20 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from DIVERTICULOSIS AND DIVERTICULITIS OF THE INTESTINE By HAROLD C. EDWARDS, C.B.E., M.S., F.R.C.S. Surgeon, King's College Hospital, London Introductory trophy of the muscularis mucosae in the wall of Primary diverticula of the small and large in- the pouch. testine are acquired by a process of herniation of The vessel whose channel through the muscular the mucosa through the muscle coat of the bowel coat determined the site of herniation can usually and are an affection of middle age and later. The be demonstrated. In the small intestine the blood mechanism, as with herniation through the ab- vessels pass through the muscle coat almost im- dominal parieties, is exceedingly complex and little mediately they leave the mesentery, hence the understood. It is generally agreed that two basic diverticula are closely related to the latter; in the factors are concerned-pressure within the cavity colon the blood vessels, after leaving the mesentery, under the serous coat to the of the of the bowel, which forces the mucosa against the pass edge Protected by copyright. muscularis; and an outlet, or locus minoris longitudinal muscle band before piercing the cir- resistentiae, such as that provided by the gap in cular coat to reach the submucosa. Hence di- the muscle coat occasioned by the passage of blood verticula of the colon appear in two rows on either vessels or, in the case of the duodenum, by the side of the mesentery and at some distance from it. common bile duct. The unknown factor lies in As the blood vessel passes under the longitudinal the behaviour of the plain muscle itself, upon muscle of the colon a small branch is given off to which layer the integrity ofthe bowel wall depends. the corresponding taenia epiploica; thus in obese It has been demonstrated that atonicity or atrophy subjects the pouches are often obscured by fat. of the muscle is not a constant, or even a common, At first the diverticulum is conical in shape, but causal factor. Not only does the microscopic eventually, when fully formed, is globular, its anatomy bear evidence against such a supposition, mouth being narrower than its maximum diameter. but it is well known that passive pressure alone, as In the duodenum and jejunum the pouch may in acute obstruction, does not produce pouching. become very large-of golf ball size and over- It has been suggested that local spasticity of the but in the colon the size rarely exceeds that of a http://pmj.bmj.com/ muscle wall is a more probable antecedent' to small grape. herniation, and there the matter rests., All those contributory factors which arrive coincidentally Si uation with middle age, and which predispose to external /Th mos mmon sites for diverticula are the abdominal herniae, are doubtless concerned and oidcol the duodenum and the upper the tendency to diverticulosis increases pro- JjIunum, m that order. It is not uncommon to gressively with find diverticula in all three sites in the same age. individual. Radiological evidence of the coexist- on September 27, 2021 by guest. Anatomy ence of diverticula of the colon was present in 17 The muscle coat of the intestine usually ends of a consecutive series of 8o cases of diverticula abruptly at the orifice through which the mucosa of the second part of the duodenum (2I per cent.), is extruded, though it may be everted to accompany against an anticipated incidence of approximately the hernia for a short distance. The muscularis Iz per cent. in normal people of the same age mucosae accompanies the mucous membrane, so group. that a few fibres may be present throughout the diverticulum, although in the fully-formed diver- Clihical Aspect ticulum the fundus usually consists of mucous The underlying cause for clinical symptoms due membrane covered only by the serosa. Occasion- to diverticula is retention of intestinal contents, ally, more especially in jejunal diverticula, there to which they are predisposed by their deficient may be some evidence of compensatory hyper- musculature and their bottle-neck communication. Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from Yanuary 1953 HAROLD C. EDWARDS: Diverticulosis and Diverticulitis of the Intestine DIVERTICULOSIS Diverticulitis of Mild Degree CHRONIC DIVERTICULITIS l Pericolitis ACUTE DIVERTICULITIS I l CHRONIC Adhesions to OBSTRUCTION neighbouring PERFORATION and organs PERITONITIS LOCALIZED ABSCESS Rupture into Anaerobic Cellulitis peritoneal cavity FISTULA FORMATION I (a) SIGMOIDO-CUTANEOUS SIGMOIDO-VESICAL (b) Protected by copyright. (c) Into hollow organs other than bladder with the parent intestine. The nature of both Perivaterian diverticula. These pouches, which symptoms and complications will thus depend are usually single, nearly always arise in posterior largely upon the nature of the contents and the relationship to the common bile