Diverticulitis in
Women:
An Unappreciated Clinical Presentation J. DAVID WALKER, M.D., LAMAN A. GRAY, SR., M.D., HIRAM C. POLK, JR., M.D. A final diagnosis of diverticulosis or diverticulitis was made in 1,031 women over a 10 year period. The 69 patients who underwent abdominal operation for what proved to be diverticulitis are discussed in detail. Thirty-eight per cent of these women were believed to have gynecologic disease because of the presence of a pelvic mass. Diverticulitis is an important differential diagnosis of a pelvic mass with or without clinical and laboratory indications of infection and with or without history of diverticulosis or diverticulitis. The increasing awareness of ovarian carcinoma and its ominous prognosis make this differential diagnosis especially important. Diverticular disease should always be considered among such patients and preparations made to allow optimal treatment at that operation, whatever the ultimate cause of the mass.
presentations of diverticular disease of the colon include leftsided appendicitis, partial obstruction, peritonitis, hemorrhage, or fistula formation. By contrast, diverticulitis in women often is not recognized pre-operatively and is considered only secondarily when operation is warranted for pelvic mass. The confusion in diagnosis arises because of the large number of differential diagnoses of diverticulitis. Emphasis on the risk of gynecologic neoplasms makes any presentation as a pelvic mass of primary importance, especially when the inflammatory component of diverticulitis is not obvious. The purpose of this retrospective study is to examine the patterns of presentation of diverticulitis among women admitted to a general hospital and to clarify the discovery that a substantial portion of all women who come to operation for diverticulitis do so under a mistaken diagnosis of a pelvic mass with all the implications thereof. Between June 1965 and June 1975, 1,031 women with final diagnoses of diverticulosis and/or diverticulitis were hospitalized at Norton-Children's Hospitals T HE CONVENTIONAL CLINICAL
Submitted for publication: July 30, 1976. Reprint requests: Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville School of Medicine, Louisville,
Kentucky 40201.
From the Department of Surgery, the University of Louisville School of Medicine and Norton-Children's Hospitals, Inc., Health Sciences Center, Louisville, Kentucky
in Louisville, Kentucky. Of this group, 69 (6.7%) had abdominal operations. Twenty-six of these 69 women (38%) had a primary diagnosis of a mass of gynecologic origin. This group will subsequently be referred to as the gynecologic group, reflecting its clinical presentation. The remaining 43 patients had more conventional clinical presentations and will be noted as such. Gynecologic Group Among the 26 patients so designated, all had palpable masses: 17 presented with a mass on the left side, six in the midline, and three on the right side. Twenty of these patients had temperatures of less than 38 C (100 F) the first 24 hours after admission or until operation. Twenty-one patients (88%) had leukocyte counts less than or equal to 10,000 with a normal differential count; no patient had a leukocyte count in excess of 15,000. Twelve patients underwent sigmoidoscopy. Four of these were normal. Seven patients were not examined above 15 to 20 cm because of spasm, angulation, or discomfort. The mucosa was considered reddened or inflamed in one patient, but this was thought secondary to previous radiation therapy. The diagnosis of diverticulitis was not made in any patient on the basis of
sigmoidoscopy. A barium enema was done in 19 of the 26 patients in the gynecologic group. Diverticulosis without evidence of diverticulitis was reported in 15. Diverticulitis was suggested in only two patients. Narrowing of the sigmoid colon was believed secondary to radiation therapy in one patient, and the barium enema was reported as entirely normal in one patient. Pre-operative diagnoses are listed in Table 1. Diverticulitis was considered an alternate diagnosis in 12
402
Vol. 185 . No. 4
DIVERTICULITIS IN WOMEN
TABLE 1. Gynecologic Presentation (26 Women). Pre-operatil'e Impression as to Nature of the Pelivic Mass:
Ovarian tumor, possibly malignant Ovarian cyst Endometriosis
TABLE 2. Indications for Operation in Non-Gynecologic Groulp
22 2 2
