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·MODERN MEDICAL MONOGRAPHS
21
Fl tor: CI ef TRYING S WRIGHT MD
Consulting Ed to RICHARD II ORR MD
Diverticulitis
By SARA M JORDAN, MD
Founder and Former Head of the Depart
ment of Ga tronte ology Th Lahey
Cinc member of the Staff New Eng! d
Paptit
Ho p tal and New En land
Deaco es pital B to
Mas chu etts
and RUSSELL S BOLES JR, N D
Member of the taff Department of Gastro
enterology The Lahey Clinc New Engla d
Bapt st Hospital and New En_land
Deacones Ho p tal Bo ton Ma achusetts
GRUNE & STRATTON
1960

·(of snight Ixty ( rupe antation in
181 Fark A enu buth work 16 Ink
Istran of Longte (sallar Yumber 31
17 ans loun the wall of ma41

·Contents I REFACE V 1 NOMENCLATURE 1 2 HISTORICAL REVIEW (1901-1959) 2 3 DIVERTICULO I 45 45 Patho e es Tue and Fale Dert cula Inciden e Age and Sex 46 47 D 50 NO! Xray Study 50 Procto copy 52 Treatment 53 51 51 4 DIVERTICLLITI Pathoge et Inc dce D 56 1 57 62 69 Bt ed 66 Perforat nad Co rls ation Carcinoma d Divert cult F tul 70 Obt ct 75 Met al Teatment Progn 1987 19 REFERENCES 83 IDEX 90

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·Preface IT IS CUSTOMARY at the end of a preface for the author or authors to acknowledge their indebtedness to all those who assisted in the preparation of their book Contrary to this cu_tom I would like to acknowledge at once that Dr Jordan was a ked to write this mono graph Fortunately she had written a sub tantial part of it in which her personal viens were pre ented before her untimely illness intervened It was my rare privilege to be clo ely associated with Dr Jordan for some years and to collaborate with her when it became evident that she could not finish this undertaking Since then I have attempted to complete the volume her last contribution to medicine in accordance with her de ires I can only hope that the final product will meet with the approval of those who may choo e to read it It was her opinion that by a critical res tew of the history of diverticulosis and diverticulitis a more complete understanding of this di case would be achiesed This review is followed by a dis cussion of the subject based on an unusually broad experience with colon di orders The diagnosis and treatment of diverticulo is and diverticulitis are discussed at some length with appropriate recognition gnen to their complications The indications for surgical intervention are presented but details of surgical techmc are omitted because it was believed they would be more appropriately covered in the surgical literature I want to acknowledge for Dr Jordan and my elf our grateful appreciation to Dr Richard B Cattell and Dr Samuel F Marshall of the Clinic staff who reviewed the final draft and offered con tructive criticism to the Editorial and Photographic Departments for their helpful cooperation and to Dr Melvin hing who arded in compiling the bibliography We are al o indebted to the publi hers

·PREFACE
for their constructive sugge tion and a si tance in handling min)
of the details ini oled
RUSSELL S BOLES JR MD
Augu t 1960

·1 Nomenclature The word duerliculum was first used by Cruselhier 3 in 1819 to de cnbe the mall outpouching from the wall of a hollow organ which is now generally recognized as present singly or in numbers in the conditions known as diverticulosis and diverticulitis The Latın word diverticulum hterally means a small diversion from the normal path Perhaps no other medical word is o often used incorrectly in its suffix- the correct singular being the neuter um and the plural a wherea not infrequently the neuter plural is mistakenly used as a feminine singular and of a feminine plural duerticulae is fal ely contrived From the word duerticulum the derivative diverticulosis is used to describe the presence of such outpouchings and when there is inflammation in them the suffix its indicating inflammation and infection replaces osis and forms the word duerticulitis When such inflammation involves the structures surroundin, the pouches it is called perduerticulitis Where the words duerticulosis and dıerticulitis are used without localızıng the site of the abnormalities they are usually understood as referring to the colon where diverticula are most frequently found However diverticula are found though much less frequently in the esopha,us as well as all parts of the gastrointestinal tract and in the urinary bladder and gallbladder ·2 Historical Review Like the history of medical knowledge of many other diere that of diverticulosis ind of diserticulitis las considerable interest in that it shows the changing trends of thought in the p7 t 50 yer with regird to all aspects of the e conditions It seemed to the authors therefore that 1 review of some of the literature of more than a ulf century would throw an intere ting light upon the whole subject of diverticulitis There follow therefore in chronologicıl series abstracts of ome of the literature on this subject The etiology of the formation of the diverticulum 1179 arou ed much discussion especially in the early part of this century Cruse alluers pathologic description of this intestinal defect had been regarded with little intere e until Cra er 50 in 1899 wrote on a fal e diverticulum which he regirded a a hernial protrusion at n werk pot in the mu cular inyer of the colon produced by the entrance or exit of 1 blood ve el lle thought that uch a protru ion con tituting a diverticulum burroned along the blood vessel sheath and was e pecially likely to occur if there were any obstructions to a free return of blood through inferior me enteric icine as in valvu Tar heurt dı ense This paper of Cri er aroused interet in this con ition to winch sery little attention lied heen pince Crueller description 50 years previou ly 1904 Beer "o in n papier entitled Some Pathological and Clinical A pects of Acquired (Fal el Diverticula of the Inte tinc pointed out that the tudies on the dead colon done by previous intestigators Neb Jlechl Hannu Cood Han eminn Fichier and Cruer's did not necesarily apply to the living colon and Beer particuliy rr futed the theory tint weakne at the meenteric border and at the point of entrance and out of blood ves na thr br ic rea on for Hernil protru Jon He quoted (hlum hy? who Jizel performed 2 ·HISTORICAL REVIEW 3 studies in the inte tine of the living dog distending it to the point of rupture whuch was invariably on the nonmesenteric side of the gut a contra t to the studies on the intestine 10 hours after death when rupture occurred along the mesenteric horder He also referred to Sudsuki s work which in refutation of Graser s theory howed that only 6 of 15 ca es of acquired diverticulitis showed a conge tive condition Sudsuki 103 had still held however to the theory that diminished resistance at the points of entrance of blood vessels was responsible for the formation of diverticula Beer however pro posed the theory that old age and constipation he t accounted for the formation of diverticula which occurred both on the nonme en teric side of the gut where there are no points of entrance of blood vessels as well as along the me enteric border 1906 48 Moynihan *1 & directed attention as did Graser to the difficulty in differentiating diverticulitis from carcinoma and reported 6 cases on which he had operated with a diagnosis of malignant du ease before or at operation and in which sub equent hi tologic examinations showed false diverticula a ociated with inflammation In that same year Gordimer and Sampson ugge ted that diver licula be looked for more frequently and that acquired diverticula of the small intestine occurred much more frequently than autopsy records showed and undoubtedly caused minor symptoms He found them u ually multiple arising at the site of vessel entry into the intestinal wall and ometimes involving the whole length of the small intestine whereas acquired dnerticula of the colon were most frequently found in the si,moid arising from any portion of the circumference of the bowel and of more clinical significance than those of the small bowel 1907 The que tion of so called true and fal e diverticula was discussed by W J Mayo" and others who described the commone t and so called true variety as being that caused by traction of tumors or adherent organs while fal e diserticula were thought to be most ·4 DIVERTICULITIS probably the re ult of erce sne pre sure from within the lumen of the bowel combined with 1 congenital weakness of the wall The e authors al o called attention both to the frequency of occurrence of diverticuli in the large house and to their tendency to extend into the epiploical appendage As etiologic fictors con tipation with the impaction of hardened feces in the drerticulum was thought to be the important factor in the development of dnerticultie the irritation from the continued presence of the e hardened fece re sulting at times in ulceration This theory in their opinion nccounted for the fact that diverticulitis occurred mo t often in the sigmoid trei of the colon Muyo and others al o ob ersed that mot per ons with this du eise were over 50 years of age and tended to be obce They al o noted that chronic pr site conge tion had been mentioned 1. n factor both in the production of diverticult and 7 1 cuu e of diverticultı The e zuthor al o distingui led between diserticulita and per diverticuliti In the former tley de cribed acute inlammi tion of the muco 2 ttlun the nerticula without reduction in size of the lumen and resultant ob truction but with a tendency to acute perforation into the peritoneal cruity In periduerticuliti they muntuined that the submuco 1 was chronically inflamed around the diverticula and the bowel lumen reduced but perforation was rare becau e of the predomının reparatie proces In 1907 when thus puper 74 written 5 c? es of chronic obstructie diverticulitis with resection of igmond were de cribexi 1908 Ahhurst clescribed a cac wluch he anaumed to be duerticulitis in 1 boy of 7 yeir 9 months The boy loud fever and a firm tcndler ma s in the left lower quadrant Exploration showed a lumor the usze of 1 foo eege with serli ocrited lige lymph nodfe- in thir me o igmor Thiere *7no ob fruction and no rt (ction * 1 lone The patient recovered completely with gradual de appearance of the m3 witlun 1 period of three and one half months di cued the frequency of acquired diverticuli in the large lonel pecially the loner de ceading colon and is mord riting that thicy occurred chiefly in tno runs either at thir Telling tos por 1 ·HISTORICAL REVIEW 5 sides of the gut or clo e to the mesenteric attachment but rarely on the convexity and most commonly into the appendices epiploicae He stated that in the descending colon they were practically always filled with feces and noted that the aperture into the lumen was usu ally smaller than the maximum diameter of the diverticulum He cited three po sible explanations for the origin of diverticula (1) that they are congenital and enlarge progressively during life (2) that they arı e from pathologic causes and (3) that there is a con genital predisposition but that their formation depends on patho logic causes which operate during life HI own theory with the balance of evidence at that time was that there is a pathologic origin and that no con enital arrangement of muscle fibers pro ducing a predisposition had been demonstrated He con dered the pathologic factors to include the narrow neck of the diverticulum collections of fecal material within the diverticula constipation increased intraluminal pres ure and obesity Telling also expressed the opinion that diverticula exist much more frequently than had been previously believed 1910 Barbat" cited a long list of 126 reports on the subject of diverticu Iitis the majority from foreign literature summarized the theories of diverticula formation and etiologic factors in diverticulitis dis cussed the complications and the frequency with which this disea e is confused with carcinoma and emphasized the hugh incidence of the disease and its complications Hartwell and Cecil 5 in a pathologic and clinical study noted that a diverticulum of the intestine had been recognized as a pathologic entity for over 100 years They applied this term to any outgrowth of the intestinal wall not neoplastic in character which at some time had had a lumen connecting it with the intestine and whose walls are similar in tructure to those of the intestines with this definition both Meckel s diverticulum as a congenital diverticulum and the sermiform appendix a a vestigial diverticulum can be in cluded on this category of diverticula but they considered it u eles to distinguish between congenital and acquired diverticula since no ·4 DIVERTICULITIS probably the result of excessive pre sure from within the lumen of the bonel combined with a congenital weakness of the wall The e authors al o called attention both to the frequency of occurrence of diverticula in the large bowel and to their tendency to extend into the epiploical appendages As etiologic factors con tipation with the impaction of hardened feces in the diverticulum was thought to be the important factor in the deselopment of diverticulitis, the irritation from the continued pre ence of these hardened feces re sulting at times in ulceration This theory in their opinion accounted for the fact that diserticulitis occurred most often in the sigmoid area of the colon Mayo ind other- al o ob erved that most persons with this disease were over 50 years of age and tended to be obe e They al o noted that chronic passive congestion had been mentioned as a factor both in the production of diverticuli and is a cause of dnerliculitis The e authors al o distingur hed between drerticulitis and perıdıerticulitis In the former they described acute inflamma tion of the mucos 1 within the diverticula without reduction in size of the lumen and resultant obstruction but with a tendency to acute perforation into the peritoneal cauty In periduerticulitis they maintained that the submucosa was chronically inflamed around the diverticula and the bowel lumen reduced but perforation was rare becau e of the predominant reparatie proce - In 1907 when this paper was written 5 ci es of chronic ob tructnie dnerticuliti with sesection of sigmoid were de cribed 1908 Ashhurst described a ca e uluch he assumed to be diserticulitis in a boy of 7 years 9 months The boy had fever and a firm tender mass in the left lower quadrant Exploration showed a tumor the size of a goo e egg with everal as ociated large lymph nodes in the mesosigmoid There was no obstruction and no resection was done The patient recovered completely with gradual climapperrance of the ma > within a period of three and one half months rof 11€ di cus ed the frequency of acquired duerticuin in the large bowel especially the lower de cending colon and sig moid stating that they occurred chiefly in iso ron either at the Telling to ·HISTORICAL REVIEW 7 more to congenital weakness of the circumferential muscularıs than to any other factor and constipation seems the important element in their development He also believed that low grade proliferative changes take place in the tips of the diverticula forming segregated epithelium similar in all re pects to the cell changes which occur in the masses of epithelium egregated about the ba e of a gastric ulcer From such epithelial proliferation which fills the entire diver ticulum he conjectured that infiltration of its wall developed form ing an histologic picture which must be diagnosed as carcinoma 1912 The first case of cecal diverticulitis was described by Potier 88 McGrath wrote on the etiology and pathogenes of intestinal diverticula He described the formation of the diverticulum as a herniation of the mucosa through the mu culari in the region of the ve sels u urlly rupturing into the ve sels He observed that the e herniated structures usually involve the muco al and submu cosal coats He noted as conditions important in considering the development of diverticula obesity cachexia loss of intra ahdom inal fat in previously obese individuals areas of weakness in an otherw 19e normal inte tine intraintestinal pre ure proximity of diverticula to points of entrance of blood ve els into the intestinal wall location of epiploic appendage infection involving lymph chann Is long blood vessel all muscular deficiency congenital weaknes of muscularis constipation and old age He like Mayo" distinguished between divertzculitis and peridiverticulitis and he thought that cancer was associated with diverticulitis having ob served it in 25 per cent of hi series 1914 Bunts 14 called attention to i ca e of formation of a truly fal e diverticulum or herniation of the cecum at the ite of prior appen diceal surgery where the protrusion appeared to have taken place through a ring formed by the pur e string suture In this case the patient liad recurrent attacks of right lower quidrint pain which disappeared after surgical correction ·6 DIVERTICULITIS proof of either could be obtained except in the case of Meckels diverticulum and the vermiform appendıx These authors referred to the file diverticulum as not having all the structures found in the normal wall while the true diverticulum contains all these structures but they believed that the true might become the fal e hy the loss of some of these structures They noted that diverticula had been found in every portion of the alimentary tract from the pylorus to the anal ring there having been reported duerticuli even in the appendıx itself. They recorded however that the sigmoid was the favorite site and that in the rectum proper it was rare They ob served that small intestinal diverticula occurred between the mesen teric leases or close to them but that in the colon they were often placed laterally In their opinion the primary cause could not be determined but the existence of a congenital defect in the muscu lature was probable and contributing causes were mot likely old age constipation and obesity They referred however to Ash hurst report of the occurrence of diverticula in children and to other reports in individuals under 30 yeurs They stated that while the diverticulum itself is harmless changes may occur which are similar to those occurring in the vermiform appendıx They de cribed these changes as Mayo had previously done inflammation with or without perforation abscesy generalized peritonitis septi cemia fistula formation into another hollow u cur e pecially the uriniry bladder They mentioned also the po sibility of chronic wubacute inflammation with recurrent attacks of acute diverticulitis and they al o de cribed changes in the entire inte tinal wall and its mesentery with or without ob truction resulting from the narrowing of the lumen or econdary to adhesions for the first time in their paper they mentioned the possibility of a superimpo ed carcinoma Included in their paper were 13 ca e reports of luch 2 from autopsy material were in children age 6 and 10 years 1911 Wil on '1% formulated theory of the development of carcinoma from diverticulo ) In his opin on diverticula while they fre quently follows the course of blood ıe el probalıly owe their origin ·HISTORICAL REVIEW plete obstruction in diverticulitis ) (4) the group in which car cinoma develops in a diverticulum leading to the conclusion that when a tumor appears as diverticulitis and without acute symptoms in the colon and a chronic mass persists with les severe symptoms carcinoma should be suspected and resection performed 1924 Judd and Pollock 63 wrote on diverticulitis of the colon presenting various observations of interest They considered that it may be a static condition remaining unchanged for years and often not caus ing symptoms or it may progress to abscess formation fistulas or free perforation They had not observed it in any other part of the colon except the sigmoid They al o mentioned the difficulty of dis tinguishing dnverticulitis from carcinoma of sigmoid and stated that in their group of 137 ca es there appeared to be no relationship between the two thus being the fir t to suggest that the theory of Wilson and others that carcinoma arose from diverticulitis was probably incorrect and that their occasional coexistence was coin cidental It was their opinion that many patients with diverticulitis can be succe fully treated medically surgery being indicated for perforation absces formation and inability to diagnose the nature of a tumor formation They also sugge ted preliminary colo tomy for obstruction and for the purpose of reducing inflammation by frequent irrigations of the lower colon and later lessened surgical risk These authors regarded proctoscopy as of little value unle s the lesion was actually visualized 1929 Greensfelder and Hiller" wrote about cecal diverticulosis which in their opinion should be su pected of symptoms resembling ap pendicitis occurred in a patient who had had previous appendec tomy Cecal diverticula may be either primary with etiology similar to that of sigmoid diverticulosis and occurring frequently in younger individuals or it may be secondary to traumata resulting from an operative procedure in the right lower quadrant The e authors re ported that in 5 395 major operations and 400 adult necropsies ·8 DIVERTICULITIS 1915 Case 'was one of the first to draw attention to the x ray demon stration of diverticula and their complications and in the same yeur Carman 19 joined the x ray pioneers with two papers on cases of diverticulitis and their x ray findings pointing out that left sided appendicitis could be excluded by the finding of a normal position of the cecum He also discus ed the difficulties of differential diag nosis of dierticulitis from carcinoma, indicating that the presence of barium filled diverticula would tend to indicate diverticulitis He also suggested the taking of films in different news in order to pick up the extraluminal shadows of diverticula 1917 Mayo" wrote on duerticulitis of the large intestine reporung 42 cases which had had surgical treatment since the disease had first been recognized Of the e 37 involved the sigmoid 1 the trins verse colon 1 the ascending colon 1 the hepatic flexure and cecum and 2 the rectum The patients ranged in age from 27 to 73 and there were twice as many females as mules He mentioned its clinical similarity to appendiceal inflammation except that the symptoms were usually on the left and in 31 cases a tender mi s in the left lower quadrant was present In 13 cases (31 per cent) carcinoma coexisted with diverticulitis and the author con idered this was more than a coincidence and that chronic irritation and inflammation of the diverticul: led eventually to cancerous change lle clı sified diverticulitis into four groups (1) self limiting diverticulitis and peridnerticulitis usually occurring in the middle aged and obese and usually recurrent (This group was in lus opinion a poor risk for surgery which should only he con idered if symptoms were serious or chronic relapsing) (2) the group with ab ces es and fistulas where conservative surgery should be employed (3) the group with obstruction where it is difficult to distinguish