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Recurrent diverticulitis in a defunctionalized colonic loop
Recurrent
Diverticulitis
in a Defunctionalized
Colonic
Loop
HERBERT DARDIK, M.D., HARRY M. DELANY, M.D. AND ELLIOTT S. HURWITT, M.D., New York, New York
From the Surgical and Laboratory Divisions, the Montefiore Hospital, New York City, New York.
T
CASE REPORT C. C., an eighty-one year old white woman, was admitted to Montefiore Hospital for the first time on May 14, 1955 because of lower abdominal pain and constipation. Barium enema upon admission demonstrated diverticulitis with partial obstruction of the proximal sigmoid colon. (Fig. 1.) A right transverse colostomy was performed on May 17. Local anesthesia was employed because of her advanced arteriosclerotic cardiovascular disease. The patient’s postoperative course was complicated by pneumonia, congestive heart failure and electrolyte imbalance. Repeat barium enemas revealed extensive diverticulosis of the defunctionalized segment, with progressive diminution of the obstruction. (Fig. 2.) In view of the patient’s poor general medical status it was decided that further surgery was not warranted. She was discharged on October 20, 1955. Two weeks prior to her second admission on November 2, 1962 lower abdominal pain developed. It became progressively worse and was accompanied by vomiting on the day of admission. Her colostomy had always functioned spontaneously without irrigations or enemas. There had been no bowel movement per rectum since the establishment of the colostomy. At the time of admission the patient was in acute distress. Her temperature was 38” C. orally. The pulse was 100 per minute and irregular. The respiratory rate was 32 per minute and her blood pressure was 120/70 mm. Hg. A double-barrel colostomy was present in the right upper quadrant with a large incisional hernia. There was diffuse abdominal tenderness. No bowel sounds were audible. The rectum was filled with a pasty, slate-gray material. The hematocrit was 39 per cent and the white blood cell count was 24,600 cu. mm. with 80 polymorphonuclear leukocytes, 10 bands, 2 metamyelocytes, 7 lymphocytes and 1 monocyte. Microscopic examination of the urine showed 1 to 11 white blood cells and 0 to 1 red blood cells per high power field. Other laboratory data included: Blood urea nitrogen 25.5 mg. per
HE TIMELY EMPLOYMENT of a transverse
colostomy may often be life-saving in the surgical treatment of diverticulitis. The colostomy is usually utilized as the preliminary stage to definitive resection and for protection of the distal colonic anastomosis. There are, however, because of a precarious medical status, a number of patients in whom the colostomy remains as a permanent stoma without subsequent resection of the diseased segment of colon. The following case report was prompted by the unique clinical course of reactivation of diverticulitis due to inspissation of mucus in a colonic loop defunctionalized for seven and a half years.
FIG. 1. Spot film of left lower quadrant with barium enema showing marked narrowing of the sigmoid secondary to diverticulitis. Dilated small bowel loops are also visible. American
Journal
of Surgcvy,Vol. 108, December
1964
914
Recurrent Diverticulitis
:;
2 1’1~;. 2. Postoperative
barium study of tlefuncti~~ll:tliz~~l colollic c:~lculus and old left femoral neck fracture.
loop. Sate
t;rc. :i. Plain film of abdomw tlemonstratirlg material within the rectum. lying right mid-abdomen due to huge incisional hcrllin. cent, sodium 13’7 mEq.,‘L., potassium 2.5 mEq./L., chlorides 92.3 mEq.jL., carbon dioxide content 26.5
WE
a
3
mm
I’erforation
g:~llblatlric~
Density
OV~I
in the rcctosigmoid
corn-
municating freely with the peritoneal cavity, from which mucoid material extruded. (Fig. 4.1 and B.)
mEq./L., and serum glutamic oxalacetic transaminase 31 units. The electrocardiogram showed auricular fibrillation with premature ventricular contractions and was suggestive of an old posterior wall infarct. On roentgenogram examination material in the rectum was interpreted as feces. (Fig. 3.) The clinical impression at this time was peritonitis secondary to either a perforated carcinoma of the defunctionalized colonic loop or a recurrent diverticulitis on the basis of a fistula between the small intestine and defunctionalized loop. Treatment involved intravenous fluids, electrolytes and antibiotics, nasogastric suction and enemas. Large amounts of pasty gray material were removed from the rectum. Congestive heart failure occurred soon after admission and required digitalization and diuretic therapy. The patient continued to deteriorate, however, her course terminally marked by hypotension and unresponsiveness to vasopressors. She died on November 12, 1962. At autopsy the peritoneal cavity contained approximately 1 L. of pus, from which a culture of Proteus mirabilis and gamma enterococci was grown. The peritoneal surfaces were covered with a fibrinous exudate and numerous adhesions were present. There were no fistulous tracts and the right transverse colostomy was patent. The wall of the defunctionalized colonic segment was markedly thickened in many areas. Numerous diverticula filled with inspissated mucopurulent material were present, partitularly in the descending colon and sigmoid. There
.A
B
FIG. 4. A, inner aspect of rectosigmoid with perforation. B, outer aspect of rectosigmoid with probe passing through perforation. Xote the adjacent peritoneal exudate.
