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3 Jex RK, van Heerden JA, Carpenter PC, Grant CS. Ectopic 5 Herder WWde, Krenning EP, Malchoff CD, et al. Soma- J localiza- ACTH syndrome - diagnostic and therapeutic aspects. Am tostatin receptor scintigraphy: its value in tumour Postgrad Med J: first published as 10.1136/pgmj.73.865.739 on 1 November 1997. Downloaded from Surg 1985; 149: 276-82. tion in patients with the Cushing syndrome caused by 4 Kitchens CS, Alexander RW. Cushing's syndrome second- ectopic corticotrophin and/or CRH secretion. Am Jf Med ary to a neuroendocrine tumour: relapse after bilateral 1994; 96: 305-12. adrenalectomy. Cancer 1981; 48: 1873-6.

Perforated diverticulitis following extra-abdominal surgery

AM Gaya, EM Chisholm, HJ Scott, DR Donaldson

Summary Case 2 The of perforated diverticular A 61-year-old man presented to Accident and disease is a life-threatening condition. We Emergency with severe three report three cases where it occurred weeks after the excision of a malignant following unrelated extra-abdominal sur- glioblastoma from his right temporoparietal gery and where surgical intervention region. His medication included nonsteroidal proved to be the correct course of man- anti-inflammatory drugs, dexamethasone and agement. All cases were treated with a atenolol. On examination he was pale, with a Hartmann's procedure; this is probably pulse rate of 80 beats/min. His was the safest option for purulent peritonitis in distended and generally tender with guarding. patients who are a high operative risk and Bowel sounds were absent. An abdominal X- have recendy undergone major surgery. ray showed dilated loops of small bowel. He underwent an emergency which Keywords: perforation; diverticulitis revealed a perforated sigmoid . A Hartmann's procedure was performed. Post- operatively he made a good recovery. Diverticular disease has an increasing inci- dence in Western countries which can be Case 3

explained by an increasing elderly population A 73-year-old asthmatic woman was admitted http://pmj.bmj.com/ and also the relatively low-fibre diet of western for an elective left total hip replacement. Seven culture. Fifty per cent of the population over days postoperatively she started vomiting, and 50 years of age have , and it is experienced pain over the lower abdomen. Her estimated that diverticulitis will develop symptoms worsened over the following 48 in 15 - 20% of these cases.' Spontaneous hours. Her abdomen became distended and perforated sigmoid diverticulitis is an unusual bowel sounds were absent. A chest X-ray revealed under both diaphragms. At complication following unrelated extra-ab- gas on September 25, 2021 by guest. Protected copyright. dominal surgery. Three cases are reported laparotomy a perforated sigmoid diverticulum here, and the pathogenesis is discussed. was found. A Hartmann's procedure was performed. Postoperatively her asthma wor- Case reports sened, she developed a right pneumothorax, a right basal pneumonia and became septicae- Case 1 mic. She was ventilated and later underwent A 76-year-old man was admitted through tracheostomy. She remained in intensive care Accident and Emergency with a 24-hour for 38 days, after which her clinical condition history ofworsening abdominal pain two weeks continued to improve. She was recently dis- after triple coronary artery bypass grafting. He charged from hospital. was pyrexial, tachycardic and hypotensive. Department of Abdominal examination revealed generalised Discussion , St peritonitis. After resuscitation, a laparotomy Peter's Hospital, revealed a purulent peritonitis secondary to a Acute postoperative perforated diverticulitis Guildford Road, perforated sigmoid diverticular . A has been associated with cardiac surgery or Chertsey, Surrey UK Hartmann's procedure was performed with renal transplant surgery.2 General surgical AM Gaya cardiac surgery in- EM Chisholm end and closure of rectal stump. complications following HJ Scott Postoperatively he spent a period in intensive clude gastroduodenal ulcer, acute , DR Donaldson care and required a blood transfusion for acute small bowel ischaemia or ; colonic gastric erosions. He was discharged home after complications are relatively rare.3 Patients Correspondence to Mr DR four weeks. He has since had a successful with extensive diverticular disease are recom- Donaldson reversal of his Hartmann's procedure, and is mended for colon resection before renal Accepted 16 April 1997 well. transplantation, as the occurrence of colonic 740 Gaya, Chisholm, Scott, Donaldson

