New Diverticulitis Cure

Managing Diverticular Disease

Managing Diverticular Disease

Stop The Pain. Manage Your Diverticular Disease And Live A Pain Free Life. No Pain, No Fear, Full Control Normal Life Again. Diverticular Disease can stop you from doing all the things you love. Seeing friends, playing with the kids... even trying to watch your favorite television shows.

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New Diverticulitis Breakthrough Ebook

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Diverticular Disease Surgery Reserved for Complications Etiology

Diverticulosis is endemic in our society, likely as a result of our high-fat low-fiber diet. Pulsion pseudodiverticuli develop secondary to increased intralumi-nal pressure. The rectum is spared, while the sigmoid colon is almost always involved. Diverticulosis is usually asymptomatic. Symptoms may occur due to bleeding (described earlier), when the diverticulum erodes into the vasa recta, or due to diverticulitis, when the diverticulum becomes obstructed and perforates. The presentation of diverticulitis can range from microscopic perforation with localized inflammation to contained perforation with abscess to free intraperitoneal perforation with peritonitis (Table 10-6). Perforation may result in fistulization to adjacent organs, typically bladder, vagina, or skin, and chronic diverticulitis may lead to stricture and LBO (described earlier).

Table 106 Complications of Diverticular Disease

Patients with only inflammation or intramural abscess on CT are considered to have uncomplicated diverticulitis and respond well to medical therapy, including bowel rest and antibiotics. Most patients with uncomplicated diverticulitis will never require surgery. Young patients (under age 40), however, are believed to have more aggressive disease, higher rates of recurrence, and higher rates of complicated diverticulitis.25 The morbidity of complicated diverticulitis is high enough that traditional surgical teaching has been that young patients should be offered elective resection after their first episode of even uncomplicated diverticulitis, although this view has more recently been challenged.26

Anatomy and physiology of diverticular disease

Diverticular disease is a twentieth century disease that results in part from changes in diet, age and lifestyle although there is little research to support Diverticula are small herniations in the bowel wall they can occur anywhere in the bowel. The diverticular pouches usually appear in the descending and sigmoid colon (Stollman and Rashkin, 1999), frequently manifesting at the weakest point in the colonic wall where the blood vessels supply the mucosa in the circular muscle layer. A diverticulum is an outpouching of the mucosa of the lining of the bowel. Diverticulosis is the name give to this manifestation and most patients with these diverticula will not have any symptoms. The symptoms of diverticular disease in westernised countries usually relate to the sigmoid colon. Right-sided diverticular disease is more prevalent in the eastern countries of the world. In countries where the diet is high in fibre and very low in refined carbohydrates, diverticular disease is virtually...

Diverticular disease in New Zealand

In investigating colorectal disorders at Wellington Hospital in New Zealand, Sim and Scobie (1982) analysed 1118 air contrast enemas and found 395 with diverticular disease. Complicated diverticular disease was rare although an analysis of specific symptoms with uncomplicated diverticular disease, such as pain, bowel habit and bleeding, was no different from patients with negative barium enemas. In 1975, air contrast barium enemas became routine, allowing increased accuracy compared with a standard barium enema. Diverticular disease increased with age from 4 in the 30s rising to 66 in the 90s. Diverticular disease affected the sigmoid colon severely in 13 patients, moderately in 303 patients and to a minor degree in 70 patients. Gross disease was found in 13 patients involving most of the colon. Atypical sites were found in eight patients, four in the ascending colon, three in the splenic flexure and one in the hepatic flexure. Of the complicated diverticular disease, one suggested an...

Diverticulosis and Diverticulitis

Microcolon

Colonic diverticulosis increases in incidence with each decade of adult life and occurs in as many as 35-50 of individuals over 60 years ofage.22 Diverticula ofthe large intestine constitute a common source of lower gastrointestinal bleeding, both occult and massive, and are a particularly common cause of right-sided colonic hemorrhage.21,23,24 Colonic diverticulosis is the most frequent cause of severe rectal bleeding.25 The hemorrhage is typically acute, massive, and life threatening, in contrast to the mild and often intermittent bleeding secondary to diverticulitis, which apparently originates from highly vascularized granulation tissue lining inflamed diverticula.26 The pathogenesis of massively bleeding diverticulosis is primarily determined by their distinctive angioarchi-tecture.27 28 Histologic changes at the precise site of bleeding show asymmetric rupture of the vas rectum The predominance of hemorrhage from right-sided diverticula is noteworthy since the majority of...

Gender and Age in Diverticular Disease

Although literature subscribes to the view that Littre, in 1732, was the first to mention diverticular disease, his description of 'diverticular hernia' was not explained. The first description is attributed to Sommering in his translation into German of Baillie's Morbid Anatomy in 1794 (Oschner and Bargen, 1935). In 1968, Parks reported on the natural history of diverticular disease and found that women were more likely than men to be affected with up to 60 of patients being women. Since 1968, little work has been done to look at the difference in gender in diverticular disease. Other reported studies that have addressed selected complications of diverticular disease have made mention of gender, but there is no single study that is comprehensive and comes from an individual institution investigating all diverticular complications. In 2002, McConnell et al. presented a paper at the Tripartite Colorectal Meeting in Melbourne, Australia documenting their study of the population-based...

Diverticular disease in the Japanese in Hawaii

Diverticulitis in Hawaiian Japanese differs from that found in other races in Hawaii and occurs most often on the right side in the ascending colon (Stemmermann, 1970). This correlates with the incidence of right-sided diverticulitis previously discussed, seen in the population from far eastern countries. Chang (1965) demonstrated that 62.3 of 85 patients admitted to three hospitals in Honolulu were Japanese and the average age of patients with right-sided diverticulitis is about 20 years younger than those who experience diverticulitis on the left-sided colon. Although some disease patterns in the Japanese in Hawaii have not seen any changes, less common diseases such as right-sided diverticulitis seem to be increasing.

The History of Diverticular Disease

After the Romans the period of time until ad 1100 was to be known as the 'Dark Ages' because it has been judged as a time in the western world of un-enlightenment and obscurity with political fragmentation and a lack of centres of learning. Yet, although the history of stomas can be traced as far back as Celsus in 55 bc to ad 7, quoted by Dinnick in 1934, diverticular disease was first described by Littre (1732) when he dissected a neonate and described what he saw in the bowel as a diverticular hernia. In 1783, Matthew Baillie a Scottish physician who studied with William Hunter, succeeded to Hunter's famous anatomy school in London and in 1793 wrote the first treatise in English on morbid anatomy. It was within this treatise that Baillie mentioned diverticular disease (Oschner and Bargen, 1935). In the twentieth century Painter and Burkitt (1975) suggest that the history of diverticular disease can be divided into five phases 2. The recognition of diverticular disease as a clinical...

