Giant colonic diverticulum—a rare cause of acute abdomen

Giant colonic diverticulum—a rare cause of acute abdomen Giant colonic diverticulum (GCD), defined as diverticulum larger than 4 cm, is a rare entity. It is generally a manifestation of colonic diverticular disease and can have dramatic complications such as perforation, abscess, volvulus, infarction and adenocarcinoma. This report documents the case of a 63-year-old man coming to the Emergency Department with acute abdomen due to a perforation of a GCD. In the plain abdominal X-ray the ‘Balloon-sign’ was revealed, computed tomography scan and Hartmann’s procedure were performed. Acute abdomen can occur as a manifestation of a complication of a GCD, and this report highlights the fact that GCD should be considered for patients with a high risk of diverticular disease and abdominal pain. INTRODUCTION CASE REPORT Giant colonic diverticulum (GCD) is defined as a diverticulum A 63-year-old man was referred to the surgical emergency larger than 4 cm in diameter. It is an uncommon condition department because of severe abdominal pain, fever and with <200 studies described in the current literature. Acute abdominal distention. The patient complained of abdominal abdomen has been reported in 6% of the cases, while perfor- pain during defecation for about a week, as well as abdominal ation can occur at presentation or at the time of surgery in swelling and a sensation of weight during urination for 1 26.5% of the cases. Volvulus, colonic obstruction, infarction and month. His medical history was unremarkable and he had adenocarcinoma constitute less common complications of the never undergone a colonoscopy. The physical examination GCD [1]. Our main objective is to present this rare entity as showed tenderness and rigidity in the left iliac fossa. potential cause in the differential diagnosis of acute abdomen, A plain abdominal X-ray presented a solitary, air-filled particularly among patients aged 60 or older. structure with smooth margins in the lower abdomen, while a Received: December 20, 2017. Accepted: January 12, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy009/4841777 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 A. Syllaios et al. Figure 1: (a) Abdominal X-ray shows an air-filled structure in the lower abdomen (Balloon-sign). (b) Abdominal CT scan shows an air-filled cavity associated with the colon. chest X-ray revealed the presence of free air in the abdominal cavity (Fig. 1a). An abdominal computed tomography (CT) scan showed a large, 9 × 9.5 cm , thin-walled, cyst-like lesion with air-fluid level adherent to the sigmoid colon as shown in Fig. 1b. At exploratory laparotomy, a large cystic mass was found adherent to the sigmoid colon (Fig. 2) and Hartmann’s proced- ure was performed. The resected specimen of the GCD and sig- moid colon is shown in Fig. 3. The postoperative recovery was uneventful and the patient was discharged on postoperative Day 7. Pathological assessment of the specimen showed diverticu- losis and a 8 × 7 × 6.8 cm ruptured diverticulum with extensive acute inflammation of serosal tissue, fibrous tissue and foreign-body giant cell reaction around fecal matter. A colorec- tal polyp with sites of tubular adenoma with focal high-grade dysplasia distal of the GCD was revealed. Figure 2: Giant colonic diverticulum on laparotomy. In accordance with the classification suggested by McNutt et al., the features of the specimen were consistent with type II GCD. Colostomy reversal was performed 4 months later. DISCUSSION Diverticular disease is a common manifestation with high prevalence among individuals older than 60 years in the west- ern world. GCD is a rare condition occurring in the sigmoid colon in more than 90% of the cases, that was initially described in 1946 by Bonvin and Bonte. Concomitant diverticular disease is pre- sent in 85% of the patients. Although age at diagnosis ranges from 32 to 90 years, most cases have been described after the age of 60 [1]. In most reported cases of GCD, the diameter ranges between 4 and 9 cm, yet diverticula as large as 40 cm have been described [2]. McNutt et al. classified GCD in three distinct subtypes. Type I is a pseudodiverticulum containing remnants of muscularis mucosa or muscularis propria and gradually increasing in size (22%). Type II is an inflammatory diverticulum without any intestinal layers, which is secondary to a local perforation of the mucosa and submucosa, creating an abscess cavity that Figure 3: Resected specimen of the giant colonic diverticulum and sigmoid communicates intermittently with the bowel lumen. The par- colon. ticular type of diverticulum contains fibrous scar tissue (66%). Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy009/4841777 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Giant colonic diverticulum 3 Type III is a true diverticulum consisting of all the layers of the patients with a high risk for diverticular disease. Plain abdomen bowel (12%) [1]. X-ray and CT scan contribute to the diagnosis. Resection of the There are two main hypotheses to the pathogenesis of the diverticulum and the adjacent colon is preferred as treatment GCD. The first claims that an unidirectional ball-valve mechan- of choice. ism, through a tiny communicating diverticular neck causes air entrapment and gradual enlargement of the diverticulum [3], while the other asserts that gas forming organisms are respon- CONFLICT OF INTEREST STATEMENT sible for GCD [1]. None declared. The clinical presentation of GCD can be variable. One-third of the patients present with chronic symptoms, such as abdominal pain, distention and altered bowel habits. REFERENCES Approximately 10% of the cases are asymptomatic, as an abdominal mass constitutes an incidental finding. An acute 1. Nigri G, Petrucciani N, Giannini G, Aurello P, Magistri P, presentation (30–35%) involves the occurrence of acute abdom- Gasparrini M, et al. Giant colonic diverticulum: clinical pres- inal pain associated with fever, vomiting and rectal bleeding. entation, diagnosis and treatment: systematic review of 166 Complications of the GCD are reported in 15–35% of the cases. cases. World J Gastroenterol 2015;21:360–8. Patients may have an acute abdomen (6%) due to perforation or 2. Macht R, Sheldon HK, Fisichella PM. Giant colonic diverticu- other less common complications such as abscess, volvulus lum: a rare diagnostic and therapeutic challenge of diverticu- and infarction [1]. Adenocarcinoma within or distal to the GCD lar disease. J Gastrointest Surg 2015;19:1559–60. has been reported in 2% of the cases [4]. 3. Toiber-Levy M, Golffier-Rosete C, Martínez-Munive A, Abdominal X-ray and CT scan are the investigations of Baquera J, Stoppen ME, D’Hyver C, et al. Giant sigmoid diver- choice for diagnosing GCD. A large, smoothly marginated, air- ticulum: case report and review of the literature. Gastroenterol filled cyst (‘Balloon-sign’) with or without air-fluid level is Clin Biol 2008;32:581–4. revealed on the abdominal X-ray [5]. An abdominal CT scan 4. Abou-Nukta F, Bakhos C, Ikekpeazu N, Ciardiello K. Ruptured shows an air-filled cavity associated with the colon. Barium giant colonic diverticulum. Am Surg 2005;71:1073–4. enema can demonstrate the communication with the bowel 5. Thomas S, Peel RL, Evans LE, Haarer KA. Best cases from the lumen in 60–70% of the cases. However, perforation may occur AFIP: giant colonic diverticulum. Radiographics 2006;26: as a complication [6]. 1869–72. Resection of the diverticulum and adjacent colon with pri- 6. Sassani P, Singh HM, Gerety D, Abbas MA. Giant colonic mary anastomosis, with or without a temporary diverting ileos- diverticulum: endoscopic, imaging, and histopathologic find- tomy, is the recommended treatment for uncomplicated GCD ings. Perm J 2008;12:47–9. [7], while a laparoscopic approach may be feasible in some 7. Kam JC, Doraiswamy V, Spira RS. A rare case presentation of patients [8]. In the setting of complications, Hartmann’s pro- a perforated giant sigmoid diverticulum. Case Rep Med 2013; cedure might be performed [1]. 2013:957152. In conclusion, acute abdomen can occur as a manifestation 8. Collin JE, Atwal GS, Dunn WK, Acheson AG. Laparoscopic- of a complication of GCD such as perforation. Hence, we sug- assisted resection of a giant colonic diverticulum: a case gest that the particular condition should be considered for report. J Med Case Rep 2009;3:7075. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy009/4841777 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

