CD163L1+CXCL10+ Macrophages are Enriched Within Colonic Lamina Propria of Diverticulitis Patients

BACKGROUND

Inflammation of diverticula, which are outpouchings of the colonic bowl wall, causes diverticulitis. Severe cases of diverticulitis require surgical intervention. Through RNA-seq analysis of intestinal tissues, we previously found that the innate immune response was deregulated in surgical diverticulitis patients. In that study, pro-inflammatory and macrophage markers were differentially expressed in the colons of diverticulitis versus control patients. Here we investigate CD163L1⁺ macrophages and the pro-inflammatory chemokine, CXCL10, in diverticulitis.

MATERIALS AND METHODS

We assessed tissue from an uninvolved area adjacent to a region of the sigmoid colon chronically affected by diverticulitis and performed Spearman's correlation on transcripts associated with macrophage signaling. We identified altered CD163L1 and CXCL10 gene expression levels that we confirmed by RT-qPCR analysis on an independent cohort of diverticulitis patients and controls. We used immunofluorescence microscopy to localize CD163L1⁺ macrophages and CXCL10 levels in intestinal tissue and ELISA to measure CXCL10 levels in patient serum.

RESULTS

We found a positive correlation between intestinal CD163L1 and CXCL10 gene expression and an increased number of CD163L1⁺ macrophages in the sigmoid colons of diverticulitis patients relative to controls (P = 0.036). Macrophages at the apices of colonic crypts expressed the chemokine CXCL10. Correspondingly, these diverticulitis patients also displayed heightened CXCL10 levels in their serum (P = 0.007).

CONCLUSIONS

We identified a novel population of CD163L1⁺CXCL10⁺ macrophages in the colonic crypts of diverticulitis patients and demonstrated increased expression of serum CXCL10 in these patients. CXCL10 may serve as a prognostic biomarker to aid in clinical decision making for diverticulitis patients.

Prevalence and Clinicopathologic Features of Intestinal Perforation Caused by Segmental Absence of the Intestinal Musculature in Adults

Segmental absence of the intestinal musculature (SAIM) can cause intestinal perforation in adults. However, its prevalence and clinicopathologic features have not been well-described. This study aimed to determine the prevalence of SAIM-associated perforation and characterize its clinicopathologic features. We retrospectively examined 109 cases of intestinal perforation that underwent surgical resection from January 2009 to December 2019. SAIM was defined as the complete absence of the muscularis propria without extensive inflammation and fibrinous exudation around the perforation. SAIM was the second most frequent cause of perforation (26 cases: 24%), the most frequent cause being related to diverticulitis (39 cases: 36%). The most common site was the sigmoid colon (12 cases: 46.2%). The younger group (aged below 65 y) exhibited more frequent perforation of the upper segments of the gastrointestinal tract (from the duodenum to the descending colon) than the older group (65 y and above) (P=0.0018). No patients developed recurrence. The most common gross features were well-defined circular or small punched-out lesions, and the histologic features were complete absence of the muscularis propria and absence of hemorrhage and necrosis around the area of perforation. The characteristic features of SAIM were unique and their prevalence was higher than previously reported. The precise recognition of SAIM can aid in understanding the cause of perforation and avoiding further unnecessary examinations.

HARTMANN PROCEDURE OR RESECTION WITH PRIMARY ANASTOMOSIS FOR TREATMENT OF PERFORATED DIVERTICULITIS? SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Mortality after emergency surgery in randomized controlled trials. The Hartmann procedure remains the treatment of choice for most surgeons for the urgent surgical treatment of perforated diverticulitis; however, it is associated with high rates of ostomy non-reversion and postoperative morbidity.

AIM

To study the results after the Hartmann vs. resection with primary anastomosis, with or without ileostomy, for the treatment of perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV), and to compare the advantages between the two forms of treatment.

METHOD

Systematic search in the literature of observational and randomized articles comparing resection with primary anastomosis vs. Hartmann's procedure in the emergency treatment of perforated diverticulitis. Analyze as primary outcomes the mortality after the emergency operation and the general morbidity after it. As secondary outcomes, severe morbidity after emergency surgery, rates of non-reversion of the ostomy, general and severe morbidity after reversion.

RESULTS

There were no significant differences between surgical procedures for mortality, general morbidity and severe morbidity. However, the differences were statistically significant, favoring primary anastomosis in comparison with the Hartmann procedure in the outcome rates of stoma non-reversion, general morbidity and severe morbidity after reversion.

CONCLUSION

Primary anastomosis is a good alternative to the Hartmann procedure, with no increase in mortality and morbidity, and with better results in the operation for intestinal transit reconstruction.

