Management of surgical complications of small-bowel diverticulosis

INTRODUCTION: Diagnosis of complications of small bowel diverticulosis is difficult in the emergency setting and often delays surgical management. The aim of this study was to report our experience with seven patients presenting with a surgical complication of small-bowel diverticulosis. PATIENTS AND METHODS: From January 1, 1995 to June 30, 2001, 7 patients presenting with a complication of small-bowel diverticulosis were included in this retrospective study. The mean age of the patients was 73.1 years. Complications were bleeding in 4 cases and diverticulitis with perforation and abscess formation in 3 cases. RESULTS: The time between complication onset and its management was 20.6 days. Among paraclinical examinations small-bowel barium opacification showed diverticulosis in 4 cases. Other investigations such as endoscopy or CT-Scan imaging studies were used to eliminate other causes of acute abdomen. Patients were operated on in all cases and a segmental small bowel resection was performed in all cases while in one patient, a diversion stomy was performed. One patient died following septic peritonitis treatment. CONCLUSION: Small-bowel diverticulosis is unfrequent. In cases of gastrointestinal haemorrhage or occlusion, diagnosis is performed by eliminating other more frequent causes. If emergency surgery is not required, barium opacification seems to be the most sensitive examination.     

Diverticulosis of the jejunum with intestinal obstruction： A case report

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.     

Acute ulcerative jejunal diverticulitis： Case report of an uncommon entity

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Its reported incidence varies from 0.05% to 6%. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life threatening and require early surgical treatment. We report a case of an 88-year-old man investigated for acute abdominal pain with a high biological inflammatory syndrome. Inflammation of multiple giant jejunal diverticulum was discovered at abdominal computed tomography （CT）. As a result of the clinical and biological signs of early peritonitis, an emergency surgical exploration was performed. The first jejunal loop showed clear signs of jejunal diverticulitis. Primary segmental jejunum resection with end-toend anastomosis was performed. Histopathology report confirmed an ulcerative jejunal diverticulitis with imminent perforation and acute local peritonitis. The patient made an excellent rapid postoperative recovery. Jejunal diverticulum is rare but may cause serious complications. It should be considered a possible etiology of acute abdomen, especially in elderly patients with unusual symptomatology. Abdominal CT is the diagnostic tool of choice. The best treatment is emergency surgical management.     

Divertikulose und Divertikulitis der Appendix vermiformis

Diverticular disease and diverticulitis of the vermiform appendix are rare entities. The diagnosis is often established by histopathological examination after appendectomy or occasionally due to barium enema. Clinical findings are various from asymptomatic to chronic right lower abdominal pain. They also can cause an acute abdomen. In case of symptoms we recommend surgery for treatment of choice. We report on the case of a patient with diverticulosis of the appendix found by histopathological examination and another patient presenting a perityphlitical infiltration following perforation of an appendical diverticle.     

Reversible nicotinamide-deficiency encephalopathy in a patient with jejunal diverticulosis

A patient with severe malabsorption due to massive diverticulosis of the small intestine developed an acute encephalopathic syndrome which responded dramatically to intravenous nicotinamide. Various mechanisms are discussed whereby nicotinamide deficiency might have occurred in this clinical context.     

Complicated small-bowel diverticulosis： A case report and review of the literature

While jejunoileal diverticula are rare and often asymptomatic, they may lead to chronic non-specific or acute symptoms. The large majority of complications present with an acute abdomen similar to appendicitis, cholecystitis or colonic diverticulitis but they also may appear with atypical symptoms. As a result, diagnosis of complicated jejunoileal diverticulosis can be quite difficult, and may solely depend on the result of surgical exploration. In the absence of contra-indications, diagnostic laparoscopy has the benefit of thorough examination of the abdominal contents and helps to reach an absolute diagnosis. Surgical resection of the involved small-bowel segment with primary anastomosis is the preferred treatment in patients with symptomatic complicated jejunoileal diverticular disease. An atypical presentation of complicated jejunal diverticulitis in conjunction with sigmoid diverticulitis diagnosed with laparoscopy and treated with surgical resection is presented.     

Acute massive gastrointestinal hemorrhage in jejunal diverticulosis

Two cases which presented with acute massive lower gastrointestinal hemorrhage from jejunal diverticulosis are reported. The various clinical presentations of this rare disease are discussed. The life-threatening complication of massive bleeding is specially outlined. The cases reported in the literature resemble the Dieulafoy ulcer lesion of the stomach.     

