Diverticular disease

Diverticular disease is a gastrointestinal disorder. Christine Hyde discusses the physiology and care of related conditions in the large bowel, examining potential surgical outcomes.

How frequently do large bowel diverticula perforate? An incidence and cross-sectional study

The aetiology of perforation of large bowel diverticula is poorly understood and a case-control study is required to identify the causes. Before such a study can be attempted, the incidence must be determined and groups at particular risk identified. Cases of perforated large bowel diverticula living in the Norwich postal code region treated between 1995 and 1997 were identified. Fifty-eight cases presented in a population of 531 241. The incidence was 4.0 cases per 100,000 per year, increased with age and was higher in men than women (5.8 vs 3.1). The most frequently used drugs were non-steroidal anti-inflammatory drugs (NSAIDs) (29%) and opiate analgesics (26% of cases). This is the first report of the incidence of perforated diverticular disease and allows a calculation of the population size needed to recruit sufficient cases for an aetiological investigation. The differences in incidence between genders should prompt a search for factors which differ between the sexes such as diet. NSAIDs are a known risk factor, although the data show that opiate analgesics should be investigated.

[Female urethral diverticulum]

Female urethral diverticulum is a rare condition. The reported incidence varies from 1.4-5%, depending on the population studied. The correct diagnosis is often delayed because of unspecific symptoms from the patients' lower urogenital tract. The classic triad of female urethral diverticulum is dribbling of purulent matter, dyspareunia and dysuria. The majority of patients have a palpable mass located on the anterior vaginal wall. The presentation and management of 11 women with urethral diverticulum who where admitted to the Surgical Department of the Central Hospital in Akershus during the period 1.1. 1975 to 1.4. 1996 is reviewed. Investigations included vaginal examination, urethrocystoscopy, urography and urethrography with a double balloon catheter. A palpable mass was found in all 11 patients. The urethrography was positive in eight out of ten patients. Diverticulectomy was performed on nine patients. In follow-up interviews from three months to 21 years after treatment, one patient was found to suffer from incontinence after surgery, two patients noticed recurrence of some symptoms, and six patients were completely relieved of their complaints.

The role of juxtapapillary duodenal diverticulum in the formation of gallbladder stones

BACKGROUND/AIMS

Juxtapapillary diverticula (JPD) are considered to be associated with choledocholithiasis but not with cholecystolithiasis. However, there have been few comparative studies on the relationship between JPD and cholecystolithiasis under strict matching for sex and age.

METHODOLOGY

Among 4542 consecutive ERCPs at Tokyo Metropolitan Komagome Hospital, 549 patients who were 63 years of age or older were enrolled in this study and were matched for sex and age. They were divided into two groups: with and without JPD. Firstly, the frequency of cholecystolithiasis was compared between the two groups. Next, we recruited 83 patients whose JPD size could be measured by the ERCP films and investigated the relationship between JPD size and gallstones.

RESULTS

We found no correlation between JPD and the overall frequency of cholecystolithiasis. However, an analysis of 83 patients with measurable JPD revealed that the size of JPD was closely linked to the occurrence of cholecystolithiasis. The JPD size was statistically larger in patients with cholecystolithiasis than those without. Moreover, when the mean diameter of JPD was 20 mm or more, the incidence of cholecystolithiasis rose up to 73.3%, which was significantly greater compared to the incidence in patients without JPD (p< 0.05).

CONCLUSION

A larger JPD may play a role in the formation of gallbladder stones.

The American College of Gastroenterology Bleeding Registry: preliminary findings

OBJECTIVES

The American College of Gastroenterology (ACG) Institute for Clinical Research and Education conducted a survey study to assess demographics, management strategies, and outcome for patients with gastrointestinal bleeding. This pilot project was intended to determine the feasibility of surveying the ACG membership about common clinical issues.

METHODS

Color-coded survey forms were sent to all ACG members and Fellows, with instructions to supply information about demographics, presenting symptoms, management, and outcome for bleeding patients and procedure-matched controls. Forms returned between June 1 and August 31, 1995, were tabulated and analyzed for differences between the bleeding group and procedure-matched controls.