Comparison of clinical and pathological findings of patients undergoing elective colectomy for uncomplicated diverticulitis

Diverticular disease affects ∼5-10% people worldwide, yet the indications for elective colectomy in uncomplicated diverticulitis are unclear. As there is no strong scientific evidence regarding histology in diverticular disease, the primary outcome of the study was to analyze the degree of inflammation of colonic wall in patients that underwent elective colectomy for uncomplicated diverticulitis and to retrospectively assess the correlation between patient clinical history and pathological features of surgical specimens in order to find some predictive factors that may be strictly correlated with histology. An observational retrospective study was conducted. Patients undergoing elective colectomy for uncomplicated diverticulitis between January 2014 and January 2016 in an academic medical center were collected. The majority of patients (46.2%) had previously encountered one episode of acute diverticulitis prior to colectomy, while 21.5% and 10.8% had experienced two and three or more prior episodes respectively. Most patients had recurrent or chronic abdominal pain in the left iliac fossa (66.2%) for diverticular disease and a large proportion also experienced constipation (40.0%). Diverticulitis was identified pathologically as being "mild" in 44.6% patients and "severe" in 55.4% patients. The mean age was significantly lower in patients with severe diverticulitis (56.7 years) than in patients with mild diverticulitis (67.0 years). 71.9% of males had severe diverticulitis compared to 39.4% of females. Males have a 3.9 times higher risk of histological severe diverticulitis than females (OR = 3.932; 1.390-11.122; p = 0.008). Multivariate logistic regression analysis confirmed that age and gender were independent factors associated with histological diagnosis. Single-institution data and retrospective design were main limitations of this study. Age and gender are independent factors associated with severity inflammation index derived at histological analysis and they could be translated to clinical practice to better categorize patients with uncomplicated diverticulitis at the bedside.

RNA-seq implicates deregulation of the immune system in the pathogenesis of diverticulitis

Individuals with diverticula or outpouchings of the colonic mucosa and submucosa through the colonic wall have diverticulosis, which is usually asymptomatic. In 10-25% of individuals, the diverticula become inflamed, resulting in diverticulitis. Very little is known about the pathophysiology or gene regulatory pathways involved in the development of diverticulitis. To identify these pathways, we deep sequenced RNAs isolated from full-thickness sections of sigmoid colon from diverticulitis patients and control individuals. Specifically for diverticulitis cases, we analyzed tissue adjacent to areas affected by chronic disease. Since the tissue was collected during elective sigmoid resection, the disease was in a quiescent state. A comparison of differentially expressed genes found that gene ontology (GO) pathways associated with the immune response were upregulated in diverticulitis patients compared with nondiverticulosis controls. Next, weighted gene coexpression network analysis was performed to identify the interaction among coexpressed genes. This analysis revealed RASAL3, SASH3, PTPRC, and INPP5D as hub genes within the brown module eigengene, which highly correlated (r = 0.67, P = 0.0004) with diverticulitis. Additionally, we identified elevated expression of downstream interacting genes. In summary, transcripts associated with the immune response were upregulated in adjacent tissue from the sigmoid colons of chronic, recurrent diverticulitis patients. Further elucidating the genetic or epigenetic mechanisms associated with these alterations can help identify those at risk for chronic disease and may assist in clinical decision management.NEW & NOTEWORTHY By using an unbiased approach to analyze transcripts expressed in unaffected colonic tissues adjacent to those affected by chronic diverticulitis, our study implicates that a defect in the immune response may be involved in the development of the disease. This finding expands on the current data that suggest the pathophysiology of diverticulitis is mediated by dietary, age, and obesity-related factors. Further characterizing the immunologic differences in diverticulitis may better inform clinical decision-making.

Diverticulitis of the cecal appendix: a case report

Appendicular diverticulosis is a rare condition. It is important to know its insidious form of presentation for its early diagnosis and treatment, thus diminishing morbimortality. In case of incidental findings, an appendicectomy will be performed to prevent complications and the development of malignancy.

Laparoscopic Lavage in the Management of Hinchey Grade III Diverticulitis: A Systematic Review

OBJECTIVE

To compare the outcomes of laparoscopic lavage and sigmoid resection in perforated diverticulitis with purulent peritonitis.

BACKGROUND

Peritonitis secondary to perforated diverticulitis has conventionally been managed by resection and stoma formation. Case series have suggested that patients can be safely managed with laparoscopic lavage, resulting in reduced mortality and stoma formation. Recently, 3 randomized controlled trials have published contradictory conclusions.

METHODS

MEDLINE from 1946 to present, Cochrane Database of Systematic Reviews, and Cochrane database of Registered clinical trials and EMBASE (all via OVID) were searched using the terms "laparoscopy" AND ("primary resection" OR "Hartmann procedure", OR "sigmoidectomy"), AND "Diverticulitis", AND "Peritonitis" AND "therapeutic irrigation" or "lavage" AND randomized controlled trial and any derivatives of those terms. We included all randomized controlled trials. Data were extracted from each study using a purpose-designed template. Statistical analysis was undertaken using Revman 5.

RESULTS

Three randomized controlled trials were identified from 48 potential studies. The analysis included 307 patients of whom 159 underwent laparoscopic lavage. Overall, the rate of reintervention within 30 days postoperatively was 45/159 (28.3%) in the lavage group and 13/148 (8.8%) in the resection group (relative risk 3.01, 95% confidence interval 1.15-7.90). There was no significant difference in Intensive Care Unit admissions, 30 and 90-day mortality, or stoma rates at 12 months.

