Sabiston Ch52 — Diverticular Disease, Obstruction & Pseudo-Obstruction

Citation: Galandiuk S, Netz U, Morpurgo E, Tosato SM, Abu-Freha N, Ellis CT. Chapter 52: Colon and Rectum. In: Sabiston Textbook of Surgery, 21st ed. Elsevier; pp. 1320–1344 (this chunk).

Source type: Textbook chapter — reference source, not a primary study. Filed per Stephen’s instruction to treat the two Sabiston chapters (Colon and Rectum; Small Bowel) as reference material rather than skip them. No RCT/cohort data of its own to critically appraise; content below is the chapter’s synthesis of the literature as of publication, cited here as background/ context rather than as primary evidence on par with the trial reports elsewhere in this wiki.

This is the first of several planned chunks from this chapter (82 pages total, covering far more than diverticular disease — embryology/anatomy/physiology, preop evaluation, ERPs, diverticular disease, large bowel obstruction, pseudo-obstruction, IBD, infectious/ischemic colitis, neoplasia/ staging, rectal cancer surgery, and pelvic floor disorders). Remaining sections will be filed as separate source-page chunks per Stephen’s preference to split this large reference by topic.

Scope of this chunk

Pages 1320–1344: brief anatomy/physiology/preoperative-evaluation background, then three full sections — Diverticular Disease (including special populations), Large Bowel Obstruction, and Colonic Pseudo-Obstruction (Ogilvie Syndrome).

Key content — Diverticular disease

• Hinchey classification — matches what’s already documented in Diverticulitis (no new information here).
• Complicated diverticulitis management detail:
  • Abscess: percutaneous drainage for accessible collections; failure or inaccessibility routes to surgery.
  • Colovesical fistula: most common internal fistula from diverticulitis; typically requires resection with fistula takedown.
  • Once resection is indicated, the Hartmann’s-vs-primary-anastomosis question is the same one already covered in depth via LADIES DIVA — this chapter doesn’t add new trial data here, just restates primary anastomosis ± diverting ileostomy as an accepted alternative to Hartmann’s in appropriately selected patients.
• Uncomplicated diverticulitis (new to the wiki — this closes an open item):
  • Individualized outpatient management is now standard for most uncomplicated cases.
  • Antibiotics controversy: a systematic review/meta-analysis found no benefit from antibiotics in uncomplicated diverticulitis, and this has led some clinicians to stop prescribing them routinely for this group. Chapter frames this as an evolving practice, not a settled guideline mandate.
  • Colonoscopy recommended 4–8 weeks after recovery to rule out malignancy (colitis/diverticulitis can mask an underlying colorectal cancer).
  • Recurrence rate after a first uncomplicated episode: 10–35%.
  • Elective surgery indications have shifted — away from a fixed “number of attacks” threshold (the old teaching) toward individualized assessment incorporating severity, comorbidity, and impact on quality of life. This directly answers the second open item on Diverticulitis.
• Special populations:
  • Right-sided diverticulitis — common in Asian populations, rare in the West; mimics acute appendicitis; recurrent/complicated disease or diagnostic uncertainty favors resection (right hemicolectomy).
  • Immunocompromised patients (transplant, diabetes, renal failure/cirrhosis, steroids/ chemotherapy) — similar prevalence of diverticulitis as general population, but more likely to present with free perforation and complicated disease due to blunted inflammatory response; lower threshold for resection after a single attack; if emergency resection is required, primary anastomosis is generally avoided given impaired healing/immune status.
  • Young patients (historically <50) — old teaching held these patients had more “virulent” disease and should be resected after one uncomplicated episode; current evidence does not support a higher recurrence or emergency-surgery rate in this group, and current guidelines do not recommend treating them differently. This directly contradicts the historical assumption baked into some older guideline language — worth flagging if it comes up against an older source later.

