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Diverticular Disease in the Elderly. Gastroenterology Clinics of North America. 30(2): 475-496. June 2001.

The term diverticular disease refers to the entire spectrum of asymptomatic to symptomatic disease associated with colonic diverticula (a pouch or sac created by herniation of the lining of mucus membrane in the intestine). Diverticulosis is the presence of one or more diverticula; diverticulitis is diverticulosis with clinical symptoms and evidence of inflammation. This article, from a special issue on gastrointestinal (GI) disorders in the elderly, addresses diverticular disease, a condition of special significance in the elderly. The incidence and severity of diverticular disease increases with age. Elderly patients often present with complicated diverticular disease, and because of their advanced age, poor ability to provide a history, and muted symptoms and signs, the diagnosis is particularly difficult to make. Consequently, great demands are placed on the physician to diagnose and treat diverticular disease in this population. In the past, advanced age made conservative therapy the standard of care for most patients; however, recent endoscopic, radiologic, and surgical advances have helped define more definitive therapies for patients with complicated diverticular disease. Complications of diverticulitis can include abscess, fistula (an opening between the colon and surrounding structures), obstruction, free perforation, and diverticular hemorrhage. Treatment strategies include bed rest, oral broad spectrum antibiotics, bowel rest, and oral hydration for uncomplicated diverticulitis; complicated diverticulitis generally requires surgery in addition to these primary care strategies. Lack of improvement with medical management may indicate a peridiverticular abscess. Recurrent diverticulitis is less likely to respond to medical management. Elective surgery should be considered after the second attack. 4 figures. 1 table. 82 references.

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Diverticulosis and Diverticulitis: Understanding and Managing Two Common Colon Problems. [Diverticulosis y Diverticulitis: Como Entender y Controlar Problemas Comunes del Colon]. San Bruno, CA: StayWell Company. 2001. 7 p.

This patient education brochure describes two common colon problems: diverticulosis and diverticulitis. Written in nontechnical language, the brochure defines diverticulosis as small pouches in the colon wall; diverticulitis is a more serious problem that occurs when these pouches become infected or inflamed. Although aging may contribute to colon problems, food choices are the primary concern for the health of one's colon. A low fiber, high fat diet can lead to an unhealthy colon. The brochure describes how pressure can cause pouches in the colon and then the conditions that can lead to diverticulitis. Symptoms often include pain, fever, chills, cramping, bloating, constipation, or diarrhea. Diet changes or medications may be enough to bring relief; in severe cases, surgery may be needed. The diagnosis will include the patient's history, a medical exam, and diagnostic tests, including barium enema, sigmoidoscopy, and colonoscopy. The two keys to controlling diverticulosis are dietary fiber (roughage) and liquid. Fiber absorbs water as it travels through the colon, helping the stool stay soft and move smoothly with less pressure. Eating more high fiber foods and drinking more liquids can often keep diverticulosis in check. If diverticulitis symptoms are mild, the treatment may begin with a temporary liquid diet and oral antibiotics. If the diverticulitis is severe, the patient may need bed rest, hospitalization, and intravenous (IV) antibiotics and nutrients. Surgery may be indicated in some cases and the brochure outlines the typical colon surgery resection that is used. The brochure concludes by reminding readers of the importance of dietary fiber and lists common foods that are high in fiber. The brochure is illustrated with full color line drawings and is available in English or Spanish. 19 figures.

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Female Urology and Incontinence. In: Weiss, R.M.; George, N.JR.; O'Reilly, P.H. Comprehensive Urology. Orlando, FL: Mosby, Inc. 2001. p. 477-492.

Urinary incontinence (involuntary loss of urine) is most frequently related to bladder or urethral dysfunction. Characteristics that promote continence include maintenance of normal bladder pressure to volume relations, absence of uninhibited bladder contractions, reasonable bladder emptying, satisfactory intrinsic closure capabilities of the urethra, and functional support structures that maintain the urethra in its normal retropubic position. This chapter on female urology and incontinence is from a comprehensive urology textbook. The authors address the typical female urologic entities, with a particular focus on incontinence, with the exception of those (interstitial cystitis, urinary tract infection, and fistulae) that are covered elsewhere in the text. Topics include the epidemiology and pathogenesis of urinary incontinence (UI), bladder dysfunction, overflow incontinence, stress UI, pelvic prolapse, urethral diverticulum, and other vaginal wall masses. The chapter is illustrated with full-color drawings and photographs. 21 figures. 59 references.

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Flexible Sigmoidoscopy. American Family Physician. 63(7): 1375-1380. April 1, 2001.

