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• The use of corticosteroids is associated with numerous and, at times, grave complications involving the gastrointestinal tract. Perforation of peptic ulcer is one of the most frequent gastrointestinal catastrophies attributed to the use of corticosteroids. An underappreciated relationship is that of perforation of colonic diverticula and corticosteroid therapy. This report describes the course of three patients who developed perforations of colonic diverticula that were temporally related to corticosteroid use. An overview of the problem is given, and potential difficulties in managing these patients are highlighted. ( Arch Intern Med . 1990;150:1337-1338)

• We describe a case of severe bleeding from left-sided colonic diverticula, 2½ years following right-sided colectomy for massive rectal bleeding confirmed angiographically to be from the right part of the colon. This experience demonstrates that total abdominal colectomy with ileoproctostomy is the only way to ensure that there is no bleeding postoperatively from diverticula, regardless of angiographic findings. ( Arch Surg 111:913, 1976)

To the Editor.— Dr Martin Blinder 1 asks if there is a relationship between stress and diverticulitis-diverticulosis. The expert, Dr Kenneth B. Klein, answers, "There is no good evidence that pain attributed to any sort of diverticular disease is precipitated by stress." Dr Klein advises that pain results from diverticulosis only when there is associated inflammation (diverticulitis) and that the chronic pain of "irritable bowel syndrome" has no established relationship with diverticular disease. I would like to offer another opinion. Dr Felix Fleischner 2-4 showed rather convincingly that there are two causes for true, acquired, colonic diverticula. "Atrophic" diverticula occur in the elderly as normal colonic pressure pushes pockets of mucosa through denuded areas of muscularis. On the other hand, patients with spastic segments of colon, usually sigmoid, develop hypertrophic bands of circular muscle through which pockets of mucosa are popped by periodic abnormal contractions, "hypertrophic" diverticula. Dr Fleischner hypothesized that

To the Editor. — We read with interest and enjoyed the review article by Netchvolodoff and Hargrove in the July issue of theArchives(139:813-816, 1979) on the subject of diarrhea. We would like to call attention to another form of a less well-defined, iatrogenically induced diarrhea recently observed by us. Report of a Case. —A 76-year-old woman with end-stage renal failure had a ruptured colonic diverticulum requiring transverse colostomy a few weeks prior to institution of chronic hemodialysis. During her postoperative course, she required considerable volumes of intravenous (IV) fluids to compensate for large amounts of watery diarrhea, maintaining essentially a stable weight. This clinical picture remained the same for several more days until it became apparent that reduction in the amount of IV fluid administered resulted in a parallel decrement in watery stool output. Conversely, increased amounts of IV fluids led to a subsequent increase in diarrheic stools.

A study of 100 patients experiencing 144 episodes of bleeding from colonic diverticula was made. In 16, colonic bleeding was the first manifestation of diverticular disease. Surprisingly, 42 had only black, tarry stools while 58 had bright red rectal bleeding. Sixty bleeding episodes (41.5%) were massive and necessitated transfusion of more than 1,500 ml of blood. Fifty-three (37%) did not lead to transfusion. Only five were associated with signs of acute diverticulitis. Although only 19 patients, all initially treated with a medical regimen, required operation, they had often bled too much (average 5,260 ml), too long and too often before operative intervention. Frequently the wrong operation was performed. This study demonstrates that local resection is adequate only if disease is confined to a single area which is bleeding. When disease is extensive, total abdominal colectomy with ileoproctostomy is the procedure of choice.

APPENDICES epiploicae are normally present as fatty landmarks attached to the antimesenteric wall of the colon throughout its course. They are more numerous on the transverse and descending colon and are covered by the layer of visceral peritoneum which envelopes this structure. In general they receive little or no attention. However, infarction of an isolated appendices epiploica can produce hemorrhagic and inflammatory changes which lead to peritoneal irritation. When such an event takes place, the subjective complaints and physical findings that develop may be of sufficient magnitude to require operation. Inflammatory changes in these fatty appendages may occur as a primary phenomenon due to impairment of blood supply or they may be a secondary manifestation of infection in an adjacent viscus. Since these structures often serve as repositories for colonic diverticula, infection in such a culde-sac may extend to the contiguous epiploica. The incidence of primary infarction is low, and

Historical Background In 1849 Cruveilhier first described colonic diverticula. In 1853 Virchow first described the inflammatory disease and named it diverticulitis. Bristowe, Jones, Habershon, Lane, Graser, and Bland-Sutton contributed to the early literature.1In 1907 Mayo reported five cases of sigmoid resection for diverticulitis, and he is credited with the first surgical application. The greatest impetus to the study of this entity came in 1913, when de Quervain, in Switzerland, made the diagnosis by x-ray. The next year Case, in the United States, reported criteria for x-ray diagnosis.2It soon became evident that diverticulosis and diverticulitis were most frequently found in the left colon. This report, however, is concerned primarily with the right colon. The first case of cecal diverticulitis was described by Portier in 1912. Pathology Diverticulum of the right side is a pathological entity distinct from that of the left side. Right-sided diverticula are usually solitary.