The Roentgenologic Differential Diagnosis between Cancer and Diverticulitis of the Colon

THE difficulty in differentiating diverticulitis of the colon, particularly of the sigmoid colon, from a carcinoma of the bowel is as old as the knowledge of diverticulitis as a disease. Though diverticula of the colon were known to anatomists and surgeons as accidental and rare findings, their clinical importance was not recognized before Graser's demonstration in 1898. He showed the comparative frequency of diverticula, the possibility of inflammatory processes being caused by them, and the difficulty of differentiating the inflammatory mass from a malignant growth of the colon. In the following decades, a number of excellent clinical (Beer, Moynihan, W. J. Mayo, Telling and Gruner, Judd and Pollock, Spriggs and Marxer, Rankin and Brown, and others) and roentgenologic papers (Abbe, Case, Carman, George and Leonard, Spriggs and Marxer, Berg, Stewart and Illick, Golden, Singleton and Hall, and others) have decreased the differential diagnostic difficulties. Occasionally, however, there are still cases in which diverticulitis leads to such deformities as to make its differentiation from neoplastic disease extremely hard. In such a case one often asks oneself whether it is necessary to enter into an extensive differential diagnostic discussion or whether it would not be much better to transfer the responsibility to the surgeon and have him solve the problem by exploratory laparotomy. Unfortunately, the diagnosis is by no means easy or even possible at operation in a fair percentage of cases. Moynihan, in 1907, while discussing the mimicry of malignant disease in the large intestine, reported the story of a man with a long history of stomach trouble who had had, on two recent occasions, signs of intestinal obstruction which included fecal vomiting. At operation, a hard inflammatory mass was felt in the duodenum with evident duodenal obstruction. In the ileopclvic colon another hard mass was found which was thought to be a cancer. Since this was deemed to be the more important condition, the duodenal ulcer was left untreated, and the tumor was excised. The opened specimen showed no evidence of cancerous growth, but diverticulitis, the wall of the gut being in some parts one and one-half inches thick. Mayo, Wilson, and Griffin, in the same year, reported five similar cases and stated: “It is impossible to tell, even by the gross appearance of such a tumor, whether it is inflammatory or malignant.” Florian described a patient having intermittent colic, attacks of fever, and intestinal hemorrhages, who had a defect of the sigmoid, shown by x-ray examination, which was called carcinoma. The surgeon had the impression that he had resected a carcinoma, even after he had the specimen in his hand. Microscopic examination alone showed that an area of chronic diverticulitis and not a cancer had been removed.