Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Colonic diverticula Roy J. Elfrink MD & Brent W. Miedema MD To cite this article: Roy J. Elfrink MD & Brent W. Miedema MD (1992) Colonic diverticula, Postgraduate Medicine, 92:6, 97-108, DOI: 10.1080/00325481.1992.11701513 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701513
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Technology Sydney]
Date: 24 July 2016, At: 10:48
Symposium
Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
Third of three articles on diseases of the colon
Colonic diverticula When complications require surgery and when they don't
cases, but conservative treatment is usually effective and, typically, surgery is not required. 4 Fatal complications occur in less than 1 in 10,000 cases of colonic diverticulosis.5
Development of diverticular disease
Preview One of the disadvantages of "modem" living has been the refinement of food-processing methods. Many years ago, industrialized countries largely abandoned use of the whole grain in cereal products and, as a result, greatly diminished the amount of fiber in the diet. Drs Elfrink and Miedema discuss one consequence of a low-fiber diet-diverticular disease-and present an overview of therapeutic approaches.
Roy J. Elfrink, MD Brent W. Miedema, MD •:• Diverticula of the colon are acquired abnormalities resulting from a low-fiber diet. Although they are usually asymptomatic, diverticula can cause bleeding or inflammatory complications that necessitate surgical intervention. The milling of grains, which has allowed production of refined breads and cereal products, is the most important factor contributing to the inadequate intake of
dietary fiber in this and other Western nations. Milling became common in the 1870s in industrialized countries, but it took about 30 years for diverticular disease to become more than a medical curiosity. 1 By 1925, the incidence in the United States of colonic diverticulosis at autopsy was 5%. 2 As the average age of the population has increased, so too has the incidence of colonic diverticulosis. The condition is now present in 50% of people in industrialized countries. 3 Symptoms develop in 20% of
The herniation of mucosa and submucosa through the muscular layers of the colon found in diverticular disease3 occurs because of increased intraluminal pressure and weakness of segments of the colonic wall. 6 A low-fiber diet results in muscular contracture and eventually hypertrophy of the colonic muscle. Contraction of the circular muscle interrupts the continuity of the colonic lumen, markedly increasing pressure within segments of the colon. 7 Because the sigmoid portion of the colon has the smallest radius, it is especially at risk for segmentation and development of diverticula. Sites in the colonic wall where vessels penetrate the circular muscle (figure 1) have been found to be weak. 8 This weakness is exacerbated by the age-related loss of collagen tensile strength. Therefore, diverticulosis of the sigmoid colon is common in the elderly who eat a low-fiber diet.
continued
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Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
Computed tomography performed during the acute phase of diverticulitis demonstrates the extent of pericolic inflammation.
Figure 1. Schematic representation of normal colonic wall (top) and formation of diverticulum (bottom). Perforation of vas recta through circular muscle near taenia coli results in area of weakness, which, when combined with increased intraluminal pressure, allows herniation of colonic mucosa.
Diagnosis Lower abdominal pain, cramping, and bloating may be reported with colonic diverticulosis, but these symptoms are probably caused by the underlying muscle hypertrophy and not by diverticula.9 Symptoms of diverticulosis occur when bleeding or peridi-
98
verticular inflammation from microperforation (ie, diverticulitis) is present. Diverticulitis can produce sigmoid narrowing, resulting in symptoms of large-bowel disease. Differentiating diverticulitis from the symptoms of colonic muscle hypertrophy can be diffi-
cult. Patients with diverticulitis usually have pain localized to the left lower quadrant and often have had a recent change in bowel habits. Fever, anorexia, malaise, and leukocytosis are more common with diverticulitis than with hypertrophy. Localized peritoneal signs are the rule in diverticulitis and usually allow physicians to confidently make a diagnosis on clinical grounds alone. Diverticulitis can often be confirmed on colonoscopy or barium enema examination after the acute phase of the disease has resolved. During the acute phase, however, these diagnostic methods may not be entirely safe. For example, if perforation is present, the addition of air, as is required with colonoscopy, may disseminate peritonitis. (Sigmoidoscopy, which involves minimal air insufflation, is advocated by many endoscopists and is relatively safe.) With barium enema examination, leakage of barium and stool through a diverticulum can cause virulent peritonitis that is difficult to control, even with surgery. Use of a water-soluble contrast solution is safer than use of barium in the acute phase, but diagnostic quality is sacrificed. Computed tomography (CT) has recently been shown to be as good as or better than barium continued
DIVERTICULA • VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
Surgery should be delayed 6 to 8 weeks after an acute attack of diverticulitis to allow inflammation to subside.
