:h of at the top on the left is capable of contraction. The This appearance occurs stercolith-bearing one below it keeps its shape. but its the prediverticular state. without excess of fat or evidence of any thickening position has changed with the movement of the part of the bowel from which it arises. of the wall. Formation of Potiches.-NVIieii the small hernia The Onset of Inflammation about a Diverticulum.— forms, local conditions determine the size and position Fig. I shows again a pouch containing a stercolith. of the orifice, and upon these depend the type of pouch The block is, as before, the tracing of an actual which will be developed. The dotted line represents schematically film. In Carman and Miller’s book on the " Roentgen, the peritoneum. This is taut over the stercolith Diagnosis of Diseases of the Alimentary Canal " (1917, where the other coats of the diverticulum will

in the

mav

n-471) is an excel-

lent photograph of a microscopical

also be This is

FiG. H.

pouches

section, showing a

and

trating

penethe

out

pear-shaped tion. When

inflam.mation sets in there is a limitation of the flexibility of the bowel wa,ll. The study of serial films a,t intervals s h o w s

pouch depends

the size of its neck. This conon

sideration, which is obvious enough, grows in importance

with of

study

that

further

change—begins at the necks of diverticula, and particularly of those w h i c h carry Tenstercoliths. sion or friction in the narrow neck

The diverticula. pouch which is in the future to set up is diverticulitis the one which cannot easily discharge its contents, and which barium enters in

likely

suggests itself a

microscopi cal H

=

Tracing of two instantaneous photographs from the descending colon shown in Fig. V, being phases 1 and 6 of a serial film—that is, at about six Phase 1 is the continuous and phase G the seconds’ interval—superimposed. dotted line. (See description of Fig. V.) the

appearance

of

at an early stage. The bowel wall from which it arises is soft and flexible. The small pouch itself is spherical, but owing to its narrow neck it retained inopaque material when the food residues left that part of the gut, and there was no room for the opaque barium mixture except at its

basal part.

Fig. E is from the same case four years later. The haustrum is unaltered, though the pouch is much bigger. As before, the barium has crept round the fæcal content

near the neck. F shows two phases of a serial film. There is pouch with a stercolith. The dotted line shows the position in phase 1, and the continuous outline that In phase 2. There is a moderate degree of contraction of the dome of the haustrum. Fig. G, a later phase, shows the maximmu contraction. The neck of the diverticulum is no longer showing, which means that its mucosal surfaces were

Fig.

apposed.

Fig.

in diverticula which emit fsecal material with appearances

d i ffi c u l t y, herniae witti

stercolith-bearing diverticula. Fig. D shows such a diverticulum

graphs

as

though stagna-

tion beneath a stercolith is an equally harmful factor. Dr. A. P. Cawadias6 has described the

a

minute

cause,

perhaps

part only, giving

see often

rigidity-

i.e., inflammatory

sma!]I

crescentic shadow. The content of such a pouch is liable to become i n s p i s sated and form a stercolith. We fiud that some pouchess show these characteristics at a very early stagp, for we

contrac-

during

in

former publications that the rate of emptying of a

stiff

spheri-

become somewhat

muscular layer. We have

pointed

are

more

cal; whilst those with flexible muscular walls

pouch of mucous

membrane

thinnest.

why such

tI shows tracings of two instantaneous photoat about six seconds’ interval-i.e., phases 1

round-celled infiltration extending towards the

env elope.

the

serous

,

The earliest radiological sign is an encroachment on the haustrum as shown by a widening of the re-entering angle between the diverticulum and widened angle is This cup-shaped the bowel. shown by the arrows in Fig. J. The encroachment is seen most plainly during inhibition. It may be symmetrical or one-sided ; in the latter case there will be a tilting of the diverticulum. In other words, two deep indurations, which have the appearance of invagination, are seen during stages of relaxation. Fig. K is a tracing from another film. The arrow shows such early inflammatory changes. Note the apparent sinking into the haustrum of the diverticulum. The peritoneal surfece is added schematically, the shaded area representing fat. In Fig. L the inflammatory thickening (often called hypertrophy) is more advanced and is asymmetric. The lumen of the neck does not show ; it is squeezed and contains no barium. 6

Proc. Roy. Soc. Med., loc. cit., p. 691.