CONCLUSION

Laparoscopic lavage used in the management of Hinchey grade III diverticulitis leads to more reinterventions within 30 days postoperatively, but does not increase the 30 or 90-day mortality rates compared with sigmoid resection.

Complicated diverticulitis in a de novo kidney transplanted patient

Diverticular disease is frequent amongst the elderly and immunosuppressed patients. It mainly presents as sigmoid diverticulitis, but severe complications, like bleedings, infections and colon perforation may occur, frequently due to immunosuppressive therapy. Moreover, antibiotherapy and hemostatics may not efficiently control evolution in such cases. Early diagnose and adequate treatment of colonic diverticulosis complicated with lower gastrointestinal bleeding and diverticulitis in immunocompromised patients. We report a 55-year-old patient who underwent de novo renal transplantation one year ago and recently developed a severe diverticular bleeding complicated by hemorrhagic shock. Colonoscopic examination revealed diverticular disease with diverticulitis and severe, diffuse bleeding, mainly in the descending colon. Due to his immunocompromised status and unfavorable evolution under hemostatics, recombinant coagulation factor VIIa (rFVIIa) was given to avoid surgery. The bleeding stopped after two doses of rFVIIa. Unfortunately, after three weeks, lower quadrant pain, tenderness, abdominal distention, and fever occurred, in spite of immunosuppressive drug changing and adequate conservative therapy. Abdominal computed tomography (CT) scan revealed complicated diverticulitis, so patient underwent surgery, with partial colectomy, followed by total recovery. In conclusion, diverticulosis coli complicated with lower gastrointestinal bleeding and diverticulitis in immunocompromised patients was for us a challenging diagnosis, as well as a therapeutic issue. Treatment options, usually based on our local resources and expertise, considered conservatory therapy as the first choice, keeping surgical maneuvers just as a rescue solution.

An Unexpected Discovery

Meckel's Diverticulum is the most common congenital malformation of the gastrointestinal tract with a prevalence of 2 % in the general population, being twice as common and symptomatic in males. Not seldom is the diagnosis made incidentally, upon laparotomy for other intra-abdominal conditions, namely acute appendicitis. Simple Diverticulectomy is the surgical treatment of choice. We present the case of S.M., a 38 year-old male who was admitted to the Surgery Department of the Bucharest Clinical Emergency Hospital for sudden onset of initially periumbilical pain, which later migrated and localized in the right iliac fossa (RIF) accompanied by vomiting after the onset of pain, approximately 24 hours prior to admission. Examination of the abdomen revealed localized peritoneal signs. An Alvarado score of 8 was calculated. A laparotomy for appendectomy was performed, upon which the sigmoid colon was found in the RIF, and an appendix of 10 cm in length was visualized in a subhepatic, ascendant position. At a distance of 90 cm from the ileocecal valve, a Meckel's Diverticulum with dimensions of 7/4 cm was discovered. A retrograde appendectomy was performed first, along with a simple diverticulectomy, with the use of a TA 30 mm stapler. The operative time was 90 minutes without intraoperative complications, and an uneventful postoperative recovery, culminating with discharge of the patient on the fifth postoperative day. Despite its high prevalence, Meckel's Diverticulum still represents a diagnostic challenge, especially in the adult population, notably in asymptomatic patients. Moreover, ectopic gastric or pancreatic tissue, present in 50% of the cases, leads to a vast array of differential diagnoses. Due to its numerous life-threatening complications such as bleeding, intestinal obstruction, volvulus, intussusception, diverticulitis, fistulization and perforation, accurate diagnosis and timely treatment is crucial.

[Duodenal diverticulitis: unusual complication not always easy to manage]

Les diverticules duodénaux sont assez fréquents, la majorité reste asymptomatique. Les complications les plus fréquemment rapportées sont les hémorragies et les pancréatites. Contrairement aux diverticules coliques, la survenue de diverticulite est rare. Nous rapportons le cas d'une infection d'un gros diverticule duodénal en mettant le point sur la difficulté de la prise en charge de cette entité pathologique.

IgG4-related lacrimal sac diverticulitis

IgG4-related disease is characterized by elevated serum IgG4 and tissue infiltration by IgG4-positive plasma cells. We herein report a case of lacrimal sac diverticulitis with marked IgG4-positive plasma cell infiltration. An 89-year-old woman presenting with right lower eyelid mass. Imaging modalities demonstrated a cystic orbital mass located beneath the globe and adjacent to enlarged lacrimal sac. Serological tests showed high IgG4 and normal IgG levels, measuring 242 and 1603 mg/dl, respectively. The orbital mass was surgically excised. Histologically, the excised tissue demonstrated marked inflammation with fibrosis surrounded by mononuclear epithelial cells. A variety of IgG and IgG4-positive plasma cells infiltrated the stroma. This patient was diagnosed as an IgG4-related lacrimal sac diverticulitis, based on current diagnostic criteria of IgG4-related disease. It is likely that IgG4-related inflammation occurs in a lacrimal sac diverticulum, which should be considered a differential diagnosis in inferior orbital tumors.