diverticu Intis from carcinoma (The author here offers two differentiating points (a) a long history of symptoms in diverticulitis (h) com plete obstruction frequent in carcinoma as contrasted with incom ·HISTORICAL REVIEW II Small doses of mineral oil and an anti constipation diet are pre scribed the dietary regimen being lughly essential With complica tions they thought surgery should be done but it was accompanied by a high mortality rate The authors recommended as an operation of choice a graded procedure con isting of drainage and subsequent resection and anastomosis Often prolonged drunage alone pro duced rece sion of tumefactions and disappearance of clinical symp toms rendering further intervention unnecessary The pathologic changes in diverticulitis occurred probably because of stasis of the fecal stream in this portion of the colon with formed stool preventing emptying of the diverticulum when it was packed with feces They thought that local inflammatory changes then began in the mucous membrane of the diverticulum which became atrophied There wa round cell infiltration of the submucous cort and later ulceration With progressive change of this type in the bowel wall and the mesentery itself symptoms of inflammation and obstruction occurred with perisigmoiditis and mesenteriti The changes in the coats of the diverticulum varied from attenuation of the musculature to its complete absence when the wall was made up only of mucosa and serosa The mesentery and its attachment became thickened and contracted with considerable tumefaction while free perforation was rare localized perforation with ab cess and fistula wa not uncommon 1933 Wilkinson "17 wrote a paper on diverticulitis in which he referred to the fact that Friend noted diverticula of the large bowel as early as 1730 more than a century before Cruveilhier » pathologic de scription of them Wilkinson also referred to Klebs6 papers in 1869 which first directed attention to the relation of diverticula to the point in the bowel wall at which blood vessels traverse at Wilkin on al o credited Graser with arousing interest in 1899 in the entity of diverticulosis following a long period after Cruverthiers de crip tion in which nothing had been written about it Wilkinson dis counted the value of differentiation of true and fal e diverticula lle mentioned the inck of symptoms until inflammation occurred mani ·To DIVERTICULITIS performed at the Michael Reese Ho pital there were 1 cases of traumatic solitary cecal diverticula 2 at operation and 2 at autop y They considered their etiology to be either eversion of cecum between tio constricting adhesive hands or traction of a narrow adhesion or ever-ion at the stump site as a result of weakne s due to migration of 1 silk purse string suture into the cecum or following the rupture of a stump absce s into the bowel lumen 1930 Rankın and Brown *) writing about diverticulitis stated that di verticulosis occurred probably in about 1 per cent of all persons and in about 5 per cent of patients with symptoms referable to the large bowel Of tho e individuals with duerticulosis they e ti mated that about 17 per cent had verticulitis in most ca es chronic with exacerbations Concerning etiology the authors tend to agree with Beer that the chief factor is inherent weaknes of the muscle wall abetted by obesity and constipation and that diverticulitis is probably the result of improper emptying of bottle shaped sacculations with subsequent inflammatory reaction necrosi and occasional perforation In 227 ca es reviewed in their paper a malignant condition was as ociated with diverticulites in only 1 ca ex and in 679 ca es of carcinoma of the colon only 4 case of diverticulosis were found The e authors believed that diverticu litis occurred almot entirely in persons of middle age and inclined to be corpulent and leading sedentary lises They believed it u ui ally ran a chronic cour e with exacerbutions and yielded at, fic torily to medical treatment They noted that the outstanding symp tom was pain in the left lower abdomen frequently a ocrited with con tipation They thought that shule bleeding was not usually ciated with duerticulitis it might occur guing n e to a u picion of 1 malignant lesion which was frequently not found Bleeding usu ally aro e in the opinion of the e author from the anal canal They considered tumefaction the re ult of inflammatory reactions com monly a sociated with diverticulitis Medical treatment recom mended by the e authors con 1 ted of bed ret irrigations of the affected segment with warm line olation and watchful waiting a 0 ·HISTORICAL REVIEW 13 around the wall of the bowel The pouches are separated by ridgelike elevations (5) Diverticula can actually be seen more often than is usually believed especially in the absence of inflammation Buie cautions that the polyp in an unusual location should be recognized 1943 Five years later than when Bue first wrote about the proctoscopic findings another paper was written by Jackman and Buie on proc toscopic and in the diagnosis and differential diagnosis of diverticula The records of 242 patients who had had both procto copic and xray studies of the colon were studied Of these 160 cases (66 per cent) showed evidence of diverticulitis by proctoscopic examı nation in 35 cases diverticula were visualized and in an addı tional 72 cases sigmoidal sacculations as described in Bule s paper of 1939 were described in the other 53 cases such findings as immobility sharp angulation reduced lumen al o previously de scribed by Buie strongly sugge ted the presence of diverticula of the sigmoid and in all these cases the proctologic findings were con firmed by <ray The authors also reported 74 per cent successful diagnostic re ults in 50 ca es in which colostomy had to be per formed as an emergency mea ure for ob truction in the lower bowel The proctoscopy was performed either through the colonic stoma or the anus 1944 Young and Young 1 in a paper on diverticulitis of the colon emphasized the relative frequency of the disease the errors in diag nosis and the high morbidity and mortality They compiled statistics showing an incidence of 52 per cent diverticulosis in 70 572 colons examined by barium examination in the living and by autopsy They estimated that 12 to 15 per cent of the e devel oped diverticulitis but in three reported series totalıng 3 915 cases with diverticulosis of the colon the incidence of diverticulitis was 343 per cent The e statistics showed 22 per cent to have been ·12 DIVERTICULITIS fested by abdominal pun usually in the left lower quadrant or peri umbilical fever constipation with intermittent diarrhea and a palpable mass in the left lower quadrint for the first time hemor rhage was described as a complication He emphasized the impor tance of x ray dinoss for diverticulosis and of clinical and rray findings for diverticulatı in which condition x ray showed diver ticuli in proximity to a constant irregularity and narrowing of the Jumen of the gut He also mentioned the fact that clinically, roent genologically and even at surgical exploration the differentiation between diverticulitis and 1 malignant lesion might be very difficult In the treatment of both diverticulosis to prevent diverticulitis und of duerticulitis itself he idu ed against the use of laxatives and enemas since these were likely to force more material and bacteria into the diverticula le recommended the attempt to keep stools normally formed and to prevent oseractive peristalsis and increased intraluminal pressure lle suggested for the treatment of diverticu litis bed rest the avoidance of purgatres laxatives and even mineral oil the use of tincture of belladonni and of an easily digestible diet with warm fuds He considered surgery necessary only for complications 1939 Bure 14 introduced the possibility of diagnosis of sigmoidal diver ticulosis and diverticulitis by fire proctoscopic signs (1) There is limited mobility of 1 segment of bowel which is normally freely mosable Thus immobility is not confined to the rectum 4s is the ca e when there is pelvic di ease or a fixed retro verted uterus (2) There is a sharp turn of the bowel where it is immobilized liy diverticulitis with difficulty in or imposibility of passing the procto cope beyond the angulation (3) There is a mucosa showing adherent folds and 1 contracture of the lumen The muco a may also be edemitou (4) Where there is no inflammation and the igmoid is mobile sliallow sacculations may be seen extending partially or wholly ·HISTORICAL REVIEW 15 43 way mann 8 1910 and 1942 believed that diverticula developed essentially as a result of a combination of physical forces with weakening or spread ing of the circular mu cular layer at the points of entrance of its blood vessels due to intracolonie pressure from constipation muscular spasm or other causes Another view held by Fancler that in middle age degenerative changes occurred in the muscle layer followed by traumatization from hard stools and gas distention but that this damage did not necessarily occur at the points of vascular penetration Schlotthauer also referred to Wierda s 11 belief that diet was a factor since in 3 rats fed on a high fat diet he found diverticulosis of the colon Schlotthauer also cited 1 fourth theory that for the formation of a diverticulum there had to be a con gental anatomic deficiency in the wall of the colon which acted as the starting point since diverticulosis occurred sometimes in young people before the age at which degenerative changes take place For support of this theory he quotes Poate 87 Lynch 49 Erd 40 41 Badia 5 Bear e 89 and Cave + 5 Such ca es as Schlotthauer presents in this paper could he explained on this basis He reported colon dnerticulosis present in 7 brothers of one white family consisting of 7 males and 2 females the ages ranging from 49 to 70 years and their habits of living social status occupations place of abode size and weight varying greatly In this instance at would be difficult to ignore heredity as a factor in etiology Morton 80 writing on diverticulitis of the colon called attention to the fact that this disease is of interest to internists surgeons pathologists gynecologists and urologists He restated Case s defini tion of diverticulosis as the finding of diverticula in a routine radio graphic picture of the large bowel repre enting no significant path ology and no symptomatology and occurring in 5 per cent of post mortem examinations of individuals of 40 years and over at the Mayo Clinic Morton s tudy was comprised of 111 cases of diver ticulitis with spa m and 85 ca es with multiple complications In the group of 111 case with spasm the patient was typically middle aged or older obese habitually constipated and sedentary Clini cally there wa often lower abdominal pain with sudden on et and with con tipation often preceded by several loo e tools Di tention ·DIVERTICULITIS operated upon In one series 15 per cent pre ented complication requiring surgery These yuthors thought the incidence was slightly greater in men than in women and that only about 03 per cent occurred below the age of 30 They alo reported 5 to 17 per cent of bleeding in diverticulitis with rare massive bleeding They rec ommended prophylactic treatment when diserticulosis was diag nosed such treatment consisting of low roughage diet mineral oil to promote regular elimination the avoidance of all imtable ca tharties and enemas and the use of tincture of belladonna In all respects except in the u e of mineral oil the e measures coincided with those recommended by Wilkinson 11 years previously In like manner the suggestions offered for the treatment of diverticulitis agreed with those of Wilkın on The authors recommended surgery for acute perforation obstruction fistula formation localized ah scess and suspicion of cancer In an analysis of 81 cases at the Faulkner Hospital in Jamaica Plain Massachu etts 86 per cent were over 10 years old the youngest being 37 The sexes were about equally divided Blood was found in the stools in 26 per cent of cases in which no other cause for blood was found and the inci dence of blood was greater in chronic diverticulitis (33 per cent) than in acute diverticulitis (20 per cent) The mot common com plaints in acute diverticulitis were of abilominal pain (usually in the left lower quadrant) and elevation of temperature and leuko cytosis In the chronic form of diverticulitis 79 per cent of the cases in this study had abdominal pain with symptoms of indigestion especially gas distress and nau en These authors found positive sigmoidoscopic findings spa m immobility sharp angulation and mucosal edema in 71 per cent of their ca es but no actual divertic ular sacs were visualized 1946 Schlotthauer pre ented a report of 7 cases of diverticulo is in one family of 9 per ons He discued the current thought on etiology defining it as a lierniation of the mucos? and submuco a of the intestine through a defect in it circular mu cular layer Ile referred to Ceballo 26 Diron ? and Edwards 39 who in the years ·HISTORICAL REVIEW 17 colon which had been involved by diverticultı Morton al o sug gests a conservative treatment consı ting of bed rest simple diet antispasmodics heat to the abdomen and edation He believed antibiotics were unnecessary Surgery in his opinion should be reserved for complications 1949 Carl on and Hoelzel 19 reported inve tigations on rats which re vealed that diverticula were found in areas contiguous to lobulated fat deposits and that abnormally high intracolonic pres ure was a causative agent in the development of diverticula in the colon It way thought by these workers that the bowel wall was weakened as a result of fat infiltration and that hernjation of thı weakened part of the wall occurred into a far infiltrated peritoneal sacculation When a concentrated low re due diet wa fed the rats there was continuous contraction and increased intracolonic pressure whereas this did not occur when the diet was bulky a 1951 Fwell* wrote on a complication of diverticulitis the intestino vesical fistula He stated that about 50 per cent of all intestinovesical fistulas were due to diverticulitis of the colon and con equently all individuals with diverticulitis of the colon were potential candidates for this complication which bke any fistula econdary to inflamma tory di ease almost always deseloped after a localized abscess forma tion and was usually a tortuous tract For the diagnosts of this con dition the history of pneumaturia or the passage of feces through the urethra were usually considered pathognomone of intestinovesi cal fistulas The author stated that this was true of passage of feces but pneumaturia might be due to other causes as well Passage of urine through the rectum although uncommon was another cardinal symptom of intestinovesical fi tula The physical examination should be supplemented by cystoscopy excretory vrography cystograms gastrointe tinal xray and proctosigmoidoscopy With cystoscopy the opening might be visualized or bubbles of gas or fecal matter be seen extruding into the bladder A barium enema revealed the fistula ·16 DIVERTICULITIS nauser vomiting fever occasionally chills tenesmus and bladder symptoms might follow the on et of pain Tenderness and a pal pable mass in the left lower quadrant together with elevated tem perature pulse rate and white cells were the chief diagnostic signs Only 2 of these 111 cases were under 30 years of age and both sexes were about equally represented In addition to the usual pain in the lower abdomen constipation diarrhea di tention and vomit ing blood was found in 32 cases (bright red in 24 cises and tarry stool, in 8 cases. If 10 of these cases in which other possible causes for blood were found were eliminated from this group there was still an incidence of 20 per cent reasonably ascribable to diverticu litis When no complications were present the author believed that the disease was self limited ind improved or subsided in three to seven days under medical care during which time the surgeon must exercise restraint In the 85 ca es with complications perforation occurred in 39 cases fistula in 22 cases obstruction in 34 cases cancer in 17 cases some having multiple complications In the group of 39 cases with perforation 3 had perforated into the peritoneal cavity with result ing peritonitis In the other 36 there were localized abscesses and the symptoms previously de cribed for diverticulitis were increased in intensity of this group 10 died in the hospital In the 22 ca es with fistula the abscess of perforation had opened or made its way into a neighboring organ to the skin in 11 cases into the bladder in 8 ca es the urethra in 2 cases the small intestine in 2 ca es the cecum in 1 case the rectum in 2 cases the vagina in 1 ca es retro peritoneal tissues in 1 case to form an ischiorectal ainus in I case and a sinus into the me ocolon in l ca e In ll of these cases the fistulas were multiple In the 31 cases of duerticulitis with obstruc tion due to infiltration of the intestinal wall there had been repeated infections and scarring and thickening of the colon causing gradual occlusion of the lumen There were al o other possibilities to be consıdered for the cause of ob truction chiefly adhe ions around an absce s cavity and adherence of the small inte tine to an acutely infected duerticulum In the 17 cases where cancer wat 1 ociated with diverticulo is only four of the cancers were in the area of the ·HISTORICAL REVIEW 19 the lesion was a cancer even with a completely annular tumor These authors recommended the occasional use of a douhle con trast enema for identification of the lesion They al o recommended as helpful features in the differential diagnosis of diverticulitis and carcinoma (1) greater length of area of involvement in sigmoid diverticulitis than in carcinoma (2) much better preservation of the mucosal contours in diverticulitis (3) more complete ob truc tion (increased by spasm) in diverticulitis (4) if a mass was present u ually tenderness in diverticulitis (5) abrupt transition from relatively normal to abnormal bowel in carcinoma with cuffing overhanging edges or shelving often visualized Swinton 104 wrote on the surgical aspects of diverticulitis stating that the policy of the Lahey Clinic had been to operate on patients with diverticulitis only of complications had developed conservative treatment being adequate for the majority of uncomplicated cases of diverticulitıs This author also mentioned the possible occurrence of an acute exacerbation from the use of castor oil or other laxative in preparation for roentgenographie or sigmoidoscopic examina tions His indications for surgical intervention were (1) evidence of acute perforation (2) abscess formation (3) obstruction (4) inability to exclude diagnosis of a malignant tumor (5) fistulas (6) repeated hemorrhages (7) failure to obtain relief by conserva tive measures His choice of surgical procedures way (1) for acute perforation simple closure of the perforation with a proximal diver sional colostomy when indicated as in an extensive process or when obstruction is suspected (2) for ah cess formation incision and drainage followed by resection of the diseased process after the acute process subsided (3) for obstruction a three stage pro cedure a ri ht transverse Mikulicz type of colo tomy resection of the tumor and later closure of colostomy If malignant di ease could not be excluded in the presence of an obstructing tumor he recommended segmental resection of the involved area and if po sible examination of the removed tissue before a final decision was made as to the operative procedure to be used for enterove ical or other fistula he considered a three stage procedure indicated a pre liminary right transierse colostomy followed in four to six months ·18 DIVERTICULITIS in about 20 per cent of c7 es due to duverticulitis The injection of methylene blue solution into the bladder or rectum might be oh served for its passage from one to the other which was a conclusive finding Surgery wis usunlly successful and recurrences were rire One stage operations were possible since the use of sulfonamides and antibiotics but in some cases these drugs bue masked symp toms of diverticulitis and thus have allowed the development of a fistula from 1 dormant abscess when the fistulu could have been prevented with earlier surgery A two stage operation was indicated in this author s opinion when excessive induration and inflammation were present Wigh and Swenson 116 wrote on the roentgenologic aspects of diverticultis and its complications They stated that the generally accepted incidence of diverticulosis way 5 to 10 per cent and of these 12 to 22 per cent developed diverticulitis ut some time Peri diverticular abscesses were identified in two ways (1) by 1 pal pable mass contiguous with or displacing the bowel fluoroscopically (2) by their recognition as abscesses on the roentgenogrims because their opening into the lumen of a diverticulum was sufficiently large to permit the ingre s of opique mixture These authors stated that fistulns were a fairly common complication of duerticulitis (10 to 15 per cent of all cases of diverticulitis that had surgery also had bladder fistulas according to Bochus) Fifty per cent of vesicocolic fistulas from inflımmatory lesions resulted from diverticulitis and these constituted twice the number of those due to carcinoma When no diverticula were visualized carcinomı had to be considered as the origin of the fistulous tract Wule localized inflammatory processes u ually subsided and a normal bowel was restored repeated attacks of inflammation caused a tluckening of the bowel wall and reduction in the size of the lumen with possible ob truction The authors estimate that two thurds of the cases of diverticulitis had their complaints ba ed on obstruction They al o mude the observation that with the busum enema spasm was produced guing an appearance of greater oh struction than was demonstrated when the barium pas ed di tally This syas often only transitory sp? m and was not u uilly seen when ·HISTORICAL REVIEW 19 the le ion was a cancer even with a completely annular tumor The e authors recommended the occasional ue of a double con trast enema for identification of the lesion They al o recommended as helpful features in the differential diagnosis of diverticulitis and carcinoma (1) greater length of area of involvement in sigmoid diverticulitis than in carcinoma (2) much better pre ervation of the mucosal contours in diverticulitis (31 more complete obstruc tion (increased by spa mi in duerticulitis (41 of a mas wa pre ent u ually tenderness in diverticulitik (5) abrupt tran ition from relatively normal to abnormal bowel in carcinoma with cuffing Overhanging edges or shelsing often visualized Swinton 194 wrote on the surgical a pects of diverticulitis stating that the polıcy of the Lahey Clinic had been to operate on patients with diverticulitis only of complications lad developed conservative treatment being adequate for the majority of uncomplicated cases of diverticulitis This author also mentioned