915
Dardik, Delany and Hurwitt is typical of the poor risk individual in whom the higher mortality rate associated with definitive resection is obviated by the establishment of a permanent colostomy. Here, however, a free perforation developed in the defunctionalized loop and was followed by a rapidly fatal, generalized peritonitis. This occurred despite a functioning right transverse colostomy present for seven and a half years. It is postulated that the mechanism for this unusual occurrence involved impaction of mucoid material within the rectum followed by increased intraluminal pressure. Inspissated mucoliths formed within diverticula, with subsequent pressure necrosis, gangrene, abscess formation and perforation. It becomes evident that the status of longterm defunctionalized bowel loops must be periodically ascertained by digital, endoscopic and radiologic examinations. With judicious application of disimpaction and irrigation technics, one may perhaps obviate the consequences of mucoid inspissation as described.
Pericolonic abscesses and two small pedunculated benign polyps were also present in the sigmoid. Distal to the perforation the bowel was bound down and surrounded by both necrotic and fibrous tissue. The remainder of the postmortem examination was unremarkable except for the findings of extensive myocardial scarring and recent infarction of the interventricular septum. The coronary arteries were severely narrowed by atherosclerosis but no complete occlusion was present. Microscopic study of the peritoneal serosa confirmed the presence of a fibrinopurulent exudate. Sections taken from the site of perforation revealed necrotic tissue, acute cellular infiltrates and underlying organization. There was no evidence of malignancy or suggestion of a foreign body as a cause of perforation. In diverticula adjacent to the perforation the cellular response was indicative of a mild diverticulitis and almost all contained lamellar concretions consisting of mucopurulent material and bacteria. Meat or vegetable fibers were not present. COMMENTS
The establishment of a proximal vent for colonic decompression and fecal diversion frequently results in a subsidence of the inflammatory process in the diseased colonic segment. Subsequent resection is thereby vastly facilitated. In the past many colostomies were closed without definitive resection when it was
SUMMARY
1. A ,unique case is presented of free perforation secondary to recurrent diverticulitis in a defunctionalized colonic loop established seven and a half years previously. 2. A mechanism for the development of this surgical complication is described. 3. The morbidity and mortality associated with recurrent disease in long-term defunctionalized colonic loops may possibly be averted by periodic examinations and prompt institution of appropriate therapy.
believed that the disease had so abated that restoration of the fecal stream would not result in an exacerbation. William J. Mayo stated in 1930 that closure of the colostomy could be performed once the infection had regressed sufficiently to restore the lumen of the colon [I]. Other authors supported this viewpoint, but were soon aware of the risks involved [2-41. In 1939 Pemberton and associates indicated that more than two thirds of their patients sustained a recrudescence of their disease after stoma1 closure without resection of the diseased segment 151. Patterson reported almost identi-
REFERENCES
W. J. Diverticula of the sigmoid. Ann. Surg., 92: 739, 1930.
1. MAYO,
cal results with a 70 per cent recurrence rate [6]. Thompson raised this figure to 75 per cent [7].
2.
ABELL,
3.
BROWN, P. W.
I. The diagnosis and treatment of diverticulitis and diverticulosis. Surg. Gynec. b Obst., 60:
370, 1935.
Treatment and prognosis of diverticulitis of colon. Am. J. Surg., 46: 162, 1939. 4. JUDD, E. S. and PHILIPS, J. R. Diverticulitis. s. Clin. North America, 14: 542, 1934. 5. PEMBERTON, J. DEJ., BLACK, B. M. and MAINO, C. R. Progress in the surgical management of diverticulitis of the sigmoid colon. Surg. Gynec. Es Obst., 85: 523, 1947. 6. PATTERSON, H. A. The management of the compli-
On the other hand, in the majority of those patients managed by permanent colostomy, Pemberton convincingly demonstrated the value of maintaining stoma1 patency [5]. Furthermore, in patients of this group who ultimately succumbed to the complications of diverticulitis, it was believed that such an outcome could have been averted had defunctionalization of the diseased colon been performed earlier. The patient reported previously
cations
of
diverticulitis
of
the
North America, 35: 451, 1955.
colon.
S.
Clin.
7. THOMPSON, H. R. Diverticulosis and Diverticulitis, p. 1125. In R. Maingot: Abdominal Operations. New York, 1961. Appleton-Century-Crofts, Inc.
