Sigmoidovesicocutaneous fistula complicating diverticular disease of the colon

A sixty-six year old diabetic male had a draining sinus tract from the lateral portion of a fourteen year old left herniorrhaphy scar. The diagnosis of sigmoidovesicocutaneous fistula was confirmed by a sinogram and the patient was treated in one stage with left hemicolectomy and resection of the fistula site from the dome of the bladder. To our knowledge this is the first report of a sigmoidovesicocutaneous fistula.     

Vaginal-sigmoid fistula caused by diverticular disease

A case of a 66 years old patient suffering from a sigmoido-vaginal fistula and diverticulosis, previously treated with a total laparohysterectomy, is reported. Retrograde studies demonstrated the presence of fistula, whereas colonoscopy and barium enema failed. After laparotomy and an appropriate bowel preparation, surgery was restricted to the bowel resection and anastomosis, whereas the vaginal defect was not closed.     

Does uncomplicated diverticular disease produce symptoms?

A questionnaire dealing with bowel symptoms was administered to 97 outpatients referred for air-contrast barium enema. Subsequently, the barium enema was interpreted by a radiologist who did not know the results of the questionnaire. Forty-nine had normal x-rays, and 27 had uncomplicated diverticular disease. Weight loss, rectal bleeding, abdominal pain, and pain at night were as common in those with a normal examination as in those with diverticula. Symptoms of colon dysfunction included abdominal pain relieved by defecation, altered stool frequency and consistency with pain onset, abdominal distension, feeling of incomplete evacuation after defecation, and mucus in the stool. These were equally prevalent in both groups. Therefore, no symptoms could be ascribed to the presence of diverticula.     

Genital fistulas caused by diverticular disease of the sigmoid colon

OBJECTIVE: Our purpose was to bring to the attention of gynecologists a subject not mentioned in a single textbook of gynecology, namely, genital fistulas resulting from diverticular disease of the sigmoid colon. STUDY DESIGN: We report our experience with 13 genital fistulas caused by sigmoid diverticulitis. RESULTS: Ten fistulas involved the vagina, one the vagina and bladder, one the tube, and one the uterus. Average age of the patients was 68.6 years (range 54 to 89 years). Presenting symptom in 12 patients was a malodorous vaginal discharge. All with vaginal lesions had previously undergone total hysterectomy. A barium enema failed to demonstrate a fistula in 8 of 11 patients. Colonoscopy failed in 8 of 8 patients. All fistulas were demonstrated by retrograde dye studies. Ten patients operated on were cured. Three patients refused surgery; of these, 1 had intestinal obstruction, 1 may have had spontaneous closure of the fistula, and 1 is being observed. Surgery involved staged procedures in 2 patients, fistulectomy in 4, and bowel resection and anastomosis in 4. CONCLUSIONS: Sigmoidovaginal fistulas are the most prevalent variety of cologenital fistula caused by sigmoid diverticulitis. The diagnosis should be considered in a patient > 50 years old who complains of a foul vaginal discharge and has a history of total hysterectomy. Its presence is best demonstrated by vaginogram. Surgical therapy is advised, the extent of which will rest on the surgeon's judgment of the severity of the inflammatory process found at exploration.     

An audit of fatal acute pancreatitis

Acute pancreatitis has a mortality of about 10%: this figure has not changed over the last 20 years. A retrospective audit of fatal acute pancreatitis was performed in a teaching hospital with a catchment population of about 750,000 patients to examine patient characteristics. Using Hospital Activity Analysis code 577.0, all fatal cases of acute pancreatitis were studied in a six-year period 1987-93. Additionally, all post mortem diagnoses of acute pancreatitis were traced. The overall post mortem rate in Nottingham at the time of the study was about 35%. All available records, X-ray and biochemical data were studied and appropriate information recorded and analysed for 65 fatal cases. Only 15% were post mortem diagnoses, lower than in previous series; 72% had respiratory and 67% had renal complications. Only 34% had been admitted to the intensive care unit. A third of patients had had surgery; 67% of these was some form of external drainage. Of the 14 patients with proven gallstone pancreatitis only three had endoscopic retrograde cholangiopancreatography; 42% of patients had idiopathic disease. Not all the patients diagnosed ante mortem had the full biochemical predicted severity criteria analysed: pO2 and calcium analysis was performed in about 80%. Pre-mortem diagnoses of pancreatitis was achieved more frequently than in other comparable series.     