1070 The inflammatory exudation and resulting fibrosis the palisade appearance is significant of massive This patient was operated may affect certain wide-mouthed diverticula in quite inflammatory change. another way, opening tin’ir orifices until nothing isupon and these conclusions confirmed. The figure is i left of the pouch but a stiff V-shaped irregularity withi of the radiological appearance which would bn the open part facing the lumen. The small projections !given by many specimens of diverticu1itic bowel such from the black shadow on the upper border in as are removed occasionally at operation, or, men’ Figs. M and N show the remains of such pouches. often, post mortem. On the lower border in Fig. N two diverticula show evidence of thickening and rigidity of the bowel wall, but it is possible that they have been reached by extension of the process from the opposite side, just as the otherwise natural haustrum at the right on the upper L K I J border shows evidence of I — .B. stercolith-bearing diverticulum during maximum contraction of ih hau-trum. The encroachment (see arrow). peritoneum is shown diagrammatically. As the fibrous thickening J Widening mf the re-entering angle at the neck nf t diverticulnm, the cailiest radiological increases at the expense of sign of inflammatory thickening’ of the bowel wall. K the haustrum, the more Early inflammatory thickening showing the peritoncal surface schematically. L More advanced thickening Note distance of lumen from peritoneal surface. Of. 1. stercoliths the become

typical

-

separated from the me lnTtwnrumen, separated morrL as

in

Fig. 0, which shows 4 cm. of bowel much involved side by inflammatory changes. Tlie dark isolated

on one

in the by crescentic and lies areas channel represent not visible barium whichfilnx, entered The diverticular necks beneath stercoliths. a

narrow

appear

be, and no doubt almost are. oblitera.ted. The opposite, lower, aspect shows two large flexible diverticula. ; the haustra frorn which they arise, as well as the adjacent haustra, were over-active. Fig. P is from the same piece of bowel as 0. but to

four years later. It shows how far the stercoliths have become separated from the exceedingly narrow lumen. The affected area is remarkably localised, for immediately below it (to the left) the lumen widens

Swollen folds of

xnucous membrane are also the of the bulky invaginations in the shadow on the lower aspect of Fig. R, shown by arrows. The rifts in the upper border of the shadow have the same It could be seen in serial films that when the cause. haustra contracted so that the lumen was almosta thread, yet these did not recede or alter in size. The bowel passes on the left into almost normal segmentation. In this case areas ofthe prediverticular state and some minute diverticula were found close to the inflamed area. cause

Associatiorc of Early Diverticulosis with Diverticulitis. -We have several times observed thatearly diseasei.e., either the prediverticular state or very small found close to an area of old-standing diverticulitis with stereoatl three liths, stages together. and that in cases which have suddenly flared up, threatening obstruction. It would be expected that the younger areas of disease had arisen from the older. But early diverticulosis occurs in patches, and in two of our cases one of these separate areas appeared to be creeping towards the hypertrophic area rather than arising therefrom. However this may be, it appears as if the encroachment of the new upon oldstanding disease had a,,,,gravated the chronic inflammaGreat thickening of bowel %van. Diverticular necks opened up. M tion. N == Evidence of apreadiTy of inflammatory changes to opposite lower wal!. O = tsotatioa of diverticula froIl1 the lllmell of bowel. Fig. S is from a radioP - The same four ycurs later showing advanced obliterative stage. graph of n piece of bowel