enema examination in diagnosis of diverticulitis. 1° CT can be performed during the acute phase and demonstrates the extent of pericolic inflammation more accurately than does enema examination with water-soluble contrast solution. CT is now the test of choice at the University of Missouri-Columbia School of Medicine for confirming diverticulitis in the acute phase. Bleeding from colonic diverticula is generally seen in patients with asymptomatic diverticulosis and not in those with diverticulitis.11 Most diverticular bleeding stops spontaneously, but the source of intermittent recurrent bleeding can be difficult to identify. The site of bleeding often can be established by colonoscopy after rapid-lavage bowel preparation. However, if bleeding is massive enough to preclude colonoscopy, the location is best determined with arteriography.12 A bleeding scan can help detect a site of slow bleeding that cannot be identified on colonoscopy. Conservative treatment A high-fiber diet can lower intraluminal pressure in the sigmoid colon and relieve the symptoms of colonic muscle hypertrophy. 13 ·14 Outpatient treatment of
mild diverticulitis with nonnarcotic analgesics, antibiotics, a liquid diet, and occasionally anticholinergics is usually successful. Small peridiverticular abscesses usually respond to conservative treatment. A high-fiber diet should be instituted when acute symptoms have resolved. Severe diverticulitis requires bowel rest and intravenous administration of antibiotics that are effective against bowel organisms. About 15o/o to 30o/o of patients hospitalized for diverticulitis do not improve and require radiologic or surgical intervention. 15 Surgical treatment Surgical treatment of diverticular complications has continued to evolve over the last decade. Although treatment must be individualized on the basis of the patient's age and general condition, some surgical principles may be applied universally. ABSCESS DRAINAGE-A contained perforation with a large peridiverticular abscess should be drained expeditiously. The established approach consists of laparotomy, proximal colostomy, drainage of the abscess, and, if it can be accomplished safely, resection of the involved bowel segment. However, percutaneous drainage under CT guidance has
become a useful alternative. In a recent study, 16 percutaneous abscess drainage resolved the acute process in 84% of patients. This nonoperative approach allows patients to have an elective resection at a later, presumably safer, time. Whether delayed resection improves results has not been proven in a prospective randomized study. Some investigators question the need for definitive resection after percutaneous drainage, especially in high-risk elderly patients. 16 ELECTIVE RESECTION-Proper preparation of the bowel and improvement of the patient's general condition are possible with elective resection, thus reducing operative mortality. In our experience, firm indications for elective resection include sigmoid narrowing with obstructive symptoms, presence of colovesical or coloenteric fistulas, recurrent attacks of diverticulitis, one attack of diverticulitis in a patient under age 55, and any suspicion of cancer on diagnostic evaluation. Surgery should be delayed 6 to 8 weeks after an acute attack to allow inflammation to subside and decrease blood loss and risks of surgery. Resection in the absence of complications described should be done very selectively.
continued
VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE • DIVERTICULA
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Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
If leukocytosis, fever, and tenderness accompanying a diverticular abscess persist for 7 to 10 days, urgent surgical intervention is indicated.
Roy J. Elfrink, MD Brent W. Miedema, MD Dr Elfrink (left) is clinical instructor and Dr Miedema (right) is assistant professor, department of surgery, University of Missouri-Columbia School of Medicine and Harry S Truman Memorial Veterans Affairs Medical Center, Columbia. Dr Miedema is also codirector, endoscopy center, University of Missouri-Columbia School of Medicine.