[Meckel's diverticulum duplication. Case report and literature review]

BACKGROUND

Meckel's diverticulum is the most frequent congenital abnormality of the gastrointestinal tract. Preoperative diagnosis is difficult due to its variable clinical presentation that can simulate several causes of gastrointestinal bleeding or abdominal pain.

CLINICAL CASE

We present the case of a 61-year-old female patient with multiple abdominal surgeries who developed intestinal occlusion during several admissions beginning 8 months earlier. She was treated with conservative measures. During her last admission, she developed dehydration, persistent abdominal pain and bowel dilation with failure to respond to conservative treatment. Surgical intervention was decided upon, ruling out adhesions and revealing the presence of two diverticular defects at 40 and 70 cm from the ileocecal valve with torsion. Histological report described gastric heterotrophic mucosa and inflammatory hemorrhagic process.

CONCLUSION

Presence of duplicated Meckel's diverticulum is a rare finding with only nine reports in the international literature to date. Diagnosis is frequently made during surgery. Treatment for symptomatic diverticulum is surgical, whereas management for asymptomatic diverticulum is controversial and relies on the surgeon's decision and clinical characteristics of the patient.

Acute symptomatic Meckel diverticulum management. Our experience on seven consecutive cases

Meckel's diverticulum (MD ) is the most common congenital anomaly of the gastrointestinal tract. We revalued clinical records of patients discharged from Unit of Urgent and General Surgery of Highly Specialized Hospital "A.O.R.N. Antonio Cardarelli" of Naples with diagnosis of acute pathology associated to complicated MD from 1(st) January 2011 to 30(th) November 2012. Seven consecutive cases have been chosen: five males (71,4%) and two females (28,6%). The age ranges over from 13 to 50 years with a 28 years average. Four of them were submitted to emergency surgical intervention for hemorrhage from gastro-enteric tract (57%), two for bowel obstruction (29%) and one for acute appendicitis (14%). In all cases sample was send to histological examination. Two samples showed normal epithelial mucosa. Four of them showed ectopic mucosa inside the diverticulum: three gastric and one pancreatic ectopic mucosa focal areas. The last case showed normal epithelial cells but with ulcerated and hemorrhagic areas. Four samples of patients with hemorrhage from gastroenteric tract showed at histological examination: a case of normal mucosa, a case of gastric mucosa areas, one of pancreatic ectopic tissue and the last with normal mucosa but ulcerated and with bleeding areas.In our experience we never speculated that acute symptomatology depended on complicated MD and diagnosis was always done during laparotomy. We think that MD removal is always the correct choice, so that future complications such as neoplasm can be avoided. MD simple resection by Stapler at the base of diverticulum is the correct choice.

[Significance of CRP in the assessment of severity of acute diverticulitis]

Diverticulitis is suspected when the patient has pain and tenderness on palpation on the lower left abdomen, fever and an elevated CRP level. After a confirmed diagnosis, outpatient therapy of uncomplicated diverticulitis is possible, according to the latest research results even without antimicrobial drugs. CT scanning is usually unnecessary when the CRP level remains below 50 mg/l in the absence of signs of peritoneal irritation, but should always be performed when the value exceeds 150 mg/l. Unenhanced CT scan without contrast agent is well suited for the exclusion of complicated diverticulitis.

[Meckel's diverticulitis in the early postoperative course after appendectomy]

Meckel's diverticulum is the most frequent anomaly of the small intestine that results from the failure of the vitelline duct to obliterate during the gestation. It occurs on the antimesenteric border of the ileum, usually 60-80 cm proximally to the ileocecal valve. Meckel's diverticulum is true diverticulum because it has all the three layers of the terminal ileum. The heterotopic mucosa is most commonly gastric or pancreatic. Most patients are asymptomatic. Meckel's diverticulum is most frequently diagnosed as an incidental finding during laparotomy. The most frequent complications of Meckel's diverticulum are intestinal obstruction, rectal bleeding, diverticulitis and perforation due to peptic ulcer. Surgical resection is the treatment of choice for symptomatic Meckel's diverticulum.

Diverticulitis of multiple diverticulosis of the terminal ileum

Diverticulosis of the terminal ileum is very rare. We report a case of diverticulitis of multiple diverticula of the terminal ileum. A 67-year-old Japanese woman consulted to our hospital because of abdominal pain and melena. A blood laboratory revealed severe anemia increased CRP (11.21 mg/dl). The upper and lower gastrointestinal endoscopic examination revealed no significant changes. The colon was free from diverticulum. CT demonstrated two tumors in the small intestine. PET identified a few shadows identical to the tumors detected by CT. The clinical diagnosis was small intestinal tumors, particularly malignant lymphoma. Operation was performed, and it revealed multiple tumor-like masses in the terminal ileum. The ulcers are deep and appeared diverticula. Microscopically, the diverticula were located in the proper muscle and subserosa. The walls of the diverticula were composed of granulation tissue with heavy lymphocytic and neutrophilic infiltration. Diverticular mucosal walls were recognized in some areas. The lymphocytes were free from atypia, and no features of malignant lymphoma were recognized. The pathological diagnosis was severe diverticulitis of multiple diverticula in the terminal ileum.