RESULTS

A total of 1235 forms were returned by respondents, 60% of whom were in private practice. Patient demographics indicated that bleeding patients were significantly older, more likely to be male, and more likely to use alcohol, tobacco, and prescription or over-the-counter aspirin or nonsteroidal anti-inflammatory drugs and anticoagulants than were controls. Upper GI bleeding accounted for 76% of bleeding events, with duodenal and gastric ulcers being the source in more than 50% of the upper GI bleeders. Diverticula was the most common bleeding source identified in lower GI bleeders. In the bleeding group, 78.8% were anemic, with 60.9% having hemoglobin of <10 g/dl; 31% presented with orthostatic changes in blood pressure or shock. Most bleeding subjects, regardless of source, were hospitalized, 58.2% received blood transfusions, and 45.5% received endoscopic therapy. Rebleeding (11.2%), need for surgery (7.1%), and fatalities (2.1%) were uncommon. Over-the-counter aspirin and nonsteroidal anti-inflammatory drugs were used significantly more often in the bleeding population (47.6%) than in controls (19.4%).

CONCLUSIONS

The success of the GI Bleeding Registry supports the feasibility of surveying ACG members about common clinical problems. Data suggest that ACG members manage sick patients with severe gastrointestinal bleeding who require hospitalization, transfusions, and endoscopic treatment. These preliminary results will serve as an impetus to conduct further survey studies of gastrointestinal bleeding and other common digestive disease conditions.

Severe abdominal pain and thrombocytopenia--typical symptoms of occult jejunal diverticulum perforation?

Complicated small-bowel diverticula cause abdominal pain, gastrointestinal hemorrhage, small-bowel obstruction, and peritonitis. The present patient, had an occult perforation of a small-bowel diverticulum. There were diverticula throughout the whole small bowel. Preoperatively thrombocytopenia (98,000 thrombocytes/cc), was noted. Without any special treatment, i.e., transfusion, the thrombocyte level increased after surgical treatment to normal levels. Although the incidence of small-bowel diverticula appears to be low (0.1%-2.3%) complications may become life-threatening. The level of thrombocytopenia may reflect the extent of inflammation.

[Meckel's diverticulum. Study of 61 cases]

BACKGROUND

Meckel's diverticulum is a well known disease in children. The main clinical presentations are rectal bleeding and intestinal occlusion.

OBJECTIVE

To investigate the frequency, main clinical symptoms, signs, complications, localization, histology and diagnosis in a population of mexican children.

METHOD

We studied 61 children who were seen at the Instituto Nacional de Pediatria, Mexico City, during a period of 10 years. The age, sex, symptoms, complications, hematocrit, 99mTc-Pertechnetate scanning, histology, and localization of Meckel's diverticulum were analyzed in all of them.

RESULTS

15 children were female and 46 male (1:3). In infants the main clinical finding was rectal bleeding. Intestinal occlusion was the most common clinical expression in older children. Gastric mucosa was a common finding in the diverticulum of children with rectal bleeding in contrast to ileal mucosa in children with intestinal occlusion. 99mTc-pertechnetate scanning with previous administration of H2 blocking agent was the best diagnostic procedure.

CONCLUSIONS

Meckel's diverticulum must be considered an emergency in children. Meckel's diverticulum, has to be ruled cut as in infants with significant bleeding, as well as in children with intestinal occlusion. The best method for diagnosis is 99mTc-pertechnetate scanning.

The relationship between juxtapapillary duodenal diverticula and biliary stone disease

OBJECTIVE

To assess the relationship between juxtapapillary duodenal diverticula (JDD) and common bile duct stones and biliary stone disease in general.

DESIGN

A retrospective study.

METHODS

We analysed 1115 patients who underwent consecutive endoscopic retrograde cholangiopancreatography examinations. The patients were subdivided into three groups: the first group (group I; n = 482) had no biliary stone disease, the second one (group II; n = 329) had common bile duct stones, and the third group (group III; n = 304) had biliary stone disease of the gallbladder but without evidence of common bile duct stones. Additionally, the patients were subdivided into age groups of < 50, 50-59, 60-69, 70-79, and > or = 80 years of age. Logistic regression was applied for statistical analysis.

RESULTS

Juxtapapillary duodenal diverticula were diagnosed in 111 (10.0%) patients. The incidence of JDD was 6.9% in group I, 14.3% in group II and 10.2% in group III. Age was the most dominant influence factor for JDD, common bile duct stones, and biliary stone disease (P < 0.0001). Sex was also a factor, female patients having a higher risk for common bile duct stones (P = 0.01) and biliary stone disease (P < 0.0001). After adjustment for age and sex, JDD was found to have a noticeable, but not statistically significant (P = 0.073), influence on common bile duct stones and no influence on biliary stone disease (P = 0.15).

