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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 44-46

Giant sigmoid diverticulum as a lump in left iliac fossa: A rare presentation


Department of General and Minimal Access Surgery, Sir H.N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Submission16-May-2021
Date of Acceptance06-Jun-2021
Date of Web Publication09-Nov-2021

Correspondence Address:
Dr. Sushrut Pramod Tendulkar
c/o Room No. 318, 3rd Floor, Tower Block, Sir H.N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcs.ijcs_7_21

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  Abstract 

Diverticulosis of the colon is a common clinical entity affecting 35% of individuals over the age of 65 years. It is usually limited to the sigmoid colon. When a colonic diverticulum enlarges to over 4 cm in diameter, it is defined as a giant colonic diverticulum (GCD) and it is a rare manifestation of colonic diverticulosis. There have been fewer than 200 cases reported worldwide since GCD was first described in 1946. GCD can be complicated by volvulus, bowel obstruction, perforation, abscess formation, sepsis, and rectal bleeding. Here, we report a case of a 76-year-old female presenting to the emergency department with features of acute colonic obstruction and having a large palpable mass in the left iliac fossa which was diagnosed to be a GCD. She underwent prompt surgical resection of sigmoid colon with en bloc excision of GCD and had uneventful postoperative recovery.

Keywords: Abdominal lump, colonic resection, giant sigmoid diverticulum


How to cite this article:
Tendulkar SP, Kapadia KB. Giant sigmoid diverticulum as a lump in left iliac fossa: A rare presentation. Indian J Colo-Rectal Surg 2021;4:44-6

How to cite this URL:
Tendulkar SP, Kapadia KB. Giant sigmoid diverticulum as a lump in left iliac fossa: A rare presentation. Indian J Colo-Rectal Surg [serial online] 2021 [cited 2021 Dec 4];4:44-6. Available from: https://www.ijcrsonweb.org/text.asp?2021/4/2/44/330166


  Introduction Top


Giant colonic diverticulum (GCD) is defined as a diverticulum larger than 4 cm in diameter. Acute abdomen has been reported in 6% of the cases.[1],[2] Patients usually present with symptoms of abdominal pain, distension, bowel obstruction due to adhesions, or bleeding. Due to the high incidence of complications associated with GCD, surgical resection is recommended. With this case report, we want to highlight, this rare entity as a potential cause in the differential diagnosis of acute abdomen, particularly among patients aged above 60 and especially with a history of diverticulosis.


  Case Report Top


A 76-year-old female presented to the emergency department with intermittent abdominal pain of 3 months' duration; aggravated in the previous 2 days. She had nausea and not passed motions for 5 days. On examination, she was afebrile, tachycardic, and dehydrated. Abdominal examination revealed generalized abdominal distension with a 10 cm × 10 cm palpable tender firm mass with localized guarding in the left iliac fossa. Rectal examination revealed ballooning of rectum. She underwent contrast-enhanced computed tomography (CT) scan of abdomen which revealed 11 cm × 8 cm × 7 cm saccular outpouching arising from the sigmoid colon containing gas and an air-fluid level suggesting GCD [Figure 1]. The proximal large bowel loops were fecal loaded suggesting colonic obstruction. Laboratory results revealed a low hemoglobin value (8.9 g%) and leukocytosis (18,000 cells/mL) with neutrophilic predominance. Arterial blood gas revealed raised serum lactate levels. In view of colonic obstruction, she was posted for laparoscopic-assisted sigmoid colectomy with excision of GCD. Intraoperative laparoscopy findings were that of a sigmoid GCD adherent to ileal loops in pelvis, corpus of uterus, and left adnexa without fistulization. Laparoscopic mobilization of the left colon from splenic flexure to rectosigmoid junction was done. A standard sigmoid colectomy and en bloc excision of GCD was performed [Figure 2] followed by a primary colorectal anastomosis achieved. Histopathology report confirmed colonic diverticulosis with GCD. The wall of diverticulum showed abundant fibrocollagenous tissue with lymphoid aggregates along with remnant of muscularis mucosae. Postoperative recovery of the patient was uneventful and she was discharged after 7 days of hospitalization. At 12 months' follow-up, she was doing fine.
Figure 1: (a) Contrast-enhanced computed tomography images of abdomen showing 11 cm × 8 cm × 7 cm saccular out-pouching arising from the antimesocolic wall of the proximal sigmoid colon containing gas and an air-fluid level communicating with the sigmoid colon. (b) A large, round, homogeneous radiolucency in the left lower quadrant that is smoothly marginated

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Figure 2: (a) 11 cm × 8 cm cut open giant sigmoid diverticulum. (b) Resected specimen of giant colonic diverticulum along with sigmoid colon

