Colonoscopy in complicated diverticular disease Kenneth A. Forde, MD New York, New York
Colonoscopy proved to be of significant value in the evaluation of 40 patients with extensive diverticular disease by averting operative intervention in some, by comfirming or clarifying radiologic suspicions in many and by discovering unsuspected lesions occasionally. Although no endoscopic complications were encountered in this series, it is generally recognized that the acutely or chronically inflamed bowel requires special caution in endoscopic manipulation. Patients with colonic diverticular disease commonly pose a problem in radiologic diagnosis. The main difficulties are in obtaining adequate bowel cleansing and determining the co-existence of polyps or cancers in segments of extensive diverticulosis. The implication in most of these patients is whether operative intervention is indicated. Fiberoptic colonoscopy has been of help in resolving many of these problems. Materials and Methods In reviewing 450 colonoscopic procedures, we analyzed 40 consecutive cases of extensive diverticulosis. Routine or air contrast barium enemas were inconclusive in 23. For 1 patient, barium study was not considered feasible; in the same patient, mesenteric angiography at the time of active bleeding had been negative. TECHNIQUE Mechanical bowel preparation, more difficult in these patients, is one of the limitations of both endoscopic and radiologic examination. A longer period of preparation is often required, and cleansing enemas must be administered at a long enough interval before colonoscopy to allow for their complete evacuation. Colon spasm during examination is more common in these patients, and the insufflation of air should be kept at a minimum lest further spasm be induced. There is often enough spasm for the examiner to feel the bowel "grasping" the instrument both on insertion and withdrawal. The intermittent administration of 1 mg to 2 mg of glucagon parenterally is helpful in reducing colonic hyperactivity, especially during operative colonoscopy. We have not found the use of anticholinergics, before or during the procedure, to be of demonstrable value. In endoscopic examination of inflamed bowel, more gentle manipulation is required because such tissue is more prone to injury from direct instrumental trauma, overdistention of the bowel, or overstretching of the mesentery. The chronically inflamed bowel is also more rigid, making it less pliable to the customary maneuvers necessary for successful insertion. Care must be taken not to mistake large diverticular orifices for the colonic lumen (Figure 1a). The interpretation of endoscopic findings deserves more attention as well. For example, edematous mucosal folds may obscure small lesions and, by their own configuration, simulate polypoid tumors. Also, with hypertrophy and lack of distensibility of the bowel wall, especially in the descending colon, the interhaustral septa may meet in the midline and simulate the appearance of the traverse colon (Figure 1b).'
Table I. Indications for colonoscopy in 40 patients with diverticular disease. 23 10 6
Inconclusive barium enema (BE) Confirmation of BE findings (including polyps) Colonic symptoms; BE showed only diverticula BE not feasible; mesenteric angiography negative
1
RESULTS The indications for colonoscopy in this group of patients are listed in Table I. The most frequent indication was an inconclusive barium study. The barium enema diagnosis was confirmed in 12 patients and altered in 25, with 2 of these being errors in endoscopic diagnosis (Table /I). In the first of these errors, an endoscopically suspected polypoid carcinoma led to resection. The polyp proved to be benign, but the mesenteric nodes contained unsuspected prostatic carcinoma. The second error was in a patient who had a sigmoidocutaneous fistula following drainage of a perforated sigmoid mass thought to be diverticular disease clinically, radiographically, and endoscopically. "At subsequent resection a very superficial but broad carcinoma was found. Fortunately, the clinical course of neither patient was complicated by these errors. In 33 patients, the therapeutic approach was correctly altered as a resultof endoscopy. Of greatest significance is that 21 contemplated operative procedures were avoided. In some patients needing operation, the extent of the procedure could be planned more precisely after endoscopy. For example, in 6 patients resection was properly limited or delayed while in 3 patients resection was extended. There were no complications or deaths in this series of 40 patients. Table /I Comparison of barium enema (BE) and subsequent colonoscopy in diverticular disease confirmed altered
BE diagnosis Diverticulosis only Diverticulosis + polyp Diverticulosis + ? polyp Diverticulosis + carcinoma Diverticulosis + ? carcinoma Granulomatous colitis (?) Colovesical fistula, ? diverticulosis
4 5 1
o
1 9 3 1
1
10
1
1 0
o
errors 10
1b
a endoscopic diagnosis: carcinoma; pathologic diagnosis: adenoma with severe alypia. b endoscopic diagnosis: diverticulitis; pathologic diagnosis: "superficial spreading" carcinoma.
From the Department of Surgery, College of Physicians & Surgeons, Columbia University, and Presbyterian Hospital, New York, New York. Reprint requests: Kenneth A. Forde, MD, Department of Surgery, College of Physicians & Surgeons of Columbia University, 630 West 168th Street, New York, New York 10032.
