| Abstract|| |
Background: Diverticular disease of the colon is rarely seen in Saudi Arabia and this paper describes our experience with 16 patients admitted to hospital during an 8-year period (March 1990 - February 1998). Patients and Methods: A computerized data base of patients having colorectal surgery was searched to identify patients admitted to the colorectal unit suffering from diverticular disease of the colon or it's complications. The records of these patients were examined and form the basis of this report. Results: Sixteen patients were admitted to the colorectal unit for the management of diverticular disease or it's complications during an 8-year period. One patient presented with a localized abscess which was drained percutaneously. Fifteen patients underwent one or more surgical interventions. There were three female patients. One patient was referred for stoma closure, four for elective surgery and ten with acute perforation of whom one underwent right hemicolectomy for a perforated caecal diverticulum and nine underwent Hartmann's procedure for sigmoid perforation. Two patients required multiple abdominal washouts. Post-operatively two patients developed severe chest infections, one developed renal failure and two urinary infections. Four wounds became infected and two intra abdominal collections were drained percutaneously. No patient died. Eight stomata (89%) were subsequently closed. The mean duration of follow up was 2.7 yr. Four patients were lost to follow up. Conclusion: This small series documents the presence of diverticular disease and it's complications in the Kingdom of Saudi Arabia and suggests that the commonest method of presentation may be an acute one. Surgeons must thus be mindful of the condition and take appropriate action. Hartmann's' operation was safe and resulted in a low morbidity and no mortality. 89% of the stomata were closed at a later procedure.
Keywords: diverticular disease, perforation, Saudi Arabia
|How to cite this article:|
Isbister WH. Diverticular disease: An experience at King Faisal specialist hospital. Saudi J Gastroenterol 2001;7:109-12
| Introduction|| |
It has been postulated that there are two kinds of diverticular disease. One is associated with a distally situated muscle abnormality and bowel symptoms with diverticula in the left colon only, in which inflammation and perforation are common; the other without the muscle abnormality, with few bowel symptoms, in which inflammation and perforation are rare but bleeding may be common , . The former type of disease maybe caused by a low residue diet, which includes an unnatural amount of refined carbohydrate  . The latter disease may be the result of some connective tissue abnormality, which may be determined congenitally  . The asymptomatic type of disease may thus be more common in countries where the adoption of a `westernised' diet has been delayed.
Diverticular disease of the colon is rarely seen in Saudi Arabia and during a recent eight-year period only 16 patients were admitted to the King Faisal Specialist Hospital (KFSH) for treatment in the colorectal unit. This paper describes our experience with these few patients.
| Patients and Methods|| |
A computerized database of patients having colorectal surgery in the colorectal unit at King Faisal Specialist Hospital has been maintained since March 1990. The records of all patients admitted to the colorectal unit at KFSH between this time and February 1998 were searched for those patients considered to be suffering from diverticular disease of the colon or it's complications. The records of the patients identified were examined for demographic information, method of presentation, symptoms and duration, investigations, management, follow up and outcome.
Primary resection and anastomosis was undertaken in patients presenting electively with chronic complications of diverticular disease whereas patients presenting as emergencies with perforation underwent Hartmann's resection of the perforated colon. If widespread peritoneal contamination was found at laparotomy peritoneal lavage was performed on an alternate daily basis  in addition to resection of the diseased bowel until the peritoneal cavity was found to be clean and systemic signs of infection had settled.
| Results|| |
Between March 1990 and February 1998, sixteen patients were admitted to the colorectal unit for the management of diverticular disease or its complications. One of these patients presented with a localized abscess which was identified by abdominal CT scan and which was drained, per cutaneously, under ultrasonic guidance.
The remaining 15 patients underwent one or more operative surgical interventions and form the basis of this study. There were three female patients (av. age 56.8 yr.) and 12 males (av. age 47.3 yr.).
One patient was referred for stoma closure following emergency surgery at another hospital, four patients were admitted for elective surgery and ten patients were admitted acutely with perforation. One elderly woman was heavily immunosuppressed following kidney transplantation and presented with few abdominal signs except distension. A straight abdominal radiograph demonstrated free air in the peritoneal cavity, and she was found at operation to have a sigmoid perforation. Another patient was suffering from myasthenia gravis but had an uncomplicated surgical course. All except two of the patients complained of pain in the left iliac fossa. All patients, except one, claimed to have had difficulty passing bowel motions at some time prior to surgery. Five of the patients had had barium studies of the colon prior to their surgery. Four showed diverticula limited to the sigmoid colon and one was found to have more extensive disease. Five patients had had an ultrasonic examination of the abdomen prior to surgery. One examination correctly excluded the presence of an abscess in relation to the inflamed sigmoid colon. One examination showed an `ovarian cyst' and at operation the patient was found to have a diverticular associated abscess cavity in the sigmoid mesentery, two patients were said to have acutely inflamed appendices and were found to have perforated diverticula and one abscess was correctly identified.