Diverticular disease in Scandinavia

In radiological contrasts undertaken by Kohler (1963) on a Finnish and southern Swedish population, he found that the contrast enema rarely showed diverticular disease in the Finnish population, yet using the same radiological medium diverticular disease appears to be more common among the southern Swedish population. Although diverticular disease can be demonstrated by radiological studies with barium enemas and by double contrast, much of the statistical evidence is dominated by the UK and America. As far back as 1925 there were studies indicating that there may be a racial difference that predisposes to diverticular disease and Larimore (1925) suggests that it is higher among the white than the black population. Hilden (1933) suggested that European racial variations were a contributing factor to the disease. The Nordic race, from which the Swedes descend, is a different race from the one from which the Finnish people descend. The Finnish people descend from the east Baltic race....

Uncomplicated Diverticular Disease

Uncomplicated diverticular disease or diverticulosis is a disease of the twentieth century that is thought to be associated with diet. Throughout the century, a fundamental dietary and eating pattern change also took place. Food is no longer a home-cooked meal made from fresh ingredients, such as meat and two vegetables, but something that has been processed and precooked with the addition of preservatives, taste enhancers and various other additives. There is a movement away from the tradition of sitting down at the table and eating many meals are taken on the hoof and usually at speed. These changes have been the precursors of development of diverticulosis in our society (Keighley and Williams, 1997). Age has been seen to be a predominating factor in diverticular disease in the western world the older person does become more susceptible to diverticular disease (Bassotti et al., 2003) Recently there has been a tendency towards patients under the age of 50 developing diverticular...

Diverticular disease in Greece

An epidemiological study looking at biosocial factors and diet in Athens was undertaken by Manousos et al. (1985) using the dietary availability that is known in Greece, which enables an epidemiological study to be satisfactorily undertaken. A hundred cases of diverticulosis confirmed by barium enema radiological studies were hospitalized in Athens. These were consecutive cases who had been diagnosed for the first time with diverticulosis. Dietary histories were obtained and also socioeconomic and demographic details. Specifically, in this study, the dietary intake was a prime factor and patients were asked about their food consumption. Eighty food items and beverages were categorized and patients were asked about the consumption of these items in categories of daily, weekly and monthly consumption. The food items were grouped and individualized as described by Davidson and Passmore (1979). The frequency and consumption of food were itemized in terms of the number of times per month...

Diverticular disease in Africa

It is often postulated that diverticular disease is virtually unknown in black Africans who live south of the Sahara in rural environments and who have not changed their traditional high-residue diet (Segal et al., 1977). As many black South Africans began to move from the rural areas to urban industrialized areas around Johannesburg, their social and educational development became more sophisticated than their rural counterparts. When comparing the dietary intake of the two groups of black South Africans, the rural and urbanized, a major difference is seen in fibre intake. The rural diet consists mainly of maize, millet and wheat products, plus beans, dried peas, ground nuts, vegetables and fruit. Milk and meat are not often included in the diet. As a result of the social and educational upward movement of the urbanized black South African who may be in domestic employment, the diet becomes very similar to that consumed by western populations with low fibre and low residue and high...

Complications of diverticular disease

Diverticulitis has been likened to appendicitis, with a diver-ticulum becoming obstructed by inspissated stool in its neck. The inflammatory process varies in severity from inflammation alone to pericolic abscess to free perforation of the colon with faecal peritonitis. Most patients present with symptoms of pain and signs of tenderness or a mass accompanied by varying degrees of systemic inflammatory response. CT scanning is regarded as the diagnostic modality of choice. Endoscopy is generally avoided due to the increased risk of perforation. Pericolic abscess may result from the perforation of a diverticulum when identified an abscess should be drained percutaneously if possible. Diverticular disease may lead to fistulas into adjacent organs the most common is colovesi-cal fistula. Colovaginal fistula may also occur and are more common if the patient has had a previous hysterectomy. Diverticular disease is the commonest cause of major lower gastrointestinal (GI) bleeding (see...

Diverticular disease in Singapore

Diverticular disease is common in the west but rare in the east (Painter and Burkitt, 1969). The importance of high fibre has been discussed and is considered important in helping to prevent this condition. In the consumption of a low-fibre diet, not only is there the risk of developing diverticular disease, but there is also the possibility of a low-fibre diet being the precursor to appendicitis and colorectal cancer. Appendicitis and colorectal cancer are common in Singapore and colorectal cancer is rising to become the main malignant neoplasm in the twenty-first century. Early studies in Singapore show that clinically diagnosed diverticular disease is relatively rare (Kyle et al., 1967). Before 1986, 1014 consecutive large bowels from people aged 14 and over were examined postmortem. The whole of the bowel from anus to caecum was opened and cleaned and examined for diverticula. All positive cases were confirmed histologically. Ethnic grouping of the patients was into the three main...

Diverticulosis

Diverticulosis coli is a common colonic condition of the elderly in Western societies, up to two-thirds of people aged over 80 years are affected however, most are asymptomatic. Diverticulosis has been labelled a disease of Western societies, as the disorder is rare in rural Africa and Asia and highly prevalent in Europe, USA and Australia.

Diverticular Disease

In this chapter we look at the emotive subject of 'diet' in diverticular disease. In changing the terminology to 'food management', this chapter explores the myths and mysteries of the types of food that can and cannot be eaten by a patient with diverticular disease and whether food management can help control it. As has been discussed in earlier chapters, diverticular disease is a common disorder in the western world affecting between 30 and 50 of the population aged over 60 years (Manousos et al., 1967 Burkitt et al., 1985). Although as many as 6500 patients a year are admitted to hospital for treatment of diverticulitis (Kyle et al., 1967), there are many more attending hospital outpatient departments for investigation of diverticular disease, who will not need surgical intervention. Once diagnosis is confirmed and if surgery is not indicated, there appears to be little left for the doctor to offer the patient to help with the disease. Often doctors call diverticulitis the...

Diverticulitis

The patient with symptoms of diverticulosis may progress into acute diverticulitis. He or she may have experienced several episodes of diverticulosis before this change or, equally, this may be the first episode. This disease is an acute inflammation and infection of the diverticulum, giving rise to symptoms of acute pain, fever and nausea, and necessitates hospital admission. Diverticulitis can also mean perforation, fistula or abscess. Careful assessment of the patient is essential at this stage. Occasionally the diagnosis is clear as a result of the clinical picture and findings other times more investigations are required. A plain abdominal radiograph provises a baseline for subsequent comparisans. A barium enema is not indicated if there is a clinical picture of perforation and for the same criteria that apply to endoscopy. Abdominal ultrasonography may rule out female gynaecological and pelvic problems that can have similar symptoms (Ripolles et al., 2003). Computed tomography...