Postoperative perforated Summary points Postgrad Med J: first published as 10.1136/pgmj.73.865.739 on 1 November 1997. Downloaded from diverticulitis: possible causes * clinicians should be aware of an acute * age abdomen as a complication of extra-abdominal * opiate analgesia surgery in order to ensure prompt referral to * long-term steroids the appropriate specialist * diet/long standing * Hartmann's procedure is probably the safest * raised intraluminal pressures surgical option for postoperative perforated * intestinal mucosal ischaemia diverticulitis * increased collagenase activity Box 2 Box 1 Western low-fibre diets may also have a role complications following renal transplantation in the pathogenesis of perforated diverticulitis, are well recognised2 with an incidence of as they can lead to diverticulosis and chronic colonic perforation of 2-4%.6 constipation. In the postoperative period there The pathogenesis of postoperative diverticu- may be worsening constipation due to bed rest, litis is multifactorial in nature (box 1). Its high opiate analgesics, anaesthetics and the surgery incidence in association with cardiac surgery itself. Postoperative constipation may lead to may be related to the older age of this the generation of high pressures in the lumen population. It has been suggested that post- of the colon, which would increase the chance operative morphine analgesia following heart of perforation. surgery may be responsible. In other surgical Another theory in the pathogenesis of specialties, patient-controlled morphine an- diverticular perforation suggests that it is due algesia is increasingly used. Painter et aft to intestinal mucosal ischaemia induced by demonstrated that morphine increases intra- hypotension, low-flow states, the use of vaso- luminal pressure in the and constricting drugs, and microthrombi or em- causes marked distension of the diverticula, boli.4 Increasing numbers of patients now thereby increasing the risk of perforation. receive postoperative prophylactic heparin to Several authors have reported an increase in prevent thrombus formation. Increased col- diverticular perforation in patients receiving lagenase activity after surgery, with resulting steroids or long-term immunosuppressive ther- collagen breakdown in thin-walled diverticula, apy.8 One of our cases was taking long-term is suggested to be a contributing factor to dexamethasone. postoperative perforation.9

1 Hackford AW, Veidenheimer MC. Diverticular disease of 6 Carson SD, Krom RA, Uchida K, Yokota K, West JC, Weil the colon. Surg Clin NAm 1995; 65: 347-63. R. Colon perforation after transplantation. Ann Surg 2 Soravia C, Baldi A, Kartheuser A, et al. Acute colonic 1978; 188: 109-13.

complications after kidney transplantation. Acta Chir Belg 7 Painter NS, Truelove SC. The intraluminal pressure http://pmj.bmj.com/ 1995; 95: 157-61. patterns in diverticulosis ofthe colon. Gut 1964; 5: 201 - 13. 3 Lawhome TW, Davis JL, Smith GW. General surgical 8 Canter JN, Shorb PE. Acute perforation of colonic complications after cardiac surgery. Am J Surg 1978; 136: diverticula associated with prolonged adrenocorticosteroid 254-6. therapy. AmJSurg 1971; 121: 46-9. 4 Mirvis S, Scovill WA. Colonic diverticulum perforation: 9 Voitk AJ, Mustard RA. Perforated diverticulitis after report of two cases as a complication of CABG. Am J surgery. Can _Surg 1989; 32: 370-2. Gastroenterol 1985; 80: 547-9. 10 Badia-Perez JM, Valverde-Sintas J, Franch-Arcas G, Pla- 5 Reath DB, Maull KI. General surgical complications Comos J, Sitges-Serra A. Acute postoperative diverticulitis. following cardiac surgery. Am Surg 1983; 49: 11 - 14. Int J Colorectal Dis 1989; 4: 141 - 3. on September 25, 2021 by guest. Protected copyright.