patients (46%). Twenty patients (79%) had no history of diverticulosis or diverticulitis. Three patients had emergency exploratory operations based upon preoperative diagnoses of twisted ovarian mass. The diagnosis at operation in all three was perforated sigmoid diverticulitis. Seventeen patients (65%) in the gynecologic group were initially operated upon by gynecologic surgeons, although in several cases a general surgeon was consulted. Twenty-five patients had diverticulitis of the sigmoid colon; one patient had perforated diverticulitis of the ascending colon. One patient had a 5 cm papillary serous cystadenocarcinoma of the right ovary in addition to a left-sided diverticular mass. The involved area of colon was resected in 13 patients (50%). A primary anastomosis was achieved in 11 with or without proximal decompression. Two patients underwent resection with proximal colostomy and Hartmann's pouch. Twenty-one had no evidence of perforation, abscess formation, or obstruction involving the colon at the time of exploration. Nine of these 21 patients had resection with primary anastomosis. Three of the remaining 12 patients not undergoing resection at original operation subsequently required colon resection for recurrence of presistent diverticulitis. Fifteen patients in the gynecologic group had preoperative mechanical bowel preparation; 11 had no bowel preparation. Nine of the 12 patients who did not undergo resection and who were found free of perforation, obstruction, or abscess formation involving the colon at operation had not undergone mechanical bowel preparation. The fallopian tube and ovary were involved with the diverticular mass on the corresponding side of the pelvis in 5 patients. Salpingo-oophorectomy without bowel resection was performed in three women. A bilateral salpingo-oophorectomy and total abdominal hysterectomy was done for tubo-ovarian abscess in one, and salpingo-oophorectomy was combined with sigmoid resection in the fifth patient.
403
Recurrent diverticulitis Perforation Obstruction Fistula formation colovesical 6 I colovaginal colocutaneous I
11 11 11 8
Bleeding
2 43
Total patients
pable abdominal masses. Six women presented with colovesical fistulas and one with colovaginal fistula. Five of the seven (71%) with fistulas previously had undergone hysterectomies. Results Among patients in the non-gynecologic group, 47% (20/43) had a history of diverticulitis as compared with 21% in the gynecologic group. Forty-two per cent of the women in the entire series were between the ages of 40 and 60; 58% were over 60 years of age. In the gynecologic group, 54% were between 40 and 60 as contrasted with 35% in the non-gynecologic group. The age distribution of all patients is illustrated in Figure 1. Initial operative management for these 69 patients is categorized in Table 3. Twenty-eight patients (40%o) had resection and primary anastomosis. Four patients had resection with Hartmann closure or double colostomy. Two patients underwent exteriorization. Twenty-three (33%) had colostomies without resection. Twelve patients were explored without resection or diversion. All of these were in the gynecologic group.
Twenty-one patients (49%) in the non-gynecologic suffered complications. Six patients (23%) in the gynecologic group had complications. When those group
L. 0
w
Conventional Presentation The remaining 43 women underwent abdominal operations with pre-operative diagnoses of diverticulitis. Colonic carcinoma was considered in 6 women. The indications for operations are listed in Table 2. Eight women in the non-gynecologic group had pal-
z
30- 40
41-50
81- 90
AGE
FIG. 1. Age distribution of all patients.
404
WALKER, GRAY AND POLK TABLE 3. Initial Operation Procedure
Gynecologic
Resection, primary anastomosis a. only b. with colostomy c. with cecostomy Resection, Hartmann closure Resection, double colostomy Exteriorization Diversion a. loop b. double barrel c. tube colostomy d. sigmoid colostomy Exploration a. only b. with other procedure Totals
Nongynecologic
11 5 1 5 2
17 10 I 6 1 I 2
1 0 1 0 0 12 4 8 26
22 12 7 2 1
0 0 0 43
patients in the latter group who did not undergo colon resection are excluded, the complication rate rises to 46%, which is equal to that of the non-gynecologic group. A total of 42 complications occurred in 69 patients and are enumerated in Table 4. Twenty-seven patients (39o) sustained at least one complication. Forty-nine per cent of those patients who had an operation upon the colon developed a complication. The number of patients having complications according to indications for operation in the non-gynecologic group is listed in Table 5. Morbidity was frequent in those patients operated on for perforation or obstruction. Three deaths occurred for a mortality rate of 4%; all deaths were among patients with conventional presentations. One death occurred in a patient with perforation treated by proximal colostomy and drainTABLE 4. Complications
Patients
Wound infection, dehiscence, abdominal abscess Cardiovascular (i.e., chronic heart failure, cardiac arrhythmia, thrombophlebitis, pulmonary embolus, mesenteric artery thrombosis) Bowel obstruction, fistula
6
Technical complications of colostomy,
5
*
April 1977
age. A second patient died following resection and primary anastomosis for obstruction secondary to acute diverticulitis. The third patient to die developed anastomotic dehiscence in a three stage procedure.
