Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis

PURPOSE

The purpose of this study was to prospectively investigate patients with suspected acute colonic diverticulitis and to provide sensitivity, specificity, and interobserver agreement in a blinded trial.

METHODS

Fifty-five patients (29 men; 59 +/- 13 (range, 29-76) years) who reported to the emergency room with clinically suspected acute colonic diverticulitis were prospectively included in the study. All patients underwent magnetic resonance imaging scans of their abdomen before and after contrast agent administration. Two assessors blinded to all clinical, laboratory, and radiologic results evaluated the images separately.

RESULTS

The assessors reported colonic wall thickening, segmental narrowing of the colon, presence of diverticula, pericolic fatty infiltration, ascites, and abscesses. The assessors had to diagnose or rule out acute colonic diverticulitis. Sensitivities, specificities, positive, and negative likelihood ratios were derived. To determine interobserver agreement, a Cohen's kappa coefficient was calculated. The two assessors exhibited sensitivities of more than 94 percent, specificities of 88 percent, positive likelihood ratios of more than 7.5, and negative likelihood ratios of less than 0.07. The kappa coefficient showed a significant, strong correlation between both assessors (kappa = 0.68).

CONCLUSIONS

Magnetic resonance imaging is investigator independent and provides high sensitivity and specificity for the diagnosis of acute colonic diverticulitis.

Primary aorto-enteric fistula in a 52-year-old man

BACKGROUND

Aorto/ilio enteric Fistula (AEF) is defined as a communication between the aorta or iliac artery and any adjacent segment of the bowel. It may be primary or secondary. The former occurs in patients with intestinal or vascular disease and mostly complicates abdominal aortic aneurysm (AAA), whereas secondary aorto-enteric fistula is a dreadful complication of aortic reconstruction with vascular prosthesis. THE AIM of this study is to report this case of unusual presentation of PAEF as a rare cause of low enteric bleeding and discuss the path physiology, etiology, diagnosis and management of this entity.

CASE

The authors report a case of 52-year-old man who presented with acute rectal bleeding. Esophago-gastro-duodenoscopy and colonoscopy were non diagnostic. Because of persistence of bleeding and hemodynamic instability, patient underwent urgent laparotomy. At surgery, diagnosis of primary aorto enteric fistula (PAEF) was made between the right iliac artery and the sigmoid complicating an iliac pseudo aneurysm. Direct repair of the vascular and digestive defects and sigmoidostomy were performed. The patient died two hours after surgery of cardiac arrest.

CONCLUSION

AEF is a rare but a life threatening cause of GI bleeding. A delay in identification, as in our observation, may partly explain the high morality and morbidity.

[Surgical complications of the diverticular disease. A rare case of sigmoid-vaginal fistula]

The Authors report on a rare case of diverticular disease complicated by a sigmoid- vaginal fistula with personal considerations based on a review of literature. A 75 year old patient becomes to our observation suffering the lost of smelly vaginal secretions without fever or abdominalgia. In anamnesis hysterectomy cholecystectomy appendectomy and visceral adhesions lysis. Colonoscopy RX barium enema, gynaecological examination, vaginal buffer show diverticulis of colon sigma with sigmoid-vaginal fistula. After laparotomy, visceral adhesions lysis, it was done sigmoid- vaginal fistula resection with healing. Diverticular disease is a XX century pathology with incidence (for some authors) of 50% of population. Symptomatic forms affect 30-50% of patients (variable percentage based on age); the 1% of these need surgery. The colonic anatomical-functional disorder is the principal cause of diverticular disease that recognize the main localization in colon-sigma. Diverticulitis with pericolic inflammation are frequent complications; possible evolutions are local tamponed peritonitis, mechanical intestinal occlusion, hemorrhage from colonic wall and fistulas. Sigmoid-vaginal fistula is the most frequent in women previously treated with laparohysterectomy. The colonoscopy and RX barium enema are gold standard for instrumental diagnosis; the vaginography is diriment, urography excludes urological diseases. The surgical treatment is the fistula resection, with or without colonic resection. In consideration of the necessity of conservative surgery and on the basis of this case, the authors suggest, if it's possible, the simple fistula resection, although the literature report an high number of relapses.

