= 5a: 321 C 616.94-007.64 — MASSIVE DIVERTICULOSIS OF THE SMALL INTESTINE WITH STEATORRHOEA AND MEGALOBLASTIC ANAEMIA? By J. BADENOCH, P. D. BEDFORD, axp J. R. EVANS (From the Nuffield Department of Clinical Medicine, the Radeliffe Infirmary, and the Cowley Road Hospital, Oxford) With Plates 36 and 37 Srxce Badenoch and Bedford (1954) first described two cases of massive diver- ticulosis of the upper intestine presenting the syndrome of steatorthoea and megaloblastic anaemia, a third case has been reported (Dick, 1955). The purpose of the present paper is to report: additional observations on the one survivor of the two original patients and on three others, and to put forward further evidence for the view that the diverticulosis of the small intestine is responsible for both the steatorthoca and the megaloblastic anaemia. Incidence Astley Cooper (1804-7) was the first to describe the condition of jejunal diverticulosis, and since then well over 200 eases have heen reported (Edwards, 1939, 1954; Benson, Dixon, and Wangh, 1943; Walker, 1944-5; Hillemand, Chérigié, Rosenstiel, and Iglesias, 1951). Nevertheless.) massive divertioulosis is an uncommon condition, occurring as an incidental finding at post-mortem examination in from 0-1 to 0-2 per cent. of all autoeia)Eilsand, Rosenstiel, and Tglesias, 1951), or rather more commonly—0-3 per cent. people dying over the age of 50 (Bedford, unpublished observations),) ‘The diverticula are often difficult. to demonstrate radiologically, but the incidence reported in several largo series of barium meals (0-06 per eent., Edwards, 19545 0-1 per cent., King, 1949-50; 0-24 per cent., Dneprovolzhskii, 1953) agrees well with the findings at necropsy. ‘The condition is slightly more common in men than in women over the age of 50 (Hillemand, Chérigié, Rosenstiel, and Iglesias, 1951). Edwards (1954) has put forward reasons for believing that the diver- ticula are acquired and not congenital. Natural history of diverticulosis of the smalt intestine. ‘The majority of patients with jejunal diverticulosis have no symptoms, but complications which have been reported include abdominal pain, vomiting, intestinal obstruction, per- foration, adhesions, and haemorrhage. Diarrhoea has been described occasion- ally {Guthrie and Hughes, 1937; Benson, Dison, and Waugh, 1943; Wilkerson| and Coffinan, 1948; Orr and Russell, 1951-2; Dneprovolzhshii, 1953; Edwards, 1954), but never steatorthoea, although in one case with diarrhoea a singlo + Received April 28, 1955. (Quarterly Journel of Medicine, New Serie XXIV, No. 96, Otaber 1955,J. BADENOCH, P. D. BEDFORD, AND J. R. EVANS estimation of the fat in the stool had given a high result (39-6 gm, per cent,; Montuschi, 1949). Iron-deficiency anaemia is occasionally associated with jejunal diverticulosis, but megaloblastic anaemia is very rare (Taylor, 1939; Krevans, Lockard-Conley, and Sachs, 1954; Spang, 1954). Wilkinson (1955) has roported one patient with a spontaneous ileocolic fistula, steatorthoea, and a megaloblastic anaemia, who was found at operation to have jejunal diverticu- losis. The triad of jejunal diverticulosis, steatorrhoea, and megaloblastic anaemia is very unusual. ‘The four eases reported here and the one recorded by Dick (1955) appear to be all that are to be found in the literature. Case Histories Case 1 (Radeliffe Infirmary No. 73710/47). Farmer, Age at death in 1952, 64 years, ‘This patient was quite well until May 1946 when, at the age of 38 years, he suddenly developed diarthoea and abdominal discomfort. 80 sudden was the onset that he attributed the symptoms to food poisoning, but no one else in, the household was affected at the time, and the diarthoea continued with the passage of tivo to 12 loose, pale, foul motions each day. ‘There was neither blood nor mucus in the stools. "A. year later he began to tire easily, and his friends noticed that he was pale. He developed spontaneous cramps in his limbs, and his tongue became sore, especially after smoking his pipe. Formerly a kindly, placid, and tidy man, he became morose and quarrelsome, and careless of his ‘appearance and habits. In June 1947 he was admitted to hospital. On examina- tion he was pale.and emaciated. The tongue was smooth, with atrophi papillae. The hair and nails were normal. “The blood-pressure was 150/85 Latent tetany was present, both Trousseau’s and Chvostek’s signs being posi tive. ‘There were no petechiae or bruises in the skin, and the lyrmph-nodes were not eniarged. ‘The abdomen was distended, and contrasted sharply with the thin limbs and trunk and sunken cheeks, but it was not tender, and no masses could be felt in it. The urine was normal. Investigation revealed a moderate macrocytic anaemia: haemoglobin 11-9 gm. per 100 ml., red blood-cells 3-84 million per exmm., and colour index 1+. ‘The marrow was megaloblastie, and the test meal showed histamine-fast achlor- hydria. ‘The faeces contained no occult blood. A fat balance (four days) demon- strated that only 82 per cent. of the daily dictary intake of