192
GASTROINTESTINAL ENDOSCOPY
Figure 1. (a) Large diverticular orifices simulating colonic lumen. (b) Appearance of descending colon in severe diverticular disease can misleadingly simulate the transverse colon. (c) Typical segment of diverticulosis with stenosis in sigmoid segment. (d) Atypical constriction simulating carcinoma; only diverticular disease is seen in the resected specimen. DISCUSSION Acute Diverticulitis. Sometimes patients with presumed diverticulitis require exploratory laparotomy, often with creation of a proximal colostomy and drainage of a perforated mass of the left colon. It is often impossible to tell by palpation or visualization whether such a mass is inflammatory, neoplastic, or both. With perforated inflammatory disease it is preferable to wait for the process to resolve before proceeding with further operative management while a perforated carcinoma would demand earlier surgical intervention. Colonoscopy may be helpful when rigid sigmoidoscopy and barium enema are inconclusive or not feasible. Chronic Diverticulitis. As with any inflammatory process, healing may result in significant stenosis of the colonic lumen. Stenotic segments of colon resulting from diverticulitis are usually longer than those associated with neoplasm and have gradually tapering margins with an intact mucosal pattern (Figure 7c). However, there are times when the radiographic configuration is atypical (FigiJre 7d). In such selected patients, colonscopy may be definitive. Diverticular Hemorrhage. Acute diverticular hemorrhage often constitutes a medical surgical emergency. If bleeding is rapid enough, its site can be determined with increasing facility by mesenteric angiography. Nevertheless, there are VOLUME 23, NO.4, 1977
some patients in whom this modality fails to locate the site of hemorrhage. 2 Colonoscopy has been of value in some of these patients 3 and may even be helpful in the operating room at the time of emergency exploration. The surgeon can assist the endoscopist in passing the instrument to the cecum (without attempting visualization on insertion). As the instrument is withdrawn, it may be possible, if bleeding is not too brisk, to evacuate colonic contents by irrigation and suction and identify the specific bleeding site. Patients with chronic diverticular disease may bleed intermittently. Attributing the bleeding to diverticulosis in such patients is often a diagnosis of exclusion. In our experience early endoscopy has been of value in identifying other and more serious causes of bleeding, such as polyps or carcinoma.
REFERENCES 1. WAYE jE: The current status of flexible fiberoptic endoscopy. MtSinai I Med 42:21, 1975 2. CASARELLA Wj, GALLOWAY Sj, TAXIN RN, FOLLETT DA, POLLOCK Ej, SEAMAN WB: "Lower" gastrointestinal tract hemorrhage: new concepts based on arteriography. Am I Radial 121 :357, 1974 3. DEYLE P, BLUM AL, NUESCH Hj, JENNY S: Emergency coloscopy in the management of the acute per anal hemorrhage. Endoscopy 6:229, 1974
193
Colonoscopy proved to be of significant value in the evaluation of 40 patients with extensive diverticular disease by averting operative intervention in some, by comfirming or clarifying radiologic suspicions in many and by discovering unsuspected lesions occasionally. Although no endoscopic complications were encountered in this series, it is generally recognized that the acutely or chronically inflamed bowel requires special caution in endoscopic manipulation. Patients with colonic diverticular disease commonly pose a problem in radiologic diagnosis. The main difficulties are in obtaining adequate bowel cleansing and determining the co-existence of polyps or cancers in segments of extensive diverticulosis. The implication in most of these patients is whether operative intervention is indicated. Fiberoptic colonoscopy has been of help in resolving many of these problems. Materials and Methods In reviewing 450 colonoscopic procedures, we analyzed 40 consecutive cases of extensive diverticulosis. Routine or air contrast barium enemas were inconclusive in 23. For 1 patient, barium study was not considered feasible; in the same patient, mesenteric angiography at the time of active bleeding had been negative. TECHNIQUE Mechanical bowel preparation, more difficult in these patients, is one of the limitations of both endoscopic and radiologic examination. A longer period of preparation is often required, and cleansing enemas must be administered at a long enough interval before colonoscopy to allow for their complete evacuation. Colon spasm during examination is more common in these patients, and the insufflation of air should be kept at a minimum lest further spasm be induced. There is often enough spasm for the examiner to feel the bowel "grasping" the instrument both on insertion and withdrawal. The intermittent administration of 1 mg to 2 mg of glucagon parenterally is helpful in reducing colonic hyperactivity, especially during operative colonoscopy. We have not found the use of anticholinergics, before or during the procedure, to be of demonstrable value. In endoscopic examination of inflamed bowel, more gentle manipulation is required because such tissue is more prone to injury from direct instrumental trauma, overdistention of the bowel, or overstretching of the mesentery. The chronically inflamed bowel is also more rigid, making it less pliable to the customary maneuvers necessary for successful insertion. Care must be taken not to mistake large diverticular orifices for the colonic lumen (Figure 1a). The interpretation of endoscopic findings deserves more attention as well. For example, edematous mucosal folds may obscure small lesions and, by their own configuration, simulate polypoid tumors. Also, with hypertrophy and lack of distensibility of the bowel wall, especially in the descending colon, the interhaustral septa may meet in the midline and simulate the appearance of the traverse colon (Figure 1b).'
