Sigmoiditis

SIGMOIDITIS (sigmoiditis) is a disease encompassing a range of pathological processes of an inflammatory origin in the sigmoid colon. In some cases, these processes are merely a partial manifestation of inflammation of the entire large intestine (colitis); in others, they represent a segmental form of it, most frequently spreading also to the rectum, in which case it is called proctosigmoiditis. The sigmoid colon is particularly predisposed to inflammatory processes because intestinal contents physiologically stagnate here for a relatively long time to form fecal masses. Etiologically, the development of inflammatory processes is also influenced by pressure on this segment of the intestine from neighboring organs (the pregnant uterus), changes in the shape and position of the colon itself (sigma elongatum), adhesions remaining from past inflammatory processes, venous stasis, and infectious diseases—especially local ones (dysentery), but also general ones (septic tonsillitis, influenza, malaria, etc.). Finally, diverticula are most frequently encountered in this intestinal segment, along with functional protrusions of the large intestine recently described by radiologists (H. Berg) under the name of diverticulosis, which cause stasis on the one hand and inflammation (diverticulitis) on the other. According to their course, acute and chronic inflammation of the sigmoid colon are distinguished; by the character and localization of the inflammatory process, one distinguishes catarrhal or mucous sigmoiditis (sigmoiditis mucosa, levis)—a milder form—and purulent-hemorrhagic sigmoiditis—a more severe form most frequently proceeding with tissue breakdown in the form of an ulcerative process (sigmoiditis suppurativa, exulcerans, gravis). Finally, there is a third form, perisgmoiditis, when the process extends to the serous membrane of the intestine and produces an infiltrate in the paracolon, forming paracolitis or mesosigmoiditis (see Mesentery, Retroperitoneal space, Paracolitis). Naturally, these various anatomical processes can combine with one another and provide the substrate for highly diverse clinical manifestations of sigmoiditis, which are sometimes very difficult to diagnose.

Acute sigmoiditis of the catarrhal type was first described by Mayor; in 1893, he presented a clinical picture resembling perityphlitis, but with localization in the left iliac region, and it is easily confused with appendicitis when the appendix has a medial position. Sharp pains appear in the left iliac region, radiating to the lower back and left leg, along with nausea, vomiting, constipation with tenesmus, and a febrile state. Objectively, there is meteorism, tenderness in the region of the sigmoid colon as well as on the left during examination through the rectum; the colon is thickened and filled with fecal masses. Purulent and hemorrhagic forms of sigmoiditis most frequently proceed as a subacute and chronic disease. However, if acute sigmoiditis is accompanied by proctitis (proctosigmoiditis), the stools consist solely of bloody mucus without feces (see Feces); conversely, with a more prolonged course of the process, stubborn diarrhea appears with bloody, meat-water-like stools that are liquid and foul-smelling. Phenomena of perisgmoiditis very frequently join in (see below). As a rule, the disease runs a favorable course unless complications on the part of the cellular tissue surrounding the intestine arise. Thrombophlebitis of the left lower extremity has been described as a result of sigmoiditis. However, sigmoiditis is encountered in the described acute form relatively infrequently. — Treatment: rest with obligatory bed rest, ice on the abdomen in the first days, alcohol compresses, heating pads, and poultices after the temperature falls and acute phenomena disappear. Nutrition: liquid and mushy food, plenty of butter, enemas of provencal or other vegetable oil, or liquid paraffin. Of medications: pantopon, atropine. Chronic sigmoiditis develops from acute or arises directly as a chronic disease. Here, all transitions are observed from mucous, catarrhal forms to purulent-hemorrhagic ones. Patients usually complain of irregular defecation, more frequently of diarrhea than of constipation; tenesmus with the discharge of mucous or bloody-purulent stools containing a significant amount of erythrocytes, leukocytes, pus cells, epithelium, and sometimes eosinophilic cells must be considered characteristic of chronic sigmoiditis. Patients also complain of unpleasant sensations in the left iliac region, general weakness, and emaciation. Upon examining the patient, the sigmoid colon is determined as a cylinder, usually filled with fecal masses, tender upon palpation, yet well mobile. Digital examination per anum yields no deviations in pure forms of sigmoiditis. The diagnosis is easily established by means of sigmoidoscopy, which yields various pictures starting from a sharp reddening of the mucosa, usually not diffuse but focal; in other cases, alongside reddening, superficial excoriations and erosions of the mucosa can be discovered, sometimes bleeding; finally, in more severe cases, true ulcerations are present. Sometimes the intestine is covered with proliferations, yielding a picture resembling trachoma of the eyes. In far-advanced cases, the intestinal wall is infiltrated and loses its elasticity, which significantly hinders endoscopic examination. In addition to endoscopy, the recognition of sigmoiditis is facilitated by X-ray examination utilizing the mucosal "relief" technique, which easily reveals not only organic changes, diverticulitis, and ulcers, but also functional disorders in the region of the sigmoid colon, especially spastic states of the intestine. Differential diagnosis of sigmoiditis must take into account other intestinal diseases, especially its neoplasms, diseases of the left renal pelvis and ureters, and diseases of the uterine adnexa in women. If the inflammatory process extends beyond the limits of the serous membrane, sigmoiditis is complicated by perisgmoiditis. Depending on the character of the exudate, it is a matter either of an infiltrate of varying density, sometimes encircling the entire sigmoid colon like a ring, or of tumor-like formations giving reason to suspect a malignant neoplasm, a gumma, or localized tuberculous peritonitis. In addition to painful sensations upon intestinal distension, movement, and physical strain, these infiltrates can also cause phenomena of partial intestinal obstruction. Chronic sigmoiditis and perisgmoiditis have a very varied course; periods of remission for the most part appear, followed by exacerbation under the influence of dietary indiscretions, trauma, physical strain, cold, and infection (influenza, tonsillitis).

— Treatment of chronic sigmoiditis requires the prescription of a diet with a restriction of cellulose, i.e., a diet yielding few residues but containing sufficient carbohydrates in the form of porridge, macaroni, puddings, followed by egg dishes, ground meat, and especially a large amount of fats—butter and provencal oil. Of medications, bismuth preparations and tanalbin are given. The use of tannin enemas is not recommended; warm enemas of chamomile decoction or vegetable oil act significantly better, administered under low pressure from a bulb with a long and soft tip. Atropine and papaverine are indicated to reduce spasm and regulate defecation, a matter the patient must constantly attend to upon the appearance of constipation. A certain benefit is brought by treatment with mineral waters (Essentuki, Zheleznovodsk). Great benefit can be obtained, especially in perisgmoiditis and chronic forms of sigmoiditis, from systematically conducted mud therapy. In individual cases, diathermy is beneficial. In severe cases of ulcerative sigmoiditis with debilitating purulent-bloody stools (sigmoiditis gravis), repeated blood transfusions are necessary; this can spare the patient a severe surgical intervention involving the formation of an artificial anus.