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338
C. McCarthy et al.
Constipation •
Obesity •
High intake of meat, particularly red meat •
Smoking •
Immunosuppression •
Structural abnormalities of the bowel, i.e., hyperelasticity such as Marfan’s •
syndrome
People who have an active lifestyle and eat a healthy, high-fi ber diet have been
shown to have a reduced incidence of diverticular disease [
5 ] . Similarly, patients
with ulcerative colitis who have a reduced bowel wall muscle tone and contractility
have a lower incidence of diverticular disease [ 6 ] .
24.3 Complications
Diverticulitis is an acute infl ammatory condition affecting one or more divertic-
ula. Fecal impaction within the neck of a diverticulum leads to mucosal ulcer-
ation and acute infl ammation [ 7 ] . As the wall of the diverticulum is only made up
of mucosa, rapid deterioration to peritonitis can occur. Bacterial infection lead-
ing to localized or generalized sepsis is the major complication associated with
this condition.
Acute presentations (Box 24.1 ) are usually septic with left iliac fossa symptoms
and signs and raised infl ammatory markers (elevated CRP) – a phlegmon, an
abscess, or peritonitis. Less commonly colonic bleeding may result from a segment
of diverticular disease. In the longer term, episodes of self-limiting diverticulitis
may evoke a fi brotic reaction resulting in muscular thickening and stricture forma-
tion. Bowel obstruction can develop, and a tortuous sigmoid colon can make the
detection of an underlying carcinoma diffi cult. Fistulation may also occur to any
nearby structure, commonly the bladder/vagina.
Box 24.1: Complications of Diverticular Disease
I n fl ammatory phlegmon with or without involvement of other organs •
Paracolic abscess •
Fistula: colovesical (resulting in recurrent/persistent UTI and pneumatu-•
ria) and colovaginal (passage of wind/feces per vaginam – past history of
hysterectomy)
Purulent peritonitis secondary to rupture of a paracolic abscess. •
Perforation with fecal peritonitis resulting from pressure necrosis in a rup-•
tured diverticulum
Profuse, acute rectal bleeding due to erosion of a nearby vessel •
Bowel obstruction due to diverticular stricture •
339
24 Diverticular Disease
24.4 Classifi cation of Sepsis
The extent of the infl ammatory response associated with this condition is variable.
There is a high mortality associated with peritonitis. An infl ammatory exudate,
however, has a much better outcome than a purulent one which usually contains a
high load of bacterium. Fecal peritonitis is associated with the highest mortality
(approximately 50%) [
8 ] .
The Hinchey classifi cation for perforated diverticulitis should be more com-
monly used [ 9 ] as it accurately defi nes the severity of the condition:
• Stage I : diverticulitis with pericolic abscess
• Stage II : diverticulitis with distant abscess
• Stage III : purulent peritonitis
• Stage IV : fecal peritonitis
Accurate description of disease extent is imperative for future comparisons of
case series. Without precise descriptions, it is impossible to draw conclusions on the
appropriateness of emergency operations and the effect on mortality.
24.5 Investigation
Acute diverticulitis complicated by sepsis may present with anything from a mild
pyrexia and left iliac fossa pain to generalized peritonitis and septic shock. In the
acute setting, a CT scan should be performed to confi rm the diagnosis. This radio-
logical modality has been shown to be superior to both contrast enema and colonos-
copy – as it evaluates the extraluminal extent of the disease and any other pathology
which may be present [ 10 ] . It may be necessary to perform mesenteric angiography
if the acute presentation is brisk rectal bleeding. In such circumstances, identifi ca-
tion of a bleeding vessel will allow a more conservative bowel resection [ 11 ] .
Ambrosetti et al. have devised a CT staging classifi cation in order to guide man-
agement of acute diverticulitis [ 12 ] (Box 24.2 ). On the basis of this classifi cation,
they recommend that mild cases are managed conservatively with antibiotics.
Percutaneous drainage of abscess collection with or without surgery should be
reserved for complicated/severe cases of the disease (Fig. 24.1 ) (Box 24.3 ).
Box 24.2: The Ambrosetti’s CT Staging of Acute Diverticulitis
Mild diverticulitis Severe diverticulitis
Localized sigmoid wall thickening
(<5 mm)
Abscess
Infl ammation of pericolic fat Extraluminal air
Extraluminal contrast
340
C. McCarthy et al.
In the nonacute setting, a barium enema used to be standard practice to diagnose
and assess diverticular disease. Now, it is more common to perform a colonoscopy
to assess intraluminal diverticular disease and to exclude an underlying carcinoma.
If stricturing of the sigmoid colon (Fig. 24.2 ) will not allow passage of the colono-
scope, then CT colonography is an alternative investigation to a contrast study.