Flexible sigmoidoscopy remains a common tool used for the periodic screening of colorectal cancer. This article reminds family care physicians of the recommendations for the use of flexible sigmoidoscopy. Most organizations recommend screening at three to five year intervals beginning at age 50 for persons with average risk. Extensive training in endoscopic maneuvering, colorectal anatomy, and pathologic recognition is required. Most physicians report comfort performing the procedure unsupervised after 10 to 25 supervised sessions. The procedure itself involves the insertion of the sigmoidoscope through the anus and distal rectum and advancement of the scope tip to an average depth of 48 to 55 centimeters in the sigmoid colon. Once the sigmoidoscope has been appropriately advanced, the scope is slowly withdrawn, allowing for the inspection of colon mucosa during withdrawal. Polyps less than 5 millimeters in diameter should be biopsied. Polyps 5 to 10 millimeters or greater can be assumed to be adenomatous, and follow up colonoscopy for complete polypectomy is required. Diverticulosis, hemorrhoids, nonspecific colitis and pseudomembranes may also be encountered during inspection. Use of preprocedural benzodiazepines can be helpful in reducing patient discomfort. 2 figures. 10 references.

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Flexible Sigmoidoscopy: A Pictorial Atlas. Patient Care. 35(18): 13-27. September 30, 2001.

Endoscopy continues to play an important role in colorectal screening. It is important to identify the members of those families that are at high risk for colon cancer and diligently screen them using colonoscopy. This article helps readers update their clinical skills regarding colorectal screening with direct instruction and a full color pictorial atlas. The author notes that the entire 360 degrees of the colon wall in each segment should be scrutinized as the instrument is slowly and deliberately withdrawn. In order to maximize the depth of insertion, it is important to minimize overinflation of the colon. The majority of pathologies seen in primary care are diverticulosis, hemorrhoids, and polyps. Approximately 95 percent of all colorectal cancers arise from benign polyps. Some experts recommend colonoscopy for all average risk persons older than 50. Mixed screening strategies may be employed more frequently in the future, or it may be appropriate to switch strategies as people age. Performing flexible sigmoidoscopy can be time intensive for a busy primary care physician. Experts have suggested that nurse practitioners and physician assistants be trained so that more patients can be screened (one sidebar summarizes this concept). 9 figures. 12 references.

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Hemorrhoids and More: Common Causes of Blood in the Stool. Digestive Health and Nutrition. 3(4): 24-26. July-August 2001.

Most rectal bleeding is caused by hemorrhoids, which usually can be simply and effectively treated. This article reviews the many other conditions, including some serious disorders, that can cause blood in the stool. The author reminds readers that bleeding from any part of the nearly 40 foot long digestive tract can cause blood in the stool. Accurate and timely diagnostic tests are important to determine the cause of any bleeding. Bleeding higher up in the gut, from the esophagus or stomach, can result in stools with a black, tarry appearance. Bleeding from the lower end, such as the colon, or in large amounts, can appear as pure blood, blood clots, or as blood mixed with or streaking the stool. Another kind of blood, occult or hidden blood, may not be visible at all. A number of prescription and over the counter (OTC) medications can cause bleeding in the stomach and small intestine. The blood thinning drug warfarin also can induce bleeding in the intestine, as can some antibiotics. Other causes of bleeding can include ulcers, gastritis (inflammation of the stomach lining), ulcerative colitis, Crohn's disease, polyps (small growths inside the intestine), diverticular disease, abnormalities in the blood vessels (vascular anomalies), anal fissures (tears) and fistulas (abnormal openings between the anal canal and other organs, such as the bladder), and abscesses (pockets of infection. The author reiterates the importance of timely diagnosis, including a thorough patient history and evaluation of symptoms. Diagnostic tests can include blood tests, digital rectal examination, endoscopy, colonoscopy, sigmoidoscopy, fecal occult blood test, barium x rays, angiography (x rays of blood vessels), and nuclear scanning. Treatment depends on the source and extent of the bleeding.

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Inflammatory Bowel Disease in the Elderly. Gastroenterology Clinics of North America. 30(2): 409-426. June 2001.