Symptoms and Treatment

Diverticular disease may cause only mild abdominal symptoms that are not of any real concern to the sufferer. Patients are reluctant to visit their GP for every minor ailment and the trend, today, is to look on the internet and fit symptoms to a disease or read a magazine's health pages. This leads to self-diagnosis and often self-medication this can have a detrimental affect on the patient because he or she may incorrectly diagnose the symptoms and therefore take the incorrect medications. Other patients do not want to know what is wrong with them because, either they do not care or they think the symptoms too insignificant to warrant investigations more worryingly, they are afraid that their symptoms are an indication of a life-threatening illness and delay seeking professional advice. This group of patients are the ones who may find themselves in the accident and emergency department (A& E) in a serious condition. Others will not have any consequences of ignoring their symptoms...

New Terminology and Guidelines for Fibre Intake

Consumers or patients this can lead to confusion for the nurse or consumer when trying to understand current health education and the benefit from a higher fibre intake in their diet. If the nurse understands the current issues and new terminology surrounding fibre, she or he will be ideally placed to help and guide the patient with diverticular disease. Burkitt's original hypothesis focused on the effects of indigestible fibre in the colon and its effect on faecal bulk and consistency, intraintestinal pressures, diverticular disease, transit times, atonia, and the effect of bacterial metabolism and bowel cancer. Through research it was seen that substantial proportions of all the components of the plant cell wall, with the exception of lignin, which is a non-carbohydrate, were fermented by microflora in the colon.

Teaching the Adult Stoma Patient

In teaching the process of self-care to the stoma patient, the nurse must use assessment, diagnosis, planning, implementation and evaluation, and understand the patient's needs and expectations. During the patient's stay in hospital, he or she has had to take on a lot of new and confusing information about the disease that has caused surgery and a stoma to be raised. Often, in the case of diverticulitis, surgery has been done as an emergency, no preoperative preparation has taken place and the next thing that the patient knows is that he or she has woken up with a stoma. Often the patient can feel so overwhelmed by what has happened in the last hours that his or her attention wanes when different members of the multidisciplinary team all approach at different times with information. It also has to be remembered that patients learn in different ways and use many strategies to cope with learning new ways of caring for themselves with a stoma, and attention span and motivation will occur...

Cultural Issues

Diverticular disease of the large bowel in western societies is common and it appears that the prevalence of this disease increases with age (Horner, 1958 Hughes, 1969 Parks, 1968 Sim and Scobie, 1982 Thompson et al., 1982). Much of the population in Europe, North America and Australia may develop the disease and it is often quoted by healthcare professionals that diverticular disease is rare among African peoples yet Africans adopting a western lifestyle become susceptible to the disease (Keeley, 1958 Burkitt et al., 1985). It was noticeable that war-time Britons and vegetarians whose diet is high in fibre appear to be less susceptible to the disease, therefore reinforcing the view that the disease is one of western civilization resulting from a fibre-deficient diet (Almy and Howell, 1980). In the USA, the minority with complications of the disease (200 000 hospitalizations per annum) cost three quarters of a billion US dollars annually in healthcare bills (US Department of Health,...

Hidden Problems in Stoma Care

A fear that many elderly people have is that their spouse may be asked to help with the changing of the appliance and that they will become dependent on another. The family may worry that they will have to have the relative to live with them after discharge from hospital or may be asked to participate in some part of the patient's care. Family support and acceptance of the ostomate are essential for the successful rehabilitation of the patient and his or her discharge back into the community. Usually patients with diverticular disease who have had a stoma are in the older age group (see Chapter 7) and feel that they will find it difficult to continue in their own home, and may express the wish to sell their home and move into a nursing home or sheltered accommodation because they feel that they will not be able cope with a stoma. At this stage patients should be encouraged not to make any wide-ranging decisions until they have had a chance to go home and assess their situation as they...

The Surgery Figures 71 and

Stoma Hartmann

The laparotomy enables the surgeon to view the abdominal cavity in order to see where the perforation has occurred in the bowel. The CT should indicate the site of the perforation and the site for resection. The presence of faecal contamination can preclude anastomosis of the bowel and surgery can be a Hartmann's operation that includes an end-stoma in the form of a colostomy. This type of surgery is intended to be a two-stage procedure, because the colostomy, at a future date, will need to be reversed and the bowel anastomosed. The severity of the condition will frequently determine the type of surgery (Krukowski, 1998). In 2001, a study in Spain of the efficacy of surgical management of acute complications in diverticular disease concluded that resection and intraoperative colonic lavage and primary anastomosis provided an alternative procedure for achieving a one-stage resection (Biondo et al., 2001). The patient with diverticulitis undergoing surgery is nursed on the colorectal...

Plain abdominal radiograph and barium enema

Pancreatic Cancer Barium Enema

A barium enema (Figures 3.1 and 3.2) is the gold standard for demonstrating the severity of colonic diverticular disease (Halligan and Saunders, 2002). The radiograph involves the radio-opaque substance barium being inserted into the colon as an enema. There are two different barium enemas a single contrast where barium alone is used and barium and air as a double-contrast barium enema. Figure 3.1 Barium enema progress of barium through the colon, showing diverticular disease. (Courtesy of C. Bateman.) Figure 3.1 Barium enema progress of barium through the colon, showing diverticular disease. (Courtesy of C. Bateman.)

Colonoscopy Figure

What Does Diverticulosis Look Like

A patient who has known diverticular disease may present a problem for the inexperienced endoscopist. The diverticula look like the bowel lumen but in fact are blind ends it takes a skilled endoscopist to negotiate the diverticular bowel. The examination is usually one where diverticular disease is an incidental finding. The investigation is not one of choice in the acute stage because of the risk of the perforation with the endoscope.

Current Thinking

As has been seen, diverticular disease is common in the western world and can carry a significant morbidity. Although diverticular disease is common, it is still poorly understood and recent advances in the field continue to focus on the technological side (Cima and Young-Fadok, 2001). Improved computed tomography (CT) allows diagnosis and assessment to be made of severe acute diverticular disease and specialized teams using advanced endoscopic techniques are able to control diverticular bleeding, thereby removing the need for surgical intervention. As yet there are few randomized controlled trials to examine the evidence looking at this approach. The Scientific Committee of the European Association for Endoscopic Surgery reported on their consensus development conference with the aim of resolving the current controversy over the diagnosis and treatment of diverticular disease (Kohler et al., 1999). A multidisciplinary team of international experts was convened to take part in the...