Answers to 10 key questions on diverticular disease of the colon

Diverticular disease is common in industrialized countries, and will become more prevalent in the future. Although it is usually a benign condition, treatment with high-fiber diet may prevent complications such as infection, stricture, or bleeding.     

Fecal characteristics contrasted in the irritable bowel syndrome and diverticular disease

A comparison has been made of the fecal characteristics in controls and patients with the irritable bowel syndrome and diverticular disease. No detectable difference was found in the fecal wet weight, dry weight, or total bile acid excretion in the four groups. A significant increase in the percentage of the water content of the stool was seen in the idiopathic diarrhea group with irritable bowel syndrome. Significantly less magnesium, potassium, and calcium was found in the stools of patients with diverticular disease and a similar trend was noted in patients with the spastic colon. These changes did not relate to the age of the patients. This suggests a common etiology for these disorders. The presence of increased water and primary bile acids in the feces of patients with idiopathic diarrhea suggests that this is a separate entity.     

Natural history of diverticular disease: when to operate?

PURPOSE: The natural history of patients admitted because of acute diverticulitis is largely unknown, and the selection of patients for surgical treatment varies notably. This study presents our experience concerning the outcome for 366 patients admitted during a 10-year period. METHODS: Three hundred sixty-six patients admitted to our hospital with acute diverticulitis from 1981 to 1990 were identified from a computer database, and their clinical data up to the end of 1996 were reviewed from the database and patient records. RESULTS: There were significantly more males than females in the age group less than 50 years old, and young males underwent surgical treatment during the first treatment period more frequently than the others. Young patients were operated on without mortality, and all their temporary colostomies were closed. Older patients died more often of diseases unrelated to the diverticular disease during the years after the first episode of acute diverticulitis. Recurrences of diverticular disease developed in 22 percent of patients, and they were significantly more common in patients less than 50 years old than in the older age groups. Males less than 50 years old more often developed complications of diverticular disease after two hospital admissions. CONCLUSIONS: Males first admitted when less than 50 years of age undergo more primary operations and develop more recurrences of diverticular disease than do older people. Based on our data, however, we recommend surgery for all patients after two episodes of acute diverticulitis that resolves after conservative treatment with antibiotics.     

Giant sigmoid diverticulum: a rare manifestation of diverticular disease

We report two unusual cases of giant sigmoid diverticulum, which is a rare manifestation of diverticular disease. Giant diverticula are 3 to 4 cm or greater in size and are produced by gradual enlargement of an acquired pseudodiverticulum that has had superimposed infection, abscess formation, and healing. For more than 3 years, we have observed and managed the first case conservatively, without surgery. The second case represents the largest recorded giant sigmoid diverticulum (33 cm) in the literature. We review the pathogenesis, clinical features, differential diagnosis, and management of this condition.     

Neuro-ophthalmic complications of acute varicella

In 16 patients suffering from migraine without aura, we examined quantitative EEG and steady-state visual evoked potentials (SSVEPs) at 27 Hz stimulation during the critical phase of migraine and in attack-free periods. The main spontaneous EEG abnormalities found during the critical phase were the slowing and asymmetry of the dominant frequency in the alpha range. The amplitude of the SSVEP F1 component was significantly reduced during the attack phase compared with the intercritical phase; in the latter condition the visual reactivity to 27 Hz stimulus was increased over almost the entire scalp compared with normal subjects. The EEG abnormalities confirm a fluctuating modification of alpha activity during the migraine attack, probably related to a functional disorder. The suppression of visual reactivity during the migraine attack could be related to a phenomenon of neuronal depolarization such as spreading depression, occurring in a situation of central neuronal increased excitability predisposing to migraine attacks.     

Serious complications of acute sinusitis

Acute sinusitis is common and usually the result of edema around the sinus ostia from the common cold. Chronic sinusitis and recurrent sinusitis are common complications of untreated or undertreated infection. Serious and life-threatening complications are uncommon but demand a high index of suspicion, accurate diagnosis, and rapid intervention by medical and surgical methods. Immediate parenteral administration of antibiotics may be necessary to prevent permanent disabilities or death, and early consultation with an otolaryngologist or neurosurgeon is prudent. Computed tomography is the imaging method of choice for detection of serious intracranial complications of acute sinusitis. Increasing numbers of immunocompromised patients and seriously ill hospitalized patients with problems related to complications of acute sinusitis are being seen.     