Discussion
Diverticulosis of the colon exists in about 5% of the American population; half the people with this disease are over 50. The incidence appears to have increased in recent years. One analysis of over 70,000 patients disclosed the incidence of diverticulosis to be 5.2%.1" No apparent difference exists in the incidence for sex.' Women less frequently develop colovesical fistulas secondary to diverticulitis. The uterus and adnexa may protect the bladder from the diverticular process.6'8 In this series, 5 of 7 patients (71%) with fistulas had had hysterectomies. Of the total group, 34 women (50%) had palpable masses, 26 of which were thought to be of gynecologic origin. Colcock4 discovered 20 abdominal masses in 163 patients; in 13 of these patients, masses were apparent only on pelvic or rectal examination. He observed that a palpable mass may simulate carcinoma of the ovary. The present series included only women; therefore, a slightly higher incidence of pelvic masses would be expected because of the accessibility of the true pelvis in a rectovaginal examination. Because of the nature of medical recording systems, we do not know how often gynecologic disease (e.g., ovarian carcinoma) presents clinically as possible diverticulitis; we have seen at least two such patients in the last three years. Neither can we determine the frequency with which pelvic masses prove to be diverticular in origin. We can estimate that perhaps it is one in 50. The patients' history, temperature, leukocyte count, sigmoidoscopic findings, and barium enema as outlined previously were not sufficiently marked to make diverticulitis a differential diagnostic consideration of the pelvic mass in the gynecologic group. The slight leukocytosis and low grade fever classically seen with abdominal tenderness were not present in most of these patients. The mass, however, was always tender. DiTABLE 5. Complications by Indication
cecostomy
Anastomotic leak Hemorrhage Renal failure
Ann. Surg.
3
2 42
Indication
Number of Patients with Complication
Total Patients with Indication
Recurrent diverticulitis Perforation Obstruction Fistula
4 7* 7* 3
11 11 11 8
* Fourteen of 22 patients (64%) with either perforation or obstruction found at operation developed postoperative complications.
Vol. 185 . No. 4
DIVERTICULITIS IN WOMEN
verticulitis was considered a possible diagnosis in 12 of the 26 patients. In 12 women, sigmoidoscopy was performed but in none was a diagnosis of diverticulitis made. Seven could not be examined above 15-20 cm, which is common. Buie2 found that 5 signs suggested diverticulitis at sigmoidoscopy: immobility of the bowel, angulation of the lumen, reduced lumen, sigmoidal sacculation not disappearing with inflation, and actual visualization of the diverticula. The first two were common observations among those women so examined. In the gynecologic group, 21% had a history of diverticulosis or diverticulitis, a proportion similar to that noted by Tolins10 among patients operated upon for diverticulitis, but only half that appreciated among our patients with conventional presentations. One-fourth of those patients who were not resected in the gynecologic group subsequently required colon resection. This frequency is based on a single hospital's records and is undoubtedly higher, as would be reflected by complete and life-long followup. Some 58% of patients in Marshall's series7 with more than one attack of diverticulitis suffered complications from this disease. According to Colcock,3 the complications of perforation, obstruction, and fistula are associated with a history of multiple attacks in a similar percentage. Mechanical bowel preparation was carried out in 25% of those not undergoing resection in the gynecologic group. This may have influenced the operating surgeon not to resect the involved colon in those patients without perforation, obstruction, or abscess formation. Diverticulitis which produces a pelvic mass should ordinarily be resected. The diverticular mass represents an inflammatory process, and complications of diverticulitis occur much more frequently in those patients having inflammatory or multiple attacks of diverticulitis.3
405