Fig. 24.2 A barium enema
demonstrating a stricturing
segment of diverticular
disease
Box 24.3
A quarter of patients undergoing elective sigmoid colonic resection for diver-
ticular disease are symptomatic at long-term follow-up.
Munson et al. [ 13 ]
Fig. 24.1 A CT scan
demonstrating a severe case
of acute diverticulitis. The
sigmoid colon can be seen to
be infl amed with a thick wall,
stranding in the mesentery,
and a paracolic abscess
containing free gas
341
24 Diverticular Disease
24.6 Management
Diverticular disease is a benign condition. There are no uniform guidelines on man-
agement, and a large amount of variability exists among surgeons who may only see
three or four severe cases a year. A recent position statement on elective resection
for diverticulitis [
2 ] produced by the Association of Coloproctology of Great Britain
and Ireland [ 2 ] ( www.acpgbi.org.uk/guidelines ) clarifi es many of the issues.
24.6.1 Dietary
After diagnosis, most patients are advised to take a high-fi ber diet, reassured, and
discharged back to the community.
24.6.2 Elective Surgery
It is questionable whether uninfl amed segment of colonic diverticulosis produces
symptoms, and there is highly signifi cant crossover with irritable bowel symp-
tomatology [ 14 ] . It is therefore not surprising that elective resection of diverticular
disease does not reliably relieve abdominal pain and other symptoms commonly
attributed to this condition. Many patients undergoing elective sigmoid colonic
resection for diverticular disease are symptomatic at long-term follow-up [ 13 ] .
The decision to operate in the elective setting should, therefore, be carefully con-
sidered and determined on an individual basis. Demonstration of episodes of
infl ammation (left iliac fossa signs and elevated CRP) with infl ammatory changes
on abdominal CT scan, and not just diverticulosis, is the prerequisite for elective
resection.
The aim of surgery should be to resect all of the colon affected by diverticulitis.
It is good practice to routinely mobilize the splenic fl exure, and the distal margin of
resection must be onto true rectum to avoid recurrent diverticulitis [ 15 ] . It is also
extremely important to identify and safeguard the left ureter as the retroperitoneal
tissues lose their normal architecture with repeated episodes of infl ammation.
24.6.3 Emergency Surgery
Emergency surgery is controversial and is centered on management of sepsis. The
decision to operate is diffi cult. Current practice is a trial of conservative measures
which involves fl uid resuscitation, intravenous antibiotics, and consideration of per-
cutaneous drainage of abscesses greater than 5 cm [
16 ] . Impressive results have
342
C. McCarthy et al.
been documented in effective conservative management with antibiotics [ 17 ] .
Emergency surgery may then be considered where conservative measures have
failed or, if generalized, fecal peritonitis is present.
Previous surgical dogma has dictated that resection is mandatory to remove the
source of sepsis [
18 ] . This would usually take the form of a Hartmann’s procedure
which involves an end colostomy in the left iliac fossa. However, there is a high rate
of permanent stoma with this type of management. In addition, emergency colonic
resection for acute diverticulitis is associated with a 27% mortality [ 19, 20 ] .
24.7 Current Controversies
24.7.1 Acute Laparoscopy
Recent studies have reported laparoscopic peritoneal lavage, abscess drainage,
and antibiotic treatment as an alternative to a Hartmann’s procedure [ 21– 23 ] .
This experience indicates that laparoscopic drainage of acute diverticular sepsis
is safe, effective, and associated with a low morbidity, mortality, and a reduced
need for a stoma.
Thus, laparoscopic lavage can provide adequate control of perforated diver-
ticulitis which is purulent (Hinchey III) in up to 95% of cases [ 24 ] , with a low
overall mortality of 1.7%. By contrast, there is a general consensus that laparo-
scopic lavage is not appropriate in the presence of fecal peritonitis (Hinchey IV)
and for those who have a pelvic abscess [ 25– 28 ] – due to a high rate of failure of
treatment.
24.7.2 Elective Laparoscopic Resection
Elective laparoscopic resection of sigmoid diverticular disease has been reported
to be a safe alternative to open resection [ 14, 29 ] in experienced hands. Two
randomized controlled trials reported a shorter ileus and a shorter length of hos-
pital stay after laparoscopic diverticular resection. Klarenbeek et al. demon-
strated that there was less pain and less analgesic requirement in the laparoscopic
group; however, Gervaz et al. who blinded the patients by using a universal
opaque wound dressing did not demonstrate any difference in postoperative
pain between the two groups. Both studies reported that the median operating
time was signifi cantly longer for laparoscopic resection. This may refl ect the
advanced laparoscopic skills required for laparoscopic resection of diverticular
disease, which can often be more demanding than a cancer resection as a result
of distortion of the “holy plane.” The overall conversion rate is reported at
9–19% [ 14, 29 ] .