Resection for lower abdominal pain or bowel irregularity has had only limited success, 17 and the disappointing results may indicate that symptoms were incorrectly attributed to colonic diverticula. IMMEDIATE SURGERY-Free perforation and general peritonitis are indications for immediate surgery to control ongoing peritonitis, clean the soiled peritoneum, and drain associated ab-
102
scesses. The site of perforation can be managed with proximal colostomy and drainage or with resection of the inflamed segment and end colostomy. Historically, standard treatment of diverticulitis has been a three-stage procedure consisting of an initial proximal colostomy and drainage, later resection of the involved segment, and delayed closure of the colostomy stoma. However, a recent studi 8
showed that resection of the perforated segment during the initial operation reduced mortality. Surgical judgment is vital in determining whether resection is safe or the standard three-stage procedure should be used. URGENT INTERVENTION-If leukocytosis, fever, and tenderness accompanying a diverticular abscess persist for 7 to 10 days, urgent surgical intervention is indicated. In such cases, careful bowel preparation, a one-stage resection, and primary anastomosis are usually possible. If bowel preparation is inadequate, intraoperative colonic lavage for mechanical cleansing of the colon may allow primary anastomosis. 19 Adding a transverse loop colostomy to the operation may be useful if inflammation is present at the site of primary anastomosis. This procedure ameliorates septic complications if a leak develops. In addition, closure of the loop colostomy stoma is easier than is anastomosis to the rectum, which is necessary after a Hartmann procedure. FOR BLEEDING-When the site of bleeding is known, segmental colectomy is curative in 94% of cases and should be performed when blood loss exceeds 1,500 mL. 20 When the exact site of bleeding is unknown, intraoperacontinued
DIVERTICULA • VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
all diverticula can be removed. 18 However, this small risk of recurrent diverticulitis probably does not justifY the increased morbidity and mortality of a more extensive colectomy. 22 Sepsis and its sequelae remain the primary cause of death.
tive enteroscopy and colonoscopy are essential. Their use greatly reduces the need for subtotal colectomy and its accompanying 10% mortality rate. 21 With slow, chronic bleeding, transfusions and continued evaluation with aggressive diagnostic studies are preferable to blind colonic resection. OVERALL RFS~Over the past 50 years, results of surgical treatment of diverticulitis have not changed. Although surgical advances have occurred, the elderly and other high-risk groups, such as patients who are immunosuppressed, now form a greater percentage of cases than ever before. Mortality rates are 10% for emergency operation and urgent intervention and less than 2% for elective surgery. 18 The risk of recurrent diverticulitis after segmental colectomy is 3%, and it increases to 11% when not
The value of a high-fiber diet in preventing and treating colonic diverticula is finnly established. Although the diagnosis of diverticulosis is usually made with colonoscopy or barium enema examination, computed tomography has become the test of choice during acute diverticulitis, when the diagnosis cannot be confidendy made clinically. Recendy developed surgical principles for diverticulitis in-
References 1. Painter NS, Burkitt D P. Diverticular disease of the colon: a 20th century problem. Clin Gastroenterol 1975;4(1 ):3-21 2. Rankin FW; Brown PW. Diverticulitis of the colon. Surg Gynecol Obstet 1930;50(5): 836-47 3. Cotran RS, Kumar V, Robbins SL Robbins pathologic basis of disease. 4th ed. Philadelphia: WB Saunders, 1989:884-5 4. Zollinger RW. The prognosis in diverticuli-
tis of the colon. Arch Surg 1968;97(3):418-22 5. Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of Western civilization. BMJ 1971;2(759):450-4 6. Alrny TP, Howell DA. Medical progress: diverticular disease of the colon. N Eng! J Med 1980;302(6):324-31 7. Painter NS, Truelove SC, Ardran GM, et al. Segmentation and the localization of intraluminal pressures in the human colon, with spe-
Summary
elude radiographically directed drainage with delayed operation for peridiverticular abscess, resection of the site of disease in patients with general peritonitis, and primary anastomosis in most cases requiring urgent intervention. Diverticulosis accompanied by abdominal pain or irregular bowel habits is by itself rarely an indication for surgery. Diverticular bleeding usually resolves spontaneously; but persistent bleeding can usually be successfully treated with segmental colectomy after localization of the bleeding site with colonoscopy or arteriography. PCIWI
-®
Earn credit on this article. See CME Quiz.