The role of surgery in treatment of diverticular disease of lower gastrointestinal tract

Diverticulosis of lower gastrointestinal tract is a common disease with potentially lethal complications. Recent studies demonstrated that the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in defining the appropriateness of surgery so the approach has to be more individualized. On the other hand, the complicated diverticular disease requires surgical treatment, often matter of urgency, and depends on localization and severity of the process. There is not sufficient evidence supporting the aggressive approach to treatment in younger patients. The available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.

Clinical features of symptomatic uncomplicated diverticular disease: a multicenter Italian survey

PURPOSE

Clinical features of symptomatic uncomplicated diverticular disease are poorly investigated. Abdominal symptoms may be similar to those of irritable bowel syndrome. This survey aimed to assess clinical features associated with symptomatic uncomplicated diverticular disease.

METHODS

This multicenter survey included consecutive outpatients with symptomatic uncomplicated diverticular disease to whom a detailed clinical questionnaire regarding demographic, lifestyle, and clinical features was administered. Diagnosis was based on the presence of diverticula and abdominal pain/discomfort. Irritable bowel syndrome and functional dyspepsia were assessed according to Rome III criteria.

RESULTS

A total of 598 patients (50 % female, age 69 years), 71 % with newly diagnosed symptomatic uncomplicated diverticular disease and 29 % with history of colonic diverticula, were recruited. Diverticula were localized in the left colon in 78 % of the patients. Recurrent short-lived abdominal pain (<24 h) was present in 70 % (relieved by evacuation in 73 %), prolonged abdominal pain (>24 h) in 27 %, and recurrent abdominal bloating in 61 % of the patients. Normal, loose, or hard stools were reported by 58, 29, and 13 % of patients, respectively. Irritable bowel syndrome (IBS)-like and functional dyspepsia-like symptoms were recorded in 59 and 7 % of patients, respectively. IBS-like symptoms (odds ratio, 4.3) were associated in patients with prolonged abdominal pain.

CONCLUSIONS

Symptomatic uncomplicated diverticular disease is associated with a gender ratio of 1:1 and an unspecific clinical picture mainly characterized by normal stools, short-lived abdominal pain, abdominal bloating, IBS-like symptoms, while functional dyspepsia-like symptoms are not commonly present. These findings suggest that symptomatic uncomplicated diverticular disease often shows similar findings rather than overlaps IBS.

Clinical characteristics of 12 cases of appendiceal diverticulitis: a comparison with 378 cases of acute appendicitis

PURPOSE

Previous authors have suggested that a diverticulum of the vermiform appendix has a higher risk of perforation than acute appendicitis. Therefore, this study compared appendiceal diverticulitis with acute appendicitis to explain the characteristics of appendiceal diverticulitis.

METHODS

Data for this study came from a retrospective analysis at the Department of Surgery at Fukuoka Tokushukai Hospital from January 2005 to June 2008. Twelve cases of appendiceal diverticulitis and 378 cases of acute appendicitis were analyzed.

RESULTS

The patients with appendiceal diverticulitis were older than those with acute appendicitis (42.7 ± 15.4 vs. 29.1 ± 17.7; p = 0.009). The white blood cell (WBC) level was lower (11332 ± 4658 vs. 14236 ± 3861; p = 0.011) and the CRP level was higher (8.65 ± 8.94 vs. 4.34 ± 6.34, p = 0.022) in those with appendiceal diverticulitis than in those with acute appendicitis. A preoperative diagnosis for appendiceal diverticulitis was made in 4 out of 12 (33.3%) by ultrasonography (US). The perforation rate was higher in appendiceal diverticulitis than that in acute appendicitis (33.3 vs. 9.8%; p = 0.009).

CONCLUSIONS

Appendiceal diverticulitis is more likely to perforate over the progression of the clinical course, which would mandate appendectomy when appendiceal diverticulitis is detected by US, even if the patient has no severe abdominal pain.

Nervous structure of Meckel's diverticulum in children

Meckel's diverticulum, being considered as the most frequent malformation of the digestive tract, has been largely presented in scientific papers, but a complete physiopathological mechanism for its natural history has not been yet described. We have studied the nervous system and the differences observed in eight Meckel's diverticulums with enteric or ectopic gastric mucosa, using specific immunohistochemical markers. It has been noted a significantly higher density of myenteric nerve fibers in areas with enteric mucosa compared with the areas with gastric heterotopias, while the transition zone had intermediate nerve fibers density. The ileal wall near the diverticulum had a myenteric plexus density similar to gastric mucosa intradiverticular area. The density of Meckel's diverticulum myenteric plexuses determines the local peristalsis. The enteric type mucosa diverticulums has more intense peristaltic activity which leads more frequent to intussusception or, in case of intraluminal obstruction, might be also involved in germ spreading and progression of infectious process. The lower density of Auerbach's plexus nerve fibers in cases with gastric heterotopia Meckel's diverticulum determines less effective drainage of diverticular content, favoring the contact of intradiverticular mucosa with acid secretion of gastric mucosa area. The gastric mucosa's defense mechanisms and the intense peristaltic activity in the zone with enteric mucosa offer a certain protection against the apparition of intradiverticular ulcerative lesions, which usually are observed on the ileum, near the diverticulum. The age related decreasing number of myenteric nerve fibers density explains the higher frequency of Meckel's diverticulum complications in children.