Myenteric plexuses and colonic diverticulosis: results of a histological study

The implication of intraluminal hyperpressure in the pathogenesis of colonic diverticulosis was investigated. Since colonic motricity depends on the anatomical integrity of the myenteric plexuses, we looked for morphological abnormalities of these plexuses in diverticulosis of the sigmoid, using the silver impregnation technique devised by Smith. Fifteen sigmoidectomy specimens (including the rectosigmoid junction) were studied in patients afflicted with diverticulosis. Operations were not performed during the acute phases of the illness. The results were compared to those obtained in 5 colectomy specimens in patients with cancer of the rectum, without colonic diverticulosis (control series). Conventional histology as well as the silver impregnation did not reveal any morphological abnormalities of the myenteric plexuses in the rectosigmoid junction or in the remaining sigmoid. The count of argyrophilic ganglion cells (10 to 15 per plexus) was identical in the colons affected with diverticulosis and in the control specimens. These results show that impairment of motricity in sigmoid diverticulosis is not a consequence of morphological abnormalities of the myenteric plexuses. They do not, however, exclude chemical or functional modifications in these plexuses.     

Practice Guidelines for Primary Care of Acute Abdomen 2015

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine, in collaboration with four other medical societies, launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all clinical questions and recommendations were shown in supplementary information). A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. A total of 108 questions based on nine subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two‐step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence‐based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.     

Clinical features of colonic diverticular disease

Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.     

Clinical features of colonic diverticular disease

Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.     

Spontaneous rectus sheath hematoma presenting as acute surgical abdomen: an important differential in elderly coagulopathic patients

Rectus sheath hematoma (RSH) presenting as acute surgical abdomen is a rare clinical entity. Failing to establish an early diagnosis will probably result in increased morbidity or unnecessary surgical intervention. We describe herein a case of an 85-year-old woman receiving anticoagulants who presented with typical clinical manifestations of acute surgical abdomen and a slightly palpable abdominal mass. Ultrasonography was inconclusive whereas computed tomography scans demonstrated a large right rectus sheath hematoma associated with hemoperitoneum. The patient was treated conservatively with success. It is therefore concluded that RSH must be considered in any elderly patient on anticoagulant therapy who presents with manifestations of acute surgical abdomen.     

内镜诊断十二指肠憩室病

目的:探讨十二指肠镜诊断十二指肠憩室病的方法要点和临床意义,指导临床治疗.方法:按内镜常规操作方法,用日本PEXT FD-32A十二指肠镜,对十二指肠进行观察.结果:本组25例,检出率为11%,其中合并出血3例,有11例曾先后经上消化道X线钡剂及十二指肠镜,对比检查,其结果差异显著.结论:十二指肠憩室病临床症状缺乏特异性,诊断困难,临床症状虽不严重,但并发症常危及生命,其发病率与年龄无关,经与X线造影比较,其检出率显著高于X线造影,说明十二指肠镜检查,是本病可靠的诊断手段     

Scrub typhus presenting as acute abdomen

Scrub typhus, a zoonosis, is a systemic febrile illness with diverse clinical manifestations. It may also present with signs and symptoms of acute abdomen. We present two serologically confirmed cases of scrub typhus presenting with acute abdomen that were managed conservatively with antibiotics.     

Diverticula,diverticulosis and diverticulitis of the colon

Summary Solitary diverticula, diverticulosis, and diverticulitis are defined and discussed as separate clinical entities. Diverticula of the “true” and “false” varieties are differentiated from each other with respect to their embryologic and physiopathologic characteristics. The diagnosis of diverticulosis and diverticulitis is discussed. The problem of colonic hemorrhage in the elderly patient with diverticulosis and hypertensive cardiovascular disease is presented. The cause of bleeding in diverticulosis and diverticulitis is discussed. A one-stage resection of the sigmoid flexure for diverticulitis is described and illustrated.     

Comparison between technetium-99m hexamethylpropyleneamineoxide labeled white blood cell abdomen scan and abdominal sonography to detect appendicitis in children with an atypical clinical presentation