916
Diverticulitis
in a Defunctionalized
Colonic
Loop
HERBERT DARDIK, M.D., HARRY M. DELANY, M.D. AND ELLIOTT S. HURWITT, M.D., New York, New York
From the Surgical and Laboratory Divisions, the Montefiore Hospital, New York City, New York.
T
CASE REPORT C. C., an eighty-one year old white woman, was admitted to Montefiore Hospital for the first time on May 14, 1955 because of lower abdominal pain and constipation. Barium enema upon admission demonstrated diverticulitis with partial obstruction of the proximal sigmoid colon. (Fig. 1.) A right transverse colostomy was performed on May 17. Local anesthesia was employed because of her advanced arteriosclerotic cardiovascular disease. The patient’s postoperative course was complicated by pneumonia, congestive heart failure and electrolyte imbalance. Repeat barium enemas revealed extensive diverticulosis of the defunctionalized segment, with progressive diminution of the obstruction. (Fig. 2.) In view of the patient’s poor general medical status it was decided that further surgery was not warranted. She was discharged on October 20, 1955. Two weeks prior to her second admission on November 2, 1962 lower abdominal pain developed. It became progressively worse and was accompanied by vomiting on the day of admission. Her colostomy had always functioned spontaneously without irrigations or enemas. There had been no bowel movement per rectum since the establishment of the colostomy. At the time of admission the patient was in acute distress. Her temperature was 38” C. orally. The pulse was 100 per minute and irregular. The respiratory rate was 32 per minute and her blood pressure was 120/70 mm. Hg. A double-barrel colostomy was present in the right upper quadrant with a large incisional hernia. There was diffuse abdominal tenderness. No bowel sounds were audible. The rectum was filled with a pasty, slate-gray material. The hematocrit was 39 per cent and the white blood cell count was 24,600 cu. mm. with 80 polymorphonuclear leukocytes, 10 bands, 2 metamyelocytes, 7 lymphocytes and 1 monocyte. Microscopic examination of the urine showed 1 to 11 white blood cells and 0 to 1 red blood cells per high power field. Other laboratory data included: Blood urea nitrogen 25.5 mg. per
HE TIMELY EMPLOYMENT of a transverse
colostomy may often be life-saving in the surgical treatment of diverticulitis. The colostomy is usually utilized as the preliminary stage to definitive resection and for protection of the distal colonic anastomosis. There are, however, because of a precarious medical status, a number of patients in whom the colostomy remains as a permanent stoma without subsequent resection of the diseased segment of colon. The following case report was prompted by the unique clinical course of reactivation of diverticulitis due to inspissation of mucus in a colonic loop defunctionalized for seven and a half years.
FIG. 1. Spot film of left lower quadrant with barium enema showing marked narrowing of the sigmoid secondary to diverticulitis. Dilated small bowel loops are also visible. American
Journal
of Surgcvy,Vol. 108, December
1964
914
Recurrent Diverticulitis
:;
2 1’1~;. 2. Postoperative
barium study of tlefuncti~~ll:tliz~~l colollic c:~lculus and old left femoral neck fracture.
loop. Sate
t;rc. :i. Plain film of abdomw tlemonstratirlg material within the rectum. lying right mid-abdomen due to huge incisional hcrllin. cent, sodium 13’7 mEq.,‘L., potassium 2.5 mEq./L., chlorides 92.3 mEq.jL., carbon dioxide content 26.5
WE
a
3
mm
I’erforation
g:~llblatlric~
Density
OV~I
in the rcctosigmoid
corn-
municating freely with the peritoneal cavity, from which mucoid material extruded. (Fig. 4.1 and B.)
mEq./L., and serum glutamic oxalacetic transaminase 31 units. The electrocardiogram showed auricular fibrillation with premature ventricular contractions and was suggestive of an old posterior wall infarct. On roentgenogram examination material in the rectum was interpreted as feces. (Fig. 3.) The clinical impression at this time was peritonitis secondary to either a perforated carcinoma of the defunctionalized colonic loop or a recurrent diverticulitis on the basis of a fistula between the small intestine and defunctionalized loop. Treatment involved intravenous fluids, electrolytes and antibiotics, nasogastric suction and enemas. Large amounts of pasty gray material were removed from the rectum. Congestive heart failure occurred soon after admission and required digitalization and diuretic therapy. The patient continued to deteriorate, however, her course terminally marked by hypotension and unresponsiveness to vasopressors. She died on November 12, 1962. At autopsy the peritoneal cavity contained approximately 1 L. of pus, from which a culture of Proteus mirabilis and gamma enterococci was grown. The peritoneal surfaces were covered with a fibrinous exudate and numerous adhesions were present. There were no fistulous tracts and the right transverse colostomy was patent. The wall of the defunctionalized colonic segment was markedly thickened in many areas. Numerous diverticula filled with inspissated mucopurulent material were present, partitularly in the descending colon and sigmoid. There
.A
B
FIG. 4. A, inner aspect of rectosigmoid with perforation. B, outer aspect of rectosigmoid with probe passing through perforation. Xote the adjacent peritoneal exudate.