CONCLUSION

Our data support only moderately the existence of a relationship, which had been conjectured in a part of the literature, between JDD and common bile duct stones. No noticeable influence on biliary stone disease was found.

[Pyelocaliceal diverticuli]

Pyelocalyceal diverticula are eventrations of the upper collector system in an intraparenchymatous location which communicate with the main collector system through a narrow channel. They have a thin wall and are lined with a transitional cells epithelium and surrounded by a muscle layer. Although these are non-secretory cavities they contain urine as a result of a passive filling from the adjacent collector system. The large majority of these lesions have less than 1 cm in diameter. Many are asymptomatic and are frequently found incidentally during elimination urography for other reasons. They rarely require treatment but may cause symptoms related to size or associated complications (infection or lithiasis). A number of years ago, definite treatment of complicated calyceal diverticulum was open surgery, but this has been defeated lately by less invasive techniques such as shock wave and percutaneous nephrolythotomy.

An analysis of the relationship between bile duct stones and periampullary duodenal diverticula

Previous studies have suggested a relationship between bile duct stones and periampullary duodenal diverticula. The aim of the present study was to examine this association in more detail, including step-wise logistic regression to identify independent predictors for the presence of diverticula. Clinical, endoscopic and radiological data were analysed from 794 consecutive subjects with bile duct stones; 44 with primary duct stones (without gall-bladder stones) and 750 with bile duct stones associated with current or previous gall-bladder stones. Frequencies of diverticula in subjects with bile duct stones were compared with those in age-matched controls who had undergone upper gastro-intestinal endoscopy using a side-viewing endoscope (n = 100) or who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic cancer (n = 100). The frequencies of diverticula in subjects with primary duct stones (70%) and bile duct stones with current or previous gall-bladder stones (25%) were significantly higher than in both control groups (7 and 8%, respectively). When subjects with bile duct stones were analysed by step-wise logistic regression, age and bile duct diameter were independent predictors of the presence of diverticula, but diverticula were unrelated to gender, mode of presentation, number of bile duct stones and outcome after endoscopic sphincterotomy. A significant association exists between duodenal diverticula and bile duct stones, perhaps because diverticula predispose to stone formation through the combined effects of bile stasis and bacterial contamination of bile.

Duodenal diverticulum at endoscopic retrograde cholangiopancreatography, analysis of 123 patients

BACKGROUND/AIMS

The aim of this study was to investigate the frequency, clinical characteristics, findings and possible varieties of treatment of duodenal diverticula in Finnish patients diagnosed by endoscopic retrograde cholangiopancreatography.

MATERIAL AND METHODS

Among 1735 patients investigated by endoscopic retrograde cholangiopancreatography, there were 123 patients with one or more duodenal diverticula and with sufficient clinical data available for this study. Mean age of the patients was 63 years. The male/female ratio was 61/62. Three hundred twenty age and sex matched patients undergoing ERCP during the same time period, but without duodenal diverticula, served as controls.

RESULTS

Sixty-one percent of the diverticula were juxtapapillary. Pain and jaundice were the symptoms indicating ERCP in 62% of patients. Laboratory findings were mostly within normal limits. A hepatic or pancreatic tumor was suspected in twelve patients at ultrasound and computer tomography, and five of them had cancer. In 65 patients, both ducts were cannulated at ERCP. In eleven patients, the finding was normal. There was no significant difference in the incidence of pathologic ERCP findings between the patients with juxtapapillary diverticula and diverticula in other parts of duodenum, except pancreatic duct, which was more frequently abnormal in patients with a non-juxtapapillary diverticulum. The patients with juxtapapillary diverticula had not had previous related complications or operations significantly more often than patients with diverticula in other parts of duodenum. The patients with juxtapapillary diverticula had significantly more often biliary stones at ERCP than control patients and they had idiopathic pancreatitis twice as often as control patients, but the difference was not statistically significant. In three patients, the therapy was directed to the diverticulum and 80 patients had some other treatment.

CONCLUSION

These data do not reveal any clear correlation between a juxtapapillary diverticulum and pancreato-biliary disorders. However, common bile duct stones were more often found in patients with a juxtapapillary diverticulum than in controls.