Address for correspondence: Brent W. Miedema, MD, One Hospital Dr, NW301, Columbia, MO 65212.
cia! reference to the pathogenesis of colonic diverticula. Gastroenterology 1965;49(2):169-77 8. Slack WW. The anatomy, pathology, and some clinical features of diverticulitis of the colon. Br J Surg 1962;50(Sep):185-90 9. Ranson JH, Lawrence LR, Localio SA. Colomyotomy: a new approach to surgery for colonic diverticular disease. Am J Surg 1972; 123(2):185-91 10. Hulnick DH, Megibow AJ, Balthazar EJ,
continued on page 108
VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE • DIVERTICULA
105
AEROBID"/AEROBID'-M (tlunisolicte) Effective asthma control BID
For oral inhalation only CONTRAINDICATIONS AEROBIO/AEROBIO-M Inhaler is conlraindicaled in Jhe primary Jrealmenl ol slalus aslhmalicus or olher acule episodes of aslhma whereinlensivemeasuresarerequired. Hypersensilivilyloany of the ingredients olthis preparation contraindicates ils use WARNINGS Particular care is needed in palients who are transferred from syslemically active corticosteroids to AEROBID/AEROBID·M Inhaler becausedealhsduetoadrenal insulliciencyhaveoccurred inaslhmalicpatienlsduringandaltertranslerlromsystemic corticosteroids to aerosol corlicosteroids. Alter withdrawatlrom systemic corlicosleroids, anumber ol monlhs are required lor recovery ol hypothalamic-pituitary-adrenal (HPA) function. During this period ot HPA suppression, palients may exhibit signs and symploms of adrenal insulliciency when exposed lo trauma, surgery or infections, particularly gaslroenteritis. Although AEROBID/AEROBID-M Inhaler may provide control ol aslhmalic symptoms during t~ese episodes. it does NOT provide the syslemicsleroidthatisnecessarylorcopingwilhtheseemergencies. During periods of stress or asevere asthmatic attack, patients who have been withdrawn from syslemic corlicosteroids should be instrucledloresumesystemicsteroids(inlargedoses)immediatelyandtoconlacllheirphysicianlorlurtherinslruclion. These patientsshouldalsobeinstrucledlocarryawarningcardindicatingthattheymayneedsupplemenlarysyslemicsteroidsduring periodsolslressorasevereasthmaallack. Toassesslheriskoladrenalinsulliciencyinemergencysituations,routineleslsol adrenalcorJicallunc\ion,includmgmeasuremenlolearlymorningreslmgcortisollevels,shouldbeperlormedperiodrcallyinall patients. An early morning resling cortisol level may be accepted as normal if if falls at or near lhe normal mean level. Localized inleclions with Candida a/biuns or Aspergillus niger have occurred in the mouth and pharynx and occasionally 10 the larynx. Positive cultures lor oral Candida may be present in up to 34% of patienls. Allhough lhe frequency of clinically apparenl inleclron is considerably lower, lhese inleclions may require lrealmenl wrlh appropilale anlrlungallherapy or disconlinuance wrlh AEROBID/AEROBID·M Inhaler. AEROBID/AEROBID·M Inhaler is nollo be regarded as a bronchodilalor and is no! indiuled lor rapid relief of bronchospasm. Palienls should be inslrucled lo conlacllheir physician immedialely when episodes of asthma !hal are nol responsive lo broncho· dilalors occur during Jhe course oltrealmenl. During such episodes, palienls may require therapy wilh syslemic corticosleroids
Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
Thereisnoevidencelhalconlrololaslhmacanbeachievedbyadminislralionollhedruginamounlsgrealerlhanlhereco~
mendeddoses, whichappearlobelhelherapeulicequivalenlolapproximalely10mg/dayoloralprednisone. Theorelicalty,lhe use of inhaled corticosteroids with alternale-day prednisone syslemic trealmenl should be accompanied by more HPA suppression thana l~erapeulicallyequivalenl regi~en of eilher alone. Transfer of palienls from syslemic sleroid lherapy lo AEROBID/AEROBID·M Inhaler may unmask allergic condilions previously suppressedbylhesyslemicsJeroidlherapy,e.g,rhinilis,conjunclivitis,andeczema. Children who are on immunosuppressant drugs are more susceplible lo inleclions !han heallhy children. Chicken pox and measles, lor example, can have a more serious or even !alai course in children on immunosuppressanl corticosleroids. In such children, or inadullswhohavenolhadlhesediseases,particularcareshouldbelakenloavoidexposure. llexposed,lherapywilhvaricella zosler immune globulin (VII G) or pooled inlravenous immunoglobulin (lVI G). as appropriale, may be indicated. II chic
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Colonic diverticula Roy J. Elfrink MD & Brent W. Miedema MD To cite this article: Roy J. Elfrink MD & Brent W. Miedema MD (1992) Colonic diverticula, Postgraduate Medicine, 92:6, 97-108, DOI: 10.1080/00325481.1992.11701513 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701513
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [University of Technology Sydney]
Date: 24 July 2016, At: 10:48
Symposium
Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
Third of three articles on diseases of the colon
Colonic diverticula When complications require surgery and when they don't
cases, but conservative treatment is usually effective and, typically, surgery is not required. 4 Fatal complications occur in less than 1 in 10,000 cases of colonic diverticulosis.5
Development of diverticular disease
Preview One of the disadvantages of "modem" living has been the refinement of food-processing methods. Many years ago, industrialized countries largely abandoned use of the whole grain in cereal products and, as a result, greatly diminished the amount of fiber in the diet. Drs Elfrink and Miedema discuss one consequence of a low-fiber diet-diverticular disease-and present an overview of therapeutic approaches.
