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CASE
48
Diverticulitis: Large Bowel Obstruction
History
Recurrent diverticulitis had been diagnosed 15 years
previously, and mild episodes, always responding
to antibiotic therapy, continued during this period.
The patient presented with a 4-week history of
lower abdominal colicky pain, constipation, and
rectal bleeding on 1 occasion. A firm pelvic mass was
present on rectal examination. A short colonoscopy
was performed with the small caliber panendoscope,
and a tight sigmoid stricture was negotiated, establishing the diagnosis of sigmoid diverticulitis. A
cautious contrast enema showed dilatation of the
colon above the stricture and no pathology in the
proximal colon (Figure 48.1). Within a few weeks,
the patient developed further severe pain, nausea,
and vomiting. Operation was expedited.
Female, 66 Years
cannula and irrigated clear of feces. The bowel was
resected from upper descending colon to lower third
of the rectum, and a hand sutured anastomosis was
performed. The operation was completed with a
loop ileostomy.
Pathology
Examination confirmed the diagnosis of chronic
diverticulitis with stricture formation at which
point the thickness of the bowel wall measured
15mm. There was an abscess within the strictured
area, and the mucosa immediately proximal to the
stricture was cyanotic, edematous, and ulcerated.
Histologically these ulcers revealed no specific
features; several diverticula in the sigmoid colon
showed early abscess formation.
Operation (6.24.94)
Laparotomy revealed marked dilatation of the colon
above the pathology in the mid sigmoid colon. The
wall of the colon was thickened, indicative of longstanding obstruction. The colon was deflated with a
Figure 48.1: A barium enema demonstrates the
diverticular stricture (arrow) and dilated colon.
Operation (8.15.94)
The postoperative recovery was satisfactory. The
ileostomy was closed 7 weeks after the resection.
Follow-Up
No further bowel problems occurred. Six months
after operation, the patient was found to have a high
grade transitional cell carcinoma of the bladder.
Radical surgery was performed, but the patient died
of metastatic disease 2 years later.
Comment
Surprisingly, chronic diverticular disease does not
often present with the degree of acute obstruction
seen in this case. The abscess (extramural) in the
strictured segment may have precipitated the
presenting obstruction. The multiple sites of
early abscesses in diverticula is also uncommon.
The mucosal ulceration may have been stercoral in
origin. This mucosal pathology is sometimes seen
in the vicinity of an obstructing left-sided carcinoma. It may be related to an alteration in the
integrity of the mucosal defense system. The technical difficulties and potential risks caused by the
presence of the dilated and thickened colon with its
fecal content were overcome by intraoperative
colonic irrigation.
104
Diagram 48 105
PART
VI
Inflammatory Bowel Disease
CASE
49
Ulceration in Crohn’s Disease of the Small Bowel
The composite diagram illustrates some of the morphological types of ulceration that may be seen in
small bowel Crohn’s disease. Although a number of
these ulcer types may appear in a patient in a contiguous segment or in skip lesions, one would not
expect to see the full spectrum of ulceration in any
one patient.
1. Small aphthous ulcers are the initial ulcerative
lesion. They may be the only lesions or be adjacent to more severely affected bowel.
2. Slit-like fissure ulcers in otherwise normal
mucosa.
3. Edema accentuates the “cobblestone” effect
caused by transverse extensions of the linear
ulcers. Some of the ulcers are covered with a
fibrinous exudate.
4. Deep parallel ulcers adjacent to near normal
mucosa. The linear ulceration is usually located
on the mesenteric side of the lumen.
5. Extensive linear ulceration with more loss of
mucosa isolating mucosal islands. This chronic
disease is associated with thickening of all layers
of the bowel wall and, as fibrosis predominates,
a long stricture will form.
6. Recent ulceration that is solitary, deep, and situated in normal mucosa. Such a lesion can be the
only focus of Crohn’s disease present in the
intestinal tract.
7. Healed ulceration that is covered with atrophic
mucosa and is associated with loss of mucosal
features and fibrosis.
8. Acute foci of ulceration surrounded by normal
mucosa. The histological diagnosis of Crohn’s
disease may be difficult in this stage of the
disease.
9. Acute severe and extensive ulceration usually
affects only the terminal ileum in association
with the fulminant form of acute Crohn’s
colitis. The mucosa is “shredded” by the severe
inflammatory process, exposing the underlying
muscle.
108
Diagram 49 109
9
1
2
8
3
7
4
6
5
CASE
50
History
1971 At 25 years of age resection of Crohn’s
1978 Resection of terminal ileum (40 cm) for
1981 Resection of right colon (25 cm) and
1996 X-ray and colonoscopy evidence of
1997 The patient remained debilitated with
Recurrent Crohn’s Disease
disease of the ileum. Severe diarrhea
continued despite medical treatment.
recurrent Crohn’s disease (Figure 50.1).