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Abstract

Giant colonic diverticulum (GCD), defined as diverticulum larger than 4 cm, is a rare entity. It is generally a manifestation of colonic diverticular disease and can have dramatic complications such as perforation, abscess, volvulus, infarction and adenocarcinoma. This report documents the case of a 63-year-old man coming to the Emergency Department with acute abdomen due to a perforation of a GCD. In the plain abdominal X-ray the ‘Balloon-sign’ was revealed, computed tomography scan and Hartmann’s procedure were performed. Acute abdomen can occur as a manifestation of a complication of a GCD, and this report highlights the fact that GCD should be considered for patients with a high risk of diverticular disease and abdominal pain. INTRODUCTION CASE REPORT Giant colonic diverticulum (GCD) is defined as a diverticulum A 63-year-old man was referred to the surgical emergency larger than 4 cm in diameter. It is an uncommon condition department because of severe abdominal pain, fever and with <200 studies described in the current literature. Acute abdominal distention. The patient complained of abdominal abdomen has been reported in 6% of the cases, while perfor- pain during defecation for about a week, as well as abdominal ation can occur at presentation or at the time of surgery in swelling and a sensation of weight during urination for 1 26.5% of the cases. Volvulus, colonic obstruction, infarction and month. His medical history was unremarkable and he had adenocarcinoma constitute less common complications of the never undergone a colonoscopy. The physical examination GCD [1]. Our main objective is to present this rare entity as showed tenderness and rigidity in the left iliac fossa. potential cause in the differential diagnosis of acute abdomen, A plain abdominal X-ray presented a solitary, air-filled particularly among patients aged 60 or older. structure with smooth margins in the lower abdomen, while a Received: December 20, 2017. Accepted: January 12, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy009/4841777 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 A. Syllaios et al. Figure 1: (a) Abdominal X-ray shows an air-filled structure in the lower abdomen (Balloon-sign). (b) Abdominal CT scan shows an air-filled cavity associated with the colon. chest X-ray revealed the presence of free air in the abdominal cavity (Fig. 1a). An abdominal computed tomography (CT) scan showed a large, 9 × 9.5 cm , thin-walled, cyst-like lesion with air-fluid level adherent to the sigmoid colon as shown in Fig. 1b. At exploratory laparotomy, a large cystic mass was found adherent to the sigmoid colon (Fig. 2) and Hartmann’s proced- ure was performed. The resected specimen of the GCD and sig- moid colon is shown in Fig. 3. The postoperative recovery was uneventful and the patient was discharged on postoperative Day 7. Pathological assessment of the specimen showed diverticu- losis and a 8 × 7 × 6.8 cm ruptured diverticulum with extensive acute inflammation of serosal tissue, fibrous tissue and foreign-body giant cell reaction around fecal matter. A colorec- tal polyp with sites of tubular adenoma with focal high-grade dysplasia distal of the GCD was revealed. Figure 2: Giant colonic diverticulum on laparotomy. In accordance with the classification suggested by McNutt et al., the features of the specimen were consistent with type II GCD. Colostomy reversal was performed 4 months later. DISCUSSION Diverticular disease is a common manifestation with high prevalence among individuals older than 60 years in the west- ern world. GCD is a rare condition occurring in the sigmoid colon in more than 90% of the cases, that was initially described in 1946 by Bonvin and Bonte. Concomitant diverticular disease is pre- sent in 85% of the patients. Although age at diagnosis ranges from 32 to 90 years, most cases have been described after the age of 60 [1]. In most reported cases of GCD, the diameter ranges between 4 and 9 cm, yet diverticula as large as 40 cm have been described [2]. McNutt et al. classified GCD in three distinct subtypes. Type I is a pseudodiverticulum containing remnants of muscularis mucosa or muscularis propria and gradually increasing in size (22%). Type II is an inflammatory diverticulum without any intestinal layers, which is secondary to a local perforation of the mucosa and submucosa, creating an abscess cavity that Figure 3: Resected specimen of the giant colonic diverticulum and sigmoid communicates intermittently with the bowel lumen. The par- colon. ticular type of diverticulum contains fibrous scar tissue (66%). Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy009/4841777 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Giant colonic diverticulum 3 Type III is a true diverticulum consisting of all the layers of the patients with a high risk for diverticular disease. Plain abdomen bowel (12%) [1]. X-ray and CT scan contribute to the diagnosis. Resection of the There are two main hypotheses to the pathogenesis of the diverticulum and the adjacent colon is preferred as treatment GCD. The first claims that an unidirectional ball-valve mechan- of choice. ism, through a tiny communicating diverticular neck causes air entrapment and gradual enlargement of the diverticulum [3], while the other asserts that gas forming organisms are respon- CONFLICT OF INTEREST STATEMENT sible for GCD [1]. None declared. The clinical presentation of GCD can be variable. One-third of the patients present with chronic symptoms, such as abdominal pain, distention and altered bowel habits. REFERENCES Approximately 10% of the cases are asymptomatic, as an abdominal mass constitutes an incidental finding. An acute 1. Nigri G, Petrucciani N, Giannini G, Aurello P, Magistri P, presentation (30–35%) involves the occurrence of acute abdom- Gasparrini M, et al. Giant colonic diverticulum: clinical pres- inal pain associated with fever, vomiting and rectal bleeding. entation, diagnosis and treatment: systematic review of 166 Complications of the GCD are reported in 15–35% of the cases. cases. World J Gastroenterol 2015;21:360–8. Patients may have an acute abdomen (6%) due to perforation or 2. Macht R, Sheldon HK, Fisichella PM. Giant colonic diverticu- other less common complications such as abscess, volvulus lum: a rare diagnostic and therapeutic challenge of diverticu- and infarction [1]. Adenocarcinoma within or distal to the GCD lar disease. J Gastrointest Surg 2015;19:1559–60. has been reported in 2% of the cases [4]. 3. Toiber-Levy M, Golffier-Rosete C, Martínez-Munive A, Abdominal X-ray and CT scan are the investigations of Baquera J, Stoppen ME, D’Hyver C, et al. Giant sigmoid diver- choice for diagnosing GCD. A large, smoothly marginated, air- ticulum: case report and review of the literature. Gastroenterol filled cyst (‘Balloon-sign’) with or without air-fluid level is Clin Biol 2008;32:581–4. revealed on the abdominal X-ray [5]. An abdominal CT scan 4. Abou-Nukta F, Bakhos C, Ikekpeazu N, Ciardiello K. Ruptured shows an air-filled cavity associated with the colon. Barium giant colonic diverticulum. Am Surg 2005;71:1073–4. enema can demonstrate the communication with the bowel 5. Thomas S, Peel RL, Evans LE, Haarer KA. Best cases from the lumen in 60–70% of the cases. However, perforation may occur AFIP: giant colonic diverticulum. Radiographics 2006;26: as a complication [6]. 1869–72. Resection of the diverticulum and adjacent colon with pri- 6. Sassani P, Singh HM, Gerety D, Abbas MA. Giant colonic mary anastomosis, with or without a temporary diverting ileos- diverticulum: endoscopic, imaging, and histopathologic find- tomy, is the recommended treatment for uncomplicated GCD ings. Perm J 2008;12:47–9. [7], while a laparoscopic approach may be feasible in some 7. Kam JC, Doraiswamy V, Spira RS. A rare case presentation of patients [8]. In the setting of complications, Hartmann’s pro- a perforated giant sigmoid diverticulum. Case Rep Med 2013; cedure might be performed [1]. 2013:957152. In conclusion, acute abdomen can occur as a manifestation 8. Collin JE, Atwal GS, Dunn WK, Acheson AG. Laparoscopic- of a complication of GCD such as perforation. Hence, we sug- assisted resection of a giant colonic diverticulum: a case gest that the particular condition should be considered for report. J Med Case Rep 2009;3:7075. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy009/4841777 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Published: Feb 1, 2018

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