Roy J. Elfrink, MD Brent W. Miedema, MD •:• Diverticula of the colon are acquired abnormalities resulting from a low-fiber diet. Although they are usually asymptomatic, diverticula can cause bleeding or inflammatory complications that necessitate surgical intervention. The milling of grains, which has allowed production of refined breads and cereal products, is the most important factor contributing to the inadequate intake of
dietary fiber in this and other Western nations. Milling became common in the 1870s in industrialized countries, but it took about 30 years for diverticular disease to become more than a medical curiosity. 1 By 1925, the incidence in the United States of colonic diverticulosis at autopsy was 5%. 2 As the average age of the population has increased, so too has the incidence of colonic diverticulosis. The condition is now present in 50% of people in industrialized countries. 3 Symptoms develop in 20% of
The herniation of mucosa and submucosa through the muscular layers of the colon found in diverticular disease3 occurs because of increased intraluminal pressure and weakness of segments of the colonic wall. 6 A low-fiber diet results in muscular contracture and eventually hypertrophy of the colonic muscle. Contraction of the circular muscle interrupts the continuity of the colonic lumen, markedly increasing pressure within segments of the colon. 7 Because the sigmoid portion of the colon has the smallest radius, it is especially at risk for segmentation and development of diverticula. Sites in the colonic wall where vessels penetrate the circular muscle (figure 1) have been found to be weak. 8 This weakness is exacerbated by the age-related loss of collagen tensile strength. Therefore, diverticulosis of the sigmoid colon is common in the elderly who eat a low-fiber diet.
continued
VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE • DNERTICULA
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Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
Computed tomography performed during the acute phase of diverticulitis demonstrates the extent of pericolic inflammation.
Figure 1. Schematic representation of normal colonic wall (top) and formation of diverticulum (bottom). Perforation of vas recta through circular muscle near taenia coli results in area of weakness, which, when combined with increased intraluminal pressure, allows herniation of colonic mucosa.
Diagnosis Lower abdominal pain, cramping, and bloating may be reported with colonic diverticulosis, but these symptoms are probably caused by the underlying muscle hypertrophy and not by diverticula.9 Symptoms of diverticulosis occur when bleeding or peridi-
98
verticular inflammation from microperforation (ie, diverticulitis) is present. Diverticulitis can produce sigmoid narrowing, resulting in symptoms of large-bowel disease. Differentiating diverticulitis from the symptoms of colonic muscle hypertrophy can be diffi-
cult. Patients with diverticulitis usually have pain localized to the left lower quadrant and often have had a recent change in bowel habits. Fever, anorexia, malaise, and leukocytosis are more common with diverticulitis than with hypertrophy. Localized peritoneal signs are the rule in diverticulitis and usually allow physicians to confidently make a diagnosis on clinical grounds alone. Diverticulitis can often be confirmed on colonoscopy or barium enema examination after the acute phase of the disease has resolved. During the acute phase, however, these diagnostic methods may not be entirely safe. For example, if perforation is present, the addition of air, as is required with colonoscopy, may disseminate peritonitis. (Sigmoidoscopy, which involves minimal air insufflation, is advocated by many endoscopists and is relatively safe.) With barium enema examination, leakage of barium and stool through a diverticulum can cause virulent peritonitis that is difficult to control, even with surgery. Use of a water-soluble contrast solution is safer than use of barium in the acute phase, but diagnostic quality is sacrificed. Computed tomography (CT) has recently been shown to be as good as or better than barium continued
DIVERTICULA • VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
Surgery should be delayed 6 to 8 weeks after an acute attack of diverticulitis to allow inflammation to subside.