Morbidity and Mortality

The surgical management of left-sided colon emergencies such as diverticular disease and colorectal cancer is moving towards a single surgical procedure but patient selection for a single or staged procedure appears to In a retrospective study covering 10 years by Zorcolo et al. (2003), 336 patients in a large UK hospital, who presented with an acute abdomen, underwent surgery for left-sided diverticular disease or colorectal cancer without bowel preparation. Patients were operated on by surgeons whose major interest was either colorectal surgery or upper gastrointestinal conditions. Patients were assigned to a particular surgeon by chance, although the colorectal surgeons tended to diagnose and treat more cases. Of the 336 patients, 65.8 were operated on by the colorectal surgeons and 34.2 by the upper gastrointestinal team. Complicated diverticular disease was present in 58.6 of patients 193 patients were operated on within 24 hours of admission and the remainder were operated on...

Surgery

Surgery is reserved for recurrent episodes, complications or severe attacks of diverticulitis, or when there is no response to medical treatment. Surgery in the form of a one- or two-stage operation is considered to be a safe and reliable option. Hartmann's (1923) procedure is a two-stage operation in diverticular disease it is usually performed in an emergency for perforation and faecal peritonitis of a diverticular abscess or obstruction. The one-stage primary anastomosis is proving to be a viable option (Belmonte et al., 1996 Regenet et al., 2003 Zorcolo et al., 2003). Elective surgery is performed for recurrent episodes of diverticulitis, complications or severe attacks. However, there is a trend to perform surgery as an elective procedure, especially in the younger patient, and in some cases laparoscopically (Bruce et al., 1996). Surgical treatment is usually necessary in 20-30 of patients with acute diverticulitis.

Abscess

The formation of an abscess is more likely in the patient who has had previous attacks of diverticulitis. The treatment for the diverticular abscess depends on its size and location, and the clinical condition of the patient (Hinchey et al., 1978). The patient's condition is also an indication of the severity of the abscess. The abscess that resolves with medical treatment will not necessarily become a candidate for surgery. Drainage may also be a solution and this can be achieved with the assistance of the radiographer using computed tomography (CT)-guided percutaneous drainage. Patients for whom drainage is not possible and who do not respond to drug therapy will require an operation.

Obstruction

Obstruction is associated not only with diverticular disease but also with colorectal cancer where the tumour obstructs the bowel. Usually the obstruction in diverticulitis is caused by a stricture not all obstructions need surgical intervention and unless there is a clear clinical need the patient should be treated medically to allow the obstruction to resolve. This can be achieved by resting the bowel, intravenous fluids and nasogastric suction on either continuous drainage or regular aspirations. Histology becomes paramount in any surgical procedure for obstruction to determine the actual cause (Wong and Wexner, 2000).

Laparoscopic surgery

The current trend to treat recurrent episodes of diverticulitis with surgery is becoming more acceptable, especially in the younger patient, aged under 50 years. Many centres worldwide have adopted laparoscopic elective surgery for recurrent diverticulitis. This prevents the risk of complicated diverticulitis with perforation and the emergency laparotomy and Hartmann's procedure, which have a mortality and morbidity consequence. With the current trend of early discharge after surgery and the pressure on beds, an elective operation should produce a quicker turn-round than emergency surgery with its postoperative complications (Gonzalez et al., 2003). Laparoscopic surgery can be used for patients of all ages after the patient's assessment for suitability. The laparoscopic resection is not a faster method of surgery and one concern is the length of time that the procedure takes as opposed to conventional laparotomy. A study carried out by Dwivedi et al. (2002) concluded that the surgery...

Emergency Surgery

Patients who have diverticulitis may suddenly find that they have an exacerbation of the disease and an emergency admission to hospital is needed. After initial investigations are done the patient will be prepared for an emergency operation. It is often not the reason for the emergency When a patient undergoes emergency bowel surgery for diverticulitis, there is little or no time for preoperative preparation, let alone siting of the stoma. Many patients are admitted to A& E at night or in the early hours of the morning, and proceed to theatre from the department, going to a ward only on return from theatre. Many patients therefore wake to find that they have a stoma without either understanding or even knowing beforehand of its possibility. Morrison (1978) suggests subsequently that it is not surprising that many patients may feel that they have been assaulted or unable to accept a stoma to which they never agreed in the first place. It appears that the obstacles to rehabilitation...

Case study

At operation an appendix incision was made but the surgeon quickly noted that the appendix was normal and proceeded to a midline laparotomy wound. In the descending sigmoid colon they found a perforated bowel significant of diverticulitis. The bowel was removed in a Hartmann's procedure resulting in a colostomy.

Stoma Siting

The careful siting of a stoma, whether temporary or permanent, plays an essential role in the rehabilitation of the patient. In elective cases, whatever the reason for a stoma, it is usual for the stoma care nurse to site the stoma preoperatively and to counsel the patient about the possible outcomes. All this takes place in a far more relaxed atmosphere where the patient can ask coherent questions about what is going to happen to him- or herself. Often, in the case of diverticulitis where surgical intervention will be as an emergency, the stoma is not sited preoperatively because the patient goes to theatre for surgery via the accident and emergency department (A& E), often The importance of having a stoma sited correctly cannot be stressed enough (CORCE, 1997). For most caucasian patients the stoma will be sited below the umbilicus, but patients from ethnic minorities may need the stoma to be sited on a different area of the abdomen. If the patient is to have elective surgery, as...

Computed tomography

In the acute phase of diverticulitis it is important to have an accurate diagnosis. A straight abdominal radiograph is regularly the first to be ordered. This is followed by computed tomography (CT) if the results from the straight abdominal radiograph show that this is necessary. A variety of other abdominal radiological investigations is also available. The gastrogaffin swallow and follow-through or gastrogaffin enema is regularly

Ayurvedic Medicine

Although Ayurvedic medicine is more common in the USA than in the UK, it is possible that a herbal prescription could precipitate a flare-up of diverticular disease in a susceptible person using a powerful bowel-cleansing routine. When there is a flare-up of diverticular disease causing abdominal pain and discomfort, Ayurvedic practitioners recommend massaging sesame seed oil into the skin over the stomach and bowel area in the morning and evening.

Aetiology

The historical perspective on the aetiology of diverticular disease can be recognized as far back as 1853 when Virchow (Rankin and Brown, 1930) described inflammatory areas, particularly in the sigmoid colon flexures, as 'isolated circumscribed adhesive peritonitis' and in 1869 when Klebs investigated the relationship of diverticula and their associated blood vessels in the intestinal wall. In 1930, Rankin and Brown were describing diverticula and their aetiology as a controversial subject, whereas Erdmann (1932) postulated that the presence of diverticula in the intestine was of no more importance than diverticula in other organs. Bell (1929) considered that multiple diverticula, i.e. diverticulosis, was mainly of academic interest. Mayo (1930) suggested that muscular weakness of the colon and not constipation or obesity was the underlying cause of diverticular disease. Lockhart-Mummery and Hodgson (1931) suggested that after a certain age (45 years) the muscle sheath of the colon...