Appendiceal diverticulitis: multidetector CT features

PURPOSE

Appendiceal diverticulitis has been difficult to distinguish from acute appendicitis clinically and radiologically. The purpose of this study was to describe multidetector computed tomography (MDCT) features of cases of pathologically proved appendiceal diverticulitis at our institution over a 36-month period.

MATERIALS AND METHODS

Seven of 156 patients who underwent appendectomy with the preoperative diagnosis of acute appendicitis were pathologically diagnosed with appendiceal diverticulitis. Two radiologists reviewed the MDCT images for these 7 patients.

RESULTS

On MDCT, a total of 8 inflamed diverticula were visualized as small fluid-filled luminal structures with thick enhanced walls or as solid enhanced masses protruding from the appendix for 6 of 7 patients. For 2 of these 6 patients, MDCT revealed a total of 5 normal diverticula visualized as small air-filled luminal structures with thin walls. For 1 of the 7 patients, neither inflamed or normal diverticula could be identified on MDCT. MDCT revealed appendiceal wall thickening with a tiny or no luminal fluid collection for 5 patients and with a moderate fluid collection for 1 patient, and a normal appendiceal wall for 1 patient.

CONCLUSION

Our results suggest that MDCT can reveal appendiceal diverticula and has potential in the preoperative diagnosis of appendiceal diverticulitis.

Correlation between complicated diverticulitis and visceral fat

The aim of this study was to examine the relationship of complications related to diverticulitis and visceral obesity. The study was based on a retrospective case note review conducted at the Hanyang University Hospital. Patients were diagnosed with diverticulitis based on clinical symptoms and abdominal computed tomography (CT) findings and divided into two groups: those admitted with complicated diverticulitis and those with a simple diverticulitis episode. We compared the body mass index (BMI) and degree of visceral obesity, measured by abdominal CT. The study included 140 patients, 87 (62.1%) were simple diverticulitis and 53 (37.9%) were complicated diverticulitis. In the complicated diverticulitis group, 9 (6.4%) cases were recurrent, 29 (20.7%) were perforation or abscess patients, and 28 (20%) were patients with systemic inflammatory response syndrome (SIRS). Of the SIRS patients, 13 were involved in other complication groups. When comparing in the two groups, the complicated diverticulitis group had a significantly higher visceral fat area (128.57 cm(2) vs 102.80 cm(2), P = 0.032) and a higher ratio of visceral fat area/subcutaneous fat area (0.997 vs 0.799, P = 0.014). Visceral obesity is significantly associated with complications of diverticulitis.

[Pseudodiverticulitis coeci--the atypical etiology of right iliac fossa pain--a case report]

The aim of our paper is to show on the diagnosis of coecal diverticul as infrequent reason of right iliac fossa pain. We present the case report of 43-years old woman, which underwent appendectomy some years sooner, and was accepted into the hospital because of 48-hours taking right iliac fossa pain. Local peritoneal irritation was present. During laparotomy resection of right colon with the toilette of abdominal cavity was performed. Histology diagnosed the right colon pseudodiverticulitis. In case of diagnosis of right colon pseudodiverticulitis before surgery and without peritoneal irritation, the most of authors recommend the conservative management with antibiotics. If the surgery is required, the local resection of diverticul with appendectomy is recommended. If the local resection is not possible, the ileocoecal resection has lower mortality as the right hemicolectomy.

Abdominal pain in a young woman (2009: 8b)

Juxtapapillary duodenal diverticula and their possible complications are not frequent findings. We present the case of a woman with a giant juxtapapillary diverticulum, complicated by diverticulitis and areas of perforation of the wall that required urgent surgical treatment. We present the preoperative findings on computed tomography and magnetic resonance imaging.

Perforated ileal diverticulitis: CT findings

Diverticulosis of the ileum is very uncommon. The differential diagnosis for any inflammatory process in the right lower quadrant of the abdomen includes appendicitis, Crohn's disease, and other infectious and inflammatory conditions of the terminal ileum and cecum. Diagnosis of small bowel diverticulitis is based on radiological findings, and computed tomography is the method of choice to demonstrate mural changes and the mesenteric extent of the inflammation. Preoperative knowledge of this condition may influence surgical and medical management.