enema examination in diagnosis of diverticulitis. 1° CT can be performed during the acute phase and demonstrates the extent of pericolic inflammation more accurately than does enema examination with water-soluble contrast solution. CT is now the test of choice at the University of Missouri-Columbia School of Medicine for confirming diverticulitis in the acute phase. Bleeding from colonic diverticula is generally seen in patients with asymptomatic diverticulosis and not in those with diverticulitis.11 Most diverticular bleeding stops spontaneously, but the source of intermittent recurrent bleeding can be difficult to identify. The site of bleeding often can be established by colonoscopy after rapid-lavage bowel preparation. However, if bleeding is massive enough to preclude colonoscopy, the location is best determined with arteriography.12 A bleeding scan can help detect a site of slow bleeding that cannot be identified on colonoscopy. Conservative treatment A high-fiber diet can lower intraluminal pressure in the sigmoid colon and relieve the symptoms of colonic muscle hypertrophy. 13 ·14 Outpatient treatment of
mild diverticulitis with nonnarcotic analgesics, antibiotics, a liquid diet, and occasionally anticholinergics is usually successful. Small peridiverticular abscesses usually respond to conservative treatment. A high-fiber diet should be instituted when acute symptoms have resolved. Severe diverticulitis requires bowel rest and intravenous administration of antibiotics that are effective against bowel organisms. About 15o/o to 30o/o of patients hospitalized for diverticulitis do not improve and require radiologic or surgical intervention. 15 Surgical treatment Surgical treatment of diverticular complications has continued to evolve over the last decade. Although treatment must be individualized on the basis of the patient's age and general condition, some surgical principles may be applied universally. ABSCESS DRAINAGE-A contained perforation with a large peridiverticular abscess should be drained expeditiously. The established approach consists of laparotomy, proximal colostomy, drainage of the abscess, and, if it can be accomplished safely, resection of the involved bowel segment. However, percutaneous drainage under CT guidance has
become a useful alternative. In a recent study, 16 percutaneous abscess drainage resolved the acute process in 84% of patients. This nonoperative approach allows patients to have an elective resection at a later, presumably safer, time. Whether delayed resection improves results has not been proven in a prospective randomized study. Some investigators question the need for definitive resection after percutaneous drainage, especially in high-risk elderly patients. 16 ELECTIVE RESECTION-Proper preparation of the bowel and improvement of the patient's general condition are possible with elective resection, thus reducing operative mortality. In our experience, firm indications for elective resection include sigmoid narrowing with obstructive symptoms, presence of colovesical or coloenteric fistulas, recurrent attacks of diverticulitis, one attack of diverticulitis in a patient under age 55, and any suspicion of cancer on diagnostic evaluation. Surgery should be delayed 6 to 8 weeks after an acute attack to allow inflammation to subside and decrease blood loss and risks of surgery. Resection in the absence of complications described should be done very selectively.
continued
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Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
If leukocytosis, fever, and tenderness accompanying a diverticular abscess persist for 7 to 10 days, urgent surgical intervention is indicated.
Roy J. Elfrink, MD Brent W. Miedema, MD Dr Elfrink (left) is clinical instructor and Dr Miedema (right) is assistant professor, department of surgery, University of Missouri-Columbia School of Medicine and Harry S Truman Memorial Veterans Affairs Medical Center, Columbia. Dr Miedema is also codirector, endoscopy center, University of Missouri-Columbia School of Medicine.