Primary aorto enteric fistula: report of 18 Belgian cases and literature review

BACKGROUND AND STUDY AIMS

We searched for Belgian cases of primary aorto enteric fistula (PAEF). After reviewing the literature we compared our data concerning incidence, types, pathogenesis, aetiology, clinical presentation, diagnostic modalities, treatment and prognosis of PAEF. We especially focus on the clinical picture and diagnostic options.

PATIENTS AND METHODS

We present our atypical case report. A questionnaire was send to 196 Belgian vascular surgeons in order to evaluate retrospectively the Belgian experience with PAEF. A Medline search of relevant literature from January 1980 to February 2006 was conducted.

RESULTS

In total 18 Belgian cases of PAEF were detected usually originating from infrarenal abdominal aorta (83%), ending in the third or fourth part of the duodenum (67%) and affecting men (94%) with a mean age of 70-years-old. Main cause is aneurysm (89%). Gastrointestinal bleeding is the main symptom (83%). Untreated, no one survives and overall mortality is 29%. Most patients are treated with in situ grafts (83%). With our experience we propose a diagnostic flow chart to obtain early diagnosis of PAEF.

CONCLUSIONS

PAEF is suspected when a patient presents with (considerable) (upper) gastrointestinal blood loss and has a known aneurysm, initial herald bleed or pulsating abdominal mass. In case of hemodynamic instability, prompt surgical exploration is mandatory. Hemodynamically stable patients must undergo contrast enhanced multislice computerized tomography rather than gastroduodenoscopy or arteriography to make early diagnosis. Surgery is the only definitive life saving treatment. Overall mortality is at least 30%. Late diagnosis, positive peroperative cultures and shock are indicators of poor prognosis.

Perforated sigmoid diverticulum mimicking acute appendicitis in a young patient: a case report

Acute colonic diverticula are uncommon in patients <40 years of age, with an incidence between 2% and 10%. In such patients, the condition may be misdiagnosed in the acute setting, because it is often not considered and may be mistaken for acute appendicitis, particularly if there are predominantly right-sided signs. As a result, it may result in diagnostic delay and complications. We report a case of a young patient who presented with a perforated sigmoid diverticulum mimicking acute appendicitis, which was not diagnosed initially, and the resulting course of events.

Extraovarian peritoneal serous papillary carcinoma mimicking colonic obstruction

Involvement of the colon by extraovarian peritoneal serous papillary carcinoma (EPSPC) is considered as rare. During a 10-year period the records of five female patients with a mean age of 73.4 years who were admitted for colonic obstruction due to EPSPC were reviewed. Preoperative and postoperative data were studied. All patients presented with symptoms of colonic obstruction and high concentrations of CA-125. Involvement of the sigmoid colon was demonstrated preoperatively both in CT and colonoscopy. Operative findings of multiple peritoneal implantations involving the surface of the ovaries in two cases, the greater omentum in three cases and invasion of the sigmoid colon in all cases prompted us to perform sigmoidectomy and omentectomy in all cases with bilateral salpingo-oophorectomy in four of them. All patients received adjuvant paclitaxel plus platinum-based combination chemotherapy.

Chilaiditi sign on FDG-PET

A 66-year-old woman with a history of endometrial cancer underwent a F-18 fluorodeoxyglucose positron emission tomography (FDG-PET). Abnormal uptake was noted in the right lower chest. CT scan showed a loop of colon interposed between the liver and the diaphragm, an entity known as the Chilaiditi sign. This case illustrates the importance to correlate abnormal PET findings with CT images. The Chilaiditi sign should be included in the differential diagnosis of lower chest uptake on an FDG-PET study.