the po ible orcurrence of an acute exacerbation from the use of castor oil or other laxative in preparation for roentgenographic or sigmoidoscopic examina tions His indications for surgical intervention were (11 evidence of arute perforation (2) ab ce s formation (3) ob truction (11 inability to exclude diagnosis of a malignant tumor (51 fi tula (6) repeated hemorrhagen 171 failure to obtain relief by ron eria tive measures His choice of surgical proredures was (11 for acute perforation simple closure of the perforation with a proximal diver sional colostomy when indicated as in an extensive proces or when obstruction is suspected (2) for ab ce s formation incision and drainage followed by resection of the di ea id process after the acute process aubsided (3) for obstruction a three stage pro cedure a right transverse Mikulicz type of colo tomy resection of the tumor and later clo ure of colo tomy If malignant disease could not be excluded in the presence of an ob tructing tumor lie recommended segmental te ection of the involved area and f po ible examination of the removed tissue helore a final decision wa made as to the operative procedure to be u ed For enterove rral or other fistulas he considered a three tage procedure indicated 1 pre liminary right transserse colostomy followed in four to six months ·18 DIVERTICULITIS in about 20 per cent of cases due to diverticulitis The injection of methylene blue solution into the bladder or rectum might he ob served for its passage from one to the other which was a conclusive finding Surgery was u ually successful and recurrences were rare One stage operations were possible since the use of sulfonamides and antibiotics but in some cases these drugs have masked symp toms of diverticuliti and thus have allowed the development of a fistula from a dormant ab ce when the fistula could have been prevented with earlier surgery A two stage operation was indicated in this authors opinion when excessive induration and inflammation were pre ent Wigh and Swen on 118 wrote on the roentgenologic aspects of diverticulitis and its complications They stated that the generally accepted incidence of diverticulosis was 5 to 10 per cent and of these 12 to 22 per cent developed diverticulitis at some time Peri diverticular absce ses were identified in two ways (1) by 1 pal pable mass contiguous with or displacing the bowel fluoroscopically (2) by their recognition as abscesses on the roentgenograms becau e their opening into the lumen of a diverticulum was sufficiently large to permit the ingress of opaque mixture These authors stated that fistulas were a fairly common complication of diverticulitis (10 to 15 per cent of all cases of diverticulitis that had surgery also had bladder fistulas according to Bockus) Fifty per cent of vesicocolic fistulas from inflammatory lessons re ulted from diverticulitis and the e constituted twice the number of those due to carcinoma When no diverticula were visualized carcinoma had to he considered as the origin of the fistulous tract While localized inflammatory processes usually sub ided and a normal bowel was restored repeated attacks of inflammation caused a thickening of the bowel wall and reduction in the size of the lumen with po sible obstruction The wuthors estimate that two thirds of the cases of diverticulitis had their complaints ba ed on obstruction They al o made the observation that with the barium enema spasm was produced giving an appearance of greater oh struction than was demonstrated when the barium p7 ed distally This was often only transitory spasm and was not usually seen when ·HISTORICAL REVIEW 19 the fusion a canrer even with a completely annular tumor The e authors recommended the occasional use of a double con trast enema for identifiration of the lesson They al-o recommended 1 helpful features in the differential diagno is of diverticulitis and carcinoma 11) greater Jength of trea of involvement in sigmoid diverticulitis than in circitoma (21 much better preepriation of the muco al contours in duerticulitis (31 more complete obstruc tron (increased by pasm) in diverticulst (4) if a mass was present usually tenderness in diverticulitis (5) abrupt transition from relatively normal to abnormal bowel in carcinoma with cufling overhanging edges or shelving oiten visualized Swinton 14 wrote on the surgical aspects of diverliculitis Mating that the policy of the Labey Clinic had been to operate on patients with kerticulitis only if complıcalions had developed con ervatie treatment being adequate for the majority of uncomplicated cases of diverticulit. This author also mentioned the possible occurrence of an acute exacerhation from the use of ca tor oil or other laxative in preparation for roentgenographic or sigmoidoscopic examina tions His indirations for surgical intervention were (1) evidence of acute perforation (21 ab cess fortnation (31 ol truction (11 inability to exclude dignosis of a malı, nast tumor (5) fistulas (6) repeated hemorrhages (7) failure to obtain relief by con erva tive measures His choice of surgical procedures was (11 for acute perforation simple closure of the perforation with a proximal dner 2onal colo tomy when indicated as in an extensive proress or when ob truction 19 uspected (2) for abscess formation inci son and drainage followed by resection of the di eased process after the acute proces tb ided (3) for obstruction a three stage pro cedure a night transver e Vlıkulicz type of colo torny resestion of the tumor and later closure of colostomy If malignant diere could not be excluded in the pre-ence of an obstructing tumor he tucommended segmental resection of the involved area and if po sible examination of the removed teeue efort a final deci ion was made as to the operative procedure to be used for enterose cal or other fi tulns he considered a three sta procedure indicated a pre liminyy right transier e colo tomy followed in lour to «ux months ·20 DIVERTICULITIS by resection of the diseased sigmoid with primary anastomosis closure of the bladder defect and a later third stage closure of the colostomy Smith®discussed the theories of etiology with regard to con stipation and he con dered it 1 factor but wlule constipation is more common in females than in males diverticulo is occurred more frequently in males He mentioned the theory of Devine and Devine ** sho stated that straining at stool was a contributory fac tor yet while the expul ive effect way more marked in the rectum than in the sigmoid diverticula appeared more often in the sigmoid and fecal material was former in the rectum than in the sigmoid The theory that increased intraluminal pressure caused the pulsion type of diverticula could be contested in his opinion by the fact that although these positive pressure relationships were present from birth diverticula occurred chiefly in later life lle referred to leo mans ? four possible reasons for the development of diverticula (1) hernial protrusion following emerging reins (2) increa ed intraluminal pre sure causing herniation through real points as a result of irregular contraction (theory of heith) (3) In final analy sis it was a matter of neakness exi ting for some cau e in the intes tinal coats because of which a pouching of the coats occurred when undue pres ure aro e as suggested by Hartwell and Cecil (1) It was Erdmanns opinion that all uere of congenital origin and no single factor could explain all duerticula Smith al o di cussed the place of sigmoidoscopy in diagnosis as having increasing value with experience and reviewed Bune and Jackmins findings Smith al o noted that the pre ence of diverticula ? sometimes disclo ed during sigmoido copy by displacement of their fecal content as a result of slight pressure from the distal tip of the sigmoidoscope He lind obsened the diameters of the orifices to vary from several milli meters to 2 centimeters Rurely an inverted duerticulum would re emble a polyp hy sigmoido copic examination When dnerticu Iitis was pre entgmoido copic diagnosis become more difficult and there was no typical picture it often being impossible to rule out carcinoma A long hi tory sugge ting gradually increang ob ·HISTORICAL REVIEW 21 truction the pre ence of edema the lack of bleeding and the oc currence of more pain than va u ual in the pre-ence of carcinoma might suggest that the underlying proce s was dnerticulitis Smith al o mentioned the fact that a previous ly terectomy endometriosis and uterine myomas might give the file impression that fixation was secondary to diverticulitis Albright and Leonard' wrote on the management of dnverticulitis coh In general they believed that presentable bowel insalıdı m serious surgical complications and fatalities from diverticulitis might sometimes be avoided by good management including the establishment of a simple effective bowel management regimen maintenance of an adequate anal outlet and proper election and timing of surgical intervention in the authors opinion more em phasis should be placed on the role of spa tic con tipation and anal back pressure in perpetuating symptomatic diverticulitis and initiat ang complications Bed rest bland low residue diet avoidance of cold fluids antispa modics sedation heat to abdomen and hot water to drink with the avoidance of cathartics were recommended Anal spasm or fibro is may require anal dilatation under ane thesia external sphincterotomy or the operative correction of associated anal disorder The authors also emphasized the fact that with recent surgical advance re ection in symptomatic cases can be done in selected patients They used a proximal diverting colostomy before re ection and stated that colo tomy clo ure without re ection failed in over two thurds of cases in which it is done While pre resection bowel preparation for a week is adequate in carcinoma 1 first stage fecal diversion for everal month is be t in inflammatory diverticu litis They al o believed that re ection by exteriorization was u ually afer than primary re ection unless the egment involved was hort the inflammation chronic or slight and di tal obstruction was ał sent 1952 Rowe and Kollmar" di cussed diverticulitis of the colon compli czted by carcinoma Since duerticulitis often cannot be distin guished from carcinoma the e authors believed that a more aggre ·20 DIVERTICULITIS mans 10 by resection of the diseased sigmoid with primary anastomosis closure of the bladder defect and a later third stage closure of the colostomy Smith ? di-cussed the theories of etiology with regard to con tipation and he considered it a factor but while constipation is more common in females than in males diverticulosis occurred more frequently in males He mentioned the theory of Devine and Devine 34 who stated that training at stool was a contributory fro tor yet while the expulsive effect was more marked in the rectum than in the sigmoid diverticula appeared more often in the sigmoid and fecal material was firmer in the rectum than in the sigmoid The theory that increased intriluminal pressure caused the pulsion type of diverticula could be contested in his opinion by the fact that although these positive pressure relationships were present from birth diverticula occurred chiefly in later lıfe He referred to Yeo four possible reasons for the development of diverticula (1) hernial protrusion following emergin, veins (2) increased intraluminal pressure causing herniation through weak points as a result of trregular contraction (theory of Keith) (3) In final analy sis it was a matter of weakness existing for some cause in the intes tinal coats because of which a pouching of the coats occurred when undue pressure arose as sugge ted by Hartwell and Cecil (4) It was Erdmanns opinion that all were of congenital origin and no single factor could explain all dierlicula Smith also discussed the place of sigmoido-copy in diagnosis as having increasing value with experience and reviewed Buie and Jackman findings Smith also noted that the presence of duerticula 18 sometimes disclosed during sigmoidoscopy by di placement of their fecal content as a result of slight pressure from the distal tıp of the sigmoidoscope He had observed the diameters of the orifices to vary from several mıllı meters to 2 centimeters Rarely in inverted diverticulum would resemble a polyp by sigmoidoscopic examination When divertica litis was present sigmoidoscopic dignosis becime more difficult and there was no typical picture it often being impo sible to rule out carcinoma A long lu-tory suggesting gradually increasing ol ·HISTORICAL REVIEW 21 truction the pre ence of edem the lack of bleeding and the oc currence of more pain than w7 wunl in the presence of carcinoma might suggest that the underlying proces was diverticulitis Smith al o mentioned the fact that previous hy terectomy endometriosis and uterine myomas might give the file impresion that fixation was secondary to diverticulitis Albright and Leonard' wrote on the management of diverticulitis col In general they beliesed that preventable bowel inı alıdı»m erious urgical complications and fatalities from diverticulitis might sometimes be avoided lyy good management including the e tablishment of a simple effectie bowel management regimen maintenance of an adequate anal outlet and proper selection and timing of surgical intervention In the authors opinion more em pha is should be placed on the role of pastic constipation and anal back pre ure in perpetuating symptomatic diverticulitis and initiat ing complications Bed ret bland low residue diet avoidance of cold fluid, anti po modics sedlation heat to abdomen and hot water to drink with the avoidance of cituarhics were recommended Anal spasm or fibrosis may require anal dilatation under anesthesia external sphincterotomy or the operative correction of associated anal disorder The authors al o emphasized the fact that with recent surgical advances resection in symptomatic cases can be done in selected patients They used a proximal diverting colo tomy before resection and tated that colo tomy clo ure without resection failed in over two thirds of ca es in which it was done Wlule pre re ection bowel preparation for a week is adequate in carcinoma a fir t stage fecal diversion for everal monthis is best in inflammatory diverticu liti» They al o believed that resection by exteriorization was u ually safer than primary resection unle s the segment involved was hort the inflammation chronic or light and distal obstruction was absent 1952 Rone and hollmarº di cussed dnerticuliti of the colon complı cated by carcinoma Since dnserticuliti often cannot be di tin guished from carcinoma the e authors believed that a more aggres ·22 DIVERTICULITIS sive attitude should be taken le primary resection rather than the defunchoning of the bowel for a period of several months before resection is done a form of treatment often advised for diverticulitis These authors found only 62 definite cases of coexisting carcinoma and diverticulitis of the colon in the literature up to May 1950 They also reviewed the historical data on diverticulosi and diver ticulitis mentioning the description in Buillies Anatomy in 1794 They called attention to Virchow si description of isolated cir cumscribed adhesive peritonitis of the colon Virchow failed how ever to associate this lesion with diverticula which he had described The authors stated that Graser 19 in 1898 was the first to consider the inflammatory stenosis of the sigmoid and rectum as simulating car cinoma of the colon while Beer in 1904 raised the question of pre disposition of the inflamed bowel to the development of carcinoma Folloning Wil on s paper various authors already reviewed in this hook perpetuated the theory that diverticulitis predispo ed to car cinomatous development However Rowe and Kollmar believed that since 1924 sufficient statistical evidence had shown that the occurrence of carcinoma and diverticulitis wis merely coincidence Their survey of several ho pitals showed that among 700 patients with carcinoma of the colon only 7 had coexisting diverticulitis and carcinoma and these authors made the point that only 3 (043 per cent) had carcinoma and diverticulitis in the same egment The authors stated that a strong suspicion of cancer is justified only if weight loss and bleeding with obstruction and anemia are present while a palpable mass and fistula formation are more suggestive of diverticulitis They stated that bleeding occurs with both diverticu litis and diverticulosis in variously reported incidence (5 to 26 per cent) but that an exhau tive Wearch for other origin should always be made In addition to proctoscopy as a helpful dingnostic and occasionally cytologic studies with the Papanicolaou technic are helpful but precise x ray examination is still the most accurate method of diagnosis These authors also recommend the more fre quent u e of primary resections and anastomoses to care for possible carcinoma and to decrea e surgical morbidity ·HISTORICAL REVIEW 23 1953 Case and Shea wrote on acute diverticulitis of the cecum They tated that all inflammatory di ea es of the cecum are rarely diag nosed correctly even at operation where drverticula may be buried in a mass of inflamed elematous tissue and thought to be neopla tic and therefore requiring unnece sanly radıcal surgery They re viewed 7 cases (17 per cent) of cecal diverticula at St Vincents Hospital They discus ed the etiology dividing them into true and false type considering that some are congenital and represent per si tence of an early embryologic appendix They quoted Greens felder and Heller concerning the other mechanical etiologic factors but they stated that mot solitary cecal diverticula are congenital true diverticula with all the muscle layers represented in their walls Since signs and symptoms are usually identical with those of acute appendicitis acute diverticulitis can usually be diagnosed only at operation In the chronic form radiography is u-eful but here too at may be difficult to di tingu, h from carcinoma tuberculosis of the cecum actinomycosis of the bowel or nonspecific ulcers of the cecum many of which the authors believed may be the end result of necrotic processes in a diverticulum of the cecum Regional iletis with extension to the cecum and amebic ulcer of the cecum must also be differentiated The authors reported 4 ca es of cecal diverticu hitis in 2 of which the complications of perforation ab, ces formu tion and fistula formation were pre ent Starkloff and Bindbeutal 100 discusserl the differential diagno 15 of diverticulitis and carcinoma of the colon and pre ented a tudy of 259 ca es of carcinoma of the colon and 30 ca es of duerticulitis Of the e 25 patients had coexisting carcinoma and diverticulo is of the same egment the rectosigmoid and 6 had coev ting car cinoma and duerticuiltis 4 of whom had the coexi ting lesions in the same egment (1 5 per cent) This figure agrees with other pre vous statistics and emphasizes that the relation hip is coincidental In 5 ca es however the clinical diagnosis of diverticuliti prosed to be incorrect the lesion being carcinoma without duerticula In their conclusions they empha ized the fact that no reliance can be ·24 DIVERTICULITIS placed on symptoms and signs except for bleeding and cachexia which should arouse suspicion of carcinoma In their series bleeding uas present in 62 per cent of carcinoma and 19 per cent of diverticu litus X ray examination with reliance on a normal appearance above and below the malignant growth is subject to pitfalls The authors advised a more radical surgical approach especially if carcinoma is strongly suspected Lewis and Hurwitz €8 wrote on surgical treatment of sigmoid diverticulitis reporting 10 consecutive cases of severe and compl cated diverticulitis of the sigmoid with re ection of the diseased segment and end to end anastomosis without mortality Sır patients did not require previous or complementary diverting colostomy while 4 had an earlier diverting colostomy all of which were closed later These authors laid down principles for the treatment of three complications For acute perforation they recommended incision and drainage closure of perforation and a proximal diverting colos tomy with later closure for obstruction a proximal diverting colos tomy was al o necessary with re ection of the diseased segment and redundant sigmoid in three to six weeks following the preliminary procedure (These authors believed that intraperitoneal closure of the colostomy should be done after the integrity of the suture line has been demonstrated which usually is the case in approximately three weeks ) for fistulas they use a deserting colostomy early resection of the colon with excision of fistulas and later closure of colostomy In their opinion a more aggressive surgical approach 19 necessary because of the morbidity and mortality associated with this disea e diverticulitis Vaughn and Narsete 109 110 wrote on the rare form of diverticulıtı that of the ascending col They stated that up to 1953 only 14 cases of drverticulitis of the ascending colon had been reported to which they added 2 of their own Of the previously reported cases most had been in patients between 10 and 40 years old whereas of their 2 cases 1 occurred in 7 50 year old man and the other in 1 67 year old woman and in both cases the atypical finding of melena was present One patient had diarrhea and melena for four days occurring two months and again one week before adm, ion There ·HISTORICAL REVIEW 25 was bright blood hy rectum but the patient al o had hemorrhoids The other patient had left subco tal pain intermittently for two years ind melena for two weeks The diagnosis of these le ions 19 made by the u e of barium enema examination with serial er posure Treatment of the disease is usually surgical because acute appendicitis cannot be ruled out In 14 cases previously reported their location varied 6 being medial 6 lateral and 2 antenor The syndrome of this condition simulates appendicitis but when dier ticula are located in the ascending colon the appendix is less hkely to be involved than when they are in the cecum The incidence of all diverticula of the large howel 1 according to these authors 3 to 7 per cent and of these only 15 to 2 per cent occur in the right half of the colon These authors estimate that in about 15 per cent the howel becomes inflamed The cau ntive factors of diverticula in the right colon have not been accurately determined but the following should be considered 1 E te o ou ystemmonest in leoc cal areas 2 Hered taryf tor not pos ble of p oof 3 Eve si n of a weakened bowel wall 4 Taton on th rp nd ces er ploc me e tery om ntum by int a ab dom nal dhe 114 5 Weaken of the bowel wall by a cular entry 6 I rea edtraluminal pregue 7 Cathart cs and purgatives 8 Mucot ulcerations In previously reported cases the ratio of females to males was 2 to 1 whereas in diverticula of the cecum itself it was about equal Diverticula of the ascending colon had a greater tendency to occur in the younger age group when compared with cecal diverticula Another paper on right colon diverticulitis was written by Unger who