The patients in this series presenting with a pelvic mass secondary to diverticulitis without evidence of perforation, obstruction, or abscess formation could have been managed by primary resection. Among patients having elective resection, the hospital mortality rate was under 2%.9 Giffen and colleagues5 observed that primary resection of diseased colon was a safe procedure, provided obstruction and inflammatory complications of the disease were not present. Unquestionably, diverticulitis is an important differential diagnosis when a pelvic mass is presentregardless of history of diverticular disease or laboratory and clinical findings of infection. It should always be recognized as a possibility, and preparations should be made for optimal surgical treatment. References 1. Boles, R. S., Jr. and Jordan, S. M.: The Clinical Significance of Diverticulosis. Gastroenterology 35:579-582, 1958. 2. Buie, L. A.: Practical Proctology. 2nd ed., Springfield, Charles C Thomas, Pub., 1960, p. 448. 3. Colcock, B. P.: Indications for Surgery in Diverticulitis. Surg. Clin. North. Am. 44: 785-790, 1964. 4. Colcock, B. P.: Surgical Treatment of Diverticulitis. Twenty Years' Experience. Am. J. Surg. 115: 264-270, 1968. 5. Giffen, J. M., Butcher, H. R., Jr. and Ackerman, L. V.: Surgical Management of Colonic Diverticulitis. Arch. Surg. 94: 619-
626, 1967. 6. Hafner, C. D., Ponka, J. L. and Brush, B. E.: Genitourinary Manifestations of Diverticulitis of the Colon. A Study of 500 Cases. JAMA 179: 76-78, 1962. 7. Marshall, S. F.: Earlier Resection in One Stage for Diverticulitis of the Colon. Am. Surg. 29: 337-346, 1963. 8. McSherry, C. K. and Deal, J. M.: Sigmoidovesical Fistulae Complicating Diverticulitis. Arch. Surg. 85: 1024-1027, 1962. 9. Rodkey, G. V. and Welch, C. E.: Diverticulitis of the Colon: Evolution in Concept and Therapy. Surg. Clin. North. Am. 45: 1231-1243, 1965. 10. Tolins, S. H.: Surgical Treatment of Diverticulitis. Experience at a Large Municipal Hospital. JAMA 232: 830-832, 1975. 11. Young, E. L. and Young, E. L., III: Diverticulitis of the Colon: A Review of the Literature and an Analysis of Ninety-one Cases. N. Engl. J. Med. 230: 33-38, 1944.
Women:
An Unappreciated Clinical Presentation J. DAVID WALKER, M.D., LAMAN A. GRAY, SR., M.D., HIRAM C. POLK, JR., M.D. A final diagnosis of diverticulosis or diverticulitis was made in 1,031 women over a 10 year period. The 69 patients who underwent abdominal operation for what proved to be diverticulitis are discussed in detail. Thirty-eight per cent of these women were believed to have gynecologic disease because of the presence of a pelvic mass. Diverticulitis is an important differential diagnosis of a pelvic mass with or without clinical and laboratory indications of infection and with or without history of diverticulosis or diverticulitis. The increasing awareness of ovarian carcinoma and its ominous prognosis make this differential diagnosis especially important. Diverticular disease should always be considered among such patients and preparations made to allow optimal treatment at that operation, whatever the ultimate cause of the mass.
presentations of diverticular disease of the colon include leftsided appendicitis, partial obstruction, peritonitis, hemorrhage, or fistula formation. By contrast, diverticulitis in women often is not recognized pre-operatively and is considered only secondarily when operation is warranted for pelvic mass. The confusion in diagnosis arises because of the large number of differential diagnoses of diverticulitis. Emphasis on the risk of gynecologic neoplasms makes any presentation as a pelvic mass of primary importance, especially when the inflammatory component of diverticulitis is not obvious. The purpose of this retrospective study is to examine the patterns of presentation of diverticulitis among women admitted to a general hospital and to clarify the discovery that a substantial portion of all women who come to operation for diverticulitis do so under a mistaken diagnosis of a pelvic mass with all the implications thereof. Between June 1965 and June 1975, 1,031 women with final diagnoses of diverticulosis and/or diverticulitis were hospitalized at Norton-Children's Hospitals T HE CONVENTIONAL CLINICAL
Submitted for publication: July 30, 1976. Reprint requests: Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville School of Medicine, Louisville,
Kentucky 40201.