[Sigmoido-vesical fistula: a case report]

BACKGROUND

Colovesical fistula is a rare complication of inflammatory and neoplasic pelvic diseases (0.2%).

AIM

To report a new case.

CASE

We report the case of a 74-year-old woman, with a charged previous medical history and had not had hysterectomy. She was admitted because of cystitis with haematuria associated to faecaluria and pneumaturia confirmed by an intravenous pyelogram. Water-soluble contrast medium show the sigmoidovesical fistula. A sigoid sticture is identified at colonoscopy and biopsy was realised. The patient had had sigmoidectomy with Hartmann's procedure. Histologic study confirm the diverticulatis with peridiverticular abcess and fistula. We suggest that early diagnosis and management of sigmoid diverticulatis is required to prevent complicatins like stricture and fistula.

[Massive lower gastrointestinal bleeding due to diverticular disease during antiplatelet therapy. Case report]

Diverticular disease is very frequent in Western countries; in 5% of the cases it is the cause of serious bleeding, haemodynamic instability and death. The authors report a case of 74 years old patient with severe lower gastrointestinal bleeding. She was in antiplatelet treatment with acetylsalicylic acid (100 mg/die) and clopidogrel (75 mg/die) for preventing the restenosis of medicated stents positioned to treat an acute coronary syndrome. At the same time the patient was under treatment for primary hypercholesterolemia with rosuvastatin (20 mg/die). The severe haemorrhage demanded haemodynamic stabilization, achieved by colloid infusion and blood transfusions. The bleeding continued; selective arteriography showed it's origin from the areas of the sigmoid and superior hemorrhoidal arteries. During the procedure, embolization of the inferior mesenteric artery using spiral type BALT was performed, with consequent bleeding interruption. Fifteen days after the embolization, a rectosigmoid colonoscopy showed a sigmoid diverticular disease. The treatment with acetylsalicylic acid and clopidogrel has surely contributed to the severity of the hemorrhage. Recent experimental and clinical evidence suggests a possible antiplatelet effect of the statins.

A giant sigmoid diverticulum presenting as an upper abdominal mass

AIM

We report a case of a giant diverticulum of the sigmoid colon presenting as a mass in the left upper quadrant of the abdomen in an elderly man.

METHODS

This report highlights a rare complication of diverticular disease. At operation, the giant cyst was situated in the supracolic compartment of the abdomen. The management options and a review of the literature are presented.

CONCLUSION

CT scan is the investigation of choice. Early surgical intervention is important in order to reduce the risk of perforation.

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

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

Incarcerated Spigelian hernia mimicking obstructing colon carcinoma

Spigelian hernia is a ventral abdominal hernia that only rarely causes incarceration or strangulation of the bowel. There are few reports in the surgical literature of colonic obstruction secondary to incarcerated Spigelian hernia. In this paper, we present a patient with an incarcerated sigmoid colon in a Spigelian hernia sac, mimicking on contrast enema an obstructing carcinoma. Accurate diagnosis was made pre-operatively by computed tomography (CT), and the hernia was repaired by polypropylene mesh in a tension-free manner.

An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases

PURPOSE

This study was designed to review the outcomes of emergent treatment of sigmoid colon volvulus.

METHODS

The records of 827 patients were reviewed retrospectively.

RESULTS

The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2 percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent, complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with Hartmann's procedure in 146, resection with Mikulicz procedure in 14, resection with primary anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in 1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early recurrence of 0.8 percent, and late recurrence of 6.7 percent.

CONCLUSIONS

Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus, definitive surgical techniques must be preferred.

Acute diverticulitis in very young patients: a frequent surgical management

PURPOSE

The natural history of sigmoid diverticulitis in terms of the virulence and management in young patients is an ongoing controversy. This retrospective study was designed to assess the severity and early management of acute diverticulitis according to age.