Abnormal expression of M1/MUC5AC mucin in distal colon of patients with diverticulitis, ulcerative colitis and cancer

The abnormal expression of gastric M1/MUC5AC mucin in precancerous lesions and colon cancer evidenced by immunohistochemistry led us to check for its presence in the mucus obtained directly from patients undergoing surgery for cancerous (adenocarcinoma) or inflammatory (diverticulitis or ulcerative colitis) diseases. In parallel, the authors quantified aberrant crypt foci (ACF) and their immunolabelling by M1/MUC5AC in mucosae of cancer and diverticulitis patients. Immuno-Radio-Metric Assay of M1/MUC5AC mucin developed by the authors was used to detect M1/MUC5AC mucin in the colonic mucus scraped from surgical specimens. M1/MUC5AC mucin was detected in the mucus of 51/69 (74%) patients with colon adenocarcinoma, versus 7/27 (26%) patients with diverticulitis (threshold: 30 units of M1 mucin per mg protein, area under ROC curve: 0.80). M1/MUC5AC was present in significantly (p < 0.001) larger amounts in the mucus of cancer versus diverticulitis patients. All (10/10) patients with ulcerative colitis tested showed levels above the threshold and their mucosae were strongly labelled with the anti-M1/MUC5AC antibody by immunohistochemistry. Patients with cancer exhibited 3 fold more ACF than those with diverticulitis, but no significant difference was observed in the mean size and M1/MUC5AC expression pattern of ACF between these two groups. The expression of M1/MUC5AC was in correlation with their size. In macroscopically normal mucosa, ACF were the most important source of M1/MUC5AC mucin. Testing of M1/MUC5AC can enhance the detection of precancerous lesions and colon cancer.

Soluble galectin-3 is a strong, colonic epithelial-cell-derived, lamina propria fibroblast-stimulating factor

BACKGROUND

Colonic lamina propria fibroblasts (CLPFs) play an important role in the pathogenesis of fibrosis and strictures in Crohn's disease.

AIM

To identify colonic epithelial cell (CEC)-derived factors that activate CLPFs.

METHODS

Primary human CECs and CLPFs were isolated from control mucosa and interleukin 8 (IL8) of CLPF cultures was quantified by ELISA. Activation of nuclear factor kappaB (NF-kappaB) was shown, and translocation of NF-kappaB was inhibited by a dominant-negative IkappaB-expressing adenovirus. The major CLPF-activating and IL8 inducing protein was purified using fast-performance liquid chromatography (HiPrep 16/60 Sephacryl S-200 High Resolution Column) and sodium dodecyl sulphate gel electrophoresis.

RESULTS

A considerable increase in IL8 secretion by CLPFs cultured in CEC-conditioned media compared with that in unconditioned media (155.00 (10.00) pg/microg v 1.434 (0.695) pg/microg) was found. The effect of CEC-conditioned media on CLPF IL8 secretion was NF-kappaB dependent. A protein or DNA array confirmed the involvement of NF-kappaB and activator protein-1. Purification of a candidate band isolated with the use of sodium dodecyl sulphate-polyacrylamide gel electrophoresis and subsequent sequencing showed soluble galectin-3 to be a strong CLPF-activating factor. Depletion of galectin-3 from conditioned media by immunoprecipitation abolished the CLPF stimulatory effect.

CONCLUSIONS

Using a classical biochemical approach, soluble galectin-3 was identified as a strong activator of CLPFs produced by CEC. Galectin-3 induced NF-kappaB activation and IL8 secretion in these cells and may be a target for future therapeutic approaches to reduce or avoid stricture formation.

[Identification of a Meckel's diverticulum bleeding by urgent capsule endoscopy]

A 10 year-old patient was admitted to our hospital due to severe gastrointestinal bleeding. His symptoms included hematochezia and fainting. Neither emergency upper endoscopy nor colonoscopy had identified the site of bleeding. During the colonoscopy they noticed that fresh blood entered the cecum from the ileum. An urgent capsule endoscopy was performed 8 hours after the patient admission. They placed the capsule with specific endoscopic technique into the proximal duodenum under general anesthesia. During 3,5 hours by the small bowel passage the capsule moved to the ileum and a focal bleeding lesion was detected at this site, suggesting the typical picture of bleeding Meckel's diverticulum. The patient was transfused by 1 unit of blood, with a minimum haemoglobin level 95 g/l. By surgery the ulcerated Meckel's diverticulum was identified and resected. Histopathology showed ectopic gastric mucosa. Surgical resection of the diverticulum resulted complete healing of this patient. The capsule endoscopy diagnosis was prompt, precise, and the all examinations were carried out within 24 hours. Involving urgent small bowel capsule endoscopy into the diagnostic workup of the obscure bleeding patient could considerably shorten the time to achieve a correct diagnosis and allowed the early institution of definitive treatment. By this one could spare a great number of costly alternative investigations with low diagnostic yield.

Duodenal diverticulitis: CT and MR findings

We report a case of duodenal diverticulitis and describe the helical computed tomography and contrast-enhanced magnetic resonance imaging (MRI) study findings. Due to its uncommon appearance, this lesion is not typically included in the differential diagnosis of pancreatitis or cholecystitis. The imaging findings of duodenal diverticulitis can be very suggestive of its diagnosis or can narrow the differential diagnosis. To our knowledge and in spite of the wide use of MRI, the contrast-enhanced MRI features of this entity, as described below, have not yet been reported in the literature.