diverticula—is

=

which

is

Lue

seau

UI

ear

abruptly to its natural diameter. This point was about and late stages of the disease. The arrows point 28 cm. from the internal anal sphincter. to minute diverticula in process of formation in an The characteristic radiological sign of diverticulitis, area of the prediverticular state. On the upper border as mentioned below, is rigidity of the deformed bowel are stercoliths and established rigid diverticulitic wall (Fig. Y on illustrative plate and Fig. Z). fibrosis. Inflamed mucosal folds give confusing appearances Fig. T is from a patient who was admitted after an in diverticulitic films. Serial photography is often the attack of subacute obstruction. We could not find only means by which they can be differentiated from evidence of inflammatory thickening though numerous the fibrous thickening of the outer layers of the gut. large diverticula were present and some small ones. These folds are, of course, transparent to X rays and Seven years later he had a recurrence of subacute form the apparent clefts between the opaque barium-symptoms and was readmitted. The same piece of filled haustra. In Fig. Q mucosal folds (see arrows) bowel now gave Fig. U. Small areas of the prehave swollen into missive jagged nodes. The peri- diverticular state were seen and some minute pouches. pheral inflammatory thickening was slight ; there was No evidence of gross thickening could be found in enough to give some small diverticula an invaginated spite of careful search. As there is no evidence of appearance, but not enough to prevent the bowel wall inflamed mucosal folds, although the last attack was on which they lay from registering some movement in recent, it appears probable that the threatened serial films. To the right of the middle of Q, however, obstruction was due to severe spasrn. The discomfort

1071 4)r

’ each occasion with the I div erticala. (See also Fig. X on!

pain corresponded

formation of new illustrative plate.)

Symptoms.

on

As

rule, in the prediverticular state, no symptoms ’are , recognised, though with increasing experience this ti

Ætiology. rule is found to have exceptions, especially if large The eetiology of the disease is not yet understood. areas are involved. The area of the bowel affected, as Iu the first stage (the prediverticular state) there is with the X rays, is often in a more irritation of the bowel wall with tenderness in thati1’l’ih1 h]p condition than when diverticula are estabarea on the X ray table and in some cases, in wliiell a.lished, and is sometimes tender to palpation on the large part of the bowel is involved, pain is complainedI llf clinically, though generally this stage is passed unnoticed by the patient. We have brougllt forward evidence7 tu show the frequent association of early diverticulosis with septic foci in other parts of the

observed

body, particularly the teeth, and with early arthritis of the spine-i.e., spondyl-

itis. This evidence leads to the view that the change is an inflammatory one in the first instance, probably bacterial, and not degenera-

Shows the picture given by inflamed lixuc:o::al folds, also some miiallne«-iliwert.icula superau old area of div erticulitis. it - Swollen folds of mucous membrane shown by arrows; also acute hrediverticular stage suppervening um chronic diverticulitis.

Q

—

imposed on

In one case pain had been complained of are prone to occur where the blood- X ray table. the lower and left parts of the abdomen for some vessels penetrate the bowel wall has been taken as evidence that they are passiveextrusions from theweeks. A greatpart of the descending and pelvic was found to be tender and in the prediverticular beginning. The lymphatics also penetrate with blood-vessels, and it is possible that any inflammatorystate, and the symptoms yielded to treatment. In in which the colon was strewn with patches process, which would affect them more than blood-vessels, would lead to weakness in of the prediverticuiar state, pain was complained of neighbourhood.I.as the barium entered the affected part of the bowel. How much constipation plays a part is not known. In another in which most of the descending and pelvic The subjects are frequently constipated, but apparently colon was in the prediverticular state, these parts ,mall herniæ

in

theI clllon theanother

their

not more so than other patients. It is delay in of the gut, were tender and rigid, and there was aching the pouch, rather than in the bowel, which is over the sacrum after evacuation. The stage of establi.:hed diverticula, short of harmful. Flatulent distension of the bowel would be expected ! diverticulitis, may be quiescent for years. In our to aid in the formation of pouches and to cause series half the subjects complained of no symptoms to the pouches. In the others there was some enlargement of those already formed whose lumen clinical evidence of irritation of the bowel, or, less often, of the peritoneum or The symbladder. ptoms mentioned were, in order of frequency, flatulence, pain, distension or indigestion, generally below the navel and most often on the left side, pain or discomfort before or after defecation, diarrhcea, or alternating constipation and A few have diarrhœa. or discomof, irregularity S Acute early diverticulosis (lower border) supervening on an area of old diverticulitis fort with, micturition. (upper border). The symptoms of T Divcrtieutous bowel. U The same piece of ltusv-el seven years later showing ncBv disease supervening on the old of a pouch into rupture area of diverticulo;,;::,.. the peritoneum are those

