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Diverticular Hemorrhage: Pathogenesis, Diagnosis and Management. Practical Gastroenterology. 26(1): 13-14, 19-20, 22. January 2002.

Colonic diverticular bleeding is common cause of lower gastrointestinal tract hemorrhage. This article discusses the pathogenesis (development), diagnosis, and management of diverticular hemorrhage. Diagnostic techniques involved in determining the extent and location of diverticular bleeding include scintigraphy, angiography, and colonoscopy. Therapeutic radiographic options in controlling diverticular bleeding involve the infusion of vasopressin or selective embolization. Recently, the role of colonoscopy has expanded to allow endoscopic hemostasis of bleeding diverticuli. Current options involve electrocoagulation, injection therapy, or endoscopic hemoclipping. Surgery may be required in patients who fail attempts at hemostasis with medical, angiographic, or endoscopic therapy. 1 figure. 35 references.

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Facts and Fallacies About Digestive Diseases. Practical Gastroenterology. 26(6): 76. June 2002.

This brief patient information handout reviews facts and fallacies about digestive diseases. Four false statements are considered: diverticulosis is an uncommon and serious problem; inflammatory bowel disease is caused by psychological problems; cirrhosis (liver scarring) is only caused by alcoholism; and after ostomy surgery, men become impotent and women have impaired sexual function and are unable to become pregnant. Each of these false statements is clarified and the accurate information is provided.

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Flexible Ureteroscopy Comes of Age. Contemporary Urology. 14(6): 32-33,36, 38, 40, 42, 47-50, 53-54. June 2002.

Since its introduction, major milestones in the evolution of flexible ureteroscopy have included the development of reliable active deflection, improved range of deflection, the combination of active and passive segments in the same endoscope, the addition of a throughput channel for irrigation and instrumentation passage, improvement in image resolution and light transmission, miniaturization of endoscopes to 7.5F or smaller, the advent of the holmium-yttrium-aluminum-garnet laser for lithotripsy and upper tract surgery, and the development of 2F to 3F accessory instrumentation. This article, the first in a two part series, brings readers up to date on the use of flexible ureteroscopy. The authors discuss current flexible ureteroscopes, and instrumentation, and clinical results of this procedure, as it is used for urinary tract stones, diagnostic procedures, upper tract tumors, ureteral strictures, and calyceal diverticulum. 1 figure. 6 tables. 36 references.

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Handbook of Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams and Wilkins. 2002. 931 p.

This handbook provides a more portable version of the larger textbook with the same title: Colon and Rectal Surgery, 4th Edition. The coverage addresses the entire range of diseases affecting the colon, rectum, and anus. A stepwise approach to treatment guides physicians from evaluation to follow up with incisive coverage of symptoms, testing and diagnosis, preparation, medical and surgical management, and postoperative care. Thirty-three chapters cover anatomy and embryology of the anus, rectum, and colon; physiology of the colon; diet and drugs in colorectal surgery; evaluation and diagnostic techniques; flexible sigmoidoscopy and colonoscopy; setting up a colorectal physiology laboratory; analgesia (pain killing) in colon and rectal surgery; hemorrhoids; anal fissure; anorectal abscess; anal fistula; rectovaginal and rectourethral fistulas; anal incontinence; colorectal trauma; management of foreign bodies; disorders of defecation; rectal prolapse, solitary rectal ulcer, syndrome of the descending perineum, and rectocele; pediatric surgical problems; cutaneous conditions; colorectal manifestations of acquired immunodeficiency syndrome (HIV); polypoid diseases; carcinoma (cancer) of the colon; carcinoma of the rectum; malignant tumors of the anal canal; less common tumors and tumorlike lesions of the colon, rectum, and anus; diverticular disease; laparoscopic-assisted colon and rectal surgery; vascular diseases; ulcerative colitis; Crohn's disease and indeterminate colitis; intestinal stomas; enterostomal therapy; and miscellaneous colitides. The handbook includes the same illustrations as the larger text. A subject index concludes the volume.

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Lower Gastrointestinal Bleeding and Ischemic Colitis. Canadian Journal of Gastroenterology. 16(9): 597-600. September 2002.

This article reports on a study that compared the incidence and clinical characteristics of lower gastrointestinal (LGI) bleeding due to ischemic colitis with those with LGI bleeding of other causes. A chart review was performed of patients admitted with LGI bleeding to Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, between July 1, 1997 and January 31, 2000. Of 124 patients with LGI bleeding, 24 cases were due to ischemic colitis, 62 to diverticulosis, 11 to inflammatory bowel disease (IBD), and 27 to all other causes ('others'). The average ages of patients in each group were 66.5, 76.5, 40.5, and 77.5 years, respectively. Patients with ischemic colitis were statistically younger than those with diverticular bleeding and 'others.' Patients with IBD were younger than those in the other three groups. The only statistical difference for vascular disease risks was hypertension, because of its absence from the IBD group. Three patients with ischemic colitis underwent blood transfusions, while 23 with diverticulosis, 15 'others' and none with IBD received blood. Three patients with ischemic colitis and one patient from the 'others' group died. More women (75) than men (49) had LGI bleeding, in total and within each subgroup. Of women with LGI bleeding, many more with ischemic colitis (44.4 percent) than with diverticulosis (3.0 percent), IBD (0 percent) or 'others' (5.6 percent) were taking estrogen. 16 references.

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Meeting the Challenge of Complex Urethral Diverticula. Contemporary Urology. 14(9): 52-54, 59, 62, 64, 66-68, 70. September 2002.

