- Email: [email protected]
Case report: Uncommon radiological and pathological features of giant colonic diverticula
Clinical Radiology (1991) 44, 125-127
Case Report: Uncommon Radiological and Pathological Features of Giant Colonic Diverticula D. J. C A S A S , M. T E N E S A , A. A L A S T R U I ~ * , F. H I D A L G O * , L. C. B A R R A N C O ] " a n d A. O L A Z A B A L
Departments of Radiology, *Surgery and ~Pathology, Autonomous University of Barcelona, Germans Trias i Pujol Hospital, Badalona, Spain A case of multiple giant sigmoid diverticula is described in which a barium enema revealed two giant diverticula communicating with the sigmoid lumen. Both diverticula were located on t h e mesenteric border of the sigmoid colon, and histologic examination showed mucosal and serosal layers with no evidence of smooth muscle. The pathogenesis, pathology, radiological manifestations and differential diagnosis of this rare condition are discussed. Casas, D.J., Tenesa, M., Alastru6, A., H i d a l g o , F., B a r r a n c o , L.C. & O l a z a b a l , A. (1991). Clinical Radiology 44, 125-127. Case R e p o r t : U n c o m m o n R a d i o l o g i c a l a n d P a t h o l o g i c a l F e a t u r e s of Giant Colonic Diverticula
A b o u t 100 cases o f giant colonic d i v e r t i c u l u m ( G C D ) have been d e s c r i b e d in the w o r l d literature ( w i t h o u t histology in 20% o f the cases) using the following terminology: ' s o l i t a r y air cyst', ' g i a n t air cyst', ' g i a n t gas cyst', ' g i a n t s i g m o i d d i v e r t i c u l u m ' a n d 'giant gas filled cyst o f the s i g m o i d c o l o n ' . Nevertheless, three distinct p a t h o l o g i c entities o f the c o l o n have been included under these terms: giant p s e u d o d i v e r t i c u l a (five cases), i n f l a m m a t o r y g i a n t diverticula ( a b o u t 60 cases), a n d true giant diverticula (12 cases) ( M c N u t t et al., 1988). W e r e p o r t the u n u s u a l case o f two giant p s e u d o d i v e r t i c u l a both o r i g i n a t i n g on the mesenteric b o r d e r o f the sigmoid. CASE REPORT An 80-year-old white man was admitted to our hospital with abdominal pain and a mass in the right lower quadrant (RLQ) of the abdomen of 3 days duration. He also complained of alternating periods of diarrhoea and constipation, with a 10 kg weight loss over the 3 months prior to admission. Physical examination revealed a soft, tender, mobile mass in the RLQ, approximately 10 cm in size. A supine radiograph of the abdomen revealed two round, smooth air collections, one located in the RLQ, with a maximum diameter of 11.5 cm, and the other of 6.5 cm projected against the sacrum (Fig. 1). A barium enema revealed sigmoid diverticulosis and showed the two air cysts communicating with the sigmoid colon and filled with barium (Fig. 2). Laparotomy confirmed the presence of diverticulosis predominating on the mesenteric border of the sigmoid. Two large diverticula with multiple adhesions were situated in the interior of the mesosigma. Both could be deflated manually and communicated with the sigmoid lumen through small orifices (Fig. 3). The affected sigmoid was resected. Pathologic examination of both diverticula revealed an intact serosal wall and a mucosal lining with scattered focal ulceration, deposits of fibrin and acute inflammatory changes (Fig. 4). There was no evidence of smooth muscle or nervous tissue in the wall. Post-operative recovery was uneventful.
DISCUSSION M c N u t t et al. (1988) clearly distinguished for the first time three types o f g i a n t colonic d i v e r t i c u l u m ( G C D ) c o r r e s p o n d i n g to three distinct entities with different etiology a n d h i s t o l o g y b u t having similar clinical a n d r a d i o l o g i c a l presentations. Correspondence to: Dr Dario J. Casas, Department of Radiology, Hospital Germans Trias y Pujol, Carretera de Canyet s/n, Ap. Correus 72, Badalona, Spain.
Fig. 1 Abdominal film showing a round, smooth margined radiolucency in the right lower quadrant (arrowheads) and an oval, smooth air collection within the true pelvis (arrows).