Key content — Large bowel obstruction (new condition page: Large Bowel Obstruction)

• Defined as obstruction distal to the ileocecal valve. Classified mechanical (intraluminal, mural, extraluminal — see etiology table on the new page) vs. functional (pseudo-obstruction, toxic megacolon, paralytic ileus).
• Most common etiology in the US: colorectal cancer. Volvulus (mostly sigmoid) dominates worldwide in regions with high-fiber diets (Russia, Eastern Europe, Africa, Middle East, India).
• Closed-loop obstruction (both proximal and distal segment blocked, e.g. volvulus, strangulated hernia, competent ileocecal valve with obstructing cancer) is the dangerous pattern — rapid progression to ischemia/perforation, needs prompt recognition.
• Diagnosis: plain films first-line for localizing/screening; water-soluble or IV-contrast CT for location, etiology, and ischemia/perforation signs; endoscopy for diagnosis + treatment (sigmoid volvulus detorsion, stenting).
• Treatment is etiology-specific: sigmoid volvulus → endoscopic decompression + rectal tube, if unsuccessful → resection/colostomy/Hartmann’s, if decompression succeeds → elective sigmoid resection with primary anastomosis given high recurrence risk without it. Cecal volvulus → primary resection and anastomosis (endoscopic reduction generally not durable). Malignant obstruction of sigmoid/left colon → endoscopic stenting as bridge to surgery, or straight to surgery (Hartmann’s, or primary anastomosis ± diverting stoma); ischemic/nonviable cecum → subtotal colectomy; right-sided obstruction → right hemicolectomy with primary anastomosis (higher-flow, thinner-walled anastomosis tolerates this better than left-sided).

Key content — Colonic pseudo-obstruction / Ogilvie syndrome (new condition page:

Colonic Pseudo-Obstruction (Ogilvie Syndrome))

• Acute colonic dilation without mechanical obstruction; rare (~100/100,000 admissions); hypothesized autonomic dysregulation (relative sympathetic excess).
• Classic setting: elderly, multiple comorbidities, following an acute medical/surgical event. Common associated conditions: postsurgical (esp. orthopedic/spinal, transplant, cardiac), neurologic disease, cardiac/pulmonary disease, trauma, metabolic derangement, infection (CMV, VZV), obstetric/gynecologic procedures, drugs (opiates, anticholinergics, antipsychotics, clonidine).
• Diagnosis: plain film (cecum/right colon most dilated, up to 10–12 cm), water-soluble contrast enema or CT to exclude mechanical cause; cecal diameter >12 cm, fever, leukocytosis, and tenderness raise concern for ischemia/impending perforation.
• Management is escalating: supportive care (NPO, correct electrolytes, stop causative drugs, avoid laxatives, ambulate/prone/knee-chest positioning) for cecal diameter <12 cm without toxicity/ischemia → neostigmine (2–2.5 mg IV bolus, monitored setting with atropine available; contraindicated in mechanical obstruction, ischemia/perforation; success 60–94%, ~31% recurrence) → colonoscopic decompression (for neostigmine failure/contraindication; success 61–95% initial, 70–90% sustained; perforation risk 1–3%) → surgery for those who fail conservative measures or show toxicity/ischemia/perforation (tube cecostomy if viable colon and good surgical risk, resection with diverting stoma if ischemic/perforated).
• Ischemia/perforation risk reported 3–15% of cases, ~50% associated mortality when it occurs — the driver for the escalating-intervention protocol above.

Relevance

Directly closes the two open items already flagged on Diverticulitis (uncomplicated diverticulitis management/antibiotics, and elective surgery timing) and adds useful context on special populations. Also introduces two new condition pages the wiki didn’t have yet — Large Bowel Obstruction and Colonic Pseudo-Obstruction (Ogilvie Syndrome) — both general surgical topics rather than colorectal-cancer/diverticulitis-specific, but squarely within a colorectal surgeon’s scope. As a textbook chapter rather than primary literature, this source is best used as background/orientation and a pointer to what further primary literature to seek out, not as the basis for strong claims on its own.