reported 6 ca ex He tated that 132 ca es had already heen reported in the literature Clinically it is indistingui hable from acute appendicitis In Unger s cises the age range was from 26 to 61 yeurs and er distribution equal In all ca e acute diser ticult was su pected Diverticulectomy complemented by appen dectomy if feasible is the operation of choice but when cecal neo plasm cannot be excluded ileocolic resection is justified Wherever 108 ·28 DIVERTICULITIS 1 experience attended this operation and serious complications can thus be prevented Hour and Bernhard 'wrote about the complication of bleeding in duerticular disease They stated that this complication had re ceived Istile attention They considered is still not conclusively proved the theory of pathogenesis which assumes that the out pouching of the mucosa occurs through the muscle layers at the point of emergence of a nutrient artery to an appendix epiploica They reported on the incidence of rectal bleeding in 3 17 cases from 10 year period at the Peter Bent Brigham Hospital in which the bleeding originated from diverticulosis or diverticulitis An addi tional 38 cues of diverticula and concomitant carcinoma were also reviewed There were 111 patients with diverticulitis 42 (37 per cent) had rectal bleeding 31 of whom liad no gross evidence of rectal bleeding or melena but had two or more positive stools for occult blood Nine patients had z kustory and gross endence of bleeding or the stool was strongly positive to the guaiac test Two patients had uncontrolled rectal hemorrhage and required surgical treatment as a life saving procedure of the e 12 cases 11 Ind associated obstruction and I had absces, formation The other 30 had no major complication The e data showed that bleed ing per se associated with diverticulitis has no significint relation słup to other complications except obstruction of the total group of 385 ca es a carcinoma was present in an area of diverticuliti in only 14 (36 per cent) As a correlating study the authors re ported that of 466 cases of carcinoma of the colon and rectum over a 10 year period a concomitant xriy diagnosis of diverticulo,13 was made in 38 ca es (8 per cent) which is approximately the expected figure in the middle or old age group of the entire popula tion The e authors reported 4 cases of musle hemorrhage with dverticular di ea e 3 of the e patients died thich led the authors to recommend early operation prouded other sources of bleeding are eliminated ulceratre colitis is ab ent by procto copy and diverticula are pre ent by x ray erimination The authors tated that while cancer of the colon is the commonest cause of rectal bleeding it is relatııely uncommon as a cause of massite hemor ·HISTORICAL REVIEW 29 thage Of 236 case of diverticulo is (without carcinoma) detectable rectal bleeding 19 present in 39 or 16 per cent Higgins and Burger wrote on an uncommon form of diver ticulosis and diverticulitis that of the vermiform appendix stating that it occurs in about 1 of every 200 appendices and may be congenital with all layers of the bowel intact or acquired with no muscularis layer Edel 37 in 1894 described the e appendiceal di verticula and since then there has been considerable discrepancy in the reported incidence and some controversy over the classifica tion and pathogenesis These diverticula are often overlooked at surgery and the diagnosis is made only by the pathologist They are not an extension of diverticulosis of the colon The authors reported a case of retrocecal appendix with five diverticula projecting from the antımesenteric border one acutely inflamed and perforated Colcock and Sass $ $1 wrote on the occurrence and complications of diverticulitis in the aged They stated that the highest incidence of this disease occurs in the sixth or seventh decade of life and that it is more common in overweight patients with sedentary occupa trons who suffer from con tipation Therefore it hould be suspected in any patient over 40 years of age who is overweight and complains of repeated attacks of left lower quadrant distres. Thiey mentioned the possibility of occlu ion from inflammatory reaction in the bowel and called attention to the fact the dysuria should be considered a warning that the inflammatory proces may be involving the bladder wall They regarded rectal bleeding is an unimportant symptom of diverticuliti and suggested the need for earching for other sources of bleeding of this is pre ent They mentioned the fact that the ray finding of a rather long arei of narrowing suggests diverticulitis rather than cancer in which the narrowed area is shorter They also mentioned the picket fence or saw tooth appearance of the mucosa which is u ually seen throughout the in volved area in contrast to its absence in malignant lesions Abo in diverticulitis the area is more tender and rigid when palpated during fluoro copy and the o called lipping 1 zb ent In a review of 50 case of carcinoma and 50 ca es of diverticuliti the complıca tions of perforation and ab cess and fi tule occurred much more ·30 DIVERTICULITIS often in diverticulitis (40 per cent and 31 per cent) than in car cinoma (6 per cent and 2 per cent) obstruction like he was present more often in diverticulitis (22 per cent) than in carcinoma (16 per cent) They believed that most cises of diverticuhtis can be ade quately managed by conservative treatment but about 10 to 20 per cent of these patients will hue repented attacks or complıcations They recommended surgical treatment for recurrent or extensive dı verticulitis to avoid complications which they believed are especially lizzardous in old patients in such cases they thought the bet operation is a proximal transverse colostomy followed in everal months by re ection and anastomous and finally by closure of the colostomy but if carcinoma is su pected resection must be done in two to three weeks with further procedures depending upon the pathologic findings 1955 Friesen and Schmidt 8 reviewed 301 cases in which the dingno 15 of diverticulosis or diverticulitis had been made of these 7 per cent required surgery with stenosing obstruction as the chief indication The authors mentioned the fact that antibiotics huve decren ed the incidence of ab-cess and fistula formation The choice of surgical procedure depended on many fictors such as the age and general condition of the patient the acuteness of the process the pre ence or absence and degree of obstruction the number and duration of previous attacks the extent of inflammatory reaction the pre ence of fistula or abscess and the mobility and accessibility of the in volved segment Gilchri t and Economou " syrote on urgical treatment of diserti culitis of the colon They stated that one third of persons over 15 Inse duerticula of the colon most commonly in the sigmoid next frequently in the de cending colon but at times scattered throughout the colon They al o stated that drverticuli are not een below the peritoneal reflection and in their opinion they are pul son diverti culi Increa ed intraluminal pres ure ? an influence on ilıcır formation is indicated by the fact that in ca e of carcinomi of the sigmoid with ob truction duerticult neare tille ob truction are ·HISTORICAL REVIEW 31 deeper and more inflamed than the more distant ones The e authors behered al o that inflammation a ociated with the diverticula may he the actual cru e of fixation in carcinoma of the sigmoid which makes the prognosis better in the e cases Abscesses are formed by the trapping of feces in the diverticulum Their indications for surgery are the usual ones (1) free perforation which may occur in a rather movable portion of the sigmoid (2) abscess formation (3) partial or complete obstruction (4) fi tula formation (5) in ability to exclude carcinoma (6) recurrent disability and pain These authors also discuss the problem of bleeding in the presence of diverticulitis stating that it must be assumed that polyps or carcinoma are also pre ent and even if they are not definitely found the involved portion of the colon should be removed and the ret of the colon explored When surgery is performed and the descending colon as well as the sigmoid is involved both should be removed thus excising mo t of the disea ed bowel and promoting loose stool resulting in leas danger from remaining diverticula McMillan and Jamieson 18 wrote on trends in surgical treatment of diverticulitis of the colon They considered the five complıca tions of diverticulitis to be (1) perforation (2) ob truction (3) fistula formation (4) carcinoma and (5) bleeding They con sidered the small slowly developing and walled off perforation as possibly subsiding but frequently recurring A right transver e colostomy with inci ion and drainage of abscess is indicated if medical management is unsuccessful They also thought that acute perforation into the peritoneal cavity is more common than usually believed and requires drainage and colo tomy For obstruction they believed that failure to use prompt surgical treatment leads to disastrous results when obstruction is cau ed by fibrotic edematou or granulomatous stenosis or di fortion of the colon in which ca es intubation enemas and antibiotics are unsucce sful They regarded treatment of external or internal fistulas without resection of the di essed colon as de couraging They al o stated that inability to distingui h carcinoma from diverticulitis i one of the mot definite indications for re ection They al o found that bleeding is often setere enough to uarrant operation They expres ed the opinion ·32 DIVERTICULITIS that diverticulitis may be disabling and ha ardous of not consistently controlled by a good medical program They considered the di ease more severe in patients under 50 years of age and that resection 1 indicated while the patient is in good general condition Unex plained urinary symptoms and severe residual deformity of the sigmord are in their opinion indications for surgery The surgical measures discussed by them are (1) cecostomy wluch they consider frequently inadequate and unsatisfactory as a definitive or pre liminary operation (2) colostomy as a necessarily palliative or preliminary operation in patients in poor condition (but they re garded closure of the colostomy without resection as frequently resulting in further exacerbation or complication of the di ease) The best operation is in their opinion re ection with anastomosis which may be done in two or three stages depending upon condi tion of the patient Tlus can usually be accomplished safely in three to four weeks and be followed in another three or four weeks by closure of the colostomy Judd and Mears & wrote on the surgical progress toward a wider applıcation of a single stage re ection of diverticulitis of the sigmoid They believed that in the past surgery las been used only in cases with complications and that from experience a multiple stage opera tron was considered necessary They thought that llurs approach should be re evaluated and that 1 propłıylactic re ection of the colon during a quiescent interval of the diseasc luze much to recom mend at Under these circumstances 1 single stage primary re ection can be done with very low morbidity and very little risk becau e of modern improvements in anesthesia and advances in antibiotic therapy and preoperative and po toperative care They recom mended this elective surgery in patients with a hustory of recurrent attacks of diverticultus esen though the patient is in apparent good health and v rays how only scattered dnserticula the purpo e of such surgery being to spare the patient the increased r k discomfort incontientence and expen e of multiple stage procedures when serious complications are pre ent They emphasized the in dıcations of such elective surgery not only for patients with recurrent attacks in spite of good medical care but also for all patients with ·HISTORICAL REVIEW 33 winary symptoms a ociated with an attack of diverticulitis (u ually male patients) and when carcinoma cannot be ruled out in their experience 6 of 68 patients had hemorrhage which could not be attributed to any other cause 1956 Bacon and Valiente' wrote on the surgical management of diver ticulitis They emphasized the greater need for preventue re ection particularly because of the low mortality and morbidity now possible through control of colic bacterial fora improved nutritional control and electrolyte replacement Presentive resection can usually be done in one stage urth consentate preoperatite treatment in ca es of acute diverticulitis delaying the operation until the acute infection has subsided If a hberal segment of bowel is re ected by left hemicolectomy and ana tomo is of the distal transver e colon to the low igmoid or rectosigmoid rehabilitation of the patient is excellent in mo t cases Even when the policy of preventive resection ued there will til he pecial problems arising from the fact that diverticulitis is often first diagno ed when a complication occurs For acute sudden perforation of the colon the authors recommended repair of the site of rupture with or without transver e colostomy When the bowel wall 19 frable local repair cannot be done and er teriorization is the be treatment but if the bonel cannot be readily mobilized the inflammatory area is drained and transverse colos tomy is performed with Neomycin solution (5 Gm in 500 mal of sterile solution) directly injected into the bowel lumen and flushed through the colon by gentle manipulation Fistula, are treated by resection of the disea ed egment and removal of the fi tulous tract and the viscus penetrated by the fistula 1 repaired A three stage procedure is cho en if there is preoperatie evidence of active in fection and inflammation with three weeks to three months elapsing between colostomy and re ection Strictured areas if inflammatory reaction is minmal are best treated with primary re ection because of the high incidence of carcinoma in dizerficulitis Hemorrhage which is usually evere and accompanied by shock can be treated con ervatively but the patient mu t be prepared for re ection when ·36 DIVERTICULITIS Zinninger 1 stated that patients with chronic low grade obstruc tion and recurrent low grade inflammation should live the benefit of surgical excision This operation is in his opinion often more difficult than in cases of neoplasm since the mesentery is often thickened shortened and fibrotic and the ureter is drawn up into it necessitating accurate dissection of the ureter before any resec tion of the mesentery With acute infection or significant obstruction preliminary diverting colostomy is done before re ection is at tempted and in acute perforation local drunage plu colo tomy should be performed to be followed by whatever surgical mezsures are appropriate Simultaneous presence of diverticula or deserti culitis and carcinoma is in this author s opimon reasonably common and differentiation often very difficult particularly when inflamma tion and at least ome degree of obstruction are present A diverting colostomy is usually a necessary preliminary operation ind the time between colostomy and re ection is usually four to ix weeks with modern methods of surgery Allen and Behringer reported on 210 con ecutive patient treated by resection since 1942 27 6 per cent of whom were ad mitted and operated on after their fir t attack of diverticulitis These authors stated that about two thirds of per ons aged 85 have diverticulosis and one third have diverticuhtis sufficiently severe to warrant surgical treatment They also stated that it is their conviction that radical treatment i more logical in the young than in the old since one of the serious complications is more likely to develop during the longer life of the younger patient l'urthermore in the younger age group before serious complications occur a one stage operation can be readily done Nearly all patients of any age how ever can be treated by resection if the definitive procedure is properly planned With long standing diverticulitis and chronic obstruction a well planned re ection at an elective time usually gres safe relief Waugh and Walt" writing on changing concepts in the trent ment of diverticulitis of the sigmoid stated that about 80 per cent of patients should be able to avoid operation for diverticulitis hut when the disease does not respond to medical measures a one ·HISTORICAL REVIEW 37 stage operation can u ually be done in a quie cent period While a preliminary transier e colostomy will always be necessary in ome patients and in others a proximal colostomy at the time of anastomosis may be life saving colo tomy is no longer regarded as a routine concomitant of the surgical treatment of this di ea e The authors considered the main indications for elective operation today to be (1) intractability and recurrent episodes (2) subacute obstruction (3) walled off perſoration which respond temporarily to antihuotics and non urgical treatment (11 unexplained melena with x ray evidence of duerticulitis (5) fi tula formation between sigmoid and other organs including kin (6) recurrent or per i tent urinary symptoms cau ed by the diserticuliti and (7) inability to diagno e nature of a palpalile ma » (duerticulitis or carcinoma) Maynard and oorhees wrote on a ca e of artenal hemorrhage from a large bowel diverticulum 1957 heith and Rini de cribed the si,nificance of diverticula of the colon in ma sive melena They tated that clinicians and pathologists are reluctant to accept diverticula as the ource of hemorrhage becau e af autopsy a bleeding point may be difficult to find The incidence of diverticulosty of the colon is estimated at 5 to 10 per cent of adults over 40 years of age hence he morrhage of due to diverticula should be a fairly frequent occurrence To attribute melena to driverticult honeser certain critena hould be recog nized namely the bleeding hould be of bright red blood there should be no hemateme is all other sources of bleeding should be eliminated there hould be a negatise upper ga trointe tinal xray eries and blood coagulation hould be normal in the authors sur vey of 317 un elected patient with diserti ula of the colon 60 (19 per cent) had mas lle hemorrha, e gros bleeding or tools re peatedly positue for occult blood by the guaiac te t Nineteen 16 gres cent) had ma 91e rechal bleeding and of th group 13 patients had yncope or subjective symptoms of hock In all ca es con servalise management with replacement of blood was u ed The authors ady, ed avain t emergency urgery in most ca e and in ·38 DIVERTICULITIS of many cases in which diverticula are distributed over mo t of the colon surgical resection is inadvisable becau e the specific bleeding site is eldom located However if the diverticula are limited to the Jeft colon resection should be feasible and when they are dis tributed over the entire colon a transverse colostomy may suffice to afford relief of bleeding Knight wrote on massive hemorrhage from diverticular disease of the colon stating that hemorrhage as a complication of such disease of the colon is a fairly well accepted concept Not as well recognized however is the occurrence of massive exsanguinating hemorrhage as a complication of this di ease This author reported from the literature a varying incidence of bleeding from 10 to 30 per cent usually of minimal amounts knight reported two series of patients (1) 185 patients seen over a 10 year span with proved diagnosis of diverticulosis or diverticulitis and (2) 101 cases seen over a six year period also with proved diagnosis of diverti culosis or diverticulitis In group one 23 of the 185 patients (124 per cent i gave a history of gross bleeding from the rectum Adequate studies in all these cases showed no other cause for bleeding 7 of these 23 cases had evidence of marked blood loss requiring blood replacement In group tuo 33 (31 7 per cent) of the 101 patient gave a hı tory of grous bleeding presumed to be from diverticular disease there being no other cause found and x ray evidence of diverticulosis pre ent of the e patients 10 showed disease involung almost the entire colon In 1 case proctoscopic examination di closed bleeding from the mouth of a drerticulum in the sigmoid of the 33 patients 7 suffered ma-suse bleeding requiring blood replace ment Of these 7 1 had diverticulosis of the entire colon and 3 showed diverticula from the hepatic flexure to the rectum The author drew several inferences from this study He considered ma te bleeding a relatively rare occurrence considering the frequency of diverticulosis He believed from los tudy that the everity of the bleeding seemed to be correlated to the extent of the diverticular formation but he did not di-count the posibility of hazırdous bleed ing from localized diverticulo i He al o called attention to data observed in hı study howing that make hemorrhage seem more ·HISTORICAL REVIEW 39 likely to arıe from diverticulo is rather than from diverticulitis and that infection is not essential for hemorrhage to occur No patient in this series had signs or symptoms of diverticulitis at the time of hemorrhage or a history of it in the past His thesis therefore is that local trauma produce ulceration with subsequent hemorrhage and therefore the mo t important etiologic factor in hemorrhage from this at ease knight suggested conservative treatment at firt that is rest s dation howel management and blood replacement as indicated In most cases even in tho e with considerable bleeding he found this adequate An elective resection of the disea ed bowel eem justified in localized diverticulosis when bleeding is recurrent or severe The challenge comes when massive bleeding does not stop and emergency laparotomy is required in such ca es bleeding can be controlled hy resection of the disea e is localized If the disease is extensive involving the entire colon it is not always posible to localize the bleeding area resect it and do a subtotal resection of most of the bowel since an emergency operation for exsanguinaling hemorrhage 19 a formidable procedure The author treated 2 patients of this type with diversion of the fecal stream by means of a colostomy and hemorrhage was thereby controlled He therefore sugge ted this procedure with a po yıble elective resection at a later time as the safe t way to control massive hemorrhage from this cruse Strenger felt that diverticulitis is a chronic progressive dı ease and advocated early surgical intervention before the onset of complications His criteria for election of patients for surgery were as follows (1) a definite history of diverticulitis supported by physical findings in the lower quadrant of the abdomen (2) roentgenograms showing diverticula and persistent deformity and spa m of the sigmoid indicative of an inflammatory process (3) a specific history of more than one attack (4) rectal bleeding at tributed to diverticubtts and (5) a good surgical risk 1958 Boles and Jordan 13 reported a study of 294 patients with diverti culosis who e history through an averige follow up of 15 years (minimum of 10 years) was inve tigated for (1) increa e in ·40 DIVERTICULITIS number of diverticula (2) the development