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70–90% successful detorsion (showing as explosive passage of liquid stool and gas), but high risk for recurrence (> 50%)
Cecal/Transverse Volvulus
Contrast enema.
Colonoscopy.
high chance of immediate failure, high recurrence rate (75%).
Operative Treatment
INDICATION
Any volvulus in operable patient:
Peritoneal signs, inability to detorse: emergency surgery.
Successful detorsion: semi-elective surgery during same admission: resect or correct hypermobility.
OPERATIVE APPROACH
General
Determine bowel viability; resection mandatory if irreversible damage.
Sigmoid Volvulus
Viable: (1) resection with primary anastomosis; (2) mesosigmoidoplasty—incision/widening of mesenteric base.
Nonviable: Hartmann procedure vs primary anastomosis with/without ileostomy.
Not proven to be efficacious: percutaneous endoscopic catheter sigmoidopexy (analogous technique of percutaneous
endoscopic gastrostomy tube placement).
Cecal Volvulus
Viable: (1) resection with anastomosis, (2) cecopexy and tube cecostomy.
Nonviable: (1) resection with ileocolonic anastomosis, (2) resection with ileostomy and long Hartmann pouch or
mucous fistula.
Volvulus of Transverse Colon
Viable: segmental resection vs extended right hemicolectomy.
Nonviable: (1) extended right hemicolectomy with ileocolonic anastomosis, (2) resection with ileostomy and long
Hartmann pouch or mucous fistula.
Outcome
Mortality: 3–12% if viable bowel, 10–20% (up to 50% in some series) if nonviable bowel.
Follow-Up
Functional reassessment (constipation, incontinence) after 3 and 6 months.
Full colonic evaluation under elective conditions.
Cross-Reference
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Large bowel obstriction (LBO) (p 27), (Ch. 4)
Megacolon (Ch. 1)
Conventional x-rays (plain films) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Sigmoid resection (open, anastomies vs Hartmann) (Ch. 5)
Right hemicolectomy (open) (Ch. 5)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
DIVERTICULAR DISEASE (DIVERTICULOSIS, DIVERTICULITIS, 562.1X)
Overview
Most frequent noncancerous pathology of the colon, related to constipation and age. Clinical presentation ranges from mild
disease to life-threatening condition. Diverticulosis: colonic muscular hypertrophy with mucosal prolapse through gaps at
entry site of arterial blood supply; complications of diverticulosis: diverticulitis, acute (massive) bleeding per rectum.
Diverticulitis: inflammation of colonic wall due to stasis within diverticulum; microperforation/microabscess results in either
confined or expanding inflammation with potential complications. Complications of diverticulitis: abscess, microperforation or
macroperforation: free perforation with feculent peritonitis, development of fistulae (colovaginal fistula (particularly after
previous hysterectomy!)), colovesical fistula, etc, chronic inflammation with formation of diverticulotic stricture (caveat:
suspicious for cancer until proven otherwise!!).
Diverticular disease is not a risk factor for colon cancer, but it has the same age distribution as colon cancer. But: cancer may
present like diverticulitis: 5% of "diverticulitis" episodes are caused by a colon cancer!!
Epidemiology
Western cultures: diverticula increase with age: ie, after age of 50 almost as frequent as the patient's age (rule of thumb);
true incidence/prevalence unknown. Caveat: young age does not rule out diverticulosis/-itis. Estimated 10–20% of patients
with diverticulosis will have an episode of diverticulitis within a period of 20 years. Risk of second attack of diverticulitis is
~10–20%, of a third attack 40–60%.
Symptoms
Diverticulosis: most frequently asymptomatic, chronic constipation, acute bleeding.
Acute diverticulitis: increasing abdominal pain, fever, peritoneal signs (may be masked in immunosuppressed patients!),
small or large bowel obstruction, initially less frequently nausea/vomiting. Caveat: sepsis, dehydration.
Chronic diverticulitis: obstructive symptoms, fistular symptoms.
Differential Diagnosis
Colon cancer (masking with typical symptoms of diverticulitis).
Constipation (LLQ pain, no fever, no WBC elevation, improvement on enemas).
Ischemic colitis.
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IBD, particularly Crohn disease.
Postactinic colitis (history of radiation treatment).
IBS.
Noncolonic pathology (tubo-ovarian abscess, endometriosis, appendicitis, pyelonephritis, etc).
Perforation of other hollow viscus (peptic ulcer, small bowel, etc).
Pathology
Muscular hypertrophy, diverticula with acute/subacute/chronic inflammation (polymorphonuclear leucocytes, lymphocytes),
abscess formation.