The Evidence

In deciding the best treatment for diverticular disease information needs to be converted into questions that can be answered The best international source regarding evidence on the effects of common clinical interventions in diverticular disease is available in Clinical Evidence Concise (BMA, 2003). This summarizes the current state of knowledge and uncertainties about the prevention and treatment of clinical conditions, based on thorough searches and appraisal of the literature describing the best available evidence from systematic reviews and randomized controlled trials (RCTs). The most recent evidence for the treatment of uncomplicated diverticular disease from systematic searches in October 2002 is divided into sections.

Conclusion

In current thinking the authors have attempted to give the best evidence that was available at the time of writing. Use of the best clinical evidence, research and systematic searches (Clinical Evidence Concise BMA, 2003) allows the best evidence to be shown for anyone making decisions about patient care. Discussion of current RCTs and information about current effectiveness of various interventions in diverticular disease have been searched for by using explicit methodology to identify gaps in evidence, the effectiveness of various treatments and the benefits versus harm in related treatments. In January 2003, the Association of Coloproctology of Great Britain and Ireland set up an audit into diverticular disease, the National Complications of Diverticular Disease Audit, and has invited all surgeons across the UK to participate as an online database.

Colostomy

A colostomy may be formed in the sigmoid colon, descending colon, transverse colon or ascending colon, and the type of output will depend on the location of the colostomy. When a colostomy is situated in the ascending colon or the transverse colon, the faecal output may vary from a fluid output to a semi-formed stool. For these stomas the optimal appliance to use is a drainable appliance such as would be used if the stoma were an ileostomy. Transverse loop colostomies are often positioned in the upper right quadrant of the abdomen and are usually temporary. Often the size of the stoma when in the transverse position is large, often a loop, and causes difficult management problems for the nurse and patient. Finding a suitable appliance that the patient can use may also cause problems. Often this type of stoma is done on the elderly patient who is debilitated and admitted during the early hours of the morning with a bowel obstruction or problem such as diverticular disease. Emergency...

Fibre in the Diet

Lack of fibre or a decrease in dietary fibre has been the leading theory in the aetiology of diverticular disease since 1971. Studies undertaken by Painter and Burkitt (1971), using geographical and historical research, have continually received support for this hypothesis. Studies undertaken with case-controls by Brodribb and Humphreys (1976) suggested that patients with diverticular disease had low dietary intakes of crude fibre, but this is not an indicator of overall dietary fibre intake. Gear et al. (1979) and Berry et al. (1984) undertook studies on rats and found that they develop more and more diverticula when they are given less and less bran in their diet. Yet vegetarians have been shown to have less than half the expected prevalence of asymptomatic diverticulosis, which results only partly from their higher fibre intake (Gear et al., 1979). Although diverticular disease of the colon is viewed as a disease of western civilization and ascribed to inadequate dietary fibre...

Case

This case study demonstrates how an episode of diverticulitis developed and eventually resulted in surgery. James was a 48-year-old man who lived with his wife and two grown-up children. He was a plumber by trade with his own company. James was first admitted to hospital with an episode of acute diverticulitis about 6 months before he eventually had surgery. On James's first admission his symptoms of abdominal pain, fever, nausea and change in bowel habit resolved in 3 days with the administration of broad-spectrum antibiotics and intravenous fluids. He experienced three more episodes during the following 8 months, although none of these required admission into hospital. Following James's only admission to hospital, he and his wife had a consultation with the colorectal nurse specialist (CNS) to discuss his diagnosis of diverticular disease. The CNS had explained about the aetiology of the diverticula, how they are thought to arise and the long-term outcomes. Ivy, James's wife, asked...

Left Upper Quadrant Pain

Left upper quadrant pain can be secondary to pancreatitis, peptic ulcer disease, subphrenic abscess, jejunal diverticulitis, splenic rupture or infarction, and left lower lobe pneumonia. Splenic infarction is commonly associated with sickle cell disease. This diagnosis does not always require surgical resection. Treatment should be considered if the patient exhibits clinical signs of infection such as a leukocytosis or has elevated temperatures. Refractory pain is also an indication for surgical resection.

Left Lower Quadrant Pain

Sources of left lower quadrant abdominal pain include diverticulitis, incarcerated hernia, and sigmoid volvulus. Incarcerated hernias and sigmoid volvulus will present with signs and symptoms of small bowel obstruction, which will be discussed later in this chapter. Diverticulitis is the inflammation of divertic-ula, small, thin-walled outpouchings in the bowel usually at points of inherent weakness, such as where the vasa recta enter into the colon wall. In Western populations, it is found more commonly in the descending colon, whereas in Asian populations, it is more commonly found in the ascending colon. Unless perforated, obstructed, or actively bleeding, it is treated medically during the initial diagnosis of the disease, with antibiotics and bowel rest being used until the patient's diverticulitis flare has resolved. Then special dietary recommendations, such as high fiber, low fat, and low-meat diets, are usually suggested. Surgical therapy is considered when the disease recurs...

Specific Diagnoses And Issues

This section reviews the major diagnostic causes of abdominal pain in the older patient and points out specific diagnostic issues to consider in this population. The frequency of each particular disease varies in the reported case series of elderly patients presenting to the ED with abdominal pain. Cholecystitis (12 to 41 percent) is generally the most frequently encountered disease of a surgical nature, followed by bowel obstruction (7 to 14 percent). Nonspecific abdominal pain is also a frequent diagnosis (10 to 23 percent). Perforated viscus, appendicitis, diverticulitis, and pancreatitis each generally represent around 4 to 7 percent, depending on the case series. Aortic aneurysms and mesenteric ischemia are less common.8,68 General coverage of the following conditions can also be found in other chapters.

Causes of Lower Gastrointestinal Bleeding

Among patients with an established lower GI source of their bleeding, the most common etiology is hemorrhoids. Among nonhemorrhoidal bleeding, angiodysplasia and diverticular disease are most common, followed by adenomatous polyps and malignancies.4 DIVERTICULOSIS Diverticular bleeding is usually painless and is thought to result from erosion into the penetrating artery of the diverticulum. Diverticular bleeding may be massive. Patients are often elderly with underlying medical illnesses that contribute to both the morbidity and the mortality rates.