915
Dardik, Delany and Hurwitt is typical of the poor risk individual in whom the higher mortality rate associated with definitive resection is obviated by the establishment of a permanent colostomy. Here, however, a free perforation developed in the defunctionalized loop and was followed by a rapidly fatal, generalized peritonitis. This occurred despite a functioning right transverse colostomy present for seven and a half years. It is postulated that the mechanism for this unusual occurrence involved impaction of mucoid material within the rectum followed by increased intraluminal pressure. Inspissated mucoliths formed within diverticula, with subsequent pressure necrosis, gangrene, abscess formation and perforation. It becomes evident that the status of longterm defunctionalized bowel loops must be periodically ascertained by digital, endoscopic and radiologic examinations. With judicious application of disimpaction and irrigation technics, one may perhaps obviate the consequences of mucoid inspissation as described.
Pericolonic abscesses and two small pedunculated benign polyps were also present in the sigmoid. Distal to the perforation the bowel was bound down and surrounded by both necrotic and fibrous tissue. The remainder of the postmortem examination was unremarkable except for the findings of extensive myocardial scarring and recent infarction of the interventricular septum. The coronary arteries were severely narrowed by atherosclerosis but no complete occlusion was present. Microscopic study of the peritoneal serosa confirmed the presence of a fibrinopurulent exudate. Sections taken from the site of perforation revealed necrotic tissue, acute cellular infiltrates and underlying organization. There was no evidence of malignancy or suggestion of a foreign body as a cause of perforation. In diverticula adjacent to the perforation the cellular response was indicative of a mild diverticulitis and almost all contained lamellar concretions consisting of mucopurulent material and bacteria. Meat or vegetable fibers were not present. COMMENTS
The establishment of a proximal vent for colonic decompression and fecal diversion frequently results in a subsidence of the inflammatory process in the diseased colonic segment. Subsequent resection is thereby vastly facilitated. In the past many colostomies were closed without definitive resection when it was
SUMMARY
1. A ,unique case is presented of free perforation secondary to recurrent diverticulitis in a defunctionalized colonic loop established seven and a half years previously. 2. A mechanism for the development of this surgical complication is described. 3. The morbidity and mortality associated with recurrent disease in long-term defunctionalized colonic loops may possibly be averted by periodic examinations and prompt institution of appropriate therapy.
believed that the disease had so abated that restoration of the fecal stream would not result in an exacerbation. William J. Mayo stated in 1930 that closure of the colostomy could be performed once the infection had regressed sufficiently to restore the lumen of the colon [I]. Other authors supported this viewpoint, but were soon aware of the risks involved [2-41. In 1939 Pemberton and associates indicated that more than two thirds of their patients sustained a recrudescence of their disease after stoma1 closure without resection of the diseased segment 151. Patterson reported almost identi-
REFERENCES
W. J. Diverticula of the sigmoid. Ann. Surg., 92: 739, 1930.
1. MAYO,
cal results with a 70 per cent recurrence rate [6]. Thompson raised this figure to 75 per cent [7].
2.
ABELL,
3.
BROWN, P. W.
I. The diagnosis and treatment of diverticulitis and diverticulosis. Surg. Gynec. b Obst., 60:
370, 1935.
Treatment and prognosis of diverticulitis of colon. Am. J. Surg., 46: 162, 1939. 4. JUDD, E. S. and PHILIPS, J. R. Diverticulitis. s. Clin. North America, 14: 542, 1934. 5. PEMBERTON, J. DEJ., BLACK, B. M. and MAINO, C. R. Progress in the surgical management of diverticulitis of the sigmoid colon. Surg. Gynec. Es Obst., 85: 523, 1947. 6. PATTERSON, H. A. The management of the compli-
On the other hand, in the majority of those patients managed by permanent colostomy, Pemberton convincingly demonstrated the value of maintaining stoma1 patency [5]. Furthermore, in patients of this group who ultimately succumbed to the complications of diverticulitis, it was believed that such an outcome could have been averted had defunctionalization of the diseased colon been performed earlier. The patient reported previously
cations
of
diverticulitis
of
the
North America, 35: 451, 1955.
colon.
S.
Clin.
7. THOMPSON, H. R. Diverticulosis and Diverticulitis, p. 1125. In R. Maingot: Abdominal Operations. New York, 1961. Appleton-Century-Crofts, Inc.
916