fat was being absorbed. The pancreatic response to secretin was normal, and the excretion of nitrogen in the faeces was 21 gm. daily. ‘The oral glucose-tolerance test gave @ normal result. ‘The total plasma-proteins were 5-9 gm. per 100 ml. (albumin 3-6 gm. per 100 ml). ‘Tho serum-calcium was 7-6 mg. per 100 ml., serum-phosphate with the patient fasting 23 mg. por 100 ml.y and serum alkaline phosphatase 9 King-Armstrong units. A barium meal revealed a diverticulum of the duodenum and what was taken to be flocculation of barium in the small intestine; but in retrospect it seems that the clumps of barium may ‘well have been in the diverticula which were demonstrated post mortem. ‘These clumps of barium were still visible when the patient was screened again two days later. From the first his management proved difficult, He was given a high-protein, low-fat diet with added vitamins and calcium, and the anaemia was treated with liver extract. "The response to parenteral liver was incomplete, but later folio acid was added and the haemoglobin returned to normal. He would not eomply with his dietary instructions, and for long periods gave up treatment altogether,DIVERTICULOSIS OF SMALL INTESTINE WITH ANAEMIA 323 only to retum to it when his condition was perilous. In 1949, three years after the onset of tho illness, he had unexplained melaena, X-rays taken at the time failed to reveal the source of the haemorhage, and the prothrombin time was normal. In 1950 he developed generalized oedema with hypoproteinaemia, and in 1991 he had an attack of colic and vomiting, which lasted five days and appeared to be duo to subacute intestinal obstruction. He suffered fequent paroxysms of abdominal pain, lost weight steadily, and finally, in January 1952, died of bronchopneunionta. : ° = © Post-mortem examination revealed extensive diverticulosis of the upper part of the small intestine (Plate 36, Figs. 2 and 8). The diverticula extended alinost continuously from the second part of the duodenum along the upper three feet of tho jejunum, with others scattered more distally. Apart {rom one in the second part of the duodenum, all the diverticula were on the mesenterie border of the intestine, ‘They varied in size from one to four and a half inches in dia. meter, were thin-walled, and communicated with the lumen of the intestine by ‘openings up to one inch in diameter. ‘The pouches and the upper part of the intestine were filled with a turbid, watery fluid. ‘The lungs showed the expected bronchopneumonia, but all the other organs wero natural, Daring the course of his illness four barium-meal examinations were carried out; all revealed the diverticulum of the duodenum, but the massive jejunal diverticulosis was not suspected. In retrospect ‘levels’ of opaque medium, which were considered to be indicative of a small-bowel obstruction, were certainly in the diverticula. Most of the diverticula filled poorly or not at all, yet opaque medium remained in the pouches for at least two days on two ‘oveasions, Case 2 (Radcliffe Infirinary No. 162686). Housekeeper, aged 70 years. Her past history is interesting in that she had suffered from a severe anaemia at the age of 15 years, and at 25 developed lupus vulgaris on the faco. Apart from theso illnesses she had remained well and active until 1949, when at the age of 64 she suddenly began to have pain in the abdomen and lower chest. ‘This pain could be brought on by stooping or by eating fatty foods, and at times radiated up into the neck and down both arms, She suffered from waterbrash, and was often nauseated. ‘Two years later she began to suffer from flatulence and a painless diarthoea. The stools were pale and watery, and contained neither blood nor mucus. Her condition gradually deteriorated; she developed paraesthesiae of the fingers, cramps in the legs, shortness of breath, anid oedema of the ankles, She lost two stone in weight. In August 1952, three years after the iliess began, sho was admitted to hospital. On oxemination she was thin and pale, with a dry, pigmented skin, ‘The blood-pressure was 140/80. ‘The sears of healed lupus vulgatis were present on her face. ‘The tongue was pale, but the papillae were not atrophic; a few petechiae and bruises were present on the arms and upper chest, ‘The abdomen was tympanitio and distended, but other- wise normal, ‘There was no enlargement of the lymph-nodes. The urine was normal. . Investigation revealed that she had moderate macrocytic anaemia: haemo- globin 11-7 gm. per 100 ml., red blood-cells 3:18 million per e.mm., and colour index 1-3. The marrow was megaloblastic. Free acid was present in the gastric juice; the secretion of pepsin (38 units per ml.) and the excretion of uropepsin (206 units in 2¢hours) were both normal. ‘The faeces contained no oceult blood. A fat balance (four days) showed that only 85 per cent. of the daily dietary intake of 70 gm. of fat was absorbed. ‘The daily excretion of nitrogen in the faeces was 2-7 gm., and the result of the oral glucose-tolerance test was abnormal