From the Department of Surgery, the University of Louisville School of Medicine and Norton-Children's Hospitals, Inc., Health Sciences Center, Louisville, Kentucky
in Louisville, Kentucky. Of this group, 69 (6.7%) had abdominal operations. Twenty-six of these 69 women (38%) had a primary diagnosis of a mass of gynecologic origin. This group will subsequently be referred to as the gynecologic group, reflecting its clinical presentation. The remaining 43 patients had more conventional clinical presentations and will be noted as such. Gynecologic Group Among the 26 patients so designated, all had palpable masses: 17 presented with a mass on the left side, six in the midline, and three on the right side. Twenty of these patients had temperatures of less than 38 C (100 F) the first 24 hours after admission or until operation. Twenty-one patients (88%) had leukocyte counts less than or equal to 10,000 with a normal differential count; no patient had a leukocyte count in excess of 15,000. Twelve patients underwent sigmoidoscopy. Four of these were normal. Seven patients were not examined above 15 to 20 cm because of spasm, angulation, or discomfort. The mucosa was considered reddened or inflamed in one patient, but this was thought secondary to previous radiation therapy. The diagnosis of diverticulitis was not made in any patient on the basis of
sigmoidoscopy. A barium enema was done in 19 of the 26 patients in the gynecologic group. Diverticulosis without evidence of diverticulitis was reported in 15. Diverticulitis was suggested in only two patients. Narrowing of the sigmoid colon was believed secondary to radiation therapy in one patient, and the barium enema was reported as entirely normal in one patient. Pre-operative diagnoses are listed in Table 1. Diverticulitis was considered an alternate diagnosis in 12
402
Vol. 185 . No. 4
DIVERTICULITIS IN WOMEN
TABLE 1. Gynecologic Presentation (26 Women). Pre-operatil'e Impression as to Nature of the Pelivic Mass:
Ovarian tumor, possibly malignant Ovarian cyst Endometriosis
TABLE 2. Indications for Operation in Non-Gynecologic Groulp
22 2 2
patients (46%). Twenty patients (79%) had no history of diverticulosis or diverticulitis. Three patients had emergency exploratory operations based upon preoperative diagnoses of twisted ovarian mass. The diagnosis at operation in all three was perforated sigmoid diverticulitis. Seventeen patients (65%) in the gynecologic group were initially operated upon by gynecologic surgeons, although in several cases a general surgeon was consulted. Twenty-five patients had diverticulitis of the sigmoid colon; one patient had perforated diverticulitis of the ascending colon. One patient had a 5 cm papillary serous cystadenocarcinoma of the right ovary in addition to a left-sided diverticular mass. The involved area of colon was resected in 13 patients (50%). A primary anastomosis was achieved in 11 with or without proximal decompression. Two patients underwent resection with proximal colostomy and Hartmann's pouch. Twenty-one had no evidence of perforation, abscess formation, or obstruction involving the colon at the time of exploration. Nine of these 21 patients had resection with primary anastomosis. Three of the remaining 12 patients not undergoing resection at original operation subsequently required colon resection for recurrence of presistent diverticulitis. Fifteen patients in the gynecologic group had preoperative mechanical bowel preparation; 11 had no bowel preparation. Nine of the 12 patients who did not undergo resection and who were found free of perforation, obstruction, or abscess formation involving the colon at operation had not undergone mechanical bowel preparation. The fallopian tube and ovary were involved with the diverticular mass on the corresponding side of the pelvis in 5 patients. Salpingo-oophorectomy without bowel resection was performed in three women. A bilateral salpingo-oophorectomy and total abdominal hysterectomy was done for tubo-ovarian abscess in one, and salpingo-oophorectomy was combined with sigmoid resection in the fifth patient.
403
Recurrent diverticulitis Perforation Obstruction Fistula formation colovesical 6 I colovaginal colocutaneous I
11 11 11 8
Bleeding
2 43
Total patients
pable abdominal masses. Six women presented with colovesical fistulas and one with colovaginal fistula. Five of the seven (71%) with fistulas previously had undergone hysterectomies. Results Among patients in the non-gynecologic group, 47% (20/43) had a history of diverticulitis as compared with 21% in the gynecologic group. Forty-two per cent of the women in the entire series were between the ages of 40 and 60; 58% were over 60 years of age. In the gynecologic group, 54% were between 40 and 60 as contrasted with 35% in the non-gynecologic group. The age distribution of all patients is illustrated in Figure 1. Initial operative management for these 69 patients is categorized in Table 3. Twenty-eight patients (40%o) had resection and primary anastomosis. Four patients had resection with Hartmann closure or double colostomy. Two patients underwent exteriorization. Twenty-three (33%) had colostomies without resection. Twelve patients were explored without resection or diversion. All of these were in the gynecologic group.