Evaluation
REQUIRED MINIMAL STANDARD
History: time frame of symptoms, previous similar episodes, change in bowel habits, bleeding per rectum, anemia, passage
of stool/gas through vagina or urethra? Previous surgeries (eg, appendectomy, hysterectomy, etc)? Previous colonic
evaluations (flexible sigmoidoscopy, colonoscopy, barium enema)? Comorbidities (coronary artery disease, COPD, diabetes,
liver/kidney disease, immunosuppression, etc).
Clinical examination: localized tenderness/guarding vs diffuse peritoneal signs? Rectal mass? Fever? Fluid
status/dehydration?
Lab work: increased WBC? Anemia? Prerenal kidney dysfunction (dehydration!). Spiking temperatures: blood cultures.
Urinalysis: rule out obvious urinary tract infection, some WBCs and RBCs in urine are still consistent with diverticulitis.
Guaiac test in acute setting (diverticulitis, macroscopic bleeding) is of little value.
X-rays: upright chest x-ray/abdominal x-ray in left decubitus:
free intraperitoneal air?
Unless diffuse peritonitis: CT abdomen/pelvis with dual (PO + IV) or triple (PO + IV + rectal) contrast: most
sensitive/specific investigation! Look for: pericolonic phlegmon (Figure 4–18A), (drainable) abscess (Figure 4–18B and Figure
4–18C), extraluminal air, free intraperitoneal air, ascites, bladder thickening, air in bladder, other pathologies.
Figure 4–18A.
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Diverticular disease: acute phlegmon.
Figure 4–18B.
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Diverticular disease: pericolonic abscess.
Figure 4–18C.
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Diverticular disease: pelvic abscess.
ADDITIONAL TESTS (OPTIONAL)
Acute
Water-soluble contrast enema (barium contraindicated in acute setting): amputated diverticula as sign of diverticulitis,
localized perforation, evidence of extravasation, stenosis; visualization of the whole colon is not necessary at this (!) time,
but later. Second best primary investigation if CT not available, however, a limited enema with water-soluble contrast should
be considered during the initial hospitalization to rule out cancer-suspicious morphology!
Chronic/Elective Situation
Barium/air double contrast study (Figure 4–18D) to obtain a "road map": distribution pattern of diverticula, stricture, fistula?
Figure 4–18D.
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Diverticular disease: chronic stricture.
Classification
Hinchey or modified Hinchey classification: Table 4–7.
Table 4–7. Modified Hinchey Classification for Diverticulitis.
Hinchey Classification Modified Hinchey Classification
(Imaging- or Surgery-Defined)
Comment
0 Mild clinical diverticulitis LLQ pain, elevated WBC, fever, no
confirmation by imaging or surgery
I Pericolic abscess or phlegmon Ia Confined pericolic inflammation:
phlegmon
Ib Confined pericolic abscess
II Pelvic, intra-abdominal, or
retroperitoneal abscess
II Pelvic, distant intra-abdominal, or
retroperitoneal abscess
III Generalized purulent
peritonitis
III Generalized purulent peritonitis No open communication with bowel
lumen (ruptured abscess)
IV Generalized fecal peritonitis IV Fecal peritonitis Free perforation, open communication
with bowel lumen
FIST Colovesical/-vaginal/-enteric/-cutaneous
fistula
OBST Large and/or small bowel obstruction Acute or chronic
LLQ, left lower quadrant; WBC, white blood count.
Nonoperative Treatment
Conservative: antibiotics for 1–3 weeks, temporary bowel rest vs active bowel stimulation with small aliquots of bowel
cleansing, stool regulation with fibers, stool softener, dietary changes, limited water-soluble contrast enema during initial
hospitalization to rule out obvious cancer, formal barium enema, or colonoscopy 6 weeks after episode.
CT-guided drainage of abscess.
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Operative Treatment
INDICATION
Emergency or urgent/nonelective resection: diffuse peritonitis, free perforation, nonresponsive to conservative management
within 72 hours or worsening under conservative treatment, suspicion of cancer on limited water-soluble contrast enema.
Elective colon resection:
Two or more episodes of diverticulitis (any age, increasingly debated indication), one episode of diverticulitis in young
patient (< 40 years old, increasingly debated indication), one(?) episode in immunosuppression (transplant patient,
diabetes, chemotherapy, leukemia, etc), but taking overall prognosis (eg, tumor) into consideration!
Colonic fistula (colovaginal, colovesical, colocutaneous, etc), colonic stenosis (Figure 4–18D).
Controversial: one episode of complicated diverticulitis (eg, post–CT-guided abscess drainage), which responded to
conservative treatment.
OPERATIVE APPROACH
Commonly two-stage vs one-stage colon resection, ie, resection of inflamed segment and creation of stoma. Three-
stage almost always obsolete as patient's recovery is faster if diseased segment can be primarily removed, yet in so-
called "malignant" diverticulitis, inflammation is too extensive to allow safe mobilization of sigmoid without injury to
other structures (ureters, etc), and proximal diversion is the only first option.