Infections in the ICU

Surgical patients come to the ICU with their own unique causes of infection. Many are admitted with a primary surgical infection (cholangitis, peritonitis, diverticulitis). Furthermore, post-operative patients are at risk for infectious complications including anastomotic leaks, wound infections, abscesses, and foreign body (mesh, grafts) infections. This being said, critically ill surgical patients are afflicted by nosocomial infections the same as anybody else. Pneumonia and catheter-related infections are major causes of morbidity and mortality in the intensive care setting.

Abdominal Computed Tomography

CT is the diagnostic tool of choice for many acute abdominal conditions. CT is the first imaging study of choice for patients with suspected diverticulitis, pancreatitis, pancreatic pseudocyst, aortic aneurysm, blunt trauma, and appendicitis. The diagnosis of appendicitis can be made on clinical evaluation, but CT has been proven remarkably sensitive and specific in confirming the diagnosis.11 Whether patients with suspected appendicitis require oral, intravenous, and or rectal contrast versus no-contrast thin cuts through the ileocecal area is debated in the radiology literature. 12 CT is a useful adjunct to plain films in suspected cases of intestinal ischemia, where specific findings may include pneumotosis intestinalis, portal venous gas, mesenteric vessel occlusion, and enlargement of a thrombosed vein. 13 While patients with suspected small bowel obstruction should be imaged initially with plain radiographs, CT has similar sensitivity in revealing obstruction, both high and low...

Noncontrast Helical Abdominal Pelvic CT

Upper Urinary Tract Urothelial Carcinoma

In the emergency room setting, noncontrast helical abdominal pelvic CT has become the examination of choice in the evaluation of flank pain and obstructive anuria (Niall et al. 2002 Shokeir et al. 2002, 2004 Coli-stro et al. 2002). Introduced by Smith and colleagues in 1995, noncontrast CT is quick, relatively easy to interpret, and obviates risks associated with the use of contrast media (Smith et al. 1999). Noncontrast CT is the gold standard in the detection of urinary calculi with an associated sensitivity of more than 95 and an associated specificity greater than 98 (Fig. 10.2) (Ruk-ker et al. 2004). When upper urinary tract obstruction is related to stone disease, CT can provide a wealth of diagnostic information. In addition, when stone disease does not exist, noncontrast CT can provide an accurate first glance to the underlying etiology of upper urinary obstruction (Rucker et al. 2004). In comparison to KUB with abdominal US, Shokeir and co-workers noted that noncontrast CT...

Hormonal versus nonhormonal

Nonhormonally responsive diseases should be considered for pain that is not related to menses, including chronic pelvic inflammatory disease, adhesions inflammation from previous pelvic surgery, irritable bowel syndrome, diverticulitis, fibromyalgia, and interstitial cystitis.

Psoas Abscess and Hematoma

Iliopsoas Abscess Crohn Disease

Psoas abscesses generally do not originate within the psoas compartment but spread here from neighboring intraabdominal structures.275 Most psoas abscesses have a pyogenic origin and generally are due to direct spread from spinal or epidural infections, bowel conditions such as Crohn's disease, diverticulitis, appendicitis, perforated colon cardinoma, and perirenal abscesses. Primary abscesses rarely occur and are usually

Clinical Features

Once a physician determines that a patient truly is constipated, the physician must attempt to determine the cause. Ihe differential diagnosis is broad ( Iab e Z9.-3). Determining the onset of the constipation helps narrow the differential diagnosis. Acute constipation represents intestinal obstruction until proven otherwise. Iumors, strictures, and volvuli can all present as acute constipation. Physicians often mistake subacute for chronic constipation. Ihe important distinction here is to determine exactly when bowel habits changed. Generally, acute and subacute conditions have the same differential diagnosis. Chronic constipation, that is, a lifelong or persistent habit, is usually less ominous and, if uncomplicated, can often be managed on an outpatient basis. Ihe presence or absence of associated symptoms may help guide decision making. Vomiting rarely accompanies benign constipation. Inability to pass flatus also raises concern about obstruction. A history of gradually...

Differential Diagnosis

Gallstone pain can be very similar to that of renal colic and should generally be considered in all patients with any right upper quadrant abdominal tenderness. Unlike the symptoms of renal colic, biliary colic symptoms are often associated with oral intake, last for several hours before remitting, and include vomiting. Pancreatitis is suggested by left upper quadrant or midepigastric pain, especially in the presence of risk factors (e.g., alcohol consumption or cholelithiasis). A perforated peptic ulcer may present with severe pain in the midepigastrum or either upper quadrant. However, these patients have marked tenderness on examination and develop peritoneal signs over time. Appendicitis shares the unilateral presentation with renal colic, but the subacute prodrome usually excludes urolithiasis. Ventral hernias should also be considered in the differential diagnosis and sought on physical examination. Diverticulitis usually causes pain in lower quadrants, more commonly the left,...

Compartmentalization of the Anterior Pararenal Space

Mesentery that contain the distinct and generally separate colonic and pancreaticoduodenal subcompart-ments. Whereas the anterior renal fascia and similarly the lateroconal fascia, although fusional in nature,139 have been considered as single laminae, Molmenti et al.34 recently emphasized the existence of a dissectable set of planes on CT. The fact that these fusion planes of the mesenteric surfaces with the primary retroperitoneum may reopen by the entrance of fluid supports the clinical identification and extent of fluid collections, seen occasionally in pancreatitis, less frequently in duodenal lesions, and rarely in appendicitis, diverticulitis, or colitis.

TABLE 751 Common Causes of Intestinal Obstruction

Tables Bowel Obstruction

Colonic obstruction is almost never caused by hernia or surgical adhesions. Neoplasms are by far the most common cause of large bowel obstruction. 45 Therefore, anyone who has symptoms of colonic obstruction should be evaluated for a neoplasm. Diverticulitis may create significant secondary obstruction and mesenteric edema. Stricture formation may occur with chronic inflammation and scarring. Fecal impaction is a common problem in elderly, debilitated patients and may present with symptoms of colonic obstruction. The next most frequent cause of large bowel obstruction after cancer and diverticulitis is sigmoid volvulus. Elderly, bedridden, or psychiatric patients who are taking anticholinergic medication are most often subject to this mechanical problem. A history of constipation may precede the volvulus and presenting symptoms. Radiographic appearance is usually classic ( F,i,g,.,,,,,,7,,5, ,,l). Finally, although much less common, cecal volvulus may also cause large bowel...

TABLE 846 Complications of Laparoscopy

Perforation of the colon with pneumoperitoneum usually is evident immediately but can also take several hours to manifest. Perforation is usually secondary to intrinsic disease of the colon (e.g., diverticulitis) or to vigorous manipulation during the procedure. Most patients will require immediately laparotomy however, in some patients presenting late (1 to 2 days later) without signs of peritonitis, expectant management may be appropriate.