of diverticulitis in single or recurrent attacks and (3) development of complications bleeding obstruction perforation with or without fistula formation More extensive diverticulosis developed in about one half of the total group with one third finally having involvement of the entire colon Diverticulitis developed in 25 per cent (73 patients) of this group over one half (40 patients) had no second attack (fol low up of three to 15 years of the 33 with multiple attacks about one half (16) had only two attacks The only complication of diverticulitis which appeared to be related to multıplıcıty of attacks was obstruction (9 out of ll patients with obstruction having had multiple attacks) Melena or a brisk hemorrhage occurred in 18 of the total group (6 per cent) and of the e 18 cases I had simple diverticulosis with no evidence of duerticulitis of the total group 15 patients (5 per cent) bad large bowel obstruction (2 with associated small bowel involvement) but only 11 of thus group mutl. obstruction had a clinical picture of diverticulitis of the total group 15 (5 per cent) had perforation with or without fistula formation 10 of this group pre ented this complication during an acute attack of diverticulitis wlule in the other 5 cases perforations were slowly developing with mass or fi tula formation In 15 (5 per cent) of the 291 patients with diverticulo 14 carcinoma appenred during the follow up period 8 (36 per cent) of the e in the group of 221 patients who had had no attacks of diverticulitis In the 73 patients who had had diverticulitis carcinoma appeared in 7 (96 per cent) but 2 of these 7 patients had carcinomu in an area of the colon where no diverticula were pre ent and 2 others had car cinomatous polyps of the sigmoid In only 3 patients (1 per cent) carcinoma appeared in the area of the colon where previou duer ticulitis had occurred Horner wrote on 503 patients whom he follonel 151 from six to 10 years and none le-s than one year in an attempt to elucidate facts on the natural hi tory of the disei e le believed that aging definitely plays a role in development but that previous bonel lulut had no etiologic role However 83 per cent and an iritable colon prior to the development of the dnerticula Approximately two ·HISTORICAL REVIEW third showed no progression in the number of diverticula and 95 per cent had sigmoidal involvement The longer the follow up the better chance there was for the complication of diverticulitis to become manife t He believed that diverticulosis is a benign condi tion responding well to medical management Only 2 of the 85 patients with diverticulitis required surgical intervention and in tere tingly the complication of obstruction did not develop in any patient in this group Schapira et al 13 recommended conservative and nonoperative treatment for diverticulitı of the cecum and right colon In their experience a econd attack was quite rare They believed diverticula of the cecum and right colon are the same type as tho e in the left colon but usually they are fewer and more difficult to demonstrate especially during the acute pha e Degenshein 33 however believed that the diverticula of the right colon are pathologically distinct from those of the left in that they are true diverticula containing all coat The clinical diagno is of diverticulitis is based on pun in the right lower quadrant with a ma s and absence of nausea and vomiting He recommended for treatment the more radical approach of primary right hem colectomy Welcl 118 noted the pattern of attacks of diverticulitis to be so variable that it was impossible to be dogmatie with regard to in dications for surgery In the individual patients these considerations were important (1) other more malign symptoms pre ent such as rectal bleeding or dysuria (2) roentgenographic studies showing serious deformity of the involved segment of the colon indicating that fibrosis and sesere tructural change will lead to obstruction at a later date (3) the attachs being persistent despite compliance with good medical advice and troublesome enough to require relief (1) those patients younger than 50 years repre entative of a group who will have the di ea e longer and who appear clinically to have a disproportionate number of erous complications and (5) the patient representing a good operative risk with a limited segment of colon inyolsed with diserticuliti He believed that the changing trend in the urgical treatment ·42 DIVERTICULITIS of diverticulitis reveal a steady shift to the more radical and curative operations The 27 per cent mortality in 218 sigmoid resections at the Massachusetts General Hospital from 1912 to 1957 is im pressive and their end results have been excellent The place of one stage segmental resection as a mode of relief from diverticulitis of the colon is recommended in the carefully selected patient Jensen"1 stated that diverticula are the principal source of massive hemorrhage from the colon The anatomic b isis for such hemor rhage is that the diverticula occur near the mesenteric border at the point at which the nutrient sessels penetrate the bonel There i also an unusual vascularity in the walls of the discrticula Some degree of erosion or inflammation must be pre ent although no symptoms of such need be pre ent Usually arteriosclerosis and hypertension are accompaniments Conservatne treatment is recom mended but if surgery is mandatory segmental resection of the most involved area is the procedure of choice Scarborough º accumulated 89 patients with proven dagno es of premalignant or malignant lesions who were olserved for more than one year with a dragno is of diverticulosis or duerticulitis 15 an accepted cause for their bleeding lle advised exploratory operi tion and coloscopy when bleeding persists above the reclum and repeated roentgenograms slow only diverticulosis Colcock 0 noted from his analysis of 131 prtients operated on during the past 10 years at the Laley Clinic that in younger 117 tients (less than 50 year of age) with recurrent attacks of divertic ulitis complications necessitating surgical intervention were more likely to develop Often some degree of complication was present when the patient arrived at surgery auch 19 a portul obtruction and small ab ces es between the colon and bladder or lateral al dominal wall He found in this series that bleeding als ays responded to conseri atise management The mortality rate in this group was 15 per cent of the e patients 69 were subjected to 1 one stage resection with a primary ana tomo is with no mortality lle ad located earlier operation in tho e patients with relatacly un complicated (verticuliti thereliy lowering the mortality and hort ening the ho pıtal stay ·HISTORICAL REVIEW 43 1959 picture of Schliche und Loganº believed that surgery for diverticulitrs is rare outside the sigmoid colon in their series approximately 10 per cent of the patients were not considered preoperatively to have diverticulitis The reasons for a faulty diagnosis were as follow (1) Diverticulitis frequently presents the clinical gyneco logic di ease or carcinoma of the intestine (2) when complicated by perforation diverticulitis may mimic diseases causing general peritonitis such as appendicitis (3) there may be an absence of iny accompanying change in bowel habit (4) leukocytosis and fever may be ab ent (5) the presence of gross bleeding suggests di eases other than diverticuliti and (6) there is a discrepancy between the clinical picture of diverticulitis and the radiologic interpretation of diverticulosis without diverticulitis The indications for surgery in order of frequency are (1) in tractablity of symptoms (2) presence of paprible mass (3) in ability of the radiologist to exclude carcinoma (1) bleeding and (5) external fistula They advocated one stage resection and anas tomosis before serious complications develop necessitating multiple stage procedures Earley 31 reviewed the literature and found reports of 24 patients who were operated on to control hemorrhage from diverticular disei e Mot of the patients were older than 60 years and most pa trents had operative procedures n emergencie Adding 7 patients of his own for a total of 31 patients brought the mortality to 29 per cent Ile advised conservative management first which is often ade quate and then ruled out other causes for bleeding Cven then the bleeding may not be attributed to the diverticula If diverticula are believed to be the so ce lie then felt that one is compelled to resect all of the colon containing diverticula If the patient is too ill to tolerate resection or colectomy proximal ileo tomy or colo tomy may be helpful Inghs and Hamp on favored the embryologic origin of the diverticulum in the cecum and a cending colon They believed it ·44 DIVERTICULITIS 15 not always possible to distinguish diverticulitis in this location from acute appendicitis on a clinical basis but the suggestive trad described by Byrne hallan and Bassett (1) hi tory of previou appendectomy (2) pre ence of a ſecolith in the region of the cecum on xriy study and (3) symptoms of inflammatory disease in the right lower abdominal quadrant-1 hjelpful At surgery 70 per cent of the diagnoses are correct and the remainder usually masquerade as carcinom i Colotomy or cecotomy often provides the diagnosis in the questionable cases They thought that major colonic resec tion can usually be avoided if diverticulitis is considered The treat ment of choice in this situation is local excision or simple inversion of the diverticulum ·3 Diverticulosis PATHOGENESIS The first ob ervations by Friend in 1730 by Baille in 1794 and later by Cruveilhier konjetzny and Klebs establi hed the entity of the lesion the diverticulum The ubject then remained unnoticed in the literature at least until Gra er in 1896 became intere ted in the pathogenesis having made the observation that the Jesion was always found near the entrance of a blood vessel into the wall of the intestine and stating his belief that the herniation was associated with obstruction to the blood flow as in valı ular heart dı ea e About the same time Hanau ? did some experimental work on human intestine at autopsy by filling the inte tine with water and ob erving that rupture took place into the me entery In 1904 Beer questioned the theory that the weak spot through which herniation occurred was always on the me enteric side in fact he tated definitely that herniation occurred hecau e of a muscular deficiency on the nonmesenteric as well as the mesentericide and it was his belief that old age and constipation were the causes of herniation -old age by degeneration and constipation by intraluminal pres sure In 1907 Mayo Wilson and Giffin added obesity to old age and constipation on the list of cau es and left chronic passive con gestion as a possibility In 1911 Wil on attributed the lesion to con genital weaknes of the circumferential mu cularis and to pressure from chronic constipation In 1954 Barborka and Texter stated their belief that neither obe ity nor constipation plays a significant role in pathogenesis and again mentioned the fact that diverticula form where the intestinal wall is weakened by entry of blood ves els and that since the arteries the me entery divide into two branches and enter the intestine eparately diverticula frequently occur in pairs at the edge of the lateral longitudınal bands However they stated that while degenerative chianges of advancing age predispo e to herniation the final impetus to diverticular formation is still unrecognized 45 ·DIVERTICULITIS is not always po sible to distinguish diverticulitis in this location from acute appendicitis on a clinical basis hut the suggestive triad described by Byrne hallan and Bassett 17—(1) history of previous appendectomy (2) pre ence of a fecalıth in the region of the cecum on x ray study and (3) symptoms of inflammatory diere in the right lower abdominal quadrant—is helpful At surgery, 70 per cent of the dirgno es are correct and the remainder usually mr queride is carcinoma Colotomy or cecotomy often provides the diagnosis in the questionable cases They thought that major colonic resec trons can usually be avoided if diverticulitis is considered The treat ment of choice in this situation is local excision or simple inser son of the diverticulum ·DIVERTICULOSIS with all layers caused by fraction of tumors or adherent organs and the fal e produced by congenstal weakness of the walls and excessive sntraluminal pressure Hartwell and Cecil however in 1910 found no useful purpose in the classification of true and false or congenital and acquired and Wilkinson in 1933 stated that this classification had no clinical salue Subsequent authors also seem willing to dr» card this clasification Authors Comments With most writers of today the authors agree that the classifica tion of true and fal e or congenital and acquired has only bustorscal interest except in the case of so called traumatie diverticulitis of the cecum INCIDENCE AGE AND SEX In 1930 Rankin and Brown stated that dverticulosis occurred in about 5 per cent of persons having abdominal symptoms and prob ably in 1 per cent of all persons Ochsner and Bargen 2n 1935 re ported a 7 per cent incidence in 2 747 patients examined radiologs cally at the Mayo Chair Toung and loung in 1911 reporting on 70 572 colons studied hy autopsy or with barium x ray examination gave the figure of 5 2 per cent for the incidence of diverticulosis Authors Comments It is impossible to estimate the incidence of inerticulosis with any degree of accuracy sice usually the diagnols is made roent genologically and only a telaisely small groups of human beings fase a barium enema examination or upper gastrointestinal series in which the passage of barium through the shole digestive tract is recorded by films Autopsy reports may be used as supplemental sources but in general are le-s dependable than ropntgenograms for this dragao is It us interesting to note tint hrnkin and Brown estimate of 5 per cent incidence of drverticulo 15 i3 patients with abdominal sym? tomy corresponds approximately with thrt of Young and loun, in ·46 DIVERTICULITIS Authors Comments The authors agree with Barborka and Texter that there is as yet no proof of the exact nature of the final impetus for the formation of diverticula They also helieve that since diverticulosis is in genera} 1 condition first discovered in middle or old age the degenerative processes alone or in combination with the cumulative insult of pro cedures abusive to the colon or of abnormal influences upon the colonic musculature from psyche or coma most probally play a part in the formation of these herniated sacs Spasmn the evil phenomenon at the root of miny digestive com plaints is undoubtedly present to produce the increzaed intraluminal pressure so generally agreed upon is a causative or precipitating factor If this word spasm is substituted for the word constipanon a word meaning many things to many people the authors suggest that the two factors prenent in the formation of a diverticulum are probably degenerative changes with a po sible congenital hack round * producing weahness or a gap in the muscularis together with an abnormal degree and frequency of spastic contractions pro ducing intraluminal pressure Carlson and Hoelzels investigate work on rats was of interest suggesting that fat infiltration werkened the bowel and that a diet wluch produced increased colonic preysure through continuous contraction caused deserticul? The Iller of servation has special interest for the authors TRUE AND FALSE DIVERTICULA Tlus distinction based on the finding of all layers of the inte tinal wall in some cases and only the muco a in others was of interest during earlier studies when the designation true was thought to be dentical with congenital and false meant acquired Mayo in 1907 considered acquired diverticula to be either true or fal e depending upon the number of layers of the inte tinı) »}} the truc variety The theory of a concascal backround is supported a frequently stated in the literature by the fact that diserticulo does occa tonally occur in the young in teresting also in thi regard is Schlotthauer s report of 7 in one family of 9 person and the clinical observation made ly the sath rand oshers sai muul dis rticulo is is frequently seen ·DIVERTICULOSIS * 9.28- aged 6s have rerticulo i Thi tatement conform vith the impression of the authors Al ost has come to be the optaron oi mot ob essers today that the spy inuidenee xs about equal and the wthors arree woh that opintos llence in ed an estimate only 5 per cent of all indusiduals but 15 to 40 per cent of those oles 10 hoe dnerticulo is shule in the reylly aged the intestinal muscularis apparently becomes neak enougli to allow tle dleselopment of dierticula in varying extent I FIGLRFS 1 and 21 in aliout two tłords of the population

·48
DIVERTICULITIS
a large uncla sified group When the specific age group of indı
viduals over 40 is considered the estimated incidence in the litera
ture rises as high as 15 per cent to 10 per cent (see Johnson s Fig
276 in Bockus Gastroenterology on age distribution from Millard
and Bockus 1936) and this incidence increases with each decide
Allen and Behringer (1956) stated that about two thirds of persons
$2) 094
a
F1 1-Development of diverticula in
patient with irritable colon a 1919 6
191 and c 19,8
Fig 2 (facing page) - De lopme tol
di erticula in patient with irritabi
colon 1932 193 1910 and
1913

·DIYERTICULOSIS $1 F#4--D srticu} of fifmordth an a weated kast di este fum clinically interesting but harmles condition called by Ca e diuerticularis In 1927 Spriggs and \larxer and ra 1991 Barborka and Texter mentioned the auedge appearance of the sigmoid as indicating a prednerticular state and the fact that deserticulo!s is often best visualized in the po tesacuation film Authass Comments In the ruthors experience wloske dertsewda e la v lized In the po tevacuation barium enema film or in a blm tahen 21 hours ·50 DIVERTICULITIS DIAGNOSIS X ray Study It is generally agreed that dnerticulosis cannot even be suspected clinically until the complication of inflammation and its sequelae occur In 1915 however Case and Carman reported separately the early x ray observation of this condition Following their report all radiologi ts looked for and found what they considered a EXTENSIVE DIVERTICULOS fro 3-Exten i e divertieulo is demon tral d ali re acuation of barim ·DIVERTICULOSIS 53 duerticulitis tating that actually seeing the deserticula is possible more often than is usually belies ed In 1951 Smith added another diagno tic point to Bune s statement with his ob ersation that drs placement of the fecal content of the sac under slight pre sure from the distal tıp of the sigmoidoscope kelps to dragnose and localıze diverticulosis Authors Comments In the experience of the authors and their colleagues the open ings of the diserticular sacs are very rarely seen by proctosigmoid oscopy Other signs are present when there is an inflammation or other complications These will be discu sed later TREATMENT Authors Comments Mot writers on the subject of diverticular di ease regard treat ment of the diverticula as entirely unnecessary until complications initiated by inflammation occur They consider all disertacula of the digestive tract from the esophagus to the anus as innocuous unless inflammation 35 present in the authors opinon this is usually true of encrticula of the upper digestie tract but in the colon where strong sometimes sjo lent mu cular contractions occur it as wise to use prophylactic treat ment against the occurrence of diserticulits The authors theory is that inflammation is usually strated by the blocking of the open ings into the diverticula by extreme and sustained muscular spa m 50 common in the stable colon it is therefore their belief that when syruptoms of intable colon are present and diverticula are visualized anywhere in the colon the patient should be adused that their presence is an additional season for care of the irritable colon Further discussion on this point will follow under the ection on duerticulitis ·52 DIVERTICULITIS after the barium meal (FIGURES 3 and 1) The differentiation between polyps of the sigmoid and diverticula in that area some times becomes a problem and here Interal films poster rcuation films and double contrast films are of help in differentiating diver ticula from polyps (FIGURE 5) An inverted diverticulum pro truding into the lumen of the intestine may strongly simulate a polyp F1, 5-Diverticulosis of glompold demon treted after an air contrast study The authors urge that in all reports of barium enem1 examina tions the pre ence and location of diverticult hould be reported as well as an estimate of their size and number Such reports have importance not only for evaluation of the patient « pre ent or pos syble future abdominal symptoms but al o in aiding statistical re earch studies Proctoscopy Buie in 1939 and Jackman and Buie in 1913 reported digno fic signs by procto copy which arou ed 412 picion of duerticulosis or ·DIVERTICULITIS $5 tioned the tendency to recurrent attacks and the chronic inflamma tory changes in the whole inte final wall and its me entery obstruc tion resulting from the e factors or from adhesions in 1930 Rankın and Brown considered diverticulitis to be the result of improper emptying of the bottle shaped acculations with sub equent inflam matory reaction necrosi frequent tumefaction and occasional per foration They described the local inflammatory changes in the mucous membrane of the drverticulum which undergoes atrophy and subsequent round cell infiltration of the submucosal coat and lateral ulceration The e changes progrecs both in the wall of the bouel and in the me entery producing a pericolars and mesenteritis The changes in the coats of the deserticulum vary from attenuation of the musculature to its complete absence Authors Comments To the descriptions of the pathogenesis of dnerticulitis cited above little nes has been added in the last quarter of a century The authors would like however to emphasize again the role of *pasm in the development of inflammation in the enerticula Mor ton in 1916 in his 196 reported c7 es divided them into two groups dverticules with spa m and duerticulitis with complications He together with Wilkinson in 1933 and Albright and Leonard in 1951 in their recommendations for treatment indicated that pasm plays an important role in the development of diverticulitis and that measures to reliese spasm and restore normal motality in the intes tine are the best treatment for uncompheated disertsculitis The author s theory of the deselopment of deserticuhtı that it is an advanced stage in the whole prohlem of pathogenesis of diverticulo $is The sacs have already been formed and sath normal contrac tions of the bowel mu cularis there is an inflow and outflow of fecal material which then passes on with the res of the houel contents If honeser spasm in that arer excessne there is a light closure of the deserticular openings and the phenomena of retained feca} material inflammation secrosis and ulceration may