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Hysterosalpingography demonstrated unilateral opacification of Gartner's duct and bilateral diverticulosis (salpingitis isthmica nodosa) of the fallopian tubes. An association of two mesonephric abnormalities in the same patient is postulated. The case also serves as a reminder of the association of diverticulosis with tubal ectopic pregnancy and infertility.
HISTORY AND CLINICAL FINDINGS: A 58-year-old man was admitted to our hospital after an acute onset of rectal bleeding. He was known to have had recurrent duodenal ulcerative disease, once with upper gastrointestinal haemorrhage. Clinical examination was remarkable only for rectal bleeding. INVESTIGATIONS: After application of a nasogastric tube cherry-red blood was evacuated. Upper endoscopy showed only very small mucosal erosion in the stomach and coloscopy demonstrated several non-bleeding diverticula. Small bowel enteroclysis showed severe diverticulosis of the duodenum and jejunum. DIAGNOSIS, TREATMENT AND COURSE: We assumed that the extensive duodenojejunal diverticulosis was the most probable cause of this episode of gastrointestinal bleeding because of simultaneous signs of upper and lower gastrointestinal haemorrhage. Because this was the first such episode we preferred a conservative approach. At nineteen months follow-up there was no recurrence of bleeding. CONCLUSION: Gastrointestinal hemorrhage is a common cause of hospitalization. After exclusion of the more common bleeding sources small bowel diverticula should be considered as a possible rare cause. Surgical resection of the bleeding bowel part is the procedure of choice, but one of the major problems in such cases is to locate exactly the bleeding site. If the location is uncertain, a more conservative approach may be preferable, especially in haemodynamically stable patients with first-time diverticular bleeding.
The aim of surgery in the management of diverticulitis and complicated diverticulosis is to remove the disease process as quickly as possible. This approach reduces the likelihood of complications and often avoids the necessity of multistage procedures. Indications for resection include failure of a first attack to subside, recurrent attacks, and free perforation with spreading peritonitis. Three-stage procedures should be reserved for extremely serious disease. Other complications requiring surgery are fistula, obstruction, and massive and uncontrolled bleeding. Massive bleeding is caused by diffuse colonic diverticulosis and is rarely associated with diverticulitis. Abdominal mass, obstruction, or recurrent episodes of slight bleeding should suggest the possibility of underlying tumor and are compelling indications for early resection.
Although jejunal diverticulosis is a rare entity and usually asymptomatic, it may cause chronic symptoms and acute complications. Because of the rarity of the entity, diagnosis is often delayed, resulting in unnecessary morbidity and mortality. The purpose of this study was to draw attention to jejunal diverticula and their complications. The medical records of 8 consecutive patients with complications due to small-bowel diverticula treated at our department during the past 4 years were reviewed. All diverticula were located in the jejunum. Seven patients had acute complications, 3 patients had an intra-abdominal abscess, 2 had free perforation with diffuse peritonitis, 1 had a bowel occlusion and 1 patient had concomitant bleeding and occlusion. One patient presented with chronic symptoms. A preoperative diagnosis of jejunal diverticula, before explorative laparotomy, was not reached in any of the 7 patients with acute symptoms. In the patient with chronic symptoms, multiple jejunal diverticula complicated by a jejuno-colic fistula and foreign body were found at laparotomy. On patient died of multiorgan failure. Small-bowel diverticulosis is a rare entity, but it should not be regarded as a clinically insignificant finding. It may be difficult to make a preoperative diagnosis. Patients with incidentally detected proximal jejunal diverticula, at imaging studies or at laparotomy, warrant close observation and awareness that the diverticula may cause serious complications.
We describe two cases of oesophageal intramural pseudo-diverticulosis associated with a cervical oesophageal web presenting as intermittent dysphagia. In both cases, disruption of the web endoscopically resulted in lasting relief from symptoms. This observation, together with a review of the literature written during the past 39 years, suggests that oesophageal web formation may be under-reported in this condition and may be more important than either dysmotility or submucosal fibrosis and stricturing in the aetiology of the dysphagia seen in these patients. All patients with a radiological diagnosis of oesophageal intramural pseudo-diverticulosis should have an endoscopic examination which may be both diagnostic and potentially therapeutic.
A case control study exploring the role of diet and other biosocial factors in the aetiology of diverticulosis was undertaken in Athens, Greece, in 1981-1982. One hundred consecutive cases with radiologically confirmed diverticulosis and 110 control patients with fractures or other orthopaedic disorders were submitted to a structured interview, including frequency of consumption of about 80 food items. The main positive findings were, (i) the cases reported significantly less frequent consumption of vegetables, brown bread and, to a lesser extent, potatoes and fruits, and (ii) the cases reported significantly more frequent consumption of meat and, to a lesser extent, milk, and milk products. The difference in risk between those people who frequently consume vegetables but rarely consume meat, and those who rarely consume vegetables and frequently consume meat, was almost 50-fold.
This study determined the incidence and concentration of methane-producing bacteria in tap water enema samples of 130 individuals taken before sigmoidoscopy. The number of subjects classified in five major colonic groups were as follows: normal colon 36, diverticulosis 57, inflammatory bowel disease 11, colon polyps 34, and colon cancer 11. Some patients were placed in more than one category. Ninety four of the subjects or 72% had methanogenic bacteria ranging in concentration from 6 to about 3 X 10(10)/g dry weight of faeces. The predominant methanogen in all groups was Methanobrevibacter smithii. Chi-square analysis showed that the incidence of methanogens in concentrations of 10(7)/g dry weight of faeces or greater in patients with diverticulosis (58%) was significantly greater than in normal patients (25%). High methanogen concentrations are associated with excretion of methane in the breath.
