The literature on the anatomical distribution of diverticula in the large intestine has been reviewed and compared with the findings obtained from a survey of 5094 barium investigations carried out in the period 1967-1972. Of 310 patients with colonic diverticula the anatomical distribution of the diverticula was studied in 259. Though there is general agreement that the commonest sites of involvement are the sigmoid and descending colon, the anatomical distribution of diverticula as reported by various authors shows considerable variations; possible reasons for these variations are mentioned. The relation of the age of the patient to the extent or involvement and to the number of diverticula and the age and sex differences between patients with right sided and those with left sided colonic diverticula are discussed.peer-reviewe

Pace, Joseph L.

Podesta, Marie Therese

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133 ANATOMICAL DISTRIBUTION OF DIVERTICULA OF THE LARGE INTESTINE MARI£ T. PODESTA and J.L. PACE Department of Anatomy, Royal Univer'sity of Malta IntroducHon The anatomical distribution of diverti-cula of the large intestine as reported by different authors varies widely. This may be due to s~veral factors, including the geograph:cal since the r:ght colon is much more oftsn involved in Orientals than in Europeans (Peck et al., 1968). The methods of investigations used by different authors (viz. surgery, radiology, necropsy) involve population selection and so influence rresults. Thus surgery is undertaken for symptomatic or complicated cases only and small d:verticula scattered throughout the colon are liable to be missed at operation. Barium investigations are usually under-taken because of alimentary symptoms and may not give a true picture of the distri-bution of diverticula due to inadequate filling by barium. Necropsy studies include older subjects but allow direct examination both of mucosal and serosal colonic sur-faces and are probably the most reliable method of study of the anatomical distri-bution of divert:cula. Furthermore, the number and age of the patients studied varies with the different investigations; the greater the number of patients surveyed the more reliable is the investigation, while the average age of the patients investigated is also important since diver-t~cula of the right colon occur in a younger age group. Materials and Methods The literature on the anatomical dis-tribution of diverEcula of the large intes-tine was reviewed and compared with the findings obtained from a survey of 5094 barium investigations carried out in the period 1967-1972. Of 310 patients with colonic diverticula the anatomical distri-bution of the diverticula was studied in 259. Observations In the present survey, diverticula were found to involve predominantly the 12ft colon (98.4%). Involvement of the right colon was uncommon (18.9%) and generally occurred as part of more extensive involve-ment (18.1). The commonest regions affected were the sigmoid only (48%), thl:. sigmoid with the descending colon (24.4%) and the descending colon (13%). The sig-moid was involved alone or in combination with other regions in 84% of cases. The average age of patients with extensive involvement was 62.6 years, while that 01 patient8 with diverticula limited to the sigmoid or s:gmoid and descending colon was 61.1 years. Patients with few diverticula were on an average significantly younger (60.5 years) than patients with many diverticula (64.6 years), 134 Discussion There is general agreement that diver-ticula occur most frequently in the sigmoid colon whilst involvement of the adjacent rectum is extremely rare (Table 1,. The sigmoid may be involved alone or in com-bination with other regions, usually the descending colon (Table 2). Some investig-ators state that diverticular disease invol-ving initially the sigmoid region may spread proximally until sometimes the entire