isreferable

=

=

=

oi

an

a c u t e

local

or

communicating with the bowel. The most serious general peritonitis. This accident is fortunately result of diverticulosis, however—namely, the develop- uncommon. The symptoms of diverticulitis are ment of diverticulitis—arises from diverticula which described in the following section. have been almost completely blocked and would be Definition of Diverticulitis. least subject to changes of pressure from the interior of the bowel. It has been suggested that excess of Diverticulitis is the final stage of diverticulosis, at fat plays an important part in the early stage of which the small pouches, as already described, become diverticulosis. The statistics of our cases, however, involved and destroyed in the chronic inflammatory show that the diverticulous are not heavier than process which in the first instance arose in themselves. other patients of the same age and sex. In later Sir Berkeley Moynihan drew attention to the clinical stages, when diverticulitis threatens, fatty tissue importance of this disease in 1907. Dr. Telling’s around the bowel is probably less able to resist a papers (1908 and 1917), from the same school, are spreading infection than the more vascular non-fatty an exhaustive pathological and clinical study of the condition. peritoneum. Some seven years ago one of us proposed the term We have not observed any special association " diverticulosis " for the earlier stages of the disease, between spasm of the bowel and diverticulosis. which are often free from symptoms, and always, 7 with the exception of the occasional rupture of a Quart. Jour. Med., loc. cit.

1072 FiG. Z.

two r i a,I superimposed films (phases 1 and 3i.e., at two seconds’ interval) from the sigmoid of Fig. Y. There is no movement at, the areas of diverticulitis shown by the arrows

Tracing

of

s e

FIG. V.

Diverticulosis: Lateral views of descending colon ; serial pictures, filrns 1, 3, and 6. There is some deformity but no rigidity as shown the super-imposition of filriis in Fig. H. The bowel seen on the right of the picture is the transverse colon. FIG. X.

FIG. Y.

Ftc. X.-Advanced diverticulosis of the descending colon. No spiked processes or rigidity. The absence of divertictilitis was confirmed at an operation for duodenal diverticulum and gall-stone. the sigmoid

being

found soft and flexible.

FIG.Y.—Sigrnoid showing these parts

are

two

areas

rigid (see Fig. Z).

of diverticulitis ; Note the jagged

V-shaped outline of the immobile parts.

DR. E. 1. SPRIGGS AND MR. O. A. MARXER:

MULTIPLE DIVERTICULA OF THE COLON.

by

1073 free from severe symptoms. We didperson, which are not accompanied by physical signs not know until this year that de Quervain,8 the Swiss fand do not yield to simple medicines such as .-.urgeon, had made the same proposal in 1914in a (carminatives or mild purges give rise to the suspicion )f diverticulosis. The diagnosis can only be estabpaper not then accessible to us. Any degree of irritation mid inflammation arising in a pcnrch may 1ished lty an X ray examination of the bowel. The But ill i of diverticula is not enough. as they logically be described as diverticulitis. practice a distinctive term is needed for the later stage. may coexist with other lesions. It must be shown, which constitutes a definite and serious disease fromso far as possible, that diverticulosis is the only which most of the subjects of diverticulosis never diseased state which is likely to be causing the