Twenty-one patients (49%) in the non-gynecologic suffered complications. Six patients (23%) in the gynecologic group had complications. When those group
L. 0
w
Conventional Presentation The remaining 43 women underwent abdominal operations with pre-operative diagnoses of diverticulitis. Colonic carcinoma was considered in 6 women. The indications for operations are listed in Table 2. Eight women in the non-gynecologic group had pal-
z
30- 40
41-50
81- 90
AGE
FIG. 1. Age distribution of all patients.
404
WALKER, GRAY AND POLK TABLE 3. Initial Operation Procedure
Gynecologic
Resection, primary anastomosis a. only b. with colostomy c. with cecostomy Resection, Hartmann closure Resection, double colostomy Exteriorization Diversion a. loop b. double barrel c. tube colostomy d. sigmoid colostomy Exploration a. only b. with other procedure Totals
Nongynecologic
11 5 1 5 2
17 10 I 6 1 I 2
1 0 1 0 0 12 4 8 26
22 12 7 2 1
0 0 0 43
patients in the latter group who did not undergo colon resection are excluded, the complication rate rises to 46%, which is equal to that of the non-gynecologic group. A total of 42 complications occurred in 69 patients and are enumerated in Table 4. Twenty-seven patients (39o) sustained at least one complication. Forty-nine per cent of those patients who had an operation upon the colon developed a complication. The number of patients having complications according to indications for operation in the non-gynecologic group is listed in Table 5. Morbidity was frequent in those patients operated on for perforation or obstruction. Three deaths occurred for a mortality rate of 4%; all deaths were among patients with conventional presentations. One death occurred in a patient with perforation treated by proximal colostomy and drainTABLE 4. Complications
Patients
Wound infection, dehiscence, abdominal abscess Cardiovascular (i.e., chronic heart failure, cardiac arrhythmia, thrombophlebitis, pulmonary embolus, mesenteric artery thrombosis) Bowel obstruction, fistula
6
Technical complications of colostomy,
5
*
April 1977
age. A second patient died following resection and primary anastomosis for obstruction secondary to acute diverticulitis. The third patient to die developed anastomotic dehiscence in a three stage procedure.
Discussion
Diverticulosis of the colon exists in about 5% of the American population; half the people with this disease are over 50. The incidence appears to have increased in recent years. One analysis of over 70,000 patients disclosed the incidence of diverticulosis to be 5.2%.1" No apparent difference exists in the incidence for sex.' Women less frequently develop colovesical fistulas secondary to diverticulitis. The uterus and adnexa may protect the bladder from the diverticular process.6'8 In this series, 5 of 7 patients (71%) with fistulas had had hysterectomies. Of the total group, 34 women (50%) had palpable masses, 26 of which were thought to be of gynecologic origin. Colcock4 discovered 20 abdominal masses in 163 patients; in 13 of these patients, masses were apparent only on pelvic or rectal examination. He observed that a palpable mass may simulate carcinoma of the ovary. The present series included only women; therefore, a slightly higher incidence of pelvic masses would be expected because of the accessibility of the true pelvis in a rectovaginal examination. Because of the nature of medical recording systems, we do not know how often gynecologic disease (e.g., ovarian carcinoma) presents clinically as possible diverticulitis; we have seen at least two such patients in the last three years. Neither can we determine the frequency with which pelvic masses prove to be diverticular in origin. We can estimate that perhaps it is one in 50. The patients' history, temperature, leukocyte count, sigmoidoscopic findings, and barium enema as outlined previously were not sufficiently marked to make diverticulitis a differential diagnostic consideration of the pelvic mass in the gynecologic group. The slight leukocytosis and low grade fever classically seen with abdominal tenderness were not present in most of these patients. The mass, however, was always tender. DiTABLE 5. Complications by Indication
cecostomy
Anastomotic leak Hemorrhage Renal failure
Ann. Surg.