METHODS

From 2000 to 2004, 284 patients were admitted for acute diverticulitis. Fifty-two patients (18 percent) were aged 50 years or younger and were divided in two groups: aged 40 years or younger (Group 1, n = 20), and patients older than aged 40 years (Group 2, n = 32). The diagnosis was confirmed by computed tomography in 49 patients (94 percent).

RESULTS

Radiologic findings showed that the rate of complicated lesions (i.e., diverticular perforation and/or abscess) was significantly higher for patients younger than aged 40 years than patients older, respectively 72 and 35 percent (P = 0.02). The risk of requiring immediate surgical treatment was significantly more frequent in Group 1 than Group 2 (40 vs.13 percent; P = 0.04). There was a trend toward a higher risk of "major surgery" (i.e., Hartmann's procedure) in Group 1 than Group 2 (15 vs. 0 percent; P = 0.05).

CONCLUSIONS

Diverticulitis in patients younger than aged 40 years seems to have a particularly aggressive and fulminant course and requires early surgical procedures for complications (associated abscess, colonic perforation) in 40 percent of cases. The use of "major procedure" (i.e., stoma) is more frequent in these patients.

Ileosigmoid knotting

Ileosigmoid knotting or compound volvulus is a very uncommon cause of intestinal obstruction, which is associated with significant morbidity and mortality. A case of compound volvulus is reported in a 24 years old male patient who presented with diagnostic dilemma.

A surprising twist to an old problem: sigmoid volvulus in a 19-year-old man

Sigmoid volvulus classically presents in the seventh or eighth decade, therefore, diagnosis of sigmoid volvulus in an adolescent may be delayed or missed. This life-threatening diagnosis should be considered in young patients presenting with abdominal pain, nausea, vomiting, and constipation. Intraoperative findings in a 19-year-old man with a sigmoid volvulus highlight the importance of considering further studies, such as an abdominal CT scan, which goes beyond the typical obstruction evaluation in the adolescent patient. When nonoperative management fails to decompress the volvulus, complicating factors should be considered, and laparotomy is indicated to provide definitive treatment for this condition.

Ileosigmoidal knotting in children: a review of 9 cases

BACKGROUND

The purpose of this study was to review nine pediatric cases of ileosigmoidal knotting (ISK), which is an unusual form of intestinal obstruction common in adults, characterized by double-loop obstruction.

METHODS

A retrospective analysis was designed to examine preoperative, operative, and postoperative findings of the nine children with ISK who were surgically treated in a university hospital throughout a 38.5-year period.

RESULTS

The mean age was 10.6 years (range: 7-16 years). Seven patients (77.8 %) were male. The most common symptoms were abdominal pain, distention, obstipation, and vomiting, and the most common signs were abdominal tenderness and distention. The most common form was type 1A in 4 patients (44.4%) in whom the active ileum encircled the passive sigmoid colon in clockwise direction. There was a gangrene in both ileum and sigmoid colon in 7 patients (77.8%), one patient (11.1%) had gangrene in only the sigmoid colon, and the bowels were viable in 1 patient (11.1%). In the gangrenous cases, nonviable small bowel segments were resected, and anastomosis was performed, while gangrenous sigmoid colon was resected and Hartmann procedure or primary anastomosis was used. In the nongangrenous case, detorsion was performed and sigmoidopexy was added. One patient in this series (11.1%) died.

CONCLUSIONS

Ileosigmoidal knotting is a rare disease in children. Its preoperative diagnosis is not easy. It is generally misdiagnosed as an obstructive emergency. Aggressive preoperative resuscitation, effective and prompt surgery, and postoperative support are the basic principles of treatment. Although resection with primary anastomosis is advised in gangrenous cases, stomas may be lifesaving in unstable patients. In nongangrenous cases, definitive surgical procedures are generally used.