Sonographic findings of acute appendiceal diverticulitis

Preoperative images of acute appendiceal diverticulitis are rarely reported because of the difficulty of distinguishing appendiceal diverticulitis from other iliocecal diseases like acute appendicitis or cecal diverticulitis. We report a case of preoperatively diagnosed acute appendiceal diverticulitis. A 30-year-old female with a presumptive diagnosis of acute appendicitis from history and physical examination was admitted to our hospital. Ultrasound sonography showed inflamed appendiceal diverticula and inflammatory changes of the surrounding tissue. The swollen appendix was detected but its findings were slightly different from those of typical acute appendicitis in the following points. One difference was the thickened wall of the appendix, the other difference was the presence of air in the appendix. The patient underwent appendectomy and the pathological specimen revealed inflammatory changes of diverticula within the appendix.

Diverticulitis in the young patient-Is it different

AIM: To prospectively study the incidence and the natural history of acute diverticulitis in young patients.

METHODS: A total of 207 patients hospitalized at our hospital between January 2000 to February 2005 with the diagnosis of acute diverticulitis were included. Their demographic characteristics, medical history, physical, radiographic and endoscopic findings as well as therapy were recorded. Patients were followed every 6 mo for the first year and later annually.

RESULTS: The mean patients’ age was 61 (range 27-92) years. Twenty- five patients (12%) were younger than 45 years. Acute diverticulitis was significantly more prevalent among male in the young age group as compared to the older age group (19/25, 76% vs 61/182, 33%, respectively, P = 0.0001). Complications occurred more often in the young age group; 32% vs 13%, (P = 0.002). During follow-up, 6 patients (28%) remained asymptomatic in the young age group as compared to 87 patients (55%) in the older age group (P = 0.024). As a result, sigmoidectomies were performed twice as often in the young age group (38% vs 13%, P = 0.002).

CONCLUSION: Diverticulitis in young patients has a male predominance, a more aggressive course with a higher rate of complications and a higher recurrence rate. An earlier surgical approach might be considered in young patients with acute diverticulitis.

Fine-needle aspiration of a paraesophageal diverticulum masquerading as a thyroid nodule

Fine-needle aspiration (FNA) is a widely utilized cost-effective method for the initial evaluation and triage of thyroid nodules. On occasion, a variety of non-thyroidal lesions can be mistaken for thyroid nodules on physical examination or in imaging studies and aspirated. Paraesophageal/ pharyngoesophageal diverticula masquerading as a thyroid nodule have been reported in the radiology literature but, as far as we know, not in the cytology literature. We describe FNA of a paraesophageal diverticulum that had been reported as a thyroid nodule on ultrasound. Cytologists should be familiar with this entity and suggest the diagnosis when appropriate.

[Clinical treatment of small bowel diverticula: review of 32 cases]

OBJECTIVE AND METHOD

To retrospectively summarize the pathological features and management of small bowel diverticula of in 32 cases.

RESULTS

Complications of small bowel diverticula were effectively treated surgically with good short-term and long-term clinical outcomes. The diverticulum found during the abdominal operation should be treated in time. The complications from the small intestine diverticulum included inflammation, bleeding, stone, perforation and bowel obstruction which arised from the stagnation, impaction, and friction of the contents in the diverticulum or from adhesion zone of long diveritculum. The complications were closely related to the histology of diverticular wall, the type of heterotopic tissue of diverticular mucosa, morphology of the diverticulum and contents in the diverticulum.

CONCLUSION

The complications of small bowel diverticulum are the rare cause of acute abdomen which would be surgically treated effectively.

Mucosal repair of posterior perforation of duodenal diverticulitis using roux loop duodenojejunostomy

Perforation of duodenal diverticulum is a rare occurrence but has a potentially fatal outcome. It is a difficult surgical problem because of delayed diagnosis and the attendant risk of duodenal fistula following primary repair. We present a case of posterior perforation of duodenal diverticulitis, diagnosed on computed tomography and successfully repaired with a Roux loop duodenojejunostomy. We also discuss the rare pathology, diagnosis and surgical options with special reference to this alternative form of mucosal repair.

Right colon, sigmoid colon, and transverse colon diverticulitis in the same patient: report of a case

Although sigmoid colon diverticulitis is frequently seen, right colon and transverse colon diverticulitis remain rare forms of the disease. This case report examined the disease course of a 46-year-old female who first presented to our institution in 1990 with perforated right-sided diverticulitis. During the next 11 years, she developed sigmoid colon diverticulitis and then transverse colon diverticulitis. The right and sigmoid colon diverticulitis were treated with surgery and the transverse colon diverticulitis was managed conservatively. This is the first reported case of a single patient who had separate episodes of diverticulitis in the right, transverse, and sigmoid colon. The evaluation and management of this patient has mirrored a trend in the literature and clinical practice.

Peridiverticular colonic hyaline rings (pulse granulomas): Report of two cases associated with perforated diverticula

Hyaline ring (pulse granuloma) is a rare benign lesion of the oral cavity soft tissues characterized by round or oval structures with scalloped borders composed by a collagenous matrix variable associated with inflammatory and foreign bogy giant cells. Vegetable fragments are variably identified. Whereas most cases occur in the oral cavity, it has also been described in other sites such as the lung and rectum. It is thought by most to represent a reaction to foreign materials. We report two incidentally discovered cases of colonic hyaline rings associated with perforated diverticulitis. Vegetable residues were seen in both cases.