Diverticula (pouches) of the female urethra present one of the more challenging diagnostic and reconstructive problems in urology. Urethral diverticula (UD) are noted for a bewildering variety of clinical presentations, ranging from completely asymptomatic lesions noted incidentally on physical examination or x-ray to very debilitating, painful vaginal masses associated with incontinence, stones, and tumors. This article reviews the diagnosis and management of UD in females with an emphasis on some of the more complicated or challenging aspects of this condition. Topics include anatomy and pathophysiology, presentation and diagnosis, imaging techniques, and surgical considerations. The authors stress that a step-wise approach to the diagnosis and management of UD should result in successful therapy of even the most complicated case. Operative techniques, including creation of a neourethra, may be necessary to restore urethral continuity when there is circumferential extension of the UD. 7 figures. 1 table. 29 references.

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Timing of Prophylactic Surgery in Prevention of Diverticulitis Recurrence: A Cost-Effectiveness Analysis. Digestive Diseases and Sciences. 47(9): 1903-1908. September 2002.

Although surgery is recommended after two or more attacks of uncomplicated diverticulitis, the optimal timing for surgery in terms of cost-effectiveness is unknown. This article reports on a study in which a Markov model was used to compare the costs and outcomes of performing surgery after one, two, or three uncomplicated attacks in hypothetical cohorts of 60 year old patients. Transition state probabilities were assigned values using published data and expert opinion. Costs were estimated from Medicare reimbursement rates. Surgery after the third attack is cost saving, yielding more years of life and quality adjusted life years at a lower cost than the other two strategies. The results were not sensitive to many of the variables tested in the model or to changes made in the discount rate. The authors conclude that performing prophylactic resection after the third attack of diverticulitis is cost saving in comparison to resection performed after the first or second attacks and remains cost-effective during sensitivity analysis. 1 figure. 3 tables. 34 references.

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Understanding Diverticular Disease. Ostomy Quarterly. 39(2): 56-57. Winter 2002.

Diverticular disease is a condition where the diverticula form in the colon; it is associated with abdominal pain and disturbed bowel habits. The symptoms are caused by intestinal muscle spasms, not from an inflammation of the diverticula. Diverticulosis is the presence of diverticula in the colon with no symptoms. This newsletter article helps readers with ostomies understand diverticular disease. Diverticular disease is very common in the United States; roughly half of Americans develop diverticula by the age of 60 and nearly all of those over 80 do. Most people with diverticula have no complications. Unless a diverticulum becomes inflamed, it will produce no symptoms (including pain). The article considers the causes of diverticular disease, the symptoms, the causes of diverticulitis (inflammation), treatment strategies for diverticulitis, and the prevention of diverticular disease. A diet high in fiber may prevent the development of diverticula within the colon and may lessen the symptoms associated with diverticular disease. Most cases of diverticulitis respond to medical treatment. Surgery is reserved for patients with recurrent bouts of diverticulitis or when complications arise. 2 figures.

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Adult Onset Nocturnal Enuresis. Journal of Urology. 165(6 Part 1): 1914-1917. June 2001.

This article reports on a study that determined the etiology and prognostic significance of adult onset nocturnal enuresis (bedwetting) with absent daytime incontinence. The authors note that adult onset nocturnal enuresis not associated with daytime incontinence is uncommon and that there is a lack of information about its incidence, significance, evaluation, and treatment. The authors present a retrospective evaluation of this condition based on a database review of 3,277 consecutive patients referred for the evaluation of lower urinary tract symptoms. Patients with daytime incontinence were excluded from the study. Evaluation consisted of history, physical examination, American Urological Association (AUA) symptom score, voiding diary, uroflowmetry (measurement of urination), estimation of postvoid residual urine, video urodynamics, cystoscopy, and radiographic evaluation of the upper urinary tract. Of 3,277 patients, 8 (0.02 percent) had adult onset nocturnal enuresis without daytime incontinence as a primary complaint. Average AUA symptom score was 12.6 (range 3 to 25), average maximum urine flow was 8.5 milliliters per second (range 5 to 15), and average postvoid residual urine (urine remaining in the bladder after urination) was 350 milliliters (range 50 to 489). All patients were men with severe prostatic or vesical neck obstruction as well as bilateral or unilateral hydronephrosis (extra urine retention in the kidneys) in 63 percent, a bladder diverticulum in 38 percent, vesicoureteral reflux (return of urine from bladder back through the ureters to the kidneys) in 50 percent, and low bladder compliance in 50 percent. Transurethral prostatic resection (TURP) was recommended to all patients, but only 5 agreed. The other 3 cases were managed by alpha adrenergic antagonists, including 2 by adjunctive clean intermittent self catheterization. In all patients who underwent TURP, symptoms resolved. 2 figures. 1 table. 12 references.

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Diagnosis and Therapy of the Female Urethral Diverticula. International Urogynecology Journal. 12(1): 51-57. February 2001.

This article reviews the various diagnostic and therapeutic modalities currently in use for female urethral diverticula. Female urethral diverticula (a pouchlike herniation) have always been considered rare. Various radiographic techniques have been reported, but only voiding cystourethrography (VCUG) and positive pressure urethrography (PPU) are currently utilized. Urethroscopy is another suitable technique for diagnosis. Various sonographic (ultrasound) techniques have been proposed, but their sensitivity is improved only by the transvaginal approach and magnetic resonance imaging (MRI). Various treatment methods have been proposed. The standard operative approach is surgical, through the vagina. The techniques currently in use to treat urethral diverticula are the Spence procedure, the typical urethral diverticulectomy, and the Tancer partial ablation technique. A full history and physical examination are the first step in screening. When the diagnosis is suspected, ultrasound and radiological imaging is necessary. Symptomatic and very large diverticula must be treated in the easiest way possible. The best treatment, except for complicated and infected diverticula, is excision. 1 table. 61 references.

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