single pocket,

recognition

suffer.;symptoms. The clinical features of diverticulitis are those of it The diagnosis of diverticulitis is less difficult when low form of inflammation in the large bowel, usually’t tender sausage-shaped swelling can be felt in the in the left lower abdomen, spreading to neighbouring ]Left iliac fossa, especially if there is pain during or structures. after evacuation, but must be established by radioAbdminal discomfort, less often pain, not as n, rulegraphy. The long history, the well-being of the patient. related to food, is situated about or below the in the intervals of symptoms, the absence as a rule of but especially in the left iliac fossa. It may be bleeding from the bowel or of much mucus are against intermittent, with intervals of severalweeks or longer. malignant disease. The possibility of a left-sided The pain may be severe, and is often accompanied by appendicitis will be remembered ; also of actinoa general feeling of ill-health ; it may take the form mycosis and pyosalpinx. When suppuration has of a dragging sensation and backache. General occurred a differential diagnosis becomes of less flatulence and a. feeling of distension are usually importance. for the abscess must in any case be mentioned and may be the only symptoms ; an drained. advanced state of diverticulitis may, indeed, be present (b) As regards the radiological diagnosis, the prewith but little complaint ; in several there was no diverticular state must be distinguished from colitis. actual pain. The latter causes inhibition or spasm without affecting Constipation, irregularity of the bowels, diarrhœa, the symmetry of the segments : the outline is smooth or a sense of incomplete evacuation is frequent. In the preor any irregularities are nondescript. The increasing constriction leads slowly, usually very diverticular state the symmetry is disturbed as above slowly, to obstruction. described, and if there is inhibition the irregularities In cases of implication of the bladder there may be show small twin convex Pericolic frejuent micturition, sometimes painful, after the affections, such as tuberculosis,impressions. or inflammation where bowels are opened ; or a painless micturition may be a jejunocolic fistula is threatening, may be indisfollowed by pain in the tumour. in appearance from the prpdiverticular tinguishable A sausage-shaped tumour, sometimes tender, but state. not always, can be felt in the left iliac fossa, except The established diverticula are generally unmistakin the very obese. It may become acutely inflamed, able. In a highly-placed mid-transverse colon. where with pyrexia and vomiting. Diverticulitis sometimes good oblique views are difficult to get, there may be occurs at other parts of the colon. confusion with haustral residues ; these, however, Hæmorrhage, per rectuur, excluding that from will become less optque as the bowel clears. In other piles, we have seen three times, but it is not usual, parts it should be possible to get. a view at the right the inflammatory lesion lying as a, rule without the angle to bring the suspected pouch into pronle. A mucous membrane. should be taken after the lumen of the bowel is The radiological features of diverticulitis are definite. With a barium rneal or enema, typical rounded, oval. Tn diverticulitis the above-described rigidity and or crescentic shadows of the barium in the diverticula deformities of the bowel (from T to S) with a narrowed will usually, though not always, be recognised in the lumen are characteristic. Diverticula. sometimes new neighbourhood. They are not, however, the character- ones, will generally be seen near by. If growth occurs istic features ; these, which we have already describedat a diverticulous area, the concave (fingerprint) above in detail, are the spilce, or palisade-like projecon the lumen may be recognised. encroachments tions of barium shadows from the lumen of the bowel. the wall of which is thickened (from inflammatory Prognosis. exudation) and fixed. Serial films, when superW’ere the outlook show no in variation the outline of the judged by the end-results of imposed, and post-nrortem shadows, although there may be vigorous and irritable diverticulitis from the operating contractions of the bowel wall above and below. or rooms of large hospitals 10 it would be grave indeed. A more hopeless condition to deal with than a supeven in the same part of the gut opposite to the rigid area. purating sigmoid, involving and infecting surrounding (See Fig. Y on illustrative plate and Fig. Z.) The pathological features are those of a chronic parts, can hardly be thought of apart from active inflammation of the pelvic colon, arising at first from’ malignant disease. But, as we have shown above, one or more diverticula, but now involving all the diverticulosis may be quiescent over long periods of coats of the gut, including, sooner or later, the time. The cause of diverticulitis is inflamniation in peritoneal coat. and spreading to surrounding parts, a pouch. What chance is there of preventing or this ? There is none unless the existence of especially to the bladder in men, but also, at times. n.llaying to the uterus, ovary, small intestine, or abdominal the pouch is known. If every case of vague persistent Wall. Yn excellent description of the morbid histology or recurrent abdominal discomfort were investigated will be found in ’I’elling and Gt-iiner’s paper. Leuco- not only would diverticulosis but many other condimost help cytosis is frequent. In late stages small, or sometimes tions be discovered at a stage when isthe that patients can he given. The doctor’s difficulty larger, abscesses form in the inilamed or septic area. want the aches and pains to be cured by a bottle of Metastatic abscesses are unusual, but have medicine or a pill ; and when such simple measures do recorded. suffice the patient still would like to " wait and We put forward 9 the suggestion that the term not The loss of health and efficiency see how he gets on." diverticulitis should be reserved for those cases which there is the combination of these three pictures from such delays is incalculable. When a case of diverticulosis or early diverticulitis -clinical, radiological, and pathological. is recognised the prognosis is good. as a rule, for health and for life. The disease responds Diagnosis. graver complications occur (n) Clinical.—Vague persistent or recurrent well tomtreatment. The in a middle-aged, well-nourished chiefly unrecognised or neglected cases. Both before abdominal