large intestine and even the rectum may be affected (Homer, 1958; Painter, 1968). Others maintain that the progress of the disease is usually limited to the seg-ments affected initially because patients with extensive involvement are younger than patients with disease localised to the lower colon (Parks, 1969). In our survey the average age of patients with extensive involvement was not significantly different from that of patients with diverticula limited to the lower colOl!. ~ = It has been previously observed and .... ~ this has been confirmed in our series that Q,) j;;, there is much variation in the distribution ~ ~ of diverticula along the colon. Thus diverti- is cuI a may be limited to the transverse colon or to peculiar combination of sites (eg. sig-moid with ascending colon) with the inter-vening area free from disease. The right colon is infrequently affected by diverticular disease: its involvement may be manifested as part of more exten-sive diverticular disease, as localised diverticular disease or as a solitary diverti-culum. In our survey the former type of involvement was by far the commonest. The number of diverticula appears to increase with the passage of '3fme, since patients with many diverticula are, on average, older than those with few diver-ticula (Parks, 1969). This was confirmed in our own study since patients with few diverticula were appreciably younger than those with many. Right-sided diverticula occur at an earlier age than the more com-mon left-sided form and are eq'.lally distri-buted between the sexes (Anderson, 1947). We found that the distribution of right-sided diverticula was equal in both sexes. ..... o .s .... CIl o o o o o:l o o:l o o o Cf:) o 0) Table 11 Location of Diverticula (in percentages) Author No. in Sigmoid Sigmoid and Sigmoid not R. Colon Whole Colon Series Desc. Colon involved only McGrath (1912) 27 74 0 22.1 0 Rankin & Brown (1930) 111 29 3 Ochsner & Bargen (1935) 208 47 19 6.25 3.8 11 Willard & Bockus (1936) 72 39 5.5 5.5 Brown & Marcley (1937) 518 56 24 2.5 8 Homer (1952) 364 47.9 29.6 8.5 2.7 Homer (1958) 503 47 33 5 1 Brassinne e't al. (1960) 86 51 18.6 25.4 11.6 4.6 Slack (1962) 26 88 4 0 Torsoli et al. (1966) 152 34 16 Molteni (1967) 154 4 6 Parks (1968) 111 44 27 6.3 2.7 5.4 Hughes (1969) 90 40 30 7 5 16 Parks (1969) 461 65.5 18 4 0 6.8 Tagart (1969) 98 78.6 16.3 2 1 3 Painter et al. (1972) 70 44.3 34.3 8.6 1.4 5.7 I-' Present Survey (1972) 259 48 24.4 16 0.8 0 CoO e.n 136 The s;gmoid colon is the s~te of elec-tion for diverticula becaus3 its spscialised function is to hold up the faecal stream by segmentation. A deficiency of dietary fibres alters the viscosity and speed of trans~t of the stools and may cause the s.i.gmo:d to s~gment excessively (Painter, 1969). Thick-ening of both longitudinal and circular layers of muscle occurs and appears to precede the development of diverticula (Morson, 1963). The circular muscle and mucosa are thrown into ridges which !:lur-round and narrow the lumen like in-complete sphincters (Painter, 1968) causing obstruction to outflow and producing zones of high pressure by contraction of the muscle wall in the segmented region; the puls'on force generated drives the mucosa through the inner segmental wall (Painter and Truelove, 1964). In diverticular disease lim:ted to the right colon, hypertrophy of the colon:c musculature has not been observed (Peck et al., 1968). Weak areas in the colon wall are exploited. The circular muscle coat is fa!:lCl-culated and diverticula are usually situated between the muscular fascicles in the parts of the colonic wall not strengthentd by the taeniae. The relation of diverticula to the blood vessels has been much d:sputed. According to Fleischner et al. (1964) arteriography shows that the relation of the diverticula to the penetrating vessels is inconstant; this was confirmed by Noer's studies (1955). In contrast, Edwards (1954) related the site