BACKGROUND/AIMS: Diagnosing acute appendicitis in children with equivocal signs and symptoms is usually difficult. The usual approach to the patient is hospital observation and frequent reexamination. However, many surgeons are reluctant to delay surgery because of the risk of perforation and a negative laparotomy. The aim of this study is to assess and compare the value of the Tc-99m HMPAO (technetium-99m hexamethylpropyleneamineoxide) labeled white blood cell abdomen scan and abdominal sonography in the diagnosis of acute appendicitis in children with an atypical clinical presentation. METHODOLOGY: Forty children with acute abdomen and possible acute appendicitis but atypical findings were included in this study. After an intravenous injection of Tc-99m HMPAO white blood cells, serial anterior abdomen scans at 30 min, 60 min, 120 min and 240 min were obtained using a gamma camera. Meanwhile, at the point of maximal tenderness, abdominal sonography was performed with a graded compression technique for both longitudinal and transverse images. RESULTS: Thirty-three children received operation for surgical and pathological diagnoses. The other 17 children did not receive operation but follow-up of at least a one-month period. The overall sensitivity, specificity, and accuracy of Tc-99m HMPAO white blood cell scan to diagnose acute appendicitis in children with atypical findings is 96.7%, 80.0%, and 90.0%, respectively. The overall sensitivity, specificity, and accuracy for abdominal sonography is 86.6%, 90.0%, and 88.0%, respectively. CONCLUSIONS: The Tc-99m HMPAO white blood cell abdomen scan provides a more sensitive and accurate method for the diagnosis of appendicitis in children with atypical clinical presentation when compared with abdominal sonography.     

Recent Advances in Diverticular Disease

Diverticular disease is common and accounts for substantial health care utilization in the USA. Recent publications in the areas of diverticulosis and diverticular disease have highlighted several notable advances that are now changing practice. Despite colonic diverticula being common, only 1–4 % of individuals with colonic diverticula will develop diverticulitis. After a first occurrence of acute diverticulitis, the risk of recurrence is 20 % at 5 years. Complications most commonly occur with the first occurrence of acute diverticulitis and not with recurrent episodes. After an episode of diverticulitis, many patients continue to experience chronic gastrointestinal symptoms. Prophylactic surgery is an option to reduce the risk of recurrence and its negative impact on quality of life. Importantly, the rationale for surgery is no longer to prevent complications because this risk is low. The review concludes with practical recommendations for patients with diverticulosis and diverticular disease.     

Rectal diverticulosis: a case report and review of the literature

The occurrence of rectal diverticulosis is rare. We report the incidental finding of a large rectal diverticulum in a patient receiving an air-contrast barium enema. The presence of uncomplicated rectal diverticulosis is probably of little clinical significance. However, there can be associated complications such as inflammation and perforation, and potential confusion with rectal carcinoma.     

Association between sigmoid diverticulitis and left-sided colon cancer: a nested, population-based, case control study

BACKGROUND: An increased risk of left-sided colon cancer in patients with diverticular disease of the sigmoid colon has been reported. The aim of this study was to investigate to what extent patients with diverticulitis of the sigmoid colon differ in long-term risk of colon cancer compared to patients with diverticulosis of the colon without any clinical signs of diverticulitis. METHODS: A total of 7159 patients (2478 M, 4681 F) discharged with a diagnosis of diverticulosis or diverticulitis in 1965-83 in the Uppsala Health Care Region were followed-up with the Swedish Cancer Registry. Sixty-four cases with colon cancer were identified and compared with 123 controls without cancer matched for sex, age and year of first discharge. Based on information from the patients' charts, an independent observer blinded to the outcome assigned a clinical diagnosis of diverticulitis or not diverticulitis to cases and controls. RESULTS: In patients classified as having sigmoid diverticulitis there was an increased risk of left-sided colon cancer compared with patients with diverticulosis without any clinical signs of diverticulitis (odds ratio = 4.2, 95% CI 1.3-13.0) which remained after mutually adjusting for several clinical parameters in a multivariate conditional logistic regression analysis. CONCLUSION: The results of the study indicate a causal association between sigmoid diverticulitis and a long-term increased risk of left-sided colon cancer.     

Rectosigmoidal mucosal puckering and diverticulosis

The association of diverticulosis with a thickened muscle wall in the pelvic colon is well known. There appeared to be a possibility that this muscular thickening might give rise to the rectosigmoidal mucosal puckering often seen through a sigmoidoscope. In 278 colonic motility studies, mucosal puckering was correlated with patient age, diverticulosis, and the symptomatology of the irritable colon syndrome. The prevalence of mucosal puckering increased with age at the same rate as that of diverticulosis, but the different percentage levels were reached some 25 years earlier in life. Mucosal puckering, which persisted in all subsequent examinations, showed no correlation with the clinical characteristics of irritable colon syndrome. Resistance of the bowel wall to distention was significantly greater in association with puckered rectosigmoidal mucosa than when the mucosa appeared smooth. It is concluded that rectosigmoidal mucosal puckering is probably caused by thickening of the underlying muscle; it is a precursor of diverticulois, and patients who have it should be kept on a high-residue diet.