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Zeit.f.Chir.,1914.cxxviii.81. 9 Proc.Roy.Soc.Med.,loc.cit.

and

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10 Fifield.

the

physician and

L. R. : THE LANCET, Feb. 5th. 1927, p.277

1074 surgeon can, between them, in a watched case, guarcI against or deal with any developments that are likel3 to occur. The accident of the rupture of a pouch intc3 the general peritoneal cavity is uncommon, but mosit "f us know of such cases. It has the same risks ass any other perforation and is dealt with in the same way

degree of occlusion may be diuicult. The practical point which has to be decided is whether colostomy shall be performed. The stoppage of diverticulitis

often be relieved even when there is a good deal of abdominal distension and constitutional disturance. If grave symptoms such as a rising pulse-rate, collapse, and intractable vomiting an’ not present, Treatment and Results. and the diagnosis has been made radiologically, then The medical treatment consists in keeping the. castor oil (with laudanum and hot fomentations if body, the alimentary canal, and especially the colon, pain is severe) and enemas may be given with contias healthy and clean as possible ; any source ojf dence. A physical sign of value when improvement sepsis that can be reached must be removed. The:; begins is the disappearance of resonance on percussion diet should be simple and regular with a good in the left lower quadrant. If, however, it has been deal of fruit and vegetables. We have describedL found with X rays that there is much dilatation of the fully elsewhere 11 a diet which is found useful, but the; bowel above the affected area a colostomy is likely t-t preferences and state of each person must be con- be needed. But in most cases with continued care, sidered. The bowels are kept regular by diet, paraffin,, even after severe obstruction, colostomy may be and especially by attention to habit ; this can nearly avoided for long periods, or indefinitely. One patient went 11years after his first attack of obstruct inn until always be done. The colon is washed out with saline every other day, a colostomy was done ; and that would probably ;n.t for a time, but at low pressure, the funnel being not have been needed had he not been abroad and away from close medical supervision. Another had a first more than 18 inches above the level of the anus. The He came fluid runs in at low pressure just as well as, or often attack of obstruction eight years ago. better than, at higher pressure, which may provoke under our observation two years later. This patient spasm. In no case, as we pointed out in our previous; is still well with regular actions. paper, should a diverticulous area be massaged. Only Surgical Treatment. recently a man was admitted in whom a quiescent area for obstruction from diverticulitis. had been awaked into subacute and painful diverticulOperation itis by a course of massage given in ignorance of his perforation of a pocket, vesicocolic fistula, and suppuration in the bowel wall with involvement Hf state, with the object of curing the constipation. We do not yet know to what extent repair may surrounding structures, are necessary procedures at result after treatment of a prediverticular bowel. which the surgeon is an opportunist. lie does what It is often considerable radiologically (cf. Figs. B can be done. llow far can we control the disease so that these and C) and in patients complaining of symptoms these of despair may be avoided ? The surgical Sir Charles be Gordon-Watson operations may entirely allayed. has described such a case 12 and we have seen others. treatment of a perforated pocket we cannot expect to avoid. The accident happens and must be dealt one of which is mentioned under the heading Symptoms above. Our observations suggest that in all cases the with ; indeed it occurs when diverticulitis, as above affected part of the bowel is benefited and the progress defined, is not present. An operation