Health Effects of Carbohydrates

High intakes of NSP, in the range of 4-32 gday-1, have been shown to contribute to the prevention and treatment of constipation. Population studies have linked the prevalence of hemorrhoids, diverticular disease, and appendicitis to NSP intakes, although there are several dietary and lifestyle confounding factors that could directly affect these relationships. High-carbohydrate diets may be related to bacterial growth in the gut and subsequent reduction of acute infective gastrointestinal disease risk.

Pathology and dysfunction

Another common infectious entity in the liver is hepatic abscess. Once the physiologic clearance of bacteria is outmatched by the influx, localized liver infection can ensue. Commonly, when stasis of fluids occurs, an abscess is formed. Abscesses can result from biliary obstruction, trauma, or secondary to intraperitoneal processes such as diverticulitis or appendicitis. Probably because of the constant assault from the gut with bacteria, the microbial flora

Large Bowel Obstruction

A carcinoma is the leading cause of large bowel obstruction, while volvulus and diverticulitis account for most of the remaining cases. All of these precipitating conditions are more common in the elderly. The overall mortality rate approximates 40 percent. Distention is common, vomiting and constipation are reported in about half the patients. Importantly, a significant percentage (up to 20 percent) will report diarrhea. A history of rectal bleeding, altered bowel habits, or weight loss may be present with underlying carcinoma.12 The pain is usually gradual in onset however, cecal volvulus can present with the acute onset of severe, colicky pain. 17 Sigmoid volvulus is two to three times more frequent than cecal volvulus and more commonly presents with a gradual onset of pain.18 Fever or the presence of peritoneal irritation suggests a perforation or gangrenous bowel.

Secondline agents consist of one of the following

Women in whom a particular disease process is suspected, such as adenomyosis, uterine leiomyomata, irritable bowel syndrome, interstitial cystitis, diverticulitis, or fibromyalgia should undergo further diagnostic testing and disease-specific treatment.

Dietary Fiber Obesity and the Etiology of Diabetes

Constipation, diverticular disease, and laxation Unquestionably, fiber is of direct benefit in relieving the symptoms of constipation and diverticular disease but there is little information about its role in the etiology of these conditions. Numerous interventions have shown that foods high in insoluble NSPs (e.g., certain cereal brans) and some soluble NSP preparations (e.g., psyllium) are very effective at controlling constipation and diverticular disease and enhancing laxation. The actual effect can vary with source. Wheat bran increases undigested residue, and fiber from fruits and vegetables and soluble polysaccharides tend to be fermented extensively and are more likely to increase microbial cell mass. Some NSP (and OS) preparations retain water in the colon. The physical form of the fiber is also important Coarsely ground wheat bran is a very effective source of fiber to increase fecal bulk, whereas finely ground wheat bran has little or no effect and may even be constipating....

Clinical presentation

In an emergency setting, patients present with the consequences of obstruction, perforation or bleeding. It may be impossible to distinguish bowel cancer from other pathology particularly diverticular disease. Plain abdominal X-ray may confirm the diagnosis with dilated large bowel, and second stage investigation with water-soluble contrast enema and CT scan should provide a definitive diagnosis and help plan appropriate management through disease staging.

Physiologic And Metabolic Effects

Burkitt and Trowell (2) were the first to report the physiological importance of dietary fiber consumption. Based on epidemiological studies, they showed associations between low-fiber diets and chronic disorders such as constipation, diverticulosis, colon cancer, diabetes, and cardiovascular disease. Since the 1970s research has been carried out that, for the most part, confirms the role of dietary fiber in disease prevention. Normal laxation is an important health benefit of dietary fiber consumption. Certain varieties of dietary fiber have been shown to increase stool weight and frequency, soften feces, increase fecal bulk, and reduce gastrointestinal transit times. This is particularly true of insoluble dietary fibers such as cellulose, found in large quantities in wheat bran, and of soluble but nonfer-mentable fibers such as psyllium gum. Constipation may be prevented, or successfully treated, by increasing dietary fiber intake. Various hypotheses have been suggested as to how...

Intestinal Fistulae Most Will Close Spontaneously Etiology

A fistula is an abnormal communication between two epithelialized organs. Fistulization of the intestine usually is a result of an iatrogenic injury, although spontaneous fistulae may develop in inflammatory conditions such as Crohn's disease or diverticulitis. Fistulae frequently involve the small bowel and may develop among the bladder, vagina, other segments of bowel, or most commonly the skin. Regardless of the cause or location, fistula closure is inhibited by a number of conditions, which are often remembered by students and residents with the mnemonic FRIEND (Table 10-3) Foreign body, Radiation, Inflammatory bowel disease, Epithelialization, Neoplasm, and Distal obstruction.

Right Lower Quadrant Pain

Right lower quadrant pain is a common complaint. It is also one of the most difficult areas of the abdomen to evaluate because the differential diagnosis is widely varied. The resulting workup is dependent on the age and sex of the patient, as well as the clinical picture. The differential diagnosis can include appendicitis, diverticulitis, inflammatory bowel disease, cecal volvulus, inguinal or femoral hernias, urinary tract infections, renal stones, and pyelonephritis. In females, organs of the female reproductive tract must be evaluated as a possible source of the pain, including evaluation for mittelschmerz, endo-metriosis, and ectopic pregnancy. In males in their 50s and 60s, other diseases should also be considered such as diverticulitis. In this population, as well as people with a history of inflammatory bowel disease, a CT scan should be used for further evaluation. Although this may lead to a slight delay in diagnosis, there is a much greater chance of having an incorrect...

Other Causes of Lumbar Pain

Based on their shared segmental innervation, pain from visceral disorders, including those of kidney, pancreas, and gallbladder duodenal ulcers colonic diverticulitis expanding abdominal aortic aneurysm epidural hematoma or abscess and endometriosis, can all mimic primary low back disorders. Pain from a leaking abdominal aortic aneurysm is constant and aching and may be referred to the lower abdomen and inguinal areas as well as the low back. In the evaluation of low back pain in the elderly, an abdominal aortic aneurysm must always be considered in the differential diagnosis. Costovertebral angle percussion pain is invariably associated with retroperitoneal pathology, most often kidney. Spinal cord compression can develop as a first sign of malignancy or as a complication. It is usually associated with back pain and should always be suspected if there are any neurologic signs or sphincter dysfunction. A history of associated systemic symptoms and a lack of therapeutic response to a...