[Diverticula and pseudodiverticula of the gallbladder in chronic calculous cholecystitis]

The study covers twenty-two patients with chronic calculous cholecystitis (CCC) subjected to operative treatment. Diverticula are discovered in three of them (1.4 per cent), and pseudodiverticula of the gallbladder--in eighteen (8.2 per cent). In all patients presenting diverticula and pseudodiverticula of the gallbladder, the clinical course of the disease is typical of CCC, and in three it is characterized by the clinical picture of obstructive jaundice. Concrements are documented echographically in all cases. Intraoperatively, numerous adhesions, gallbladder kinking at infundibulum level with inflated gallbladder type "Hartmann's pouch" are established in all 18 patients presenting pseudodiverticula. Two of them have empyema of the gallbladder, and in one a colonic-vesical fistula is detected. All patients are subjected to operative management. The immediate postoperative and long-term results are estimated as very good.

Perforated jejunal diverticula: an analysis of reported cases

We recently encountered two cases of perforated jejunal diverticula. We analyzed the data from all available cases of perforated jejunal diverticula, including our two cases. Our purpose was to increase awareness of this rare clinical entity as a cause of abdominal pain. An extensive literature review using Medline from its inception in 1972, and a manual review of all previously published reports was performed. Data collected included age, gender, length of symptoms from history and physical exam, operative findings, type of operation, and outcome (survival). Data analysis was performed using student's t test and multivariate analysis. Survival was not influenced by gender or type of operation. When the reports documented the number of diverticula present in the area of perforation (22 cases) a majority (19/22) had multiple diverticula. Perforated jejunal diverticula are a rare clinical entity in which age, type of operation, and gender does not influence outcome, but a longer duration of symptoms before operation trended towards a worse outcome. This clinical diagnosis should be entertained as part of any evaluation of abdominal pain.

Causes of death in autosomal dominant polycystic kidney disease

To determine the causes of death in autosomal dominant polycystic kidney disease (ADPKD) patients and to examine whether the extrarenal manifestations of ADPKD influence the causes of death, the medical records of 129 patients who died between 1956 and 1993 were reviewed; 58% of the 129 patients had an autopsy performed. Seventy-seven percent died after reaching ESRD. The mean age at death increased from 51 yr for those who died before 1975 to 59 yr for those who died after 1975, reflecting the introduction of renal replacement therapies. The most common cause of death before 1975 was infection (30%), followed by uremia (28%) and cardiac disease (21%); after 1975, these were cardiac disease (36%) and infection (24%). Infection was equally prevalent before and after 1975, presenting as sepsis in 94% and directly relating to ADPKD in 47% of these patients. Underlying factors for cardiac death were cardiac hypertrophy, seen in 89% of all autopsied patients, and coronary artery disease, seen in 81%. A neurologic event was the cause of death in 12% of patients; these were ruptured intracranial aneurysm in 6%, hypertensive intracranial hemorrhage in 5%, and ischemic stroke in 1%. The mean age of those who died of ruptured intracranial aneurysm was 37 yr. No patient died of renal cancer. Liver cysts were the most common extrarenal manifestation, seen in 70% of the autopsied cases; cysts in other organs were very rare. Colonic diverticula were found in 21%. Thus, the renal and extrarenal manifestations of ADPKD are important contributors to morbidity and mortality.

Association of rectal diverticula and scleroderma

Barium enema examinations of 7,200 patients were analyzed to determine the presence of rectal diverticula. Five patients with rectal diverticula, a prevalence of 0.07%, were found. Their diameters varied from 10 to 80 mm. Each of the patients had a single rectal diverticulum. Two patients had scleroderma with no other diverticula in the large bowel. None of our patients had symptoms referable to the rectal diverticula.

Diverticular disease. Epidemiology and pharmacological treatment

Diverticular disease is worldwide in distribution, but the incidence is highest in industrialised countries. It is associated with aging and low intake of dietary fibre. There is a broad range of clinical manifestations--from asymptomatic diverticula to life-threatening complications. Elderly patients often present with complicated diverticular disease, and may lack typical symptoms and signs. Treatment includes fibre supplementation, drugs or antibiotics for complications, and surgery for refractory disease. Proper diagnosis and treatment requires knowledge of the full range of presentations and careful selection and timing of medical versus surgical intervention.

[Diverticulum of the female urethra. Review of the literature]

Presentation of nine cases of diverticulum of the female urethra, and assessment of their specific features both clinical and diagnostic, as well as the surgical techniques used in their management. Review of the literature with regard to incidence, etiopathogeny and presentation of this condition. Analysis of the different diagnostic procedures available to show the presence of an urethral diverticulum and the various management options currently used in their resolution.