occur More will be sand on thy subject when treatment of diverticulitis is discursed ·4 Diverticulitis PATHOGENESIS Moynihan in 1906 called attention to inflammatory tumors many of which were quite po sbly due to the presence of fal e dover ticula and associated inflammation He was the first to point out a diagnostic difficulty which perplexes clinicians of today namely the mimicry by these tumors of malignant di ence of the large intestine Mayo in 1907 con dered the true variety to be due usually to trac tion caused by adherent tumors or organs while the false were thought to be due to intraluminal pressure combined with a con genital weakness of the bowel The e inflamed duerticula might arise in his opinion from any surface and often extended into the epiploical appendages He con dered constipation with hardened feces impacted in the diverticulum as the cause for beginning irrita tion and ulceration He thought old age and obesity were factors and he mentioned chronic passive congestion as n po sıble factor He considered the inflammatory process either diverticulitis or peri diverticulitis the former causing no great reduction in the size of the bowel lumen but having a tendency to ncute perforation into the peritoneal cavity Perıdıverticulitis on the other hand by pro ducing chronic inflammation of the subsero a wound the diverticula he considered more prone to cause obstruction and rarely to per forate because the reparative procean was so predominint Telling in 1908 considered the pathologic factors of diverticulitis to be multiple and to include the narrow neck of the diverticulum collection of fecal matter within the deserticula con tipation in creased intraluminal pre sure and obesity Hartwell and Cecil in 1910 considered the secondary changes occurring in diverticulitis to be comparable to tho e in the sermiform appendix in appende citis the inflammatory process cau ing de truction of the coats of the wall with perforation leading into a localized ab ce a generalized peritonitis or septicemia They were among the fir t to describe fistula formation especially into the urinary bladder They al o men 54 ·DIYERTÍCULITIS 57 to find out what happened to the dnerficult in 20 1 patients (average age at tume of diagnosis 55 yers! over a course of years after they were diagnosed as simple duerticula It was revealed that in 73 patients (25 per cent) diverticulitis deseloped but in 10 of these (more than 50 per cent) there was no second attack in a follow up period varying from one to 27 years 19 of these 73 had follow up study for 11 to 27 years In 33 of the 73 (45 per cent) multiple attacks occurred but of these 33 16 patients (shghtly less than half) had only two attacks in a follow up of one to six years after the second attack while 17 patients (slightly more than half of this group with more than one altack and approximately 6 per cent of the total 29+ patients I had more than two attacks of diverticulitis This group under observation was also under management for irri table colon and although the control of mismanagement was not recorded the significance of these statistics (25 per cent hasing at least one attack of duerticulitis in a follow up of 15 years average) is probably greater than in any study without follow up Of equal significance is the fact that under these conditions only 6 per cent of the total group had more than one attack during this follow up period DIAGNOSIS The symptoms related to diverticult are caused by spa m and inflammatory change which indicate that diverticulitis has occurred The sevenly of the symptoms depends on the degree of involvement and the location of the sniammatory process Pain is the cardinal symptom It is usually located in the left louer quadrant of the abdomen and reflects involvement of the lower descending or sig moid colon where the majority of diverticula occur Depending on the degree of spasm and inflammation or the development of com plications the pain may be of a dull aching character or more severe as occurs with acute appendicitis Colic or cramp-like pain suggests severe spasm or ome degree of obstruction Constipation or tenesmus and dsarthea associated with anorexia &uses and voriting may be expected in severe acute attacks ·56 DIVERTICULITIS INCIDENCE Mayo in 1917 10 years after his first paper on acquired diver ticulitis reported 42 cases in which operation had been performed 37 of which involved the sigmoid l the transverse colon I the ascending colon 1 the hepatic flexure and cecum Later writers began to estimate the percentage of diverticulitis among all patients with diverticulosis Rankin and Brown in 1930 stated that of the 5 per cent of patients with abdominal symptoms who had diverticulo sis 17 per cent had diverticulitis In 1914 Young and Young from a compilation of statistics comprisin, 70 572 colons (xray and autopsy cases) in which 5 per cent had drerticulosis 12 to 15 per cent of these liad diverticulitis in three series of their compilation however totuling 3915 cases of diverticulosis the incidence of diverticulitis was 343 per cent Wigh and Swenson in their paper in 1951 dealing with the roentgenologic a pects of diverticulitis and its complications stated that of the generally accepted 5-10 10 per cent incidence of diverticulosis diverticulitis developed in 12 to 22 per cent Barborkand Texter (1951) stated that in their experience 5 to 10 per cent of all patients hive duerticult and of this group duerticulitis deselops in 15 to 20 per cent Greene 1957 found 50 7 per cent diverticulitis in a review of 353 cases of diverticuloare The highest incidence of diverticulitis was reported by Allen and Behringer in 1956 in their paper on this condition in the very aged They stated that two thirds of persons aged 25 have diverticulosi and of this group one thurd have diverticulitis In the group of ca es of diverticulosis studied for subsequent developments by Boles and Jordan duverticulitis developed in 73 of 294 patients (25 per cent) with diverticulosis at some time during a period of 10 to 17 years 31 in Authors Comments Is with stati tics on all di enwes there can be considerable con fusion beciu e of the sanety of sources from which information 14 ohtunedIn the paper by Boles ind Jordan the precific purpo e 76 ·DIVERTICULITIS 59 regional slestis ulceratise colitis carcinom bacillary and amebic dysentery and petsie pathologic alterations in the female Boles and Hodes' in describing a group of cases with endometriosis mvolving the small and large intestine and rectum recently showed how the disease can mimic duerticuhtis in its varying forms Roentgen examination of the colon by means of the barium enema usually indicates the presence of diverticulitis both by revealing certain fairly specific changes and by eliminating other conditions mentioned in the differential diagnosis (FIGURES 6 7 and 8) # F*7-D sells of ignord a sh part al ob truction and intra iał le syssy plan ·58 DIVERTICULITIS Fug 6 - Uncomplicated di erticuliti of stomoid On physical examination the abdomen is frequently distended and tympanitic Definite localized tenderne » Is noted over the site of the inflammatory proce - ind either a painful segment of bowel or an inflammatory mass will usually he palpable On occasion the inflamed egment of bowel is more easily defined by pelvic or rectal examination Some degree of fever u uilly 1 pre cnt In the differential diagnosis one mu t consider acute appendiciti ·OSVERTICUL715 59 regional leitis ulceralııe colitis carcinoma bacillary and amehic lycentery and pelvic pathologic alterations m the female Boles and Hodes! in descnbmg a group of cases with endometriosis onvoking the small and large mte fine and rectum recently showed how the disease can mimic diverticultıe in its varying forms Roentgen examinations of the colon by means of the barium enema usually indicates the presence of dnerticulitis both by revealing certain fairly specific changes and by eliminating other conditions mentioned in the differentsal diagno i» (FIGURES 6 7 and 81 re wies of sigmond with partial ob truci on and shiraciable symptom F1- ·58 DIVERTICULITIS -- 1 Fug 6 -- Unc mpli ated di et culiti olio On physical examination the abdomen is frequently di tended and tympanitic Definite localized tenderne si noted over the site of the inflammatory proces and either a painſul segment of bonel or an inflammatory ma - will usually be pripalle On occasion the inflamed egment of bowel is more easily defined by pelvic or rectal examination Some degree of fever u unlly as pre ent In the differential diagno is one mu t consider acute appendiciti

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·60 DIVERTICULITIS Schatzki ºf stressed the following roentgenologie findings which he believes are of as istance in the diagnosis of diverticulitis (1) 1 long wegment of bowel often involved (2) mucos? remuning intact (3) bizarre fringed contour (1) a sociated spism (5) tapered ends of the involved bonelind (6) accompanying diverticulr in other segments of the bowel in the absence of duerticulitis 21 and F 8-Diverticulitis of sigmoid 18 hour examination of the bowel following barium meal will reveal the presence of duerticula more clearly than well 1 barium enemi Proctoscopy is of invaluable 7-si tance in the differentil dignosis of duerticulitis Following are five signis previously mentioned and emphasized by Buie " (1) relative immobility of the bonel in a segment which normally is freely motilole (2) angulation of the lumen of the bowel (3) reduced lumen and mucosal fold (1) sigmoidal sacculations distingui hed from spa tic contracture of the bowel in that they do not d appear with inflation and (5) actual vi ualization of the deserticulı more frequently een with ·DIVERTICULITIS 61 drerticulosis than with diverticulitis He cautioned that the rare exerted dnecticulum which ein strongly re emble a polyp should be identified If auch an errot 19 made ind fulguration is attempted perforation is an unfortunate sequela Authors Comments In the majority of patrents the exact precipitating cause of scute dnerticulitis cannot be determined Specific inquiry however will frequently reveal that fatigue su tained nervous ten von dietary or alcoholic exce+ses and indiscretion or an upper respiratory Infec trons hare usually preceded an attack The frequent indiscrimate use of laxatnes in preparation for diagno tic tudies or in bouel preparation for a procroscopy or barium enem? is an avoidable contributing factor in converting a quiescent calon with diverticula into diverticulitis Mot infrequently patients wuh an irritable colon and diverticu losus who are suffering an aggravation of their symptoms are clasa) fied as having an allack of daerticulitis without any of the accom panying feature found hy physical examination laboratory findings or roentgenologic study Errors in over diagro 1 or under diagnosis are made in this group and can lead to mi management and to unfortunate variations in statistiral reporting In radiographic tudy during an acute attack particularly when a small egment of bowel or perhaps only a single diverticulun 18 involved in the inflammatory process diverticula may not be visu alized and pasm may be the only finding We have seldom recened significant as etance from examination ----Grossly or micro coptcally of the actual rectal de charge or stool I hen blood or pus is seen our search is intensified to rule out c3cinoma Attempts to demonstrate lumor cells by means of cytolom cum inations of the specimens from the lonel with the technics 1104 recommended in acutely ill patients have heen found to be neither practscal nor dependable ·67 DIVERTICULITIS COMPLICATIONS Carcinoma and Diverticulitis The first complicating aspect of diverticulitis mentioned in the literature is one which for the clinician of today is still a perplexing problem It was mentioned by Moynihan in 1906 in the 6 ca es which he reported as having inflammatory tumors of the large intes line presenting all the clinical appearances of cancer which proved on pathologic examination to have been wrongly diagno ed Gra er also described this problem in 1899 In 1910 it was suggested by Hartwell and Cecil that a carcinoma superimposed upon diverticu litis might develop and in 1911 Wil on propo ed that low grade proliferatne changes took place in the tips of the diverticula 10 form segregated epithelium parallel in all respects with cell changes which occur in masses of epithelium segregated about the base of a gastric ulcer From this development the entire diverticulum be came involved the walls infiltrated with a lui tologic picture which mu t be diagnosed as carcinoma A year later (1912) McGrath stated that cancer was associated with diverticulitis in 25 per cent of his series of cases Case in 1915 mentioned the difficulty in differ entiating diverticulitis from carcinoma In 1917 Mayo stated that carcinoma coexisted in 13 (31 per cent) of 12 patients with diver ticulitis upon whom he had operated He considered this more than mere coincidence and was of the opinion that chronic irritation and inflammation led eventually to a cancerous change In 1924 however Judd and Pollock wlule tating that the relation Inp of carcinoma to diverticulitis was not determined noted that Mayos evidence taken from a study of 137 ci es suggested that there was no relationship between the two conditions The e authors were the first to sugge t that the relation lip between diverticulitis and carcinoma was coincidental In 1930 Rankın and Brown in a reven of 227 ca es had only 4 cases in which malignant di ea e *a so ciated with duerticuliti and in 679 ca e of carcinoma of the colon only 4 ca es of duerticulo 15 were present Wilkinson un 1933 men tioned the difficulty of differentiating the ino conditions both clini cally and roentgenologically Vorton in 1916 in Ius eries of 196 ·DIVERTICULITIS 63 cases stated that 17 patients had carcinoma associated with diver ticulosis but called attention to the important fact that in only 4 of these patients the carcinoma was in the area of the colon involved by diverticulitis In 1951 Wigh and Swenson in their paper on radiologic aspects of diverticular disea e stated that evidence of spasm and edema was rarer in carcinoma than in diverticulitis In 1952 Rowe and Kollmar in discussing diverticulitis complicated by carcinoma stated that obstruction and anemia are more suggestive of carcinoma whereas evidence of inflammation a palpable maas and fistula formation are more frequent with diverticulitis They quoted statistics from several hospitals showing that in 700 patients with carcinoma of the colon only 7 had coexisting diverticulitis and carcinoma and of the e only 3 patients (0 43 per cent) had diver ticulitis and carcinoma in the same egment Starkloff and Bind beutal mentioned in 1953 that the symptoms and igns of carcinoma and diverticulitis mimicked each other and al o coexisted with symp toms suggesting only one entity in their review of 250 patients with carcinoma of the howel and 30 patients with diverticulitis 25 had coexisting carcinoma and diverticulosis 6 had coexisting car cinoma and diverticulitis but again the point was made that only 4 of these had carcinoma and diverticulitis of the same segment the rectosigmoid an incidence of 15 per cent suggesting that the relationship was coincidental Twenty five patients had carcinom and diverticulosis of the same segment the rectosigmoid They believed bleeding and cachexia should arou e su picion of car cinoma and in their series bleeding was present in 62 per cent of carcinoma und 19 per cent of diverticulitis The best differential x ray ign for carcinoma was in their opinion a normal appearance of the colon above and below the malignant growth but this sign also had pitfalls They emphasized the need for a more aggressive surgical approach to the treatment of all patient in whom cancer is strongly suspected In 1954 Hoar and Bernhard stated that in 385 cases diagnosed as diverticulitis or duerticulosis only 14 pa lients (36 per cent) had carcinoma present in an area where diverticula were present and of 466 cases of carcinoma of the colon and rectum 38 (8 per cent) had a concomitant diagnosis of diver ·64 DIVERTICULITIS ticulosis which they stated was the expected figure in the middle aged or older population 13 1 whole In 1951 Barborka and Texter stated that coexistence of carcinoma of the colon and duerticulit * 15 relatusely rare that cachexia and rectal bleeding were more common in carcinoma while recurrent attacks of pain in the left lower quadrant fever constipation and urinary symptoms were more common in diverticulitis han om in 1951 found that in operating on 53 patients with diverticulitis carcinoma nas coexi tent in 7 In 1956 Mayo ind Delaney reviewed 50 patients (35 males and 15 females) from the ages of 11 to 82 who had diverticulitis and carcinoma of the colon simultaneously and who had lind sur gical treatment In 38 cases (76 per cent) the preoperative dingno is or impression had been correctly surmised Boles and Jordan in 1938 found 15 patients (5 per cent) of the 291 patients with duerticulo is who had cancer of the color of the 221 patients with no progression to diverticulitis cancer developed in 8 (3 6 per cent) of the 73 patients in whom diverticulitis devel oped during their observation period cancer developed in 7 (96 per cent) This apparently significant relationship however wa invalidated by the fact that in 2 of tho e 7 patient cancer developed in an area uninvolved by diverticulite, and in 2 others the carcinomis were in polyps which were detected in a period when there w is no active diverticulitis This leaves only 3 ca es or 1 per cent of the patients with duerticulitis in whom there could pos ilily be a presumptie relationship Authors Comments From the year 1951 on emphasis was placed lry everal writers on the necessity for surgery in all c? es in wluch carcinoma could not be ruled out but the impre ion perst is that this is not always feasible A per i tent ma s or an u ray deformity is usually the point There is no que tion but that a mi s or v ray deformity of any segment of the colon mu the sewed with grase cu picion of cancer and the problem of early differential diagno i of carcinoma from dverticular di ea e a more difficult becau e duerticulitis occurs equn ocal ·DIVERTICULITIS 65 mo t often in that period of life when carcinoma is likewi e most frequently found When the lesion in in the left lower quadrant where both carcinomi and diverticulitis are so often found the differential diagnosis is especially difficult because of the immo bility of the mass and its inaccessibility to sigmoido copic examination In these days when surgery is relatively safe it is imprudent to wait for cachexia to arouse suspicion Dependence mut therefore be placed to some degree upon the history to a large degree upon x ray findings and to a very minor degree upon statistics indicating the coexistence of duerticulitis and carcinoma and the possibility of considering diverticuliti as a precursor of carcinoma As has been so often aid in the literature a history of recurrent attacks of pain in the left lower quadrant usually with fever and leukocyto is and the findings of x ray evidence of diverticula are the diagnostic criteria for diverticulitis When the lumen of the bowel is narrowed as shown hy v ray findings and there is clinical evidence of obstruc tion and if a mass is palpable carcinoma is suspected and cannot be dehnitely ruled out without surgical resection and histologic exam anation There are however factors which influence one » judgment in one direction or another Statistical evidence has seemed to disprove Wilson s theory that the epithelial proliferative changes of diverticulitis lead to carcinoma It must therefore be a question of deciding whether or not the lesion in question is carcinoma co existent with diverticulitis or simple diverticuliti The precachectic evidence suspicious for carcinoma has been thought by many writers to be both bleeding and r ray signs hut in the opinion of the au thors x ray findings alore are the only suggestive evidence The complication of bleeding will be discu ed separately but its occur rence in diverticulosis and diverticulitis is a definite entity and is not necessarily a reason for suspecting carcinoma The x ray evi dence consists of the following factors—an area of narrowed lumen with obliterated mucosal patter and shelflike superior and inferior borders eparating normal bowel from the involved area (FIGURE 9) This is in contrast to a more gradual change from normal howel to the inflamed segment of diserticulitis in which perhaps edematous ·66 DIVERTICULITIS but otherwise normal mucosa cin be visualized It must always be recognized however, that the signs of cancer can he ob cured by the deformities produced by the presence of multiple dnerticula and of duerticulitis Vith persistent or increasing stenosis unuflu enced by a short period of conservative management the diagnosis must usually be determined by resection and then the only problem for the surgeon is the decision as to the extent of the resection Fog 9 - Carcinoma of sigmoid with a sociate 1 diverticula Without obvious signs of carcinoma this deci ion must be made on biopsy and frozen section eximination and an appropriate operation performed Bleeding In the earlier days of tudies of diverticular disease there was considerable reluctance to the acceptance of bleeding as a symptom of diserticulosis or herticulitis without in a socinted polyp or malignant condition Honeyer Rankın and Brown in 1930 «tates! that when bleeding occur da a symptom of uncomplicated nerlicu ·DIVERTICULIT15 67 litis or diverticulosis an associated malignant condition is always suspected but frequently not found For some years now the concept has been well established that hemorrhage may be an outstanding and often perplexing symptom of both diverticulosis and diverticulitis While this is true anal bleeding without hemateme is still remains a problem worthy of special consideration The frequent difficulty in identifying the source of such bleeding 19 emphasized throughout the literature and the exhortation prevails that before assuming that such bleeding has its source in a diver ticulum all other areas in the gastrointestinal tract be carefully examined by procto igmoidoscopy radiologic examination study of clotting mechanisms and liver function etudies Almo t all writers on this subject have urged that careful search must be made for hemorrhoids ulcerative colitis polvps and carcinoma The incidence of bleeding in diverticular disease has been van ously e timated as from 5 to 8 per cent in diverticulose and from 15 to 25 per cent in diverticulitis Smithwich Ⓡ' in 1942 reported bleed ing in 15 7 per cent of 568 cases of diverticulitis írom the Massa chusetts General Hospital and the literature Young and Young in 1941 estimated that bleeding usually minor had been thought to occur in 5 to 17 per cent of diverticulitis and was more often found in the chronic than in the acute phase of this disease Judd and Mears in 1935 found an incidence of bemorrhage of 85 per cent in