343
24 Diverticular Disease
24.7.3 Acute Versus Elective Laparoscopic Resection
The Association of Coloproctology for Great Britain and Ireland (ACPGBI) recom-
mends that acute diverticulitis should be managed medically with surgery being deferred
until the acute episode has settled down. Conversion from laparoscopic to an open
approach is much higher in the acute episode than if the resection is deferred [
30 ] .
24.8 Natural History and Selection Strategy
The most diffi cult decision a colorectal surgeon faces with diverticular disease is:
when to resect? Previously, the recommendation was for elective surgery and pri-
mary anastomosis in patients who had experienced two acute attacks or one acute
attack if under 45 years of age. Caution should be exercised, however, when offer-
ing elective resection, and the decision should be made on an individual basis.
Chautems et al. reported that 68% of patients treated medically for acute diver-
ticulitis did not suffer a complication after 9.5 years of follow-up [ 31 ] – although
mortality from unrelated causes was high at 18%. Similarly, Mueller et al. reported
that only 9% of 252 patients with conservatively managed acute diverticulitis came
to surgery over a 13-year period [ 32 ] .
The management of the younger patient also remains unclear. It has previously
been thought that younger patients with acute diverticulitis tend to run a more
aggressive course, and so the recommendation has been that younger patients
undergo elective colonic resection after one attack of acute diverticulitis [ 33, 34 ] .
However, this view is based on retrospective studies with incomplete follow-up
data, and an imprecise defi nition of disease severity as historically the use of CT
scanning was not routine in these patients.
Ambrosetti et al. reported in 1994 that the young were more likely to have a poor
secondary outcome from an attack of acute diverticulitis. These poor outcomes
included persistent diverticulitis, symptomatic stenosis, colovesical fi stula, or resid-
ual abscess [ 35 ] . Those with CT proven severe diverticulitis experienced a 54%
chance of a poor secondary outcome at 5 years. With an overall selective approach
to elective resection, however, many patients will avoid unnecessary surgery and its
potential complications. Current thinking is that younger patients may not run a
more aggressive course and should be treated as their older counterparts.
24.9 Conclusions
There is neither a clear clinical consensus nor a robust evidence base upon which a
defi nitive strategy for resecting diverticular disease can be based. Young or old, the
decision to resect depends on the individual patient’s perception of risk and benefi t
344
C. McCarthy et al.
from resection versus a conservative approach. If, after informed consent, the patient
opts for resection – the colonic resection for diverticular disease, open or laparo-
scopic, can be technically very demanding.
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CT scan of acute diverticulitis is required to stage disease. •
Medical management will be suffi cient for most acute presentations with •
acute diverticulitis.
Percutaneous drainage of abscess collections as defi nitive treatment or as a •
bridge to surgery
Consider elective resection for complicated disease, i.e., stricture or fi stula. •
No blanket rule on elective resection postacute attack.
Tailor the plan to the patient. Younger patients do not necessarily have •
more aggressive disease.
Treat as for older patients. Elective resection should not be considered to •
alleviate the symptom of abdominal pain alone.
Resection must be supported by the demonstration of persistent infl amma-•
tion on CT scan.
Ensure that a malignancy is excluded. •
When operating, routinely mobilize splenic fl exure, identify left ureter, •
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345
24 Diverticular Disease
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to acute attack. Dis Colon Rectum. 2007;50:1911–7.
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347
S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_25, © Springer-Verlag London Limited 2012
25.1 Introduction
Fecal incontinence and constipation are common conditions that have a signifi cant
impact upon a patient’s quality of life. The maintenance of continence and act of
defecation result from the complex interaction of many factors that is refl ected in
the many different etiologies of fecal incontinence and constipation, and the many
different investigations available. As with all medical practice, a thorough history
and examination forms the solid foundation required to assessing such patients,
with supplementary information from specialist tests being useful in some. The
symptoms of both constipation and fecal incontinence may in a few be the present-
ing symptoms of a colorectal or anal neoplasm. Such a diagnosis should be excluded
in the assessment and with appropriate investigations. The assessment of a patient
with incontinence and constipation is described, followed by a detailed discussion
of the most useful specialist tests of anorectal and colonic function.
P. J. Mitchell , M.D., FRCS (*) • E. S. Kiff , M.D., FRCS
Pelvic Floor Service, Department of General Surgery ,
University Hospital South Manchester ,
Southmoor Road , Manchester , M23 9LT , UK
e-mail: peter.mitchell40@btopenworld.com ; edward.kiff@uhsm.nhs.uk
Chapter 25
Assessment and Investigation of Fecal
Incontinence and Constipation
Peter J. Mitchell and Edward S. Kiff
Case Scenario 1
A 51-year-old lady presents with a 3-year history of fecal incontinence. She
has a call to stool but with urgency. The stool is soft; she has diffi culty wiping
clean and has to wear pads.
1. What other aspects of the history do you want to know about?
2. What investigations would you ask for?
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