Eight of the ten patients, admitted as emergencies, were acutely tender in the left lower quadrant of the abdomen on admission. Seven of the ten patients had rebound tenderness. The white cell count (WCC) was elevated only in five patients despite the presence of a perforation in ten (two free and eight localized). The average WCC was 11.4 x 10 9 / 1. One of the ten patients presented with pain and tenderness in the right lower quadrant of the abdomen and underwent, right hemicolectomy for a perforated caecal diverticulum. The remaining nine patients underwent Hartmann's procedure [Table - 1]. Following emergency resection, two patients developed severe chest infections. One patient who had perforated two days prior to surgery required four abdominal washouts and in the ICU developed the acute respiratory distress syndrome. A further patient was washed out on four occasions before his abdominal wound was closed. One patient developed renal failure and two patients had urinary infections. Four wounds became infected and two intra abdominal collections were drained percutaneously post surgery. There were no anastomotic leaks and no patient died following surgery. All stomata, except one in a patient considered to be too sick for further surgery, were closed (88.9%). No patient developed a recurrence of symptoms during follow up. All patients were advised to ingest a high fibre diet after surgery. In addition, because of a tendency towards poor patient compliance with dietary advice, all patients were advised to take a bulking agent (Metamucil, Searle Pharmaceuticals, and High Wycombe, England Wycombe). The mean duration of follow up was 2.7 years. Four patients were lost to follow up.
| Discussion|| |
Colorectal cancer and inflammatory bowel disease are known to be less common in the Kingdom of Saudi Arabia than elsewhere in the West ,, . Between March 1990 and February 1998, the time period of the present study, four hundred and forty seven operations were undertaken in patients with colorectal cancer. During this same time period only 16 patients were admitted for the surgery of their diverticular disease. These findings suggest that diverticular disease is much less common in Saudi Arabia than the `West'. It was not felt that referral bias was influencing our findings because the majority of patients with serious colorectal complications are referred at some time during their clinical course to KFSH.
Most of our patients with diverticular disease were male (M:F ratio = 4:1) but in the `West' there is usually a slight preponderance of females (1:1.2)  . This finding could be due to shyness but this seems to be unlikely. It has already been suggested that shyness may result in an erroneously low rate of large bowel cancer in females in Saudi Arabia  just as shyness may also prevent women from seeking medical aid for breast disease  . There is now growing evidence, however, to suggest that increasing numbers of both males and females seek and have access to medical care. For example in 1950-61 the male to female ratio for all cancers in the Kingdom was 2.7:1 but by 1984 the ratio had fallen to 1.3:1  .
The majority of our patients presented with perforation of a diverticulum (8/12) whereas in Western series this number was much lower (2-27.1%) , . and frequently followed a second attack of symptoms  . It has been suggested that the disease is more aggressive in patients under 40 years of age  but only five of our patients were in this age group and only three of them presented acutely. In contrast only one of our patients above 40 years presented electively with pain and narrowing of the colon. Perforation is more common in patients who have few diverticula because the high intraluminal pressure, which is responsible for perforation, tends to be dissipated in colons in which there are many diverticular  . All of our patients who presented with perforation had few diverticula and often the perforated diverticulum was the only one found on pathological examination of the resected specimen.
Elective patients were investigated with Barium studies but neither these nor ultrasonic methods  nor abdominal CT scanning proved to be of much value in our patients because the majority of the patients presented acutely and proceeded to surgery as a result of the clinical findings. Abdominal ultrasound missed abscesses found at laparotomy and misdiagnosed acute appendicitis  . The white cell count was of little value either in clinical decision making and was `normal' in the majority of our patients .
Right-sided diverticulitis is rarely seen in Western surgical practice although the right colon seems to be the commonest site of the disease in Japan  . Right-sided diverticulitis frequently mimics acute appendicitis  and therefore usually diagnosed first at the time of surgery. A correct radiological diagnosis is rarely made (10%), and diagnosis is usually made at operation as in our case. Failure to undertake right hemicolectomy initially may result in the need for further surgery later for persistent disease  .
Although the number of patients in this series was small no one died despite the presence of perforation and peritonitis in all the ten patients operated upon acutely. The morbidity rate was low also and may be the consequence of avoiding a colonic anastomosis in the contaminated peritoneal cavity, and waiting for about six months before attempting to close the resulting stomal ,. A high proportion (89%) of the stomata were closed and it is suggested that many of the reported difficulties  relating to and resulting in low closure rates  may be overcame by delaying closure. In patients in whom peritoneal soiling was so great that the patients underwent repeated lavage  , a group in whom stoma closure might be expected to be difficult, the stomata were closed without complication when time was allowed for resolution and maturation of peritoneal adhesions.
This small series from KFSH documents the presence of diverticular disease and it's complications in the Kingdom of Saudi Arabia and suggests that the commonest method of presentation may be an acute one. Surgeons must thus be mindful of the condition, especially in patients with acute onset lower abdominal pain, and take appropriate action. In the acute setting we found that Hartmann's' operation was safe and resulted in a low morbidity and no mortality with 89% of the stomata being closed at a later date.
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William H Isbister
Haus Tanneck, D 90537 Feucht/Moosbach, Hangstrasse 4, Germany
Source of Support: None, Conflict of Interest: None
[Table - 1]