Perforation

Free perforation is an indication for immediate surgical intervention. Patients with perforation will often present with peritoneal signs secondary to leakage of enteric contents into the peritoneal cavity with resulting inflammation and abscesses. The most common reasons for perforation are peptic ulcer disease or diverticulitis. The history should be focused to help differentiate these. A change in bowel habits and frequent constipation can suggest a colonic source. Nonsteroidal drug use and tobacco abuse are associated with peptic ulcers. Perforation from either source can be contained or freed within

Secondary

In lower GI bleeding, proctoscopy is often diagnostic in patients with anorectal sources of bleeding, such as hemorrhoids. If an anorectal source is suspected, the patient should be carefully evaluated for significant volume loss or more dangerous proximal sources of bleeding mimicking anorectal bleeding. Colonoscopy can be diagnostic in other forms of lower tract hemorrhage, such as diverticulosis or angiodysplasia, and may also allow ablation of bleeding sites by using the aforementioned technologies.

Barium Enema

Children with signs and symptoms suggestive of intussusception, such as colicky abdominal pain, vomiting, and passage of stool mixed with blood, require stabilization and a barium enema. Plain films may demonstrate signs of intestinal obstruction, such as distended loops, air-fluid levels, and a paucity of bowel gas in the right lower quadrant, the so-called Dance's sign. A barium enema is indicated, and a hydrostatic reduction of the intussusceptum is successful in 50 to 90 percent of cases.17 A barium enema may be useful for the diagnosis of bowel obstruction, volvulus, appendicitis, and diverticulitis, usually in consultation with surgical colleagues.

Bacterial Infections

Diverticulitis, often complicated by perforation, is the other common gastrointestinal infection encountered in transplant patients. 10 Patients commonly present with findings of vague abdominal pain as the only symptom of this potentially life-threatening disease. A high index of suspicion should be maintained when evaluating transplant recipients with abdominal pain.

Etiology

For many patients presenting with signs and symptoms of SBO, the differential diagnosis includes functional rather than mechanical SBO, also known as paralytic ileus. By far the most common cause of ileus is laparotomy, and some degree of ileus is normal in the first few days following surgery. In patients who are not postoperative, a number of conditions can cause ileus and mimic mechanical SBO (Table 10-1). Inflammation or infection in the peritoneum, retroperitoneum, or thorax, such as pancreatitis, diverticulitis, appendicitis, or pneumonia, can affect adjacent bowel and cause a focal ileus, as can mesenteric ischemia. Sepsis or shock due to any cause can be expected to cause a generalized ileus. Electrolyte abnormalities, particularly hypokalemia, and medications that affect bowel motility, such as narcotics, calcium channel blockers, and anticholinergic agents, are common contributing factors to if not causes of ileus.

Meckels Diverticulum

Meckels Diverticulum Barium Studies

Failure of the omphalomesenteric duct to completely involute may lead to a persistent outpouching along the antimesenteric border of the distal ileum, a Meckel's diverticulum (Fig. 2-22). Meckel's diverticulum occurs in approximately 2 of the general population, and it is the most common congenital abnormality of the gastrointestinal tract. Stasis of intestinal contents within the diverticulum predisposes to the development of enteroliths (Fig. 2-23). Obstruction is the predominant symptom (39 ). Hemorrhage, perforation, diverticulitis, and intussusception are the other symptoms (12-14 each).10,31,32 Hemorrhage and perforation are usually associated with the presence of ectopic gastric mucosa (Fig. 2-24), while perforation due to ingested foreign body has rarely been reported.33

Procedures

Culdocentesis can also be performed rapidly in the ED. However, its utility is also limited. The potential positive findings of leukocytes and bacteria are non-specific and may be a product of other inflammatory processes, such as appendicitis or diverticulitis, or due to contamination with vaginal contents.

Meckels Ulcer

Meckel's diverticulum results from postnatal incomplete obliteration of the omphalomesenteric duct adjacent to the intestine. In adults, it is located in the ileum 30-100 cm from the ileocecal valve and on the side opposite to the mesentery. A diverticular intestine on the mesenteric side is likely to be intestinal duplication (see Advice, Intestinal duplication, below). Gastric acid secreted from the fundic gland of the ectopic gastric mucosa in the diverticulum may cause ulcers of the diverticulum or the ileal mucosa in the vicinity of the diverticulum, leading to abdominal pain, gastrointestinal bleeding, or gastrointestinal perforation. It may also cause intestinal obstruction, intussusception, or diverticulitis (Fig. 10.4.4).

Williams Syndrome

Hypercalcemia is seen in infants and recurs in adults. Calcium levels should be monitored. Children who present with polydypsia, polyuria, irritability, and constipation should be evaluated for hypercalcemia. Urethral stenosis, bladder diverticuli, vesicoureteral reflux, renal artery stenosis, constipation, ulcers, diverticulitis, and arthropathy are reported in adults with the syndrome.

Bowel Disorders

Diverticular disease of the colon, characterized by the development of protrusions of mucosa through the bowel wall, is common and usually asymptomatic. It has been shown to be less likely to develop in those following a high-fiber diet, and once acquired can be managed, in many cases, by ensuring an adequate amount of fiber in the diet. Experimentally, various fiber supplements and 'bulking agents' have been shown to reduce the abnormally high peak intracolonic pressures that are characteristic of diverticular disease. Sometimes 10-20 g of coarse wheat bran as a supplement is all that is required, but some patients develop flatulence and distension at least initially. Other fiber supplements such as ispaghula husk (psyllium) may be as effective, without the initial adverse side effects. Sometimes, simple dietary changes to achieve an adequate total daily intake of dietary fiber particularly from wheat-based foods are effective. Diverticulitis (inflammation of the diverticula) is a...

Acute Abdomen

Intravenous contrast enhancement is indicated for all CT examinations performed for the evaluation of acute abdomen. Acute abdominal conditions for which CT is commonly performed include appendicitis, diverticulitis, intraabdominal abscess, and bowel obstruction. While intravenous contrast material enhances the visualization of all of these conditions, its role is not as great as in CT for abdominal trauma. For example, mesenteric inflammation is detectable in the absence of intravenous contrast enhancement in the case of appendicitis or diverticulitis. Furthermore, intravenous contrast enhancement is not involved in the detection of the complications of acute gastrointestinal inflammation, such as bowel obstruction, abscess formation, and bowel perforation. One cause of an acute abdomen, bowel ischemia, is an exception, in that intravenous contrast enhancement plays a major role in its detection, especially when strangulation is present.

General surgery

Diverticular disease of the sigmoid colon may cause abscess formation that perforates into the bladder producing a colovesical fistula. Symptoms include recurrent urine infections and air bubbles in the urine passed down from flatus in the colon (pneumaturia). It is uncommon for a carcinoma of either the bladder or colon to cause a similar fistula.