a series of 68 cases of diverticulit Bell 11 in 1953 reported that in 68 patients with diverticulosis or duerticulitis which required operation 50 per cent had blood in the stools but of these 69 patients 28 per cent had carcinoma and 10 per cent colonic polyps Anight in 1957 reported 124 per cent of gross bleeding in 185 atients with diverticulosis or diverticulitis and considered it to he more frequently found in diverticulosis than in diverticulitis Boles and Jordan in 19,8 found in their follow up study of 291 cases that during the years of observation (asesage 15 years) under more or less trict treatment 16 patients (54 per centi had bleeding and of these 16 patients 7 had diverticulita ·66 DIVERTICULITIS but otherwise normal mucost can be visualized It mu t always be recognized however that the signs of cancer can be obscured by the deformities produced by the pre ence of multiple duerticula ind of doverncultis With persi tent or increasing stenosis unifu enced by 1 short period of conservative management the diagnosis mu t usually be determined by resection and then the only problem for the surgeon is the decision as to the extent of the re ection Fig 9-Carcinoma of si mod wyth a ociated divert vla Without obvious signs of carcinoma this decision must be made on biopsy and frozen ection examination and an appropriate operation performed Bleeding In the earlier days of studies of diverticular disease there was con iderable reluctance to the acceptance of bleeding ay a symptom of diverticulosis or diverticulitis without an associated polyp or malignant condition However Rankın and Brown in 1930 stated that when bleeding occurs as a symptom of uncomplicated diverticu ·DIVERTICULITIS 67 Intis or diverticulosi an associated malignant condition is always suspected but frequently not found For some years now the concept has been well established that hemorrhage may be an outstanding and often perplexing symptom of both diverticulosis and diverticulitis Vhle this is true anal bleeding without hematemesis still remains a problem worthy of special consideration The frequent difficulty in identifying the source of such bleeding 19 emphasized throughout the literature and the exhortation prevails that before assuming that such bleeding has its source in a diver ticulum all other areas in the gastrointe tinal tract be carefully examined by proctosigmoidoscopy radiologic examination study of clotting mechanisms and liver function tudies Almo t all writers on this subject have urged that careful search must be made for hemorrhoids ulceratae colitis polyps and carcinoma The incidence of bleeding in diverticular di ease has been vari ously estimated as from 5 to 8 per cent in diverticulosis and from 15 to 25 per cent in diverticulitis Smithwick® in 1912 reported bleed ing in 15 7 per cent of 568 cases of diverticulitis from the Massa chu etts General Hospital and the literature Young and Young in 1944 estimated that bleeding usually minor had been thought to occur in 5 to 17 per cent of diverticulitis and was more often found in the chronic than in the acute phase of this disea e Judd and Mears in 1955 found an incidence of hemorrhage of 95 per cent in a enes of 68 cases of dierticulitis Bell" in 1953 reported that on 63 patients with diverticulosis or diverticulitis which required operation 50 per cent had blood in the stools but of the e 68 patients 28 per cent had carcinoma and 10 per cent colonic polyps knight in 1957 reported 124 per cent of gross bleeding in 185 patients with dnerticulosis or diverticulitis and considered it to be more frequently found in diverticulosis than in diverticulitre Boles and Jordan in 1958 found in their follow up study of 294 cases that during the years of observation (average 15 years) under more or less strict treatment 16 patients (54 per cent) had bleeding and of these 16 patients 7 had diverticuliti ·68 DIVERTICULITIS and 9 dnerticulo is showing a slight preponderance of this symptom in diverticulosis without otlier complication But the strong suspicion of cancer when bleeding is present ha persisted as is evidenced by the paper of Gilclirist and Economou in 1955 who advocated operation for dwerticulitis when bleeding occurs because it mut then be s umed that polyps or carcinoma are al o present In 1956 Vaugh and Walt while claiming that in about four fifths of patients with diverticulitis surgery could be avoided if medical management were employed stated that other wie unexplained melena with v ray evidence of diverticulitis is one of the indications for surgery Repeated bleeding had al o been mentioned by Swinton in 1951 as an indication for surgical inter vention In fact this type of continued even if intermittent blood loss when otherwi e unexplained and if per estent under medical management has become an accepted indication for re-ection of the area where diverticula are usualized even though carcinoma is not seriously suspected When no doubt of cancer exi ts in the diag nosis Mobley Dockerty and Waugh" in 1957 reporting on 31 patients who had had surgical treatment for deserticulitis as ociated with bleeding stated that conseri atne treatment was po ble in many instances heith and Rını in 1957 mentioned the reluctance of clinicians and pathologists to accept diverticula 19 a ource of hemorrhage becau e 1 bleeding point may be difficult to find at autopsy Pfeiffer 88 in 1911 in a di cu sion of a paper by Stone 101 on melena of unknown origin explained the ab ence of external evidence of the site of bleeding from a diverticulum on the basis of the con tiguous location of the diverticulum to the artery which feeds the epiploic appendage While bleeding from diserticular dı ee is generally reported as minor bleeding u ually intermittently observed the occurrence of ma ile hemorrhage from duerticular di ea e lns abo been reported in recent years Mickey in 1951 reported a ca e of ma ne exsanguinatıng bleeding in a 65 year old man in wliom surgery revealed a perforation of an area of sigmoid diserticulitis which had insolied the left inferior epigastric artery with a fistulous tract ·DIVERTICULITIS 69 carrying the blood into tlie colon Alo in 1951 Hoar und Bernliard reported 1 ca es of massive hemorrhage in patients with diverticular disea e In certain of such ca es it may become necessary to explore urgically even without completed investigation of the source of blerding The surgeon may then be confronted with a colon filled with blood and with numerous diverticula cattered throughout the extent of the bowel While some of this blood may be the result of backflow from 1 di tal arer it cannot be assumed that the source of bleeding is in the sigmoid especially ince ca es of massive hemor rhage from diverticula in other areas have also been reported A case of multiple diverticula of the cecum and colon with clotted blood in numerous diverticula at emergency operation was reported by Cate in 1993 Hoar and Bernhard reported 2 patients with diverticulitis who presented the problem of uncontrolled rectal hemorrhage requiring exploration as a lifesaving measure and 4 other patients with diverticular de ease with massne hemorrhage 3 of whom died knight in 1957 reported massive bleeding from extensive diverticulosis and in 1 case the ource of bleeding from the mouth of a diverticulum was seen on procto copic examination Mobley Dockerty and Waugh reported a patient with diverticulitis in whom death from myocardial infarction followed two weeks after massive rectal bleeding Authors Comments The reluctance of earher writers to accept bleeding as i symptom of uncomplicated diverticulosi or duerticulitis has been changed by experience to a recognition that thu, symptom may occur with both the e conditions Bleeding 13 usually of minor degree and inter mittent but massive hemorrhage has al o been reported often enough to establı h it as a po sıble occurrence in this disease Minor hemorrhage is usually described by the patient as bright blood on the surface of the tool and mucus may or may not be seen mixed with the blood From the fir t reporting of bleeding as 1 symptom of diverticular di ease up to the pre ent greit emphasis has been placed in the literature on the need for careful examination of tlie anal canal rectum and sigmoid for the pre ence of lemor ·68 DIVERTICULITIS and I diverticulosis showing a slight preponderance of this symp tom in diverticulosis without other complication But the strong suspicion of cancer when bleeding is present has persisted, as is evidenced by the paper of Gilchrist and Economou in 1955 who advocated operation for diverticulitis when bleeding occurs because it must then be assumed that polyps or carcinoma are al o present In 1956 Waugh and Walt while claiming that in about four fifths of patients with diverticulitis surgery could be avoided if medical management were employed stated that other wist unexplained melena with x ray evidence of diverticulitis is one of the indications for surgery Repeated bleeding had also been mentioned by Swinton in 1951 19 an indication for surgical inter vention In fact this type of continued even if intermittent blood loss when otherwise unexplained and if persistent under medical management has become an accepted indication for resection of the area where diverticula are visualized even though carcinoma is not seriously suspected When no doubt of cancer exists in the diag nosis Mobley Docherty and Waugh 79 in 1957 reporting on 31 patients who had had surgical treatment for diverticulitis associated with bleeding stated that conservative treatment was possible in many instances Keith and Rini in 1957 mentioned the reluctance of clinicians and pathologists to accept diverticula as 1 source of hemorrhage becruse a bleeding point may be difficult to find at autopsy Pfeiffer 88 in 1944 in a discu sion of a paper by Stone 101 on melena of unknown origin explained the ab ence of external evidence of the site of bleeding from a duerticulum on the basis of the con tiguous location of the diverticulum to the artery which feeds the epiploic appendage While bleeding from diverticular di ease is generally reported as minor bleeding usually intermittently observed the occurrence of ma she hemorrhage from dverticular di ease has al o been reported in recent years Hickey in 1954 reported a case of massive exsanguinating bleeding in a 65 year old man in whom surgery revealed a perforation of an area of sigmoid diverticulitis which had involved the left inferior epigastric artery with a fistulous tract ·DIVERTICULITIS toma Patter on 84 85 noted in he study of 131 ca es of dwerticulins that infection of the pelvic colon is well tolerated and many of the patients consulted their physicians only after the fulminant signs of generalized peritonitis appeared The first report of a perforated diverticulum with diffu e peri tonius was made from an autoj sy described by Fiedler ** 1868 In recent years there have been frequent reports of unusual v % Fig 10 -- erticult of sigmo d wth local zed perforation. cases often in sigmoid divestrulitis but orcasionally in duerticulitis of other areas of the colon for example in the report of cecal diverticulitis by Case and Shea in 1953 Morton in 1916 reported 39 perforations in 111 crees of duver et ultı, 3 of włuch were free into the peritoneal ravity the other 36 forming a localized absress of the e patient 10 died while in the hospital fi tula developed in 22 cases and more than one region was invoked in ll cases--1] to the kin 8 to the bladder 2 to the urethra 2 to the small inte tine I to the cecur 2 to the rectum I to the vagina I to the retroperitoneal tissue 1 forming an schiorectal sinus and 1 into the me ocolon hraemer and Siegelen ·70 DIVERTICULITIS rhoids polyps or carcinoma Physicians today are keenly aware of this need for thorough inve tigation The detection of sigmoid polyps in the presence of driverticulosis is often difficult even with air contrast enemas Interal projections are helpful in differentiating polyps from dnerticula although rarely a diverticulum inverted into the lumen of the bowel may be mistaken for a polyp Carcinoma must always be suspected when rectal bleeding occur but in the absence of sigmoido copic and vry findings positive for cancer polyps or other intestinal lesions duerticula if pre ent may properly be su pected The most recent trend of thought and one which conforms al o with the authors experience as that bleed ing usually minimal but occasionally mase may occur from diverticula without the presence of inflammation and infection which produces diverticulitis Perhaps the mot innocent type bleeding is the intermittent type while that due to circinoma or polyp is usually persistent in spite of treatment Apparently the intermittent bleeding cau ed by dnerticula has its source in an erosion within the diverticulum which may heal with conservative treatment Bleeding which is persistent in spite of treatment is one of the indications for surgical treatment first because of the effect of blood loss and second because under these conditions an ulceratne car cinoma cannot be satisfactorily ruled out in spite of negative exam inations The importance of repeated examinations is a great in this disea e as in suspected cancer el enliere in the dige tive tract Perforation and Fistula Perforation and fistula formation are the two most hazardous complications of diverticulitis Peridiverticulitis with or without abscess formation or generalized peritonitis is usually present when perforation occurs (FIGURFS 10 and 11) Abscesses may be small and entirely peridiverticular or larger and encapsulated in the me entery Peridiverticulitis usually cau es stenosis of the lonel lumen and in such ca es differentiation from carcinoma may be impossible even at operation Perforation may be acute and symptomatically of sudden onset or des elop slowly with gradually progressive symp- ·DIVERTICULITIS 73 urinary symptoms indicating the presence of the severe complica tion of colove ical fistula The coloresical fi tula is of course relatively common because of the anatomical proximity of bladder and sigmoid (FIGURE 12) It may be diagno ed either by the barium enema examination or by cystoscopy In 1 recent case seen by the authors the diagnosis was made by the cystoscopic finding of a piece of lettuce in the bladder BLADDER Fig 12-D erticuliti of Bomo d with formation of a 6 tula to bladder of a woman who complained of bladder symptoms In all cases but especially in males when urinary symptoms occur with an attack of diverticulitis a colovesical fi tula hould be errou ly considered Mayo and Blunt 73 in 1950 reported an incidence of sesico sigmoidal fi tulas in 46 (22 ? per cent) of 202 cases of proved duerticulitis of the large inte tine The ser incidence was 39 males and 7 females the explanation was offered again that the inter position of the uterus between bladder and sigmoid usually protects the female from this complication Urgency and frequency were noted loy them alo as the chief symptom and many of their co es

·72
DIVERTICULITIS
in 1918 reported a che of dnerticulitis of the ascending colon with
perforation abscess formation and fistulization into loops of the
ileum
These problems of perforation and fi tula formation involung
Surgery became less common with the advent of the antibiotic era
as was noted by Prlesen and Schmidt in 1955 the chief surgical
problem now being a stenosing obstruction It is still true however
thint often the symptom of which the patient is for i aware are
3 VERTULITIS OF
S MOD
MJLT PLE PERFORATION
wit ABSCESS
FORMATION
Fig 11-D. erliculitis of sigmoid Vult ple perfo ations with ab or s format on

·DIVERTICULITIS 75 which surgical drainage is required In recent years diffuse peri tonitis rarely occurs from an acute perforation Urgency and frequency of urination often occur in cases of dı verticulosis and the irritable colon syndrome and the e symptoms per se do not indicate an impending or actual vesicocolic fi tula although they are suggestive Fecaluria and pneumaturia are pathognomic When this complication occurs a multiple stage procedure is required frequently with a greater mortality and morbidity which offers a rational argument for earlier operation in those patients who have recurrent attacks of diverticulitis at relatively short intervals In the series of 69 patients of Colcock undergoing one stage proce dures however some patients had a small vesicocolic fi tula and others had localized perforations with small absces es and a primary anastomosis was carried out with very little additional risk Obstruction The complication of ohstruction I usually the result of previous attacks of acute or subacute diverticulitis with progressive involve ment of the bowel wall Mlayo et al in 1907 believed that peridiverticulitis with inflamma tion of the submucosa around the diverticula reduced the lumen of the bowel with resultant obstruction In 1917 Mayo warned of the difficulty in distinguishing tho e patients with obstructive dı verticulitis from carcinoma—the former often having a long history of symptoms of diverticulitis Carcinoma not infrequently became manifest with a complete obstruction Morton in 1916 di cussed 31 patients with diverticulitis with obstruction and related the significance of the history of repeated infections scarring and thickening of the colon causing partial obstruction Other possible causes obstruction were adhesions about an abscess and the adherence of the small intestine to an area of colonic diverticultis In 1951 Wigh and Swenson e timated that in two thirds of the patients with diverticubtis the symptoms were ba ed on some degree of obstruction They mentioned the practical point that with a ·74 DIVERTICULITIS had been treated for urinary infection since there had been feu symptoms suggestive of intestinal disease Pneumaturia was present in 10 of the 46 patients and 14 complained of suprapubic or perineal pain Of the 46 patients 21 had passed feces from the urethra and 10 had hematuria The authors ascribed pain to inflammation and engorgement of the fistulous tract with the colid material of the feces Gross hematuria kas late in appearance and thought to be caused by trauma from fecal material and cystitis The procedures used by these authors were as follows (1) proctoscopy and sig moidoscopy which showed changes suggestre of a fistula in only 3 of 38 patients (2) birium enema examination which showed the fistula in 9 of the 45 patients thus examined, and (3) cystoscopy which revealed endence of a fistulous opening in the bladder in 28 of 33 patients The e authors experience with the use of organic dyes administered orally or rectally or instilled into the bladder to detect a fistulous communication was often misleading Authors Comments The complication of perforation and fistula in our experience is frequently associated with recurrent attacks of diverticulitis and predisposes to surgical intervention in the paper by Boles and Jordan tlus complication occurred in 5 per cent of 294 patients who had follow up studies for an average of 15 years With multiple attacks of diserticulitis the incidence of this complication increased because of a smoldering of the inflammatory process and the pres ence of small abscesses with incorporation of the adjacent tissue The stage is thus set for fistula formation into the small intestine bladder vagina uterus rectum and perianal region and skın It is sometimes difficult to determine whether a localized perforation with abscess formation has taken place with the masking of symptoms by the dampening effect of the surrounding structures walling off the perforation and the oftentimes rapid response to conservative management and antibiotics Uncomplicated acute diverticulitis can mimic a small perforation in every respect Although this complica tion occurs frequently it is impossible to know the number of cases in which spontaneous resolution occurs as agunt the number in ·DIVERTICULITIS 17 Fe 11 ---Ader carcinoma of mod ob truction to be infrequent in patients who had only one attack of diverticulitis but it was the most frequent complication when multiple ałtacks occurred and required surgery in 8 of ll patients (73 per cent) The acute form in our experience le-s common and it is more difficult to identify the cau e preoperatzvely because of the inability to study the patient as carefully roentgeno graphically in the panent who re ponds to con ervatre manage ·76 DIVERTICULITIS harium enema spasm produces a picture of a more severe grade of obstruction than is demonstrated when the barium passcd distally Hickey in 1951 believed that obstruction was the most common complication of diverticulitis which is the cxperience of most stu dents of this disease in the more current literature Authors Comments With multiple attacks of diverticulitis obstruction in some form becomes the most frequently observed complication and is an out standing indication for surgical intervention The authors found F1, 13–Duserticultis of s gmold with sotractable ymptom ·DIVERTICULITIS 79 The ever present challenge of differentiating the pathologic proc exs from carcinoma is most dramatically portrayed here and the surgeon often cannot make this differentiation with any degree of certainty by gross snepection of the intact bonel (FICURES 13 14 and 15) The bowel wall adjacent tsesve and mesentery are in Wolved with the chronic infiammatory hyperpla tic proces which to the inspecting finger sa a thickened hard mase with marked nar rowing of the lumen When the specimen is 39-pected soon after removal the normalcy of the mucosa is striking in contra t to the far advanced pathologie changes of the extraluminat ti ue Whereas a multiple stage procedure with colostomy preceding re ection may be indicated in cases of acute obstruchon chronic obstruction can u ually be managed safely with segmental resection and primary end to-end anastomosis MEDICAL TREATMENT In ca es of acute apparently uncomplicated diserticulitis the first and paransount principle is to put the bowel at rest If possible the patient hould be hospitalized Bed test and a low residue warm bland dret are es ential The applıcation of heat to the abdomen administration of hot water by mouth and ants pasmodics (auch as some form of atropine) in moderate tolerated duses prouided the patient does not liave glaucoma and mild edation complete the initial phase Paregoric or deodorized tincture of opium may be required to alles sate troublesome spasm and diarrhea If the patient as afebrile and the acute symptoms suburde in the first 24 hours antibiotics are seldom indicated with per» tence of a low grade fever leukocytosi and chnical endence of continued activity sulfasuxıdıne azulfidine (amino azo ulfapyrıdırse) or neomycin rather than the broad spectrum antibiotics will be found helpful As a matter of fact azulfidine often will be useful as a prophylactic ia karding off a threatened acute attack In the presence of vomiting penicillin and streptomycin may be indicated as well as the parenteral u e of fluids for 24 to 48 hours The majority of patients will respond to the-e measures without sul equent complic?