As cancer can never be ruled out, resection should always follow oncologic principles. Extent of resection starts
distally at rectosigmoid junction (confluens of teniae) and extends proximally until normal bowel wall consistency is
found; removal of all diverticula-bearing colon is not indicated.
Emergency
Typically two-stage resection: (1) Hartmann resection, ie, removal of diseased colon segment, blind distal end, proximal end
as end-colostomy; (2) after recovery (± 3 months) Hartmann reversal, ie, descendo-rectostomy (after previous colonic
evaluation!!), possibly laparoscopically.
Alternatively: resection and primary anastomosis with or without proximal diversion in appropriate patients and healthy
appearing bowels.
Elective
Typically 1-stage resection with primary anastomosis, possible temporary ileostomy. Ideally laparoscopically assisted!
Consider preoperative ureteral stents (recurrent severe attack).
Outcomes
Acute: > 70% recover with conservative treatment.
Surgery: complete recovery, recovery with stoma (20–40% of which are never closed), sepsis/death (13th most frequent
cause of death).
Recurrent attacks, long-term sequelae (fistula, stricture).
Follow-Up
Appropriate duration of antibiotics: 1–3 weeks, depending on severity and normalization of WBCs and clinical parameters.
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Stool management with fibers, stool softener, dietary changes (popcorn/peanuts allowed).
Limited water-soluble contrast enema during initial hospitalization: rule out obvious cancer with barium enema or
colonoscopy ~6 weeks after acute episode.
Evaluate for prophylactic surgery.
Cross-Reference
Pain, abdominal (Ch. 1)
Sepsis (Ch. 1)
Conventional x-rays (plain films) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
Large bowel obstruction (LBO, 560.9) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Colovaginal and colovesical fistula (619.1, 596.1) (Ch. 4)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Laparoscopic colorectal surgery (Ch. 5)
Medications against bacterial and fungal pathogens (App. 1)
COLOVAGINAL AND COLOVESICAL FISTULA (619.1, 596.1)
Overview
Direct communication between abdominal or pelvic intestines and either vagina (uterus) or bladder. Depending on the
pressure gradient, pathologic flow most commonly occurs from the intestines to the secondary organ, ie, passage of fecal
material and gas with urine; occasionally reverse direction (leaking of urine with stool). Amount of material passing depends
on the diameter and length of the fistula track, its exact location, the stool consistency, and the absolute intestinal pressure
build-up.
Symptoms alone are not specific for high or low location: abnormal passage (stool/gas in vagina, pneumaturia/fecaluria) and
mandates distinction between distal rectal/anal origin and abdominal origin: necessary because of different treatment
approach (abdominal vs perineal).
Most common causes: diverticulitis, cancer, Crohn disease, postsurgical complications (enterotomy, leak, etc). Erosion into
the vagina or the bladder is more frequent after previous hysterectomy.
Treatment (type of repair, timing) depends on the severity of symptoms, the underlying etiology, the tissue quality (eg, after
recent surgery, postradiation, etc), and the level of the fistula (in reach from perineum or not?): need to distinguish
rectovaginal fistula from colovaginal or enterovaginal fistula (high).
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Epidemiology
Incidence: overall unknown because of various different etiologies. Up to 50% of patients do not recall acute abdominal
episode prior to onset of symptoms.
Symptoms
Vaginal fistula: vaginal passage of stool or gas, frequent urinary tract infections, incontinence, perianal skin irritation.
Urinary fistula: urinary passage of stool (fecaluria) or gas (pneumaturia), urinary tract infection, urosepsis, drainage of urine
per rectum.
Differential Diagnosis
Diverticulitis.
Cancer.
Crohn disease.
Postsurgical (eg, anastomotic leak, enterotomy).
Radiation enteropathy.
Pathology
Depending on underlying disease: most important to differentiate between malignant and benign.
Evaluation
REQUIRED MINIMAL STANDARD
History: onset and characterization of symptoms, altered bowel habits, underlying abdominal pathology, previous surgeries,
previous colonic evaluations, systemic disease.
Clinical examination: rectovaginal exam including anoscopy/rigid sigmoidoscopy to rule out distal origin (rectovaginal or
rectourinary fistula), abdominal exam (mass, tenderness).
Complete colonic evaluation.
Visualization:
– CT scan: air in bladder, thickened bladder wall, adjacency of colon (Figure 4–19)?
– Cystoscopy/colposcopy: visible stool, visible defect, inflammatory changes?
– Contrast enema: direct contrast translocation from colon into bladder/vagina?
Figure 4–19.