Resection for lower abdominal pain or bowel irregularity has had only limited success, 17 and the disappointing results may indicate that symptoms were incorrectly attributed to colonic diverticula. IMMEDIATE SURGERY-Free perforation and general peritonitis are indications for immediate surgery to control ongoing peritonitis, clean the soiled peritoneum, and drain associated ab-
102
scesses. The site of perforation can be managed with proximal colostomy and drainage or with resection of the inflamed segment and end colostomy. Historically, standard treatment of diverticulitis has been a three-stage procedure consisting of an initial proximal colostomy and drainage, later resection of the involved segment, and delayed closure of the colostomy stoma. However, a recent studi 8
showed that resection of the perforated segment during the initial operation reduced mortality. Surgical judgment is vital in determining whether resection is safe or the standard three-stage procedure should be used. URGENT INTERVENTION-If leukocytosis, fever, and tenderness accompanying a diverticular abscess persist for 7 to 10 days, urgent surgical intervention is indicated. In such cases, careful bowel preparation, a one-stage resection, and primary anastomosis are usually possible. If bowel preparation is inadequate, intraoperative colonic lavage for mechanical cleansing of the colon may allow primary anastomosis. 19 Adding a transverse loop colostomy to the operation may be useful if inflammation is present at the site of primary anastomosis. This procedure ameliorates septic complications if a leak develops. In addition, closure of the loop colostomy stoma is easier than is anastomosis to the rectum, which is necessary after a Hartmann procedure. FOR BLEEDING-When the site of bleeding is known, segmental colectomy is curative in 94% of cases and should be performed when blood loss exceeds 1,500 mL. 20 When the exact site of bleeding is unknown, intraoperacontinued
DIVERTICULA • VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE
Downloaded by [University of Technology Sydney] at 10:48 24 July 2016
all diverticula can be removed. 18 However, this small risk of recurrent diverticulitis probably does not justifY the increased morbidity and mortality of a more extensive colectomy. 22 Sepsis and its sequelae remain the primary cause of death.
tive enteroscopy and colonoscopy are essential. Their use greatly reduces the need for subtotal colectomy and its accompanying 10% mortality rate. 21 With slow, chronic bleeding, transfusions and continued evaluation with aggressive diagnostic studies are preferable to blind colonic resection. OVERALL RFS~Over the past 50 years, results of surgical treatment of diverticulitis have not changed. Although surgical advances have occurred, the elderly and other high-risk groups, such as patients who are immunosuppressed, now form a greater percentage of cases than ever before. Mortality rates are 10% for emergency operation and urgent intervention and less than 2% for elective surgery. 18 The risk of recurrent diverticulitis after segmental colectomy is 3%, and it increases to 11% when not
The value of a high-fiber diet in preventing and treating colonic diverticula is finnly established. Although the diagnosis of diverticulosis is usually made with colonoscopy or barium enema examination, computed tomography has become the test of choice during acute diverticulitis, when the diagnosis cannot be confidendy made clinically. Recendy developed surgical principles for diverticulitis in-
References 1. Painter NS, Burkitt D P. Diverticular disease of the colon: a 20th century problem. Clin Gastroenterol 1975;4(1 ):3-21 2. Rankin FW; Brown PW. Diverticulitis of the colon. Surg Gynecol Obstet 1930;50(5): 836-47 3. Cotran RS, Kumar V, Robbins SL Robbins pathologic basis of disease. 4th ed. Philadelphia: WB Saunders, 1989:884-5 4. Zollinger RW. The prognosis in diverticuli-
tis of the colon. Arch Surg 1968;97(3):418-22 5. Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of Western civilization. BMJ 1971;2(759):450-4 6. Alrny TP, Howell DA. Medical progress: diverticular disease of the colon. N Eng! J Med 1980;302(6):324-31 7. Painter NS, Truelove SC, Ardran GM, et al. Segmentation and the localization of intraluminal pressures in the human colon, with spe-
Summary
elude radiographically directed drainage with delayed operation for peridiverticular abscess, resection of the site of disease in patients with general peritonitis, and primary anastomosis in most cases requiring urgent intervention. Diverticulosis accompanied by abdominal pain or irregular bowel habits is by itself rarely an indication for surgery. Diverticular bleeding usually resolves spontaneously; but persistent bleeding can usually be successfully treated with segmental colectomy after localization of the bleeding site with colonoscopy or arteriography. PCIWI
-®
Earn credit on this article. See CME Quiz.