Roughly 15 percent of all patients with inflammatory bowel disease (IBD) first develop symptoms after age 65. As the number of elderly in the population continues to grow, clinicians should see a greater number of elderly IBD patients. This article, from a special issue on gastrointestinal (GI) disorders in the elderly, addresses IBD in the older patient. In general, the presenting features of IBD are similar to those encountered in younger patients, but the broad differential diagnosis of colitis in the elderly can make definitive diagnosis more challenging. Despite many advances in cellular and molecular biology, the precise cause of IBD is elusive. The elderly are particularly susceptible to GI infection, suggesting a possible compromise of the mucosal immune system with age. The presentation and course of both ulcerative colitis (UC) and Crohn's disease (CD) in older patients is similar to that in younger patients. Differential diagnosis can include infection, ischemic colitis, diverticular disease, microscopic colitis, medications, and other conditions (lymphoma, radiation enterocolitis, vasculitis, amyloidosis). Whereas most therapies for IBD have not been studied specifically in the elderly, as a general rule, medical and surgical treatment options are the same irrespective of age. The authors stress that osteoporosis (abnormal loss of bone density), a condition generally associated with aging, should be managed aggressively in patients with IBD because many older persons already have a substantial baseline risk for accelerated bone loss. 1 figure. 2 tables. 123 references.

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Laparoscopically Assisted Bowel Resection. In: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 453-455.

This chapter on laparoscopically assisted bowel resection is from the second edition of a book devoted to the details of medical, surgical, and supportive management of patients with Crohn's disease (CD) and Ulcerative Colitis (UC), together known as inflammatory bowel disease (IBD). Laparoscopic resection for inflammation makes good sense, but has inherent technical challenges. The most common indications for bowel resection related to inflammation are diverticulitis and inflammatory bowel disease (IBD). Inflammation can make dissection difficult and potentially dangerous. Acute indications include bleeding, obstruction, and, rarely, perforation. More chronic indications include fistulization, chronic obstruction, and perianal abscess. Since societal costs can be significant in terms of insurance expenditure for an in patient and time lost to business, a laparoscopically assisted approach may benefit some patients with Crohn's disease (and their health care provider). This approach is appropriate for virtually all patients with Crohn's disease. The only exceptions are those with known phlegmons, multiple strictures, or complex fistulae (abnormal passageways). However, the procedure is safe only if the surgeon is willing to convert to a standard surgical technique when difficulty is encountered or when the dissection becomes potentially dangerous. Obviously, no rules can be offered in this regard, since it depends upon the individual combination of the patient's diseased bowel state, the surgeon's skill level, and the sophistication of the surgeon's tools. In general, a laparoscopically assisted procedure is appropriate for nutritionally sound patients who have obstruction or intractable disease without complications. 7 references.

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Lateral Approach to Laparoscopic Sigmoid Colon Resection. Journal of the American College of Surgeons. 193(1): 105-108. July 2001.

Laparoscopic sigmoid colon resection has been traditionally performed using an anterior (front) approach with the patient placed in a modified lithotomy position. In this article, the authors report their experience and describe their technique for laparoscopic sigmoid colon resection using a lateral approach. The lateral position provides excellent visualization of the splenic flexure, and the entire left colon can be moved easily without the need for excessive retraction. This position allows gravity to aid in the retraction of the left colon. Once the lateral peritoneal reflection is incised, the left colon falls away from the retroperitoneum, exposing the ureter and the gonadal vessels on the lateral side and the mesenteric vessels, including the inferior mesenteric artery and vein, on the medial side. In addition, the cosmetic results of this approach are superior to those of the anterior approach. The authors report on 8 sigmoid colon resections that were performed using the laparoscopic lateral approach. The patients were eight men with ages ranging between 32 and 70 years (average 48.5 years). All procedures were performed for diverticular disease. Mean operative time was 152 minutes (range 125 to 216 minutes). Of the eight patients, three had the procedure using only three trocars, and five patients required the placement of four trocars. None of the patients required an open procedure. 4 figures. 4 references.

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Liver Abscesses and Hydatid Disease. In: Beckingham, I.J., ed. ABC of Liver, Pancreas and Gallbladder. London, UK: BMJ Publishing Group. 2001. p.29-32.

Liver abscesses are caused by bacterial, parasitic, or fungal infection. This chapter on liver abscesses and hydatid disease is from an atlas of the liver, pancreas and gallbladder. Topics include the etiology, microbiology, clinical features, laboratory investigations, and treatment of pyogenic liver abscesses; the pathogenesis, clinical presentation, diagnosis and treatment of amoebic liver abscess; and the presentation, diagnosis, treatment of hydatid disease (caused by the dog tapeworm) in humans. Most patients with pyogenic abscesses will require percutaneous drainage and antibiotics. A cause can be identified in 85 percent of cases of liver abscess, most commonly gallstones, diverticulitis, or appendicitis. The chapter concludes with summary points of the concepts discussed. 8 figures. 4 table. 3 references.

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