1 Giant pseudodiverticulum (Bergeron a n d Hanley, 1965; F o s t e r and Ross, 1977; K r i k u n et al., 1980; M u h t e t a l e r et al., 1981; M c N u t t et al., 1988). This is p r o d u c e d by g r a d u a l e n l a r g e m e n t o f a pre-existing pulsion p s e u d o d i v e r t i c u l u m w i t h o u t a n y evidence o f p e r f o r a t i o n . S o m e a u t h o r s have suggested t h a t i n f l a m m a t o r y changes cause n a r r o w i n g o f the neck o f the p s e u d o d i v e r t i c u l u m p r o d u c ing a ball-valve m e c h a n i s m t h a t allows colonic air to enter the p s e u d o d i v e r t i c u l u m , w h e n i n t r a l u m i n a l pressure increases, b u t n o t to exit f r o m it ( K e m p c z i n s k i a n d Ferrucci, 1974). Histologically, the true colonic m u s c u l a r -
126
CLINICALRADIOLOGY
Fig. 4 Sectionof a diverticulum with partially well preserved mucosa and areas of ulceration. Pronounced underlying fibrosis. Note the absence of smooth muscle (H&E x 100). Fig. 2 Barium enema. Post-evacuation film shows a partially filled GCD in the proximal sigmoid, a completelyfilled GCD (arrows) in the distal sigmoid, and associated diverticular disease of the sigmoid.
mucosal lining (Krikun et al., 1980; Foster and Ross, 1977).
2 Giant inflammatory diverticulum (Sibson and Edwards, 1972; Foster and Ross, 1977; Gallagher and Welch, 1979; Arianoffet al., 1979; Krikun et al., 1980; Muhletaler et al., 1981; Wallers, 1981). Its wall is composed of reactive scar tissue without any intestinal layers. It results from a focal perforation o f the mucosa and submucosa with the subsequent development of a contained cavity which remains in communication at least intermittently with the colonic lumen allowing the cavity to enlarge by some mechanism for which various theories have been proposed. Sibson and Edwards (1972) have suggested that bacteria play some part in the etiology of the gas in the cavity. Other authors have postulated a gradual enlargement of the cavity by a ball-valve effect, at least initially, that could be followed by recurring infections with intraluminal drainage of the abscess, with the possibility that peridiverticular adhesions would impede the reduction in size of the cavity (Kempczinski and Ferrucci, 1974; Gallagher and Welch, 1979; Muhletaler et al., 1981).
Fig. 3- Surgical specimen of resected sigmoid is opened on the antimesenteric border showingthe two GCD and the smallcommunication of the sigmoidlumen with one of them.
is ends abruptly at the neck of the pseudodiverticulum and there is no evidence of smooth muscle in the wall. Remnants of muscle may be found but these correspond to muscularis mucosae (Krikun et al., 1980). It is often lined by chronic granulation tissue interspersed with colonic mucosa and only rarely has a completely intact
3 True giant diverticulum (Melamed and Pantone, 1960; Sutorius and Bossert, 1974). This congenital diverticulum is caused by anomalous embryological development. It possesses all colonic layers and may therefore be considered to be a communicating partial duplication previously asymptomatic that, on developing complications, is described as GCD. Its histological examination reveals inflammatory cells and destruction of colonic layers in ratio to gravity and evolution of the inflammatory process. The age of patients at the time of diagnosis ranged from 38 to 89 years, with a maximum incidence over 70 years. Patients with a true diverticulum tend to be the youngest. The sex distribution is equal. Three clinical presentations have been described: asymptomatic abdominal mass, recurrent vague abdominal pain, and acute symptoms of
GIANT COLONIC DIVERTICULA
diverticulitis. Complications occur in about 12% of cases. A volvulus o f a GCD, an adenocarcinoma within a GCD, small bowel obstruction caused by adherence to a GCD, and different forms of perforation (including pneumoperitoneum, fistula and abscess) have been reported (Sutorius and Bossert, 1974; Krikun et al., 1980). In literature review we found only seven cases of patients with two giant colonic diverticula: a case with pseudodiverticula, a patient with inflammatory diverticula and two others with true diverticula (Melamed and Pantone, 1960; Sutorius and Bossert, 1974; Gallagher and Welch, 1979; Muhletaler et al., 1981). The histology of the other cases is not described (Bonvin and Bonte, 1946; Silberman and Thorner, 1961; Kempczinski and Ferrucci, 1974). Ninety-four per cent of G C D are located in the sigmoid, originating on the antimesenteric Side (Foster and Ross, 1977; Krikun et al., 1980). On our patient the G C D arose on the mesenteric border of the sigmoid. Only six other cases have been reported originating on the mesenteric side of the colon: two pseudodiverticula, three inflammatory diverticula and one true diverticulum (Bergeron and Hanley, 1965; Sibson and Edwards, 1972; Sutorius and Bossert, 1974; Arianoffet al., 1979; Muhlertaler et al., 1981; Wallets, 1981), The plain film, barium enema and CT findings in patients with G C D have been described (Foster and Ross, 1977; Krikun et al., 1980; McNutt et al., 1988). Plain abdominal radiography reveals a round, smooth margined radiolucency in the lower or mid abdomen, varying in diameter from 6 cm to 29 cm. An air-fluid level in the GCD is found in 25% of cases. During a barium enema the G C D remains in close apposition to the colon on all views. The G C D is filled with barium in nearly 60% of cases, showing a smooth internal wall. When irregular or lobulated, the possibility of an additional inflammatory or neoplastic process should be considered. A bilocular diverticulum has been reported (Schenken and Cochran , 1972). Small diverticula nearly always exist near the GCD. The adjacent colon is often irritated and oedematous and may be compressed by the GCD.