Table I. Indications for colonoscopy in 40 patients with diverticular disease. 23 10 6
Inconclusive barium enema (BE) Confirmation of BE findings (including polyps) Colonic symptoms; BE showed only diverticula BE not feasible; mesenteric angiography negative
1
RESULTS The indications for colonoscopy in this group of patients are listed in Table I. The most frequent indication was an inconclusive barium study. The barium enema diagnosis was confirmed in 12 patients and altered in 25, with 2 of these being errors in endoscopic diagnosis (Table /I). In the first of these errors, an endoscopically suspected polypoid carcinoma led to resection. The polyp proved to be benign, but the mesenteric nodes contained unsuspected prostatic carcinoma. The second error was in a patient who had a sigmoidocutaneous fistula following drainage of a perforated sigmoid mass thought to be diverticular disease clinically, radiographically, and endoscopically. "At subsequent resection a very superficial but broad carcinoma was found. Fortunately, the clinical course of neither patient was complicated by these errors. In 33 patients, the therapeutic approach was correctly altered as a resultof endoscopy. Of greatest significance is that 21 contemplated operative procedures were avoided. In some patients needing operation, the extent of the procedure could be planned more precisely after endoscopy. For example, in 6 patients resection was properly limited or delayed while in 3 patients resection was extended. There were no complications or deaths in this series of 40 patients. Table /I Comparison of barium enema (BE) and subsequent colonoscopy in diverticular disease confirmed altered
BE diagnosis Diverticulosis only Diverticulosis + polyp Diverticulosis + ? polyp Diverticulosis + carcinoma Diverticulosis + ? carcinoma Granulomatous colitis (?) Colovesical fistula, ? diverticulosis
4 5 1
o
1 9 3 1
1
10
1
1 0
o
errors 10
1b
a endoscopic diagnosis: carcinoma; pathologic diagnosis: adenoma with severe alypia. b endoscopic diagnosis: diverticulitis; pathologic diagnosis: "superficial spreading" carcinoma.
From the Department of Surgery, College of Physicians & Surgeons, Columbia University, and Presbyterian Hospital, New York, New York. Reprint requests: Kenneth A. Forde, MD, Department of Surgery, College of Physicians & Surgeons of Columbia University, 630 West 168th Street, New York, New York 10032.
192
GASTROINTESTINAL ENDOSCOPY
Figure 1. (a) Large diverticular orifices simulating colonic lumen. (b) Appearance of descending colon in severe diverticular disease can misleadingly simulate the transverse colon. (c) Typical segment of diverticulosis with stenosis in sigmoid segment. (d) Atypical constriction simulating carcinoma; only diverticular disease is seen in the resected specimen. DISCUSSION Acute Diverticulitis. Sometimes patients with presumed diverticulitis require exploratory laparotomy, often with creation of a proximal colostomy and drainage of a perforated mass of the left colon. It is often impossible to tell by palpation or visualization whether such a mass is inflammatory, neoplastic, or both. With perforated inflammatory disease it is preferable to wait for the process to resolve before proceeding with further operative management while a perforated carcinoma would demand earlier surgical intervention. Colonoscopy may be helpful when rigid sigmoidoscopy and barium enema are inconclusive or not feasible. Chronic Diverticulitis. As with any inflammatory process, healing may result in significant stenosis of the colonic lumen. Stenotic segments of colon resulting from diverticulitis are usually longer than those associated with neoplasm and have gradually tapering margins with an intact mucosal pattern (Figure 7c). However, there are times when the radiographic configuration is atypical (FigiJre 7d). In such selected patients, colonscopy may be definitive. Diverticular Hemorrhage. Acute diverticular hemorrhage often constitutes a medical surgical emergency. If bleeding is rapid enough, its site can be determined with increasing facility by mesenteric angiography. Nevertheless, there are VOLUME 23, NO.4, 1977
some patients in whom this modality fails to locate the site of hemorrhage. 2 Colonoscopy has been of value in some of these patients 3 and may even be helpful in the operating room at the time of emergency exploration. The surgeon can assist the endoscopist in passing the instrument to the cecum (without attempting visualization on insertion). As the instrument is withdrawn, it may be possible, if bleeding is not too brisk, to evacuate colonic contents by irrigation and suction and identify the specific bleeding site. Patients with chronic diverticular disease may bleed intermittently. Attributing the bleeding to diverticulosis in such patients is often a diagnosis of exclusion. In our experience early endoscopy has been of value in identifying other and more serious causes of bleeding, such as polyps or carcinoma.
REFERENCES 1. WAYE jE: The current status of flexible fiberoptic endoscopy. MtSinai I Med 42:21, 1975 2. CASARELLA Wj, GALLOWAY Sj, TAXIN RN, FOLLETT DA, POLLOCK Ej, SEAMAN WB: "Lower" gastrointestinal tract hemorrhage: new concepts based on arteriography. Am I Radial 121 :357, 1974 3. DEYLE P, BLUM AL, NUESCH Hj, JENNY S: Emergency coloscopy in the management of the acute per anal hemorrhage. Endoscopy 6:229, 1974
193
