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The patient complained of attacks of lower abdominal pain for 7 years. An intermittently discharging abscess in the right ischiorectal fossa had been present for 1 year (Figure 41.1). The referring doctor had been able to pass a probe into the abscess for a depth of 12cm. A sinogram demonstrated a connection with the sigmoid colon in which there was extensive diverticular disease. Rectal examination revealed marked induration anteriorly and laterally around the rectum at the level of the prostate. Rigid sigmoidoscopy revealed no pathology to 16cm. A barium enema confirmed the findings of the sinogram (Figure 41.2).

Lower abdominal pain had been present for 2 months, with an increased frequency of bowel action. At times the stools were loose. During this period there had been a fever treated with antibiotics. There was tenderness in the left iliac fossa. No pelvic mass was apparent on rectal examination. Limited colonoscopy revealed diverticular disease of the sigmoid colon with marked narrowing of the lumen, which prevented further advancement of the instrument.

The patient presented with a 5-week history of urinary frequency, hematuria (clots), and probable pneumaturia. Constipation had been present over the same period. An intravenous pyelogram revealed an extravesical mass on the upper left aspect of the bladder. A colonoscopy confirmed diverticular disease of the sigmoid colon where the lumen was narrowed and the mucosa hyperemic and edematous. A cystoscopy examination confirmed a mass bulging into the upper left wall of the bladder and covered with hyperemic mucosa. A fistula opening was not identified. Operation was advised, mindful of the fact that the patient’s husband had died some years previously after a resection for diverticular disease.

The patient, whose health problems included ischemic heart disease and atrial fibrillation, presented with an episode of rectal bleeding that occurred over a 2-day period. A barium enema showed “extensive diverticular disease involving the sigmoid colon, where there is a parallel sinus track 7cm in length, inferior to the narrowed sigmoid lumen” (Figure 44.1). Colonoscopy was only possible to 33 cm, where a stricture prevented further access to the colon. There were no endoscopic features at that level to suggest malignancy. Surgical treatment was advised for the complicated diverticular disease and the possibility of an occult colon cancer.

The patient had undergone laparotomy for a “diverticular abscess” 16 years previously, but details were not available. The present illness commenced with pain in the left iliac fossa 6 weeks previously and was accompanied by diarrhea and abdominal distention. A tender mass was present in the left iliac fossa (LIF) that was also palpable on rectal examination. The pelvic floor was subtle on palpation, indicating it was not involved. Colonoscopy was limited by a stricture in the sigmoid colon. There was no endoscopic evidence of malignancy. A limited barium enema demonstrated a stricture of the mid sigmoid colon with obstruction proximal to it (Figure 45.1). There was mucosal continuity within the stricture, suggesting it was inflammatory.

The patient had noticed left-sided abdominal discomfort, night sweats, and a discharge of pale green mucus from the rectum for 2 months. Pelvic examination revealed a soft cystic mass in the pelvis. On flexible sigmoidoscopy, there was purulent material in the sigmoid colon and rectum and diverticular disease was noted. A barium enema examination reported diverticular disease with narrowing in the sigmoid colon most likely due to benign disease (Figure 46.1). Examination under anesthesia revealed a soft fluctuant mass in the pelvis and left iliac fossa that appeared to soften during examination. A diagnosis was made of pelvic abscess due to diverticulitis.

The patient complained of pain and tenderness in the left iliac fossa for 10 days. There had been rigors during 1 night in this period. There was no disturbance of bowel function. Clinical examination was normal. A barium enema showed well marked diverticular disease in the sigmoid colon and an associated “giant cyst” containing fecal residue (Figure 47.1). Colonoscopy to the hepatic flexure revealed no stricture of the sigmoid colon or mucosal pathology.

Recurrent diverticulitis had been diagnosed 15 years previously, and mild episodes, always responding to antibiotic therapy, continued during this period. The patient presented with a 4-week history of lower abdominal colicky pain, constipation, and rectal bleeding on 1 occasion. A firm pelvic mass was present on rectal examination. A short colonoscopy was performed with the small caliber panendoscope, and a tight sigmoid stricture was negotiated, establishing the diagnosis of sigmoid diverticulitis. A cautious contrast enema showed dilatation of the colon above the stricture and no pathology in the proximal colon (Figure 48.1). Within a few weeks, the patient developed further severe pain, nausea, and vomiting. Operation was expedited.

The composite diagram illustrates some of the morphological types of ulceration that may be seen in small bowel Crohn’s disease. Although a number of these ulcer types may appear in a patient in a contiguous segment or in skip lesions, one would not expect to see the full spectrum of ulceration in any one patient.

At 25 years of age resection of Crohn’s disease of the ileum. Severe diarrhea continued despite medical treatment.