Complicated sigmoid diverticulitis

In medical practice, the colonic diverticulitis diagnosis is easy, based especially on a barium enema and an inferior digestive endoscopy, but the diverticulitis complications, especially metastatic infections, raise serious positive and differential diagnosis problems. We present the case of a 51 year old male who comes with hepatomegaly and multiple hepatic formations, in deteriorating clinical condition, context suggestive of secondary metastasis, but after investigation it was demonstrated they were of infectious nature, from a sigmoidian diverticulitic abscess. In this case, the hepatic biopsy was appropriate and it represented an important moment in the management of the patient.

Prolapsing mucosal polyps in the sigmoid colon: presenting with chronic abdominal cramping pain and colonic obstruction

Colorectal polypoid lesions are classified as either neoplastic or non-neoplastic, and the differentiation between the two lesions is important for clinical practice, however, this is not easy in some rare cases. Cases of colonic prolapsing mucosal polyps are rare. They are often, but not always, associated with diverticular disease and present with abdominal pain, obstructive symptoms or bleeding. On colonoscopic examination, the lesions are characterized by multiple polyps or elevated patches with smooth and bright red colored surface. The histological features include: glandular crypt abnormalities, fibromuscular obliteration of the lamina propria, and thickened and splayed muscularis mucosa. We report herein a case of sigmoid colonic prolapsing mucosal polyps presenting with acute lower abdominal cramping pain and colonic obstruction who was diagnosed based on colonoscopy and endosonography findings and treated with conservative management.

Rupture of abdominal aortic aneurysm into sigmoid colon: A case report

Primary aorto-colic fistula is rarely reported in the literature. Although infrequently encountered, it is an important complication since it is usually fatal unless detected. Primary aorto-colic fistula is a spontaneous rupture of abdominal aortic aneurysm into the lumen of the adjacent colon loop. Here we report a case of primary aorto-colic fistula in a 54-year old male. The fistulated sigmoid colon was repaired by end-to-end anastomosis. Despite inotropic support, the patient died of sepsis and multiorgan failure on the first postoperative day.

Kieferhöhleninfekt mit Kopfemphysem als «red herring» bei Steroid-assoziierter Kolonperforation

Jede kurz- oder langfristige Steroidtherapie ist ein Risikofaktor für eine Steroid-assoziierte Kolonperforation. Insbesondere unter einer Steroidtherapie kann die Perforation absolut asymptomatisch verlaufen und ein Emphysem das erste Zeichen der Perforation sein. Deshalb sollte eine Kolonperforation immer differential-diagnostisch in Betracht gezogen werden beim Auftreten eines Emphysems jeglicher Lokalisation, auch bei fehlender Abdominalsymptomatik.

Nurse led flexible sigmoidoscopy in primary care--the first thousand patients

OBJECTIVES

Secondary care Trusts have traditionally been providers of flexible sigmoidoscopy services in the United Kingdom. The aim of this study was to establish a Nurse-led flexible sigmoidoscopy clinic that would provide a patient orientated service in a primary care setting.

PATIENTS AND METHODS

A protocol driven flexible sigmoidoscopy clinic was established in a primary care setting. The first thousand patients who underwent flexible sigmoidoscopy at the community clinic were prospectively studied.

RESULTS

A nurse endoscopist performed 1002 procedures on 1000 patients. Median time from referral to flexible sigmoidoscopy was 35 days (Range 1-180 days). Two hundred and twenty-two (22%) patients were diagnosed with significant colonic pathology including 25 (2.5%) patients with colorectal cancer. Median time from referral to histological diagnosis of colorectal cancer was 26 days (range 7-87 days). No complications were encountered. Patients who required further follow-up were referred to a Consultant led (29%) or Nurse led clinic (5%) in secondary care. Patient satisfaction as assessed by postal questionnaire indicated that 447 (99%) patients were satisfied with the service.

CONCLUSIONS

A community endoscopy clinic can provide a safe and effective flexible sigmoidoscopy service with high levels of patient satisfaction. Nurse Endoscopists can extend their role in primary care with adequate training and support from secondary care hospitals.