·78 DIVERTICULITIS ment with or without decompression of the bowel definitive study can then be carried out for diagnosis Chronic obstruction resulting from diverticulitis with or without acute symptoms is due to the inflammatory process with edema, induration fibrosis and narrow ing of the lumen Adhesions may insolie the small intestine produc ing elements of both small and large bowel obstruction Angulation by adhesions and inflammation may be most wgnificant in contribut ing to the irreversibility of the clinical and pathologic picture . ru DIVERTICULITIS WITH NARROWING Fig 15--Diverticulitis of sigmoid with narrowing and partial ob truction ·BIVERTICULITIS $3 des elopment of chronic duerticulite or complications requiring grgical Intersentson may be averted When attacks recur or complıcatrons such as perforation fi tula formation ob truction or hemorrhage deselop surgical intervention becomes necessary The Trend us toward earlier urgery but the decision requires the utmost in clinical judgment and often the in dications are not clear cut we would include as an indication for urgery the intractable form of clinical diserticulitis manile ted by frequent recurrences despite good medical management Pallatise treatment in those patients without complications how eser is still strongly upported by the authors The opinion et pres ed that radical treatment is more logical in the young than in the old ince one of the erou complicatsons is more likely to develop during the longer life of the younger patient i not supported by the authors becau e it does not con der the po ability that duverticala are especially common later in hfe Furthermore in younger sndrusdual diverticula are quite likely to occur at some future time in other areas of the bowel in which ca e further surgical anten ention might be required In our experience the dragno i of carcinoma ss eldom as confu ing as the literature indicates Roentgenograms after a suitable period of inten ile medical hospital management -tool examination for occult blood and the utslitation of the patient clinical gastro intestinal story lend many helpful kınts A preoperative diagnosis of deserticulitis with hemorrhage has rarely been an indication for surgery In such ca es distingui hing the condition from carcinoma becomes more pres ing When surgical mtervention indicated wegmental resection is preferred because of the low mortality rate and the fasorable long range prognosis Colcock 59 stre ed the fact that inadequate surgery is te ponsible for many of the complications & ociated with the surgical treat ment of divertsculitis Welclit empha ized the need of discretion in the selection of patients for the one-stage procedure and as a safety factor preliminary to the operation he pointed out the value ·80 DIVERTICULITIS tions or chronicity developing The diet is then increased permitting only those foods that are easily digestible The following program of management for an irritable colon and diverticulosis is then in stituted The treatment of the irritable colon is al o ba ed on the principle of physiologic rest Hypermotility of the small intestine and spasm of the colon respond to the various measures conducive to rest For those patients in whom the symptoms persist under ambulatory dietary control or for those who are convale-cing from an attack of diverticulitis absolute bed rest is recommended Heat (hot water bottle electric pad or flaxseed poultice) is applied to the abdomen for one hour two or three times daily The diet consists at first of the most easily digested bland foods served in six feedings during the day as the patient becomes asymptomatic the variety is in creased to include meat cooked vegetables and fruit and the meal frequency is returned to the conventional pattern with the heavy meal preferably at noon No ice cold food or drink is permitted and supplementary hot water is given between feedings at regular intervals Excluded from the diet are pork and pork products veal and boiled meats also excluded are ras vegetables and fruits Food from the frying pan or cooked in deep fat and accessory foods such as nuts candies olives and pickles are forbidden Laxatives and lubricants are to be avoided at all times The u e of orange or prune juice diluted with equal parts of hot water before breakfast and for some patients before each meal is often an adequate stimulus for bowel function rectal injection of 3 ounces of warm mineral oil at bedtime or as an emergency procedure a salıne enema may be permitted Smoking even when not excessive is in the opinion of the authors conducive to spa m of the colon Alcohol may be used before the evening meal in the form of 1 ounce of whiskey diluted with 3 to 4 ounces of water without ice Cocktails and dry wines are often troublesome Adequate daily rest exerci e and regular vacations are encouraged to balance the patient s work schedule In this way recurrent attacks of acute diverticulitis may be prevented and the ·References I ALARICET IL AND LEOYARD F ( Management of da erti ulita coli A J Surg 8° 6 H-68? 1931 2 ALLE AW AND BEHRINGER CE Dericulo 1 and di erticultis of the colon Penn ylvania VI.J 59 1315-1330 1956 3 ASHHURST APC S mort d verticulita (nie o agmoid ts) ch Ann Surg # 300-301 1908 # BAC) HE. ANO VALIENTE VA Sur kal mana cment of derticult Am. J.Su g 91 178-183 1954 5 BADIA P C. Di eticulo : and I ert calits of the colon Am.J Surg 67 536-516 1945 6 BARBAT JH Dive t culitis of gmo d rep rt of a cae Surg Gynec & Ob 1 10 293–299 1910 7 BARBORKA CJAD TEXTER E, C Di erticul), and di ertac Bite Ch North Ames 31 20920 1951 8 BEARSE C Acut p rforat di erficult f colon in y ng per on JAVA 113 170-1722 1939 9 Derticulo and d ertculti f the cln with jart cular refere ce to pat fits unir ty Re Ga troenterol 7 318-3°1 1910 10 BEER, E Some patholog c 1 and cl nical pect of acquire fiale ! erti ula of the inte ti e AmJ Se I 8 135-115 1901 11 BELL HIG Bleedi & in re in low le del cul 119 of th South 1 J 16 433-45, 1933 12 Botes RSAD HODES PJ End metrio f the mall a d la ge die t ne Ca troenterology 31 31 380 19 8 13 BOSES RS JR AND JORDAN 5 Th chi cal nifine of delic lo G trop te of gy 3, 579 581 19 8 11 BUIE LA Dt cula of the c] n New En, nl) Ved 1 593-598 1939 15 - Pact cal Proctology Ed 2 Spri gfield !!!! Charles C Thoma 1960 1p 418-452 16 BUNTS F E Tra mic d erti ulum f cae um follow og sende tomy Surg Cy c30119 91 797 1914 17 BYRNE, JI KAILAY A GAND PASSETT A A Ac te d it cit of the um port of 5 a JAVA 1181&1 1970 gmo!

·82 DIVERTICULITIS of a protecting colostomy Buie 15 likewise cautioned that in the more serious and complicated cases ? preliminary colostomy should be performed Whenever possible the operative procedure should be performed after the acute attack has subsided This is desirable both from the standpoint of morbidity and to permit a more direct and simple surgical approach In the study of any patient with a history of diverticulitis or during the acute attack a search should be made for coexistent disease which may influence the prognosis with regard to subse quent attacks In our experience gallstones and peptic ulcer occur with sufficient frequency so that they should be considered and if present actively treated When gallstones are present cholecystec tomy is indicated after the acute attack of diverticulitis has subsided Prognosis The prognosis for patients with uncomplicated diverticulitis on a bowel management program is quite good In the authors experience with 73 patients who had had diverticulitis more than one half (40 patients, had only one attack during a follow up period of one to 27 years In 19 of these the follow up period was 11 to 27 years As would be expected multiple attacks of diverticulitis were associated with more than twice as many complications as were single attacks 21 of the 33 patients who had been having multiple attacks were free of attacks during a follow up period of three to 10 years which can be partially attributed to the fact they had adhered to their program of bowel management Depending on the type of complication and the surgical procedure used the prognosis may be extremely variable In well selected pa tients however who receive adequate surgery the prognosis should be quite favorable Following operation the patient is strongly ad vised to adhere indefinitely to the modified bowel management previously outlined in order to remain in a symptom free state ·REFERENCES 95 37 EDEL V tleb erwoh ne D rmd tikel 1 dl path Anat 138 317-361 1891 38 Edwid HCL) erti ulan 1 dic 11 ulti ctit on : 1.19 113 150 191 39 ERDVANY J F Diverticul tis and di erticulo s JANI 99 112.-1128 1939 40 D verlicul 119 New En land J Med 2 3 816-851 1910 41 - Divert culiti Proc I ter tlo grad \1 North Amer ca (1911) PP 2 5 219 1917 4 EWELL G11 Inte tinove ical f tul Am J Surg 89 59 -602 1951 43 FAYSLER A Diverticulo is nd diy ricu? 11 with rartı ular relerence to lar, bonel Tr Am Proct hoc 41 231 211 1910 41 FIEDLER | The p thologi alinif cance of diert cul of the colon Denk cht dG1 Natur u Heilk Dresden 1868 4 FISCHER VH Fal e d vertu ula of the inte tine J Exper Ved 5 333-35? 1901 * FRIESEN L. AND SCHINIOT E R Dictic lat of the col Chn No th America 35 138 1393 19 ) 47 CILCHRIST TK AND ECONOMOUS Sur cal treatment of di erticulits of colo AV 4 Arch Surg * 276-219 19 5 45 COMBIVIER II CAN SAMPSOY JA Duet ul li (nt Veck ls) ca ing te tinal ob tru ton mult ple ment nc ac jured) di erti ula of the omall inte tel IVA 46 158 1590 1906 49 Ceaser E Ent undliche Steno e de D ckdarmes bed ngt du ch le forat on Multiples f 1 cher D ert k I lent albli (kr 6 110 1898 50 Das fal h Dandt ert kel Arch kl nr 59-638-617 18 19 51 GREENE, W * Derticullis of the lonerad al con ervative treatment Am J Surg 94 8' 289 1957 52 GREENSFELDER LA AND ITILLEH R I Caecal dirt culo with p cial traumat c diet cul Surg Gy ec & OL 13 786-795 1979 53 H4X4L A Bemerkungen zu de Ytthel ng von Ihnemann Uler de Ettehung fal her D mmd ertok 1 od em A chi Bd 111 Hit S 400 Arch path A at 11 172-1 5 1896 51 HARTHELL JA AND CÆCIL RI Intestinal da erticula a path 1 g al and clinical tudy Am J VS 110 171-203 1910 5S HICKEY RC Va lon I le di se ond ry to dert culitis Ga tronter logy 6 751-7 7 1951 SF Hccresc AAD BLRCER V E. Di ert ol 3 and d ericultus of Term { mappe ds Amste on 063 -611 1991 refere ce !

·84 DIVERTICULITIS 18 CARLSON A J AND HOELZEL F Relation hip of diet to diverticulo is of the colon in rat Ca troenterology 12 103-115 1919 19 CARVAN RD Report of a ca e of diverticulitis of sigmoid with the roentgenolo ic findings Am J Roentgenol 2 652 1915 20 The roentgenolo-ic findings in 3 ca es of diverticulitis of the large Lowel Ann Surb 61 343-318 1915 21 CASE J T The roentg n demon tration of muluple diverticula of the colon Am J Roentgenol 2 601658 1915 22 Case T CAND STEA CE JR Acute diverticult of the cecum Am.J.Sur 85 131-141 1953 23 CATE W RJR Colectomy in treatment of mare mel na econdary to diverticulosis report of a ca e Ann Surg 13' 558-560 19,3 21 CAVE HR Surgical Vana,ement of Diverticulito of the Colon Frank II Lahey Birthday Volume Sprin field Charles C Thomas pp 117-123 1910 23 -- AND ALSOP WE Di erticulita of the colon S Clin North America 26 390 396 1916 26 CEBALLOS A Diverticulo 19 y diverticulitis del colon Dia med 14 612-61) 1912 27 CHLUVSKY Experimentelle Untersuchun en uber die ver chiedenen Methoden fer Darmvereinigung Beitr klan Chir 25 539 600 1899 28 Colcock B P Di erticuliti of the colon occurrence and complications in the aged S Clin North Am rica 31 137-713 1951 29 Surgical management of di erticulitis Surg Cynec 805 + 109 721-728 1956 30 Surgical managem nt of complicated di erticulitı New Englan I J Vet 259 570-573 1998 31 AND SASS RE Diverticulitis and carcinoma of the colon-differential dia nosi Surg Cynec & Ob 99-627-633 1931 39 CRUVEILHIER J Traile d anatomie patholo_ que general Vol I Pari 1819 1 590 pp 33 DECENSHEIN A Diverticulitis of the reht colon AM A Arch Surg 76 56 568 1958 31 DEVINE H AND DEVINE J The Surgery of Colon and Rectum Baltimore Williams & Wilkins Co 1918 pp 106-107 3, DIXON OF Dwerticulitis Proe Inter Po igra / M 4 North America (1940) pp 250-252 1911 36 EARLEY C M JThe mangement of na ive hemorrhage fond eticul di ca e of th colon kurs ( ynec & OJ 109 1940 1939 ·REFERENCES 15 EL 37 EDEL, MS Veier erworbene Darmd er hel Ir k sath Inał 1 3 317 364 1998 38 Edwa? It serbicu! ant is ert st Ira toner 125 150 1912 3) ERDMANN JF Diverticulitis and di ertieulo is JAVA 19 1123-1128 1937 40 Du ert cultus New En land J Med 223 816-81 1910 41 Derliculitis Proc inter t Postgrad ML A North America (1941) TE 275 279 19$ 42. 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S S60 Arch path Anat *) 1/2 175 18% 51 MARTWILL HAD LECIL RL Inte unald ert cula a paib ingcal ab! cal taty Amy 10 11+293 3910 55 MICKEY RC Haie glos blend ng secondary to dress cul 11 Gastro enterology 36 51 w 1921 56 Hicce 4 AD BLACER ELD ticule Biscuit $ erriforms " pendix Am Surgeon 70-631-641 1954 ·84 DIVERTICULITIS 18 CARLSON AJ AND HOELZFL F Relation hip of diet to diverticulosis of the colon in rats Gastroenterology 19 108-115 1919 19 CARMAN RD Report of a ca e of diverticulitis of sl.mod with th roentgenologic findings im J Roent enol 2 652 1915 20 The roent enolo, finding in 3 ca e of diverticulitis of the larve bowel Ann Surg 61 313-318 1915 21 CASE J T The roentgen demon tration of multiple diverticula of the colon Am J Roentgenol 2 654658 1915 22 CASE T C AND SHEA CE JR Acute diverticulitis of the cecum Am J Surg 85 134-141 1923 23 CATE RJR Colectomy in treatment of ma tye melena secondary to diverticulosis report of a case Ann Surg 137 558-560 1953 24 CAVE H V Survical Management of Diverticulitis of the Colon Frank II Lahey Birthday Volume Springfield Charle C Thomas pp 117-123 1910 25 -- AND ALSOP E Diverticulitis of the colon S Clin North America 390-396 1946 26 CEBALLOS A Diverticulo y diverticulitis del colon Dia med 14 612-615 1942 27 CHLUMSKY Experimentelle Untersuchungen uber die ver chiedenen Vethoden der Darmverein ung Beitr klin Chir 25 539-600 1899 28 COLCOCK BP Di erticulitis of the colon occurrence and complicat on in the awed S Clin North America 31 731-743 1954 29 Sur,cal management of di erticulitis Surg Gynec & Obst 109 721-28 1956 0 Surgical management of compla ated diverticulit: New Enolan! JM 59 570-573 1958 V 31 AND S45$ RE Diverticulitis and carcinoma of the colon-differential diagnosis Surg Gynec & Obst 99 627-633 1954 32 CRUVEILHIER J Traite d anatomie patholo que generale Vol 1 Pari 18-19 590 PP Diverticul tış of the n ht colon AM A Arch Surg 76 33 DECENSHEIN GA 561-568 1958 34 DEVINE LAND DEVIVE ) The Surgery of Colon and Re tum Baltimore William & Wilkins Co 1918 pp 106-107 3) Dixon CF Di erticuliti Proc later Pot rad M 4 North America (1910) pp 250-252 1941 36 EARLEY C M JR The mana em nt of ma i e hem rhage f om dive ticul disease of the colon Sura yn c& Olt 109 49 0 1959 ·400 Arch past 145 17 175 1896 ist guth that In 31 }{w} 1103 3 816 1942 roc inter I migra IVA ! 191) 29 194? with sort ular reference to EMELL, Intestino cal fi tula in urg 8 597 66 19 ! la e bow Trh rococ 11 231 233 1910 41 Sim LEN, H. The path cal: gssficance of deti ula el the vol n then chr FICHUK 11 ll Falstsvert cula f the mi tre ) Exer Ved 5 33 33 GILCAST RANDEVOIRS c AVA Arch Suth 026-29 2955 13 Ros Sex II CAND 4 IP OY A eri rul? Toal} inte line JAVA 15 158 15907 1906 49 CRASER E Entzun il bene de Did robotit dur } Ierf rat n Halt lal che Derti Centrall 3 f Chr * 310 2898 - Das faz te Barnd ertik 1A 11 Ch 50 438-617 1899 S GREE E, ) er cult ofco ad cal S2 CRCEN FELDER LAAND BILLER R1 zef rence to al cueriut Surg rytec Obt 19 789-79 1979 Ett hund, her Dm E est let de 11 Arch $$ REFERENCES EL V Ire erw storm Papst k crike L M H Bent el an! I pri 37 FIF 1) esculti ands ert rul 3 - Deneylin Tew England J Ved 11 - Desert cut Al Fr Sur, 1 A Dhvert culo enl dvest ul: Color Best Dre den 1868 ♡ Forex LAD SCHWIST ER Amica , 1383-1393 1935 I let nal Struct on Am Sarg 94182 B1937 Ilan sasn Beber a Bu 141 Itt 2 3:07 D) If cult of th Idert uliof Sura al treas ! 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·Index Abdomen examination of in diverticut Diverticulum See under Diverticulo litre 58 definition 1 Ab cess formation of 9 29 31 Antibiotic historical data 2 11 22 45 ue of in medical treat ment 79 Fecoliths 5 9 55 Al pendiciti and diverticulita occur Fi tula 6 9 31 70 rence and differential diagno 9 colovesical 73 25 29 44 59 Irterio clerosi hyperten son and her urinary symptom and 73 75 vesical sigmoidal 73 orrha e 42 Bleedin, see under Hemorrhage 12 14 Jlematuria and diverticuliti 74 16 21 28 29 30 37 6f Ilemorrha e massive 28 38 42 68 Sec incidence of 67 under Hyperlen ion and Hemorrhac medical care 42 42 per i lent 70 Laratite rectal 37 ue of in diverticuloi 80 ate of 68 0 O! truction in diverticuliti 18 30 31 Lancer and on erriculm 22 28 33 1 40 75 development of 3 6 33 40 62 63 occurrence 16-77 (acute and chronic) dla nosi 12 19 21 23 61 81 with cancer 19 roentgenography and 65 l'an 12 31 surgery and 68 Coecal diverticulitis 9 23 27 cardinal symptom 57 Colon irrital le 40 Pathogenesi of diverticulo 18 45 pa tic 21 16 Perforation 9 29 31 70 Colo tomy and diverticult 21 30 37 acute sudden 33 79-82 fistula and 71 Con tipation pa tic and diverticultu type and frequency 71 Per diverticulius 1 48 21 steno with o Diarrhea and diverticulitus 57 Peritones and perforation (1 74 See Diverticulitis under Perforation acute attack 61 Pneumaturia 74 cla sification of 8 55 Polyps rectal in differential dragno i complication 6 9 16 17 26 29 62 66 10 74 75 Procto copy in differential digunosis development of 40 13 52 60 different al dia, nos 57-59 Progno in diverticulitis 82 frequency of 10 13 15 29 30 36 37 medical treatment 9-80 Poentgenography 18 26 29 50 60 61 mortality 16 65 81 patholony 5. in differential d agnosis 63 surgery 32 35 42 See under Treat technics 51 52 ment ymptoms 10 12 14 15 16 57 Treatment Se unde Da erticult tumor cells and 61 medical 79-80 Dyrerticulo is surgical treatment electie 3' 37 38 42 82 etiology Seg der Pathovene familial 11 Inadequate results of 81 incidence 34 26 36 37 47 ind catton for 31 32 31 36 39 41 13 81 location 349 mortality 42 jrores ive treatment 21 53 presentive re ection 33 31 30 93 type 367 46

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