duct and pass to anatomy of the area of bowel from which the the left behind the head of the pancreas, being diverticula arise. separated from the latter by a layer of areolar tissue. Many of the patients are visceroptic. The The Duodenum diverticula do not give rise to recognizable symp- Hernial diverticula of the duodenum are to be toms until they have enlarged sufficiently to retain found in about 2 per cent. of all radiological ex- duodenal contents for a significant period. The http://pmj.bmj.com/ aminations of the gastrointestinal tract, and about symptoms are then those of a flatulent dyspepsia, 80 per cent. of these appear at the site of entry of with a sense of oppression in the epigastrium after the common bile duct into the duodenum, and are meals, and borborygmi. Pain is not a common hence called perivaterian. Except when situated symptom. The mimicry of chronic cholecystitis at the duodeno-jejunal flexure, duodenal diver- is particularly close and acquired diaphragmatic' ticula other than perivaterian very rarely give rise hernia may also produce similar symptoms. It to symptoms. must be stressed always that, unless there is The first part of the duodenum is never the seat unequivocal evidence of delay in the diverticulum, on September 27, 2021 by guest. of hernial diverticula and pouching in this situation the latter should not be regarded as the cause of is the result of chronic duodenal ulceration. The the symptoms. affected part of the duodenum is shortened by Perforation of a perivaterian diverticulum is contraction of scar tissue due to ulceration and almost unknown, but other complications are the unaffected unscarred portion of the duodenum recorded, e.g. chronic pancreatitis, obstructive balloons outwards. Though evidence of attenua- jaundice. Seldom, however, can diverticula be tion of the muscular wall may be found at the held responsible for either and any association fundus of such pouches when they are large and of between the two is likely to be coincidental. long standing, in the early stages their wall is Management. It is probably advisable to ignore normal. They never give rise to symptoms per se the presence of a small duodenal diverticulum dis- and their significance lies in furnishing absolute covered by barium meal. Knowledge of its exist- evidence of past or present chronic duodenal ence is of no material value to the patient and there ulceration. is no -known treatment which can influence it in- 22 POSTGRADUATE MEDICAL JOURNAL Yanuary '953 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from i.i..I;!·:...;,'i.c.3.-' ~~~~~~~~~........ ....... .:.: . ,, i'"... ......... ..... i.·I. ··.· ;·.. :..:: - "'f:·; :i ~ , T'·.-.spl ..r i.e i·,..·i..i--·: Y.' :~'~'~'~'~':"~ ~~.. ..........":'? ,i:. : ,. u4d ··. r S. ·;·-::·.·- ·,. b.·" .i···: ··8 .i.··".-,? I;··i: ~i: :i $r.. :.::;·):a ~ ~ ryp Bs --5 - - ---- 41i..r ly. ·i·?.:ll.I . .C9C.9p"BL. B 0 'AL-·:~ 1 l' P· ~· 1. ~ "· II... ..··i o ~ I sB.a Protected by copyright. .:: 6i FIG. Ib.-The diverticulum after removal. FIG. ia.-Perivaterian diverticulum showing retention 24 hours after ingestion of barium. to ensure that it is not violated and the pouch cut away after sealing its mouth with a clamp. Repair by two layers of catgut is recommended. The any way. Operation should be considered only removal of a pouch from the neighbourhood of the when the diverticulum retains barium after the duodeno-jejunal region is facilitated by division stomach has been empty for several hours and is of of the ligament of Treitz, after identifying and large size. In only three of a series of 8o patients safeguarding the inferior mesenteric vein. in whom a perivaterian diverticulum was revealed http://pmj.bmj.com/ by radiography could the author regard them as a The Jejunum probable cause of the symptoms. In all three Diverticula are less common in the jejunum barium was retained from I8 to 36 hours after the than the duodenum, probably because of the part stomach had emptied. (Figs. Ia and b). played in the formation ofthe latter by the common Diverticula at the duodeno-jejunal flexure. Di- bile duct. The condition is one of progressive verticula here tend to increase in size quickly, diverticulosis, with multiple pouches, which down the the probably because their mouth is at the acute turn spreads bowel, rarely reaching ileum; on September 27, 2021 by guest. of the bowel, and they are thus placed at a great it resembles diverticulosis of the colon in this mechanical disadvantage. Theby tend to burrow to tendency to progression. In old people many the ripht underneath the peritoneum and when of hundreds of pouches may be found. large size may cause intermittent duodenal obstruc- The symptoms caused are similar to those caused tion. For this reason operation for their removal by perivaterian diverticula, but may be even more should usually be undertaken.