To the Editor: I was disappointed that Ferzoco et al. (May 21issue)1 in their fine review of diverticulitis did not emphasizemore strongly that it is mandatory to do further diagnostictesting in many patients rather than to rely solely on clinicalfindings. Fleischner and Ming2 could not find evidence of inflammationin 25 percent of specimens from patients who underwent resectionfor diverticulitis; Morson3 reported that inflammation was absentin 33 percent of patients. Presumably, these patients representedthe sickest patients, because they underwent surgery.
In many patients, the distinction between inflammatory diverticulitisand muscle-spasm diverticulosis can be made only with the useof either computed tomographic (CT) scanning or barium enema.The hypothesis of Ferzoco et al. that "insufflation can actuallydislodge an obstructing fecalith and result in perforation"is totally unproved.4 Many patients who present with a clinicaldiagnosis of diverticulitis, without confirmation with eitherCT scanning or barium enema, have diverticulosis, not diverticulitis,and they will get better rapidly. Patients with inflammationshould be treated with antibiotics, whereas those with spasmshould be treated with antispasmodic agents.
Murray L. Janower, M.D. Saint Vincent Hospital Worcester, MA01604-4593
References
Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med 1998;338:1521-1526. [Free Full Text]
Fleischner FG, Ming S-C. Revised concepts on diverticular disease of the colon. II. So-called diverticulitis: diverticular sigmoiditis and perisigmoiditis: diverticular abscess, fistula, and frank peritonitis. Radiology 1965;84:599-609. [Medline]
Morson BC. The muscle abnormality in diverticular disease of the sigmoid colon. Br J Radiol 1963;36:385-392.
Dreyfuss JR, Janower ML. Radiology of the colon. 2nd ed. Baltimore: Williams & Wilkins, 1980.
To the Editor: In their thorough review of diverticulitis, Ferzocoet al. included an abdominal CT scan showing left-sided diverticulardisease (Figure 1 of the article) in a patient with a three-dayhistory of right-lower-quadrant pain and fever. Is this an exampleof a "reverse" Rovsing's sign?
Robert Baevsky, M.D. Baystate Medical Center Springfield, MA01199
To the Editor: In their review of acute diverticulitis, Ferzocoet al. recommend a combination of ciprofloxacin and metronidazoleadministered on an outpatient basis as the oral broad-spectrumantibiotic regimen for a patient with a mild first attack ofdiverticulitis. However, an alternative combination consistingof trimethoprim–sulfamethoxazole and metronidazole maybe a more prudent option for this indication.1 Controlled trialshave not been conducted to compare these regimens. Ciprofloxacinis far more expensive and without proven additional benefit.Uncontrolled evidence in the form of case reports indicatesthat the combination of ciprofloxacin and metronidazole mayresult in an unfavorable drug interaction.2 The combinationof trimethoprim–sulfamethoxazole and metronidazole providesadequate coverage against major colonic pathogens (anaerobes,gram-negative bacilli, and gram-positive coliforms).3 . . .
Aijaz Ahmed, M.D. Stanford University School of Medicine Stanford,CA 94305
References
Freeman SR, McNally PR. Diverticulitis. Med Clin North Am 1993;77:1149-1167. [Medline]
Semel JD, Allen N. Seizures in patients simultaneously receiving theophylline and imipenem or ciprofloxacin or metronidazole. South Med J 1991;84:465-468. [CrossRef][Medline]
Gorbach SL. Intraabdominal infections. Clin Infect Dis 1993;17:961-965. [Medline]
To the Editor: Ferzoco et al. state that morphine sulfate shouldbe avoided in patients with acute diverticulitis and that ifnarcotics are required, meperidine is the more appropriate choice.The reference Ferzoco et al. cite as the basis for their recommendationfor avoiding morphine is 30 years old and gives no supportingdata.1 Clinical-practice guidelines for acute pain managementrecommend morphine sulfate as the standard opioid agent andadvise that meperidine should be reserved for patients withdemonstrated allergy or intolerance of other opiates.2 Meperidineshould not be routinely used for pain because the accumulationof its toxic metabolite normeperidine results in hyperexcitabilityof the central nervous system (the risk of which is increasedwith renal impairment or repeated dosing), the duration of actionof meperidine is only two to three hours and is shorter thanthat of morphine, and there is a tendency to prescribe subtherapeuticdoses, resulting in poor pain control.3 Meperidine continuesto be used, not because data have shown its efficacy, but becauseof tradition and by habit.