3
2 42
Indication
Number of Patients with Complication
Total Patients with Indication
Recurrent diverticulitis Perforation Obstruction Fistula
4 7* 7* 3
11 11 11 8
* Fourteen of 22 patients (64%) with either perforation or obstruction found at operation developed postoperative complications.
Vol. 185 . No. 4
DIVERTICULITIS IN WOMEN
verticulitis was considered a possible diagnosis in 12 of the 26 patients. In 12 women, sigmoidoscopy was performed but in none was a diagnosis of diverticulitis made. Seven could not be examined above 15-20 cm, which is common. Buie2 found that 5 signs suggested diverticulitis at sigmoidoscopy: immobility of the bowel, angulation of the lumen, reduced lumen, sigmoidal sacculation not disappearing with inflation, and actual visualization of the diverticula. The first two were common observations among those women so examined. In the gynecologic group, 21% had a history of diverticulosis or diverticulitis, a proportion similar to that noted by Tolins10 among patients operated upon for diverticulitis, but only half that appreciated among our patients with conventional presentations. One-fourth of those patients who were not resected in the gynecologic group subsequently required colon resection. This frequency is based on a single hospital's records and is undoubtedly higher, as would be reflected by complete and life-long followup. Some 58% of patients in Marshall's series7 with more than one attack of diverticulitis suffered complications from this disease. According to Colcock,3 the complications of perforation, obstruction, and fistula are associated with a history of multiple attacks in a similar percentage. Mechanical bowel preparation was carried out in 25% of those not undergoing resection in the gynecologic group. This may have influenced the operating surgeon not to resect the involved colon in those patients without perforation, obstruction, or abscess formation. Diverticulitis which produces a pelvic mass should ordinarily be resected. The diverticular mass represents an inflammatory process, and complications of diverticulitis occur much more frequently in those patients having inflammatory or multiple attacks of diverticulitis.3
405
The patients in this series presenting with a pelvic mass secondary to diverticulitis without evidence of perforation, obstruction, or abscess formation could have been managed by primary resection. Among patients having elective resection, the hospital mortality rate was under 2%.9 Giffen and colleagues5 observed that primary resection of diseased colon was a safe procedure, provided obstruction and inflammatory complications of the disease were not present. Unquestionably, diverticulitis is an important differential diagnosis when a pelvic mass is presentregardless of history of diverticular disease or laboratory and clinical findings of infection. It should always be recognized as a possibility, and preparations should be made for optimal surgical treatment. References 1. Boles, R. S., Jr. and Jordan, S. M.: The Clinical Significance of Diverticulosis. Gastroenterology 35:579-582, 1958. 2. Buie, L. A.: Practical Proctology. 2nd ed., Springfield, Charles C Thomas, Pub., 1960, p. 448. 3. Colcock, B. P.: Indications for Surgery in Diverticulitis. Surg. Clin. North. Am. 44: 785-790, 1964. 4. Colcock, B. P.: Surgical Treatment of Diverticulitis. Twenty Years' Experience. Am. J. Surg. 115: 264-270, 1968. 5. Giffen, J. M., Butcher, H. R., Jr. and Ackerman, L. V.: Surgical Management of Colonic Diverticulitis. Arch. Surg. 94: 619-
626, 1967. 6. Hafner, C. D., Ponka, J. L. and Brush, B. E.: Genitourinary Manifestations of Diverticulitis of the Colon. A Study of 500 Cases. JAMA 179: 76-78, 1962. 7. Marshall, S. F.: Earlier Resection in One Stage for Diverticulitis of the Colon. Am. Surg. 29: 337-346, 1963. 8. McSherry, C. K. and Deal, J. M.: Sigmoidovesical Fistulae Complicating Diverticulitis. Arch. Surg. 85: 1024-1027, 1962. 9. Rodkey, G. V. and Welch, C. E.: Diverticulitis of the Colon: Evolution in Concept and Therapy. Surg. Clin. North. Am. 45: 1231-1243, 1965. 10. Tolins, S. H.: Surgical Treatment of Diverticulitis. Experience at a Large Municipal Hospital. JAMA 232: 830-832, 1975. 11. Young, E. L. and Young, E. L., III: Diverticulitis of the Colon: A Review of the Literature and an Analysis of Ninety-one Cases. N. Engl. J. Med. 230: 33-38, 1944.