Address for correspondence: Brent W. Miedema, MD, One Hospital Dr, NW301, Columbia, MO 65212.
cia! reference to the pathogenesis of colonic diverticula. Gastroenterology 1965;49(2):169-77 8. Slack WW. The anatomy, pathology, and some clinical features of diverticulitis of the colon. Br J Surg 1962;50(Sep):185-90 9. Ranson JH, Lawrence LR, Localio SA. Colomyotomy: a new approach to surgery for colonic diverticular disease. Am J Surg 1972; 123(2):185-91 10. Hulnick DH, Megibow AJ, Balthazar EJ,
continued on page 108
VOL 92/NO 6/NOVEMBER 1, 1992/POSTGRADUATE MEDICINE • DIVERTICULA
105
AEROBID"/AEROBID'-M (tlunisolicte) Effective asthma control BID
For oral inhalation only CONTRAINDICATIONS AEROBIO/AEROBIO-M Inhaler is conlraindicaled in Jhe primary Jrealmenl ol slalus aslhmalicus or olher acule episodes of aslhma whereinlensivemeasuresarerequired. Hypersensilivilyloany of the ingredients olthis preparation contraindicates ils use WARNINGS Particular care is needed in palients who are transferred from syslemically active corticosteroids to AEROBID/AEROBID·M Inhaler becausedealhsduetoadrenal insulliciencyhaveoccurred inaslhmalicpatienlsduringandaltertranslerlromsystemic corticosteroids to aerosol corlicosteroids. Alter withdrawatlrom systemic corlicosleroids, anumber ol monlhs are required lor recovery ol hypothalamic-pituitary-adrenal (HPA) function. During this period ot HPA suppression, palients may exhibit signs and symploms of adrenal insulliciency when exposed lo trauma, surgery or infections, particularly gaslroenteritis. Although AEROBID/AEROBID-M Inhaler may provide control ol aslhmalic symptoms during t~ese episodes. it does NOT provide the syslemicsleroidthatisnecessarylorcopingwilhtheseemergencies. During periods of stress or asevere asthmatic attack, patients who have been withdrawn from syslemic corlicosteroids should be instrucledloresumesystemicsteroids(inlargedoses)immediatelyandtoconlacllheirphysicianlorlurtherinslruclion. These patientsshouldalsobeinstrucledlocarryawarningcardindicatingthattheymayneedsupplemenlarysyslemicsteroidsduring periodsolslressorasevereasthmaallack. Toassesslheriskoladrenalinsulliciencyinemergencysituations,routineleslsol adrenalcorJicallunc\ion,includmgmeasuremenlolearlymorningreslmgcortisollevels,shouldbeperlormedperiodrcallyinall patients. An early morning resling cortisol level may be accepted as normal if if falls at or near lhe normal mean level. Localized inleclions with Candida a/biuns or Aspergillus niger have occurred in the mouth and pharynx and occasionally 10 the larynx. Positive cultures lor oral Candida may be present in up to 34% of patienls. Allhough lhe frequency of clinically apparenl inleclron is considerably lower, lhese inleclions may require lrealmenl wrlh appropilale anlrlungallherapy or disconlinuance wrlh AEROBID/AEROBID·M Inhaler. AEROBID/AEROBID·M Inhaler is nollo be regarded as a bronchodilalor and is no! indiuled lor rapid relief of bronchospasm. Palienls should be inslrucled lo conlacllheir physician immedialely when episodes of asthma !hal are nol responsive lo broncho· dilalors occur during Jhe course oltrealmenl. During such episodes, palienls may require therapy wilh syslemic corticosleroids
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Thereisnoevidencelhalconlrololaslhmacanbeachievedbyadminislralionollhedruginamounlsgrealerlhanlhereco~
mendeddoses, whichappearlobelhelherapeulicequivalenlolapproximalely10mg/dayoloralprednisone. Theorelicalty,lhe use of inhaled corticosteroids with alternale-day prednisone syslemic trealmenl should be accompanied by more HPA suppression thana l~erapeulicallyequivalenl regi~en of eilher alone. Transfer of palienls from syslemic sleroid lherapy lo AEROBID/AEROBID·M Inhaler may unmask allergic condilions previously suppressedbylhesyslemicsJeroidlherapy,e.g,rhinilis,conjunclivitis,andeczema. Children who are on immunosuppressant drugs are more susceplible lo inleclions !han heallhy children. Chicken pox and measles, lor example, can have a more serious or even !alai course in children on immunosuppressanl corticosleroids. In such children, or inadullswhohavenolhadlhesediseases,particularcareshouldbelakenloavoidexposure. llexposed,lherapywilhvaricella zosler immune globulin (VII G) or pooled inlravenous immunoglobulin (lVI G). as appropriale, may be indicated. II chic