Fistulisation vésicale d'une tuberculose sigmoïdienne

A sigmoid tuberculosis is very rare. We report a case of sigmoid pseudotumoral tuberculosis with a fistulization into the urinary bladder in a 10-year-old girl. The diagnosis of tuberculosis was made by histopathological examination of the surgical specimen after segmental colectomy. Surgery completed by antitubercular chemotherapy gave a good result.

Management of diverticulitis in younger patients

PURPOSE

This study was designed to evaluate the clinical course of sigmoid diverticulitis patients younger than aged 50 years examined by abdominal CT during the first episode of disease to elucidate whether the criteria used for older patients can safely be followed in their younger counterparts.

METHODS

Retrospective review of patients with sigmoid diverticulitis treated from 1990 to 2003 was performed.

INCLUSION CRITERIA

patients younger than aged 50 years with sigmoid diverticulitis documented by CT scan. Severity of disease was classified according to radiographic findings. Age, gender, treatment, recurrent disease, and need for colostomy were documented.

RESULTS

A total of 5,499 patients were identified with sigmoid diverticulitis: 962 patients were younger than aged 50 years, and 411 had a CT scan on their first episode of disease. Of the 411 patients, 335 were classified as uncomplicated and 76 were complicated. Of the uncomplicated patients, 101 underwent an elective operation and 234 were followed nonoperatively. Of those followed, 67 had a recurrent uncomplicated episode, 10 had a recurrent complicated episode, of whom 5 required emergent operation and colostomy. Of the 76 patients with complicated disease, 23 had an emergent operation with colostomy, and 38 had an elective operation. Fifteen patients were followed without an operation and seven had a recurrent uncomplicated episode. None required emergent operation or colostomy.

CONCLUSIONS

Younger patients with uncomplicated diverticulitis by CT criteria respond well to medical management and seldom required an emergent operation and colostomy. Young patients with diverticulitis should be treated according to the same criteria used for older patients.

Localized Vasculitis of the Gastrointestinal Tract

BACKGROUND AND OBJECTIVES

Isolated vasculitis of the gastrointestinal (GI) tract is a rare entity. Endoscopic biopsies have low sensitivity to diagnose intestinal vasculitis, even though the endoscopic findings may be suggestive of this condition. Our aims were to describe a case of biopsy-proven colonic leukocytoclastic vasculitis and review the literature.

METHODS

A patient with biopsy-proven colonic leukocytoclastic vasculitis is described. A Medline database search of cases with localized GI vasculitis between January 1985 and September 2005 was conducted.

RESULTS

A 32-year-old man was admitted to the hospital because of abdominal pain and diarrhea. A colonic biopsy showed leukocytoclastic vasculitis. There are very few articles on leukocytoclastic GI vasculitis as a separate disease, and most of them emphasize the difficulty in classification. Unlike our case, in former cases of localized vasculitis a diagnosis was made after surgery. Although our patient had steroid-refractory biopsy-proven isolated intestinal vasculitis, treatment with intravenous cyclophosphamide resulted in rapid resolution of symptoms and surgery was not required.

CONCLUSIONS

In patients with abdominal pain a diagnosis of intestinal vasculitis should be considered. Immunosuppressive therapy allowed our patient to avoid surgery and may be similarly beneficial in other similar cases.

Ileosigmoid knotting in a young adult in Enugu, Nigeria - a case report

A 25-year old male student who was seen in the emergency unit of our hospital with symptoms and signs of acute intestinal obstruction of 4 days duration is presented. Following resuscitation, an exploratory laparotomy revealed a long gangrenous jejunoileal segment with its base firmly knotted around the mesentery of the sigmoid colon which was also gangrenous. Resection and primary anastomosis of the small bowel was carried out. Hartmann's colostomy was also done following resection of the sigmoid colon. The features of this uncommon presentation of intestinal obstruction described in the literature as ileosigmoid knotting or compound volvolus are highlighted, with particular note that its recognition, rapid resuscitation and exploration will improve prognosis.