Three cases of chronic pancreatitis occurring in patients with small intestinal diverticulosis and bacterial overgrowth are reported. In two of the cases, pancreatic supplements were therapeutically beneficial (the third being unable to tolerate them). Two of the patients also developed diverticular perforation. The possible nature of the association between small intestinal diverticulosis and chronic pancreatitis is discussed.
Four cases of intramural diverticulosis of the oesophagus are described, and the findings are reviewed in 12 previously reported cases. Evidence is presented that this condition is a true pulsion diverticulosis due to deranged motor activity and raised intraluminal pressure. It may occur in cases of diffuse oesophageal spasm, or it may follow inflammation, stricture or surgery. The course is benign, complications being those of the underlying disorder.
Diverticulosis of the main bronchi, not associated with other organ abnormalities, developed in a 12 year old child. This abnormality caused recurrent bronchopneumonia in the lung with the main bronchi diverticulosis. Fibreoptic bronchoscopy helped to locate the lesion and selective bronchography, with injection of contrast medium through the suction channel of the fibreoptic bronchoscope, showed the morphology of this rare malformation.
Behçet's disease (BD) is a multisystem disorder characterized by vasculitis. The aim of this report is to present a patient with BD and diverticular disease of the colon and discuss the possible association between BD and diverticulosis. To our knowledge, diverticular disease of the colon has not been previously reported in a patient with BD. We conclude that the significance of this association between BD and diverticulosis needs to be clarified.
Diverticulosis of the appendix is rarely reported. Two cases with this condition, including a unique example of appendiceal diverticulosis presenting at herniorrhaphy, are described. The aetiology of the condition and factors involved in incidental appendicectomy are considered.
A description is given of the etiology and pathology of intramural esophageal diverticulosis as so far discussed in the literature. In view of the course and the clinical findings in two young patients in whom this diagnosis was established, it is suggested that intramural diverticulosis develops as a result of a devolopmental disorder in the autonomic nervous system.
Forty-four cases of diverticulosis of the colon were detected among 2,662 cases examined by barium enema in Tohoku University. This corresponds to 1.7% in frequency. On the other hand, 21 cases were found among 1,511 cases examined in Hirosaki University, giving 1.4% in frequency. It was more frequent in the male. The frequency, as calculated on the basis of the numbers of cases examined by barium enema in separate age groups, showed the gradual increase with age except for above the eighth decade. The location where the diverticulum was most frequently seen was the right colon; namely, cases in which the diverticulum occurred from the cecum to the ascending colon and those in which it was found only in the ascending colon occupied 61.4 and 71.4% of the total cases, respectively. Diverticulitis as a complication was rare, while coincidence of polyp or carcinoma was sometimes observed. Furthermore, the value of fiberscopy for the diagnosis of diverticulosis of the colon was discussed, and its usefulness for the detection of complication was emphasized.
The incidence of colonic diverticulosis was examined in 5 hospitals geographically isolated from each other in Japan during the period between mid '70s and 1986. The incidence rapidly increased in all hospitals from 3.5-9.0% in mid '70s and 8.4-23.2% in 1986. The ratio of right-sided type colonic diverticulosis was approximately 70-80% in each hospital and the ratio did not fluctuate significantly during the period. Birth cohort analysis revealed that although the incidence of right-sided diverticula had increased with aging, in groups born in more recent decades right-sided diverticula appeared in younger age than other groups. It was suggested that environmental factors rather than congenital factors may cause the increase of the incidence of right-sided colon diverticula.
Colonic diverticulosis is a common cause of acute severe rectal hemorrhage. The precise site of bleeding, etiology, and pathogenesis have not been previously identified. Arteriographic, microangiographic, and detailed histologic observations in 10 cases of massively bleeding colonic diverticulosis demonstrated strikingly consistent changes related to the characteristic angioarchitecture of colonic diverticula. These changes included: (1) asymmetric rupture of the vas rectum toward the lumen of the diverticulum precisely at its dome or its antimesenteric margin; (2) conspicuous eccentric intimal thickening of the vas rectum, often with thinning of the media and duplication of the internal elastic lamina at and near the bleeding point; and (3) general absence of diverticulitis. Comparison with control colonic diverticula suggests that traumatic factors arising within the diverticular or colonic lumen induce asymmetric intimal proliferation and segmental weakening of the associated vas rectum, predisposing to rupture and massive bleeding.
A diagnosis of intestinal diverticulosis is difficult to make pre-operatively because the clinical symptoms are usually non-specific. We report the case of a 70-year-old man who had suffered from three episodes of intestinal obstruction in 1 year. He experienced dull pain and a sensation of fullness over the whole abdomen. The symptoms did not improve after conservative treatment. The presumptive diagnosis was intestinal obstruction, and an exploratory laparotomy found diverticulosis of the proximal jejunum, with an adhesion band formed from the base of one diverticulum. Strangulation of a segment of the jejunum resulted from the internal herniation caused by the band. The band was removed and the proximal jejunum segmentally resected. His postoperative course was uneventful.
We reported a case of 79-year old woman with known large bowel diverticulosis presenting with small bowel obstruction due to stone impaction - found on plain abdominal X-ray. Contrast studies demonstrated small bowel diverticulosis. At laparotomy, the gall bladder was normal with no stones and no abnormal communication with small bowel - excluding the possibility of a gallstone ileus. Analysis of the stone revealed a composition of bile pigments and calcium oxalate. This was a rare case of small bowel obstruction due to enterolith formation - made distinctive by calcification (previously unreported in the proximal small bowel).