Sue Coppinger Warren, M.D. Kanawha Hospice Care Charleston, WV25314
References
Painter NS. Diverticular disease of the colon. BMJ 1968;3:475-479.
Acute pain management: operative or medical procedures and trauma. Clinical practice guideline no. 1. Rockville, Md.: Agency for Health Care Policy and Research, February 1992. (AHCPR publication no. 92-0032.)
Marks RM, Sachar EJ. Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78:173-181.
The authors reply:
To the Editor: Dr. Janower indicates that the distinction between"inflammatory" diverticulitis and "muscle-spasm diverticulosis"can only be made by CT scanning or barium enema. Yet, falsenegative CT scans are reported in 2 to 21 percent of cases.1,2In addition, the correlation between the estimated presenceor absence of inflammation on contrast enema by experiencedradiologists and subsequent pathological findings is poor.3Thus, it is reasonable to treat clinically presumptive mildacute diverticulitis with antibiotics without the imaging studiesif mild fever and leukocytosis are present. In the absence ofthe latter, most authorities believe that antispasmodic drugsare of dubious value. Although Dr. Janower implies that perforationof the colon by insufflation or enema is hypothetical, Goligherhas reported three cases of perforation after enema.4 Sincethe complication is so devastating, safety is the best policy.
We thank Dr. Baevsky for calling our attention to an error inthe legend to Figure 1, which should have read "left-sided lowerabdominal pain." We regret the error.
We agree with Dr. Ahmed that oral trimethoprim–sulfamethoxazoleand metronidazole are a perfectly adequate alternative to ciprofloxacinand metronidazole in the treatment of a first attack of mildacute diverticulitis.
Dr. Warren is concerned about the age of the reference we usedto support the statement that morphine sulfate increases colonicspasm and hypersegmentation. The hard data showing increasesin intracolonic pressure and distention of the diverticula inresponse to morphine actually appeared in an article publishedfour years before the one we cited.5 Since meperidine decreasescolonic spasms and since these aged studies5 are the only oneson the effects of analgesics on the colonic pressure, we shouldnot assume a priori that the results of an older study are necessarilyinvalid. One of the articles cited by Dr. Warren in supportof her position is 25 years old. The worst complication in apatient with diverticulitis is extension of the perforation,and hence, the slightly shorter duration of the action of meperidineis acceptable, especially since the pain of acute diverticulitisis usually very well controlled by these means. Rigid adherenceto practice protocols without consideration of the disease processis not always the best policy.
W. Silen, M.D. L.B. Ferzoco, M.D. V. Raptopoulos, M.D. BethIsrael Deaconess Medical Center Boston, MA 02215
References
Johnson CD, Baker ME, Rice RP, Silverman P, Thompson WM. Diagnosis of acute colonic diverticulitis: a comparison of barium enema and CT. AJR Am J Roentgenol 1987;148:541-546. [Free Full Text]
Balthazar EJ, Megibow A, Schinella RA, Gordon R. Limitations in the CT diagnosis of acute diverticulitis: comparison of CT, contrast enema, and pathologic findings in 16 patients. AJR Am J Roentgenol 1990;154:281-285. [Free Full Text]
Parks TG, Connell AM, Gough AD, Cole JO. Limitations of radiology in the differentiation of diverticulitis and diverticulosis of the colon. BMJ 1970;2:136-138.
Goligher JC. Surgery of the anus, rectum, and colon. 3rd ed. London: Bailliere Tindall, 1975:1093.
Painter NS, Truelove SC. The intraluminal pressure patterns in diverticulosis of the colon. Gut 1964;5:201-207.
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