Bladder diverticula in children

PURPOSE

The frequency, number, and underlying associations of bladder diverticula were studied in a pediatric population.

MATERIALS AND METHODS

Eighty-five children with bladder diverticula (31 girls and 54 boys) were retrospectively identified in a pediatric genitourinary data base of 5,084 children.

RESULTS

Primary bladder diverticula were seen in 20 children with vesicoureteral reflux and 14 children without reflux. Fifty-one of the 85 children (60%) had associated neurogenic dysfunction of the bladder (n = 26), outlet obstruction (n = 14), or a syndrome (n = 9) or were postoperative (n = 2). A single child of the 26 with multiple bladder diverticula had no associated condition.

CONCLUSION

In this population, bladder diverticula were found in 1.7% of the children. The presence of more than one diverticulum on a side was usually associated with neurogenic dysfunction of the bladder, bladder outlet obstruction, or syndromes such as Williams, Menkes, prune-belly, or Ehlers-Danlos type 9 syndromes.

Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate

In a prospective study, the complications observed in 242 consecutive patients after endoscopic sphincterotomy for common bile duct stones were recorded over a period of up to three months. Patients with previous gastric surgery, papillotomy, or additional pancreato-biliary disease other than gallbladder stones were excluded. The overall complication rate was 14%, 74% of these complications being moderate or severe. The complication rate due to cholangitis was higher in (1) the group with retained stones following complete papillotomy and without biliary drainage, and (2) the group with failed precut papillotomy and drainage after cholangiography, both compared to patients with successful drainage (75% vs. 2.6%: p < 0.001 and 40% vs. 2.6%: p = 0.001 respectively). Both pancreatitis and retroperitoneal air leakage occurred in 1.7% of cases. They were more frequently observed in patients with a smaller diameter (< 10 mm) in the distal common bile duct (5.6% vs. 0%: p = 0.007 for pancreatitis, and 2.8% vs. 1.2%; n.s. for perforation) and especially following precut papillotomy (13.0% for pancreatitis and 8.7% for perforation), which had to be performed more often in these patients. Bleeding following sphincterotomy was relatively frequent when the papilla was located at the lower rim of or inside a diverticulum, compared to patients without a diverticulum (16.2% vs. 2.7%: p = 0.004 and 26.7% vs. 2.7%: p < 0.001 respectively). When the papilla was located inside diverticula, both the rate of perforation and bleeding increased following precut papillotomy, compared with standard papillotomy only (33% vs. 0%, n.s., and 33% vs. 22%, n.s.).(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma in female urethral diverticulum: case reports and review of management

We report on 4 women ages 31 to 65 years with adenocarcinoma of urethral diverticulum. One patient presented with metastatic disease and died after refusing post-radiation surgery. The other 3 women were without evidence of disease 9 to 44 months after diverticulectomy with radiation (1) or radical surgery (2). Review of our 4 cases and 64 cases documented in the literature showed that irritative voiding symptoms and hematuria were the most common findings. A palpable urethral mass was described in only 56% of reported cases but was observed in all of our patients, with the smallest mass measuring 2 x 2 cm. Urethroscopy with biopsy is the most important diagnostic test. Aggressive treatment is appropriate in most patients, since local recurrence has been documented in 44% of those treated by diverticulectomy and/or radiation.

Association of juxtapapillary diverticula with choledocholithiasis but not with cholecystolithiasis

Juxtapapillary diverticula are often associated with biliary lithiasis. The aim of this study was to compare the prevalence of juxtapapillary diverticula in choledocholithiasis and in cholecystolithiasis without common bile duct stones. The results of 520 consecutive retrograde cholangiographies were retrospectively analysed. The prevalence of juxtapapillary diverticula was higher in patients with biliary lithiasis than in patients without: 26.0% vs 10.5% (p less than 0.001). However, juxtapapillary diverticula were more frequently encountered in patients with choledocholithiasis than in those with gallbladder lithiasis or previous cholecystectomy and a stone-free common bile duct: 40.0% vs 10.2% (p less than 0.001). There was no significant difference between the patients with cholecystolithiasis alone and those without biliary lithiasis. Among the patients with previous cholecystectomy or with gallbladder lithiasis, common bile duct stones were more frequently found in patients with juxtapapillary diverticula than in those without: 80.3% vs 40.6% (p less than 0.001). These data suggest that juxtapapillary diverticula are associated only with choledocholithiasis and not with gallbladder lithiasis.