Severe diarrhea continued (14–15/day,
3–4 night). Figure 50.1 shows the
involvement of the terminal ileum.
ileum (40 cm) for recurrent Crohn’s
disease associated with large inflammatory mass. Diarrhea continued (8/day,
0/night).
recurrent disease with marked stricture
formation (Figure 50.2).
diarrhea (12–15/day), abdominal pain,
and fever. Resection of ileum (26cm)
and ascending colon (6cm) was per-
Female, 51 Years
formed for advanced Crohn’s disease
with stricture formation causing
chronic obstruction. Remaining small
bowel measured 115cm.
1998 Pyelotomy for renal calculus and
infection.
2000 Diarrhea (12/day), anovaginal fistula
(June) with minor symptoms, managed
conservatively.
2000 Patient described her health as “good”
(October) with minimal symptoms from the
anovaginal fistula. No further follow-up
is available.
Comment
The case illustrates the relentless natural history of
Crohn’s disease over a 30-year period. The four
resections failed to relieve the most troublesome
symptom (diarrhea). Medical therapy was not
helpful. The patient could not tolerate steroids
which caused debilitating candidiasis. Until the last
examination in October 2000, the patient preferred
to manage without anti-inflammatory drug therapy.
Figure 50.1: Recurrence in terminal ileum in 1978 after
first resection.
110
Figure 50.2: Colonoscopy (1996) showing recurrent
Crohn’s disease and anastomotic stricture.
Diagram 50 111
6.30.97
CASE
51
Crohn’s Disease: Strictures of Ascending Colon and Doudenum
History
Crohn’s disease of the ascending colon was diagnosed in 1984. The symptoms of abdominal pain
and diarrhea were relieved by treatment with prednisolone and sulfasalazine. Five years later, the
patient was suffering from episodes of severe abdominal pain, and investigations revealed a long stricture of the ileum and ascending colon (Figure 51.1)
associated with a large right-sided abdominal mass.
Operation (5.25.89)
A large mass involving the right colon was firmly
adherent to the anterior abdominal wall and 15cm
of the adjacent terminal ileum, which was also
affected by the inflammatory process. There were no
Female, 34 Years
Figure 51.2: Recurrent disease with stenosis of the
ileocolic anastomosis indicated by the arrow: March 2000.
Figure 51.1: Demonstrating stricture and spasm of the
terminal ileum and ascending colon prior to right
hemicolectomy in 1989.
112
Figure 51.3: The stricture D2 persists with a further
narrowed segment in D3: May 2004.
Diagram 51 113
apparent “skip” areas affected in the remainder of
the gastrointestinal tract. A right hemicolectomy
with 20cm of ileum was performed.
Pathology
The mass measured 10 × 11 cm and was mainly due
to gross thickening of polypoid mucosa, muscle
wall, and pericolic fat in the ascending colon. The
mucosal surface within the stricture was atrophic,
with scars due to previous ulceration. The appendix
was markedly distended due to proximal obstruction of its lumen. There were 4 ulcers in the ileum,
the largest of which extended for 9cm along the
mucosa. Prominent enlarged mesenteric nodes were
present. The histological changes were consistent
with Crohn’s disease. Two typical granulomas were
found in a lymph node.
Follow-Up (2004)
At colonoscopy (11.30.89), a dysplastic villous
adenoma (0.9cm) of the sigmoid colon was removed.
Further colonoscopies were normal until 10 years
and 6 months after resection when a stenosis of the
anastomosis was diagnosed (Figure 51.2). A small
bowel x-ray series demonstrated a stricture of the
second part of the duodenum (0.6 cm in diameter).
This was confirmed on panendoscopy, which
revealed associated inflammation and ulceration.
Biopsies showed inflammation not diagnostic
of Crohn’s disease although this diagnosis was
accepted. The patient was treated with prednisolone
for 5 months. Azathioprine and mesalazine were
commenced in 2000 and are current therapy. The
stricture in the second part of the duodenum has
been treated at intervals with balloon dilatation.
Now 15 years since operation, x-rays show persistence of the stricture in the second part of the duodenum and a moderate narrowing in the third
part of the duodenum (Figure 51.3). Colonoscopy
demonstrates persistence of the ileocolic anastomotic stricture. The patient has infrequent bouts of
distention and reflux sometimes accompanied by
vomiting.
Comment
The right hemicolectomy specimen showed active
Crohn’s disease in addition to resolved inflammation, which caused a mass, stricture, and
pseudopolyps. The duodenal disease has persisted
with the development of a second stricture. The
patient’s symptoms at present are not troublesome
enough to justify surgical intervention. The incidence of duodenal involvement in patients with
Crohn’s disease is uncommon. Yamamoto et al have
reported an incidence of 5% in a series of patients
from Birmingham UK.
1
For a full-page image of this figure see the appendix.
5.25.98