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At the autopsy of an 80 years old women an about 60 cm long vermiform deverticulum of the colon was detected originating immediately distal from the left colic flexure and running retroperitoneally downnard versus the promontorium. On the basis of topography, histology and length this structure was interpreted as a congenital traction deverticulum.
The diagnosis and management of rectal bleeding problems varies with the urgency of the situation, the age of the patient, and the applicability of available diagnostic methods. Every instance of rectal bleeding is a problem that demands investigation by endoscopic, radiographic, and laboratory means. A physician can be misled by the patient's understatement or underobservance of bleeding. A good history obtained as quickly as possible in urgent circumstances and in great detail under more relaxed circumstances is of immeasurable diagnostic value.
Giant diverticulum of the colon is a rare complication of the colonic diverticulosis. It generally involves the sigmoid colon. In the chronic form, without symptoms or with only a few non-specific symptoms, an abdominal mass is frequently palpable. A plain abdominal radiogram, showing a gas-filled cyst, can suggest the diagnosis. If needed, an abdominal CT scan is appropriate and seems to be more accurate than a barium enema. The treatment of choice is a segmental resection of the colon involving the giant diverticulum, followed by a direct anastomosis. Despite the old age of these patients, both postoperative morbidity and mortality are low and justify such a radical approach. The acute clinical presentation (about 20%) is generally due to a peritonitis by perforation of the giant diverticulum and requires an emergency colectomy.
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The occurrence of perforated sigmoid diverticulitis in a renal transplant recipient stimulated a review of colorectal complications in renal allograft recipients. One hundred twenty-five renal transplantations were performed in 113 patients between January 1968 and December 1975. Six patients (5%) were identified as having colorectal complications and five of these patients died as a direct result. Chart analysis of these 113 transplant recipients identified 55 patients as having undergone colonic evaluation (contrast enema, postmortem examination), with seven of these 55 (13%) found to have diverticulosis and major colonic complications eventually developing in four of these seven. Since the mortality from the complications of colorectal diseases in immunosuppressed patients is so prohibitive, in patients with diverticulosis and a previous history suggestive of diverticulitis, consideration should be given to exclusion from transplantation or elective segmental colectomy prior to transplantation.
Patients undergoing elective left colectomy for colonic carcinoma or diverticulosis (n = 341) were randomly assigned to three groups. Patients in groups 1 (102 patients) and 2 (122 patients) had two 5% povidone-iodine enemas whereas those in group 3 (117 patients) had saline enemas. Groups 1 and 3 received 24-hour intravenous cefotaxime sodium and metronidazole hydrochloride. Group 2 received single injections of ceftriaxone sodium (1 g) and ornidazole (1 g). Senna concentrate was administered the evening before surgery. There was no statistically significant difference found between groups 1 and 2 concerning the number of infected patients (eight vs 11), anastomotic leakages (four vs four), extra-abdominal complications (32 vs 29), or infection-related deaths (one vs zero). Despite poorer tolerance, povidone-iodine enema was more effective than saline enemas, as there were less infected patients in group 1 (8%) or groups 1 + 2 (8.5%) than in group 3 (13%). Single-dose ceftriaxone-ornidazole combined with povidone-iodine enemas is effective against infective complications in elective left colonic surgery for carcinoma or diverticular disease. Single-dose antibiotic prophylaxis reduces costs and work for the nursing staff.
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The 3-7-year follow-up results of 37 patients undergoing the operation of distal colomyotomy are reported. Twenty-five underwent surgery for uncomplicated diverticular disease; there was no mortality but 40 per cent of patients had recurrent symptoms. Twelve patients underwent surgery for complicated diverticular disease, with an operative mortality of 16-6 per cent and a recurrent symptom rate of 37-5 per cent.
Large gas cysts of the colon are uncommon and only some 30 cases have been reported (Moss, 1975). They usually arise from the sigmoid colon and are always associated with diverticular disease (Schenken and Cochran, 1972). In view of their rarity, 2 further cases with different presenting factors are discussed.
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In a consecutive series of 122 patients who required an emergency operation for disease or injury of the colon or rectum, 80 (65 per cent) had an immediate resection of the diseased segment of bowel, with an operative mortality of 15 per cent. The free use of immediate resection is of benefit to patients, but good results depend on the experience of the surgeon and the use of a number of special techniques.
A consecutive series of 176 patients was studied prospectively in order to assess the value of full urological assessment prior to elective colorectal surgery for carcinoma or diverticular disease. Fifty-one patients had urological symptoms and 29 of these had an abnormal intravenous urogram (IVU); when compared with the 125 asymptomatic patients, they were twice as likely to develop acute retention of urine and four times more likely to require prostatectomy. Twenty of the 31 patients with an abdominal mass had an abnormal intravenous urogram, and the presence of this physical sign may be regarded as an absolute indication for IVU. Forty-five patients had a urological abnormality on the preoperative IVU; of these, 1 in 6 required treatment prior to elective large bowel surgery and 1 in 3 developed acute retention of urine postoperatively (half required prostatectomy). Twenty-two patients had a disease-related abnormality on preoperative IVU and in 12 planned urological surgery was undertaken at the time of the colorectal resection. In the 91 patients with no urological symptoms, no abnormal mass and normal blood urea and mid-stream urine sample, the incidence of IVU abnormalities and of postoperative complications was low and surgical management was not altered in these patients.
From 1966 to 1987, 177 consecutive patients were operated on electively for diverticular disease of the sigmoid colon. The indications for surgery were: colovesical fistula (n = 12), suspicion of residual abscess (n = 39), two or more previous attacks of acute inflammation (n = 52), chronic symptoms (n = 72) and suspicion of carcinoma (n = 2). An abscess was found at operation in 76 patients (43 per cent) and this was extracolic with local peritonitis in 52 patients (29 per cent). An unsuspected abscess was found in 25 of the 72 patients operated on for chronic symptoms. Colonic resection with primary anastomosis was performed in 95 per cent of the 177 patients and in 94 per cent of those 52 patients with an extracolic abscess. There were no postoperative deaths and no clinical anastomotic leakages. Long-term results were very good in 85 per cent of the 177 patients and in 82 per cent of the 72 patients operated on for chronic symptoms. The results of this series suggest that a one-stage procedure can be safely performed with some technical precautions in most patients operated on electively for diverticular disease, even if an extracolic abscess is found. The good long-term results in patients operated on for chronic symptoms suggest that such symptoms should be taken into account with respect to surgical indications.
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Over a 3-year period, all patients referred for barium enema examination had a double-contrast barium enema and flexible sigmoidoscopy performed on the same day. A total of 462 joint examinations were performed. Abnormalities were found in 193 patients by the use of barium enema, 164 patients by using sigmoidoscopy and 294 by the use of both methods of investigation. Sigmoidoscopy was superior to barium enema in the detection of polyps and inflammatory bowel disease but barium enema was more sensitive for diverticular disease. The presenting symptoms had no predictive value in distinguishing carcinoma, polyps and diverticular disease. Diverticular disease did not reduce the sensitivity of barium enema examination to polyps in the sigmoid colon. Fibreoptic sigmoidoscopy immediately before barium enema was well tolerated by patients. The investigations were complementary in the diagnosis of colonic polyps, inflammatory bowel disease and diverticular disease.