of the diverticula to the point of entry of the blood vessels, and Slack (1962), studing the locafon of sigmoidal diverticula reached a comparable conclusion. He observed that sigmoidal diverticula occur pr:ncipally in 4 rows on both sides of the mesenteric taenia, though smaller divert'cula are occas onally present between the 2 antimesenteric ta:miae. The clinical manifestations and com-plications of diverticular disease of the colon are intimately related to the anato-mical d!str~bution of the diverticula - thus, pain is usually referred to the left lower quadrant, haemorrhage, if it occurs, is oftsn massive due to the close relation of diver-ticula to large blood vessels (Nigro, 1 ~66), and the disease in the caecum and ascend-in~colon often mimics acute append:citis; fistulae open into neighbouring organs, usually the bladde:r. Conclusion The literatuI'c on tlle anatomical distn-bution of diverticula in the larg:c intesEne has been reviewed and compared with the find:ngs from a survey of 259 barium investigatlOns in which diverticula were present. Though there is general agree-ment that the commonest s~tes of mvolve-mem are the sigmoid and descending colon the anatomical distribJ.tion of diverticula as reported by various authors shows con-siderable variations; possible reasons for th8se variations are ment~oned. The rela-tion of the age of the patient to the extent or involvement and to the number of diver-ticula and the age and sex differeno3s between paCents with right sided and those with left sided colonic d:verticula are discussed. Acknowledgemems Our thanr.:s are due to the surgeons ana pi.lysicians and to the Radiology Department of St. Luke's Hospital, Malta, for permission to review their surgical, medical and rad:ological recordS. References ANDERSON, L. (1967). Surgery, 22, 479. BRASSINNE, A., RUYTERS, L. & NAOME. J. (1960). Acta gastro-ent. beLg., 23" 828. BROWN, P.W. & MARCLEY, D.M. (1937). J. Amer. med. Ass., 109, 1328. CASE, T.C. & SHEA, C.E., Jr. (1953). Amer. J. Sum .. 92, 616. EDWARDS, H.C. (1954). Ann. ray. CaLL Surg. EngL., 14, 371. FLEISCHNER, F.G., SI·CHUN MING & HENKEN, E.M. (1964). RadioLogy, 83, 859. GOODWIN, F.R. & COLLINS, E.N. (1948). CLeve-Land CUn. Quart., 15, 194. HORNER, J.L. (1952). GastroenteroLogy, 21, 223. HORNER, J.L. (1958). Amer. J. dig. dis., 3, 343. HUGHES, L.E. (1969). Gut, 10,336. LLOYD WILLIAMS, K. (1960). Brit. J. Surg., 47. 351. MARATKA, Z., ROUBKOVA, H. & KOCIANOVA. J. (1965). 16th Congress of the Italian Society of Gastroenterology, Bo~ogna, 916. MAYO, C.W. & BLUNT, C.P. (1950). Sura. Clin. N. Amer •. 30, 1005. McGRATH, B.F. (1912). Surg. Gynec. Obstet., 15, 429. MOLTENI, F., PEDRONI, G., CARESANO, A.. SCOTTI·FOGLIENI, C. & DE SANTIS. L.A. (1967). Chir. Ital.. 19. 209. MORSON, B.C. (1963). Brit. J. Radiol., 36, 385. NIGRO, N.D. (1966). Sth. med. J., 59, 1019. NOER. R.J. (1955). Ann. Surg., 141, 674. OCHSNER, H.B. & BARGEN, J.A. (1935). Ann. Intern. Med .. 9, 282. PAINTER, N.S., & TRUELOVE, S.C. (1964). Gut. 5, 20l. PAINTER, N.S. (1968). Brit. med. J., 3, 475. 137 PAINTER, N.S. (1969). Lancet, 2, 586. PAINTER, N.S., ALMEIDA, A.Z. & COLE· BOURNE, KW. (1972).Brit. med. J., 2, 137. PARKS, T.G. (1968,).Proc. roy. Soc. Med., 61, 932. PARKS, T.G. (1969). Brit. med. J., 4, 639. PECK, D.A., LABAT, R. & WAITE, V.C. (1968). Dis. CoLon Rect., 2, 49. RANKIN, F.W. & BROWN, P.W. (1930). Surg. Gynec. Obstet., 50, 836. SLACK, W.W. (1962). Brit. J. Surg., 50,185. TAGART" R.E.B. (1969). Brit. J. Surg. 56, 417. TORSOLI, A., ALESSANDRINI, A., RAMORINO, M.L., AMORUSO, R., ARULLANI, P. & CASSANO, C.C. (1966). Arch. ital. Mal. Appar. dig., 33, 202. WILLARD, J.H. & BOCKUS, H.L. (1936). Amer. J. dig. Dis., 3, 580. 

Anatomical distribution of diverticula of the large intestine

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Anatomical distribution of diverticula of the large intestine

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