for obstruction of the disease delayed. Neither can we have proof for a gradually closing irremovable infiltrated area, that in the stage of established diverticula medical which cannot be otherwise mitigatecl, is also a necessity. treatment-i.e., paraffin, douching, removal of septic It is better to do it, however, at a time of choice. foci, and attention to general health, prevents the when regular X ray observations have shownthat tln’ formation of stercoliths. We have, however, evidence channel is narrowing and the bowel above dilating. that pouches empty their contents more readily after and before the added dangers of actual obstruction treatment, and stercolith formation would thereby have arrived. In most cases the When colostomy has been done the rest given tothe be retarded if not prevented. symptoms disappear as a result of treatment. In our collapsed area, aided by douching, may lead to a subsides series out of 158 patients with diverticulosis of all great degree of recovery. The stages 87 complained of symptoms. Of these 70 were and the lurnen is restored. Sir Berkeley Moynihan treated by us, 52 of whom were completely or almost has found it possible to close the colostomy relieved ; 13 others received much benefit. again, in selected cases, to the great relief uf th,’ When diverticulitis is established the lavage is patients. If, however, the case is recognised, adequatfty continued for longer, and in some cases permanently, at regular intervals. 3-6 Enemas of of treated, and watched, with a barium enema every year oz. It is a for a simple diverticulosis, and every six months for warm olive oil are sometimes very useful. irritation, by diverticulitis, the severer complications are. ia our great advantage to avoid, if regular purges, even a weekly dose of salts. But experience, rare. The people who get into trouble are these must be used if there is a doubt about a sullicient generally those whose cases have not been diagnosed. or who, after successful treatment, escape medical evacuation. Attention to the general habits of the patient is supervision and give less and less attention to tltl’ almost as important as the local treatment of the i bowel as time passes. Radical surgical treatment is sometimes possible. One reads, or hears doctors say, that the bowel. But hardly anyone, It is true that the disease tends to spread. But in treatment is this or that. certainly no modern man over 50, can be treated practice hypertrophic inflammatory processes are entirely out of a book. He is nearly always working, generally confined to one area of bowel, and if that playing, eating, drinking, smoking, or sitting too area can be successfully resected the patient is cured much, and unless his life be regulated the local of diverticulitis. This has been done in a numberof cases, as Mr. Lockhart-Mummery13 described recently. measures will not be enough. It is remarkable how quickly the inflammation may Gerzowitsch 14 has collected 10-1from the literature. subside in subacute diverticulitis with the above Of these 54 were cured, 7 died, and the result in 43 measures. The symptoms may be gone in a week ; was not recorded. If the area can be radiographically and we have known a comparison of the radiograms defined, is not too low down, and is reasonably fn-t’ after three weeks show that the lumen was restored from involvement of surrounding structures. and if almost to normal and the rigid area of bowel wall the symptoms persist in spite of careful treatment, aud the patient is in good condition otherwise, he may be much lessened. with a view to resection. The patient must be warned about the danger of offered exploration obstruction. If it threatens, the diagnosis of the 13 Lockhart-Mummery, J. P. : Proc. Roy. Soc. Med., loc. cit., p. 694. 11 Qua rt. 12Jour. Med., loc. cit. Brit. Med. Jour., loc. cit. 14 Gerzowitsch, M.: Schweiz. Med. Wochenchr., 1925. vi., Proc. Roy. Soc. Med., loc. cit., p. 682. 124. can

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