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  Discussion Top


In 1943, Bonvin and Bonte reported the first case of a solitary air cyst of the peritoneal cavity attached to the sigmoid colon; subsequently called GCD.[1] By definition, GCDs are colonic diverticula >4 cm in size. These diverticula gradually grow over the years and approximately 90% of them occur in the sigmoid colon. GCD may be an isolated finding but in 85% they are associated with concomitant diverticular disease.[1],[3] The age at diagnosis ranges from 32 to 90 years but most cases have been described after the age of 60 years. Their diameter ranges from 4 to 9 cm but diverticula as large as 40 cm have been described. Most of GCDs are asymptomatic until they reach 7 cm or larger, as seen in our case.[4] The size of GCD waxes and wanes; increases with straining at stools and decreases after evacuation. Consequently, the lump is palpable only intermittently and hence some authors refer to it as a "phantom tumor."[1] There are different hypotheses to explain the development of GCD. One theory suggests that it is caused by a unidirectional ball-valve mechanism through a tiny communicating diverticular neck, which causes air entrapment and gradual enlargement of the diverticulum. Another hypothesis is that GCD is secondary to the action of gas-forming organisms.[1],[2] McNutt et al. classified GCD into three distinct subtypes. Type I (22%) is a pseudodiverticulum and its wall consists of chronic granulation and fibrous tissue with remnants of muscularis mucosae. Type II (66%) is an inflammatory diverticulum without any intestinal layers, which is secondary to a local perforation, creating an abscess cavity that communicates intermittently with the bowel lumen. Type III (12%) is a true diverticulum consisting of all the layers of the bowel.[1],[2],[4] Approximately 10% of the cases are asymptomatic. One-third of the patients present with chronic symptoms, such as abdominal pain, distention, and altered bowel habits. An acute presentation (30%–35%) involves the occurrence of acute abdominal pain associated with fever, vomiting, and rectal bleeding. Complications of the GCD are reported in 15%–35% of the cases.[3] The most common complication associated with GCD is peritonitis, caused by its perforation, followed by abscess formation, intestinal obstruction, volvulus, and infarction. Adenocarcinoma within or distal to the GCD has been reported in 2% of the cases.[5] Abdominal X-ray and CT scan are the investigations of choice for diagnosing GCD. A large, smoothly marginated, air-filled cyst; termed as "Balloon-sign" with or without air-fluid level is revealed on the abdominal X-ray. On abdominal CT, GCD appears as a predominantly gas-filled structure containing a small amount of fluid and communicating with the colon. Coronal and sagittal multiplanar reformatted images are important for identifying the neck of the GCD, which connects the diverticular cavity with the adjacent colon; this finding is essential for correct diagnosis.[6] Barium enema can demonstrate the communication with the bowel lumen in 60%–70% of the cases. However, several cases of perforation have occurred within 24 h of the study, leading to suspicion that barium enemas may precipitate perforation. A colonoscopy is rarely performed because it might cause GCD perforation.[2],[3] The differential diagnosis for GCD includes volvulus, bowel duplication cysts, Meckel diverticula, emphysematous cystitis, vesicoenteric fistula, and intra-abdominal abscess.[1] Resection of the diverticulum and adjacent colon with primary anastomosis, with or without a temporary diverting ileostomy, is the recommended treatment for uncomplicated GCD. A laparoscopic approach may be feasible in some patients, as done in our case.[2] A simple diverticulectomy has been rarely reported.[4] In the setting of complications, Hartmann's procedure might be performed. Conservative management such as percutaneous drainage, stent placement in the diverticular neck with drainage in the colic lumen, and antibiotics should be reserved only for high-risk patients who are unable to tolerate surgery or who are unwilling to have surgery.[3],[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kam JC, Doraiswamy V, Spira RS. A rare case presentation of a perforated giant sigmoid diverticulum. Case Rep Med 2013;2013:957152.  Back to cited text no. 1
    
2.
Syllaios A, Daskalopoulou D, Bourganos N, Papakonstantinou A, Triantafyllou E, Koutras A, et al. Giant colonic diverticulum-a rare cause of acute abdomen. J Surg Case Rep 2018;2018:rjy009.  Back to cited text no. 2
    
3.
Nigri G, Petrucciani N, Giannini G, Aurello P, Magistri P, Gasparrini M, et al. Giant colonic diverticulum: Clinical presentation, diagnosis and treatment: Systematic review of 166 cases. World J Gastroenterol 2015;21:360-8.  Back to cited text no. 3
    
4.
Carr JA. Case report of a giant colonic sigmoid diverticulum causing sigmoid volvulus. Int J Surg Case Rep 2017;31:197-9.  Back to cited text no. 4
    
5.
Muneeb A, Lam SGiant sigmoid diverticulum mimicking bowel perforationCase Reports 2018;2018: bcr-2017-223394.  Back to cited text no. 5
    
6.
Zeina AR, Mahamid A, Nachtigal A, Ashkenazi I, Shapira-Rootman M. Giant colonic diverticulum: Radiographic and MDCT characteristics. Insights Imaging 2015;6:659-64.  Back to cited text no. 6
    


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  [Figure 1], [Figure 2]



 

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