Medical and surgical therapy in diverticular disease: a comparative study

The course of 132 patients with documented acute diverticulitis was analyzed: 99 patients treated medically and 33 patients treated surgically were followed for an average of 9.2 years. Seventy-three per cent of the medical group and 79% of the surgical group had no further symptoms or hospital admissions as a result of their diverticular disease once they were recovered from the acute episode. For three-quarters of the patients, therefore, acute diverticulitis occurred as a single episode that responded to either medical or surgical management. Considering the morbidity and cost to the patient, the treatment of the patient recovered from acute diverticulitis should be medical, with operation reserved for complications.     

Preservation and peeling of the inferior mesenteric artery in the anterior resection for complicated diverticular disease

The authors, on the basis of 3 cases of complicated diverticular disease, discuss the indications to surgery, considering the advantages and disadvantages of the various surgical techniques and examining in particular the rules for a correct operation with resection and primary or secondary anastomosis. As they performed a rectosigmoidectomy with primary high colorectal anastomosis, they report the reasons why they adopted the preservation and peeling of the inferior mesenteric artery (IMA).     

Urinary complications of Crohn's disease

A 22-year review of 328 patients with Crohn's disease revealed 70 patients with urinary tract symptoms. Cystitis was the most common problem, occurring in 44 patients. The urinary tract infections were recurrent in most patients, usually with 3 or 4 attacks per year. Despite the persistence of urinary infection, only 3 patients developed chronic pyelonephritis. Forty-nine patients had intravenous urography, and many were found to have slight dilatation of the upper urinary tract on one side. Seven patients had hydronephrosis, 3 with pyonephrosis. Five of 6 patients who developed calculi had a bowel resection. All of the recovered calculi were oxalate stones, but 3 were passed spontaneously and not analyzed. Eight patients, 7 of them males, had an ileovesical fistula. In 1, the colon was also affected. It was unusual for these patients to have severe urinary symptoms. One patient had a fistula from the rectum to the urethra. Although 32 of the 70 patients were female, most of the severe complications occurred in men. Aggressive investigation is not indicated, nor is radical surgery required.     

A prospective study of dietary fiber types and symptomatic diverticular disease in men

To examine prospectively dietary fiber calculated from food composition values based on analytic techniques and specific dietary fiber types in relation to risk of diverticular disease, we analyzed data from a prospective cohort of 43,881 U.S. male health professionals 40-75 y of age at base line; subjects were free of diagnosed diverticular disease, colon or rectal polyps, ulcerative colitis and cancer. The insoluble component of fiber was inversely associated with risk of diverticular disease relative risk (RR) = 0. 63, 95% confidence interval (CI), 0.44-0.91, P for trend = 0.02, and this association was particularly strong for cellulose (RR = 0.52, 95% CI, 0.36-0.75, P for trend = 0.002). The association between diverticular disease and total dietary fiber intake calculated from the AOACstandards method was not appreciably different from results using the Southgate or Englyst method [for AOAC method, RR = 0.60, 95% CI, 0.41-0.87; for Southgate method, RR = 0.61, 95% CI, 0.42-0. 88; for Englyst method, RR = 0.60, 95% CI, 0.42-0.87, for the highest quintiles]. Our findings provide evidence for the hypothesis that a diet high in dietary fiber decreases the risk of diverticular disease, and this result was not sensitive to the use of different analytic techniques to define dietary fiber. Our findings suggest that the insoluble component of fiber was significantly associated with a decreased risk of diverticular disease, and this inverse association was particularly strong for cellulose.     

Cardiopulmonary complications in acute subarachnoid hemorrhage

Pathologic electrocardiogram (ECG) may be present in more than 90% of patients with subarachnoid haemorrhage. The ECG findings are often transient and may mimic acute myocardial ischaemia or infarction. These ECG findings may cause diagnostic problems in patients with subarachnoid haemorrhage who are unconscious or who have atypical symptoms. Life-threatening arrhythmias are also seen and may be responsible for sudden deaths in patients with subarachnoid haemorrhage. Other signs of myocardial injury, such as ventricular wall motion dysfunction, elevated enzymes, and histological evidence of contraction band necrosis are described. The myocardial dysfunction known as neurogenic stunned myocardium is reversible if the patient survives the acute phase, but it may lead to haemodynamic instability and contribute to the origin of neurogenic pulmonary oedema. The myocardial injury in subarachnoid haemorrhage may be due to a massive sympathetic stimulation of the myocardium in response to rapidly increasing intracranial pressure. We illustrate myocardial injury and dysfunction in a case report where a patient had subarachnoid haemorrhage with ventricular fibrillation, pulmonary oedema, left ventricular dysfunction and ST-segment elevation, initially thought to be acute myocardial infarction.