A suspicious sigmoid stricture?

This is a most peculiar sigmoidoscopy! There is a narrowing of the lumen in the mid-sigmoid that the endoscopist is able to traverse. On the other side of the stricture you find yourself looking at… small bowel mucosa! The patient has suffered a colonic perforation that has given rise to a fistula into the ileum, so option e is the correct answer.

Diverticular disease used to be a condition that was firmly in the surgical camp. However, uncomplicated diverticulitis is increasingly managed with conservative therapy and it appears that we don’t even need to give antibiotics in all cases.¹ Only about a quarter of patients develop complications requiring surgery. Remarkably, patients who are well but have free air in the abdomen that is visible on X-ray, may be treated with antibiotics and bowel rest²  and abscesses are usually drained radiologically.

In a case such as this, with a combined small bowel and colonic obstruction, surgery is indicated. The traditional operation is the Hartmann procedure with a proximal colostomy. The drawback is that a proportion of patients who undergo this procedure will never have their bowel continuity restored. In view of this, many colorectal surgeons have advocated that a primary anastomosis can be an equally safe but a better alternative in selected cases. There is no evidence from clinical trials to inform us which is the better option. However, the construction of a primary anastomosis is more demanding and requires the sound clinical judgment of an experienced colorectal surgeon to decide when this option is likely to fail.

The Postgraduate Course of the UEG Week 2013 dedicated a complete session to the topic of diverticular disease (Diverticular disease: Important, poorly understood and badly managed) and is well worth a look. Just sign in to myUEG, put ‘Diverticular disease’ into the UEG Education Library search box and hit enter!