127
The causes of a large radiolucent lesion adjacent to the colon on an abdominal radiograph are multiple but the differential diagnosis of G C D is basically limited to an abdominal abscess adjacent to the colon, a necrotic turnout communicating with the intestinal lumen, and air in the urinary bladder.
REFERENCES
Arianoff, AA, Vielle, C, Arianoff, V & Nouzaradan, J (1979). Diverticule g6ant du sigmoi'de. Acta Chirurgiea Belgica, 78, 223-229. Bergeron, RB & Hanley, PH (1965). Giant sigmoid diverticulum. American Journal of Surgery, 109, 660 662. Bonvin, P & Bonte, G (1946). Diverticules g6ants du sigmo~de. Archives Maladies Appareil Digestive, 35, 353-355. Foster, DR & Ross, B (1977). Giant sigmoid diverticulum: clinical and radiological features. Gut, 18, 1051 1053. Gatlagher, JJ & Welch, JP (1979). Giant diverticula of the sigmoid colon: a review of differential diagnosis and operative management. Archives of Surgery, 114, 1079-1083. Kempczinski, RF & Ferrucci, JT Jr (1974). Giant sigmoid diverticula: a review. Annals of Surgery, 180, 864-867. Kricun, R, Stasik, J J, Reither, RD & Dex, WJ (1980). Giant colonic diverticulum. American Journal of Roentgenology, 135, 507-512. Melamed, M & Pantone, A (1960). Giant diverticula of the colon. Archives of Surgery, 81, 723 725. Muhletaler, CA, Berger, JL & Robinette, CL Jr (1981). Pathogenesis of giant colonic diverticula. Gastrointestinal Radiology, 6, 217-222. McNutt, R, Schmitt, D & Schulte, W (1988). Giant colonic diverticula Three distinct entities. Report of a case. Diseases of the Colon and Rectum, 31, 624-628. Schenken, JR & Cochran, R (1972). An intestinal-gas cyst, a rare complication of diverticulitis: report of a case. Diseases of the Colon and Rectum, 15, 448-452. Sibson, DE & Edwards, AJ (1972). Giant gas-filled cyst of sigmoid colon: report of a case and review of the literature. Postgraduate Medical Journal, 48, 180 184. Silberman, EL & Thorner, MC (1961). Volvulus of giant sigmoidal diverticulum. Journal of American Medical Association, 177, 782 785. Sutorius, DJ & Bossert, JE (1974). Giant sigmoid diverticulum with perforation. American Journal of Surgery, 127, 745-748. Wallers, KJ (1981). Giant diverticulum arising from the transverse colon of a patient with diverticulosis. British Journal of Radiology, 54, 683-684.
Case Report: Uncommon Radiological and Pathological Features of Giant Colonic Diverticula D. J. C A S A S , M. T E N E S A , A. A L A S T R U I ~ * , F. H I D A L G O * , L. C. B A R R A N C O ] " a n d A. O L A Z A B A L
Departments of Radiology, *Surgery and ~Pathology, Autonomous University of Barcelona, Germans Trias i Pujol Hospital, Badalona, Spain A case of multiple giant sigmoid diverticula is described in which a barium enema revealed two giant diverticula communicating with the sigmoid lumen. Both diverticula were located on t h e mesenteric border of the sigmoid colon, and histologic examination showed mucosal and serosal layers with no evidence of smooth muscle. The pathogenesis, pathology, radiological manifestations and differential diagnosis of this rare condition are discussed. Casas, D.J., Tenesa, M., Alastru6, A., H i d a l g o , F., B a r r a n c o , L.C. & O l a z a b a l , A. (1991). Clinical Radiology 44, 125-127. Case R e p o r t : U n c o m m o n R a d i o l o g i c a l a n d P a t h o l o g i c a l F e a t u r e s of Giant Colonic Diverticula
A b o u t 100 cases o f giant colonic d i v e r t i c u l u m ( G C D ) have been d e s c r i b e d in the w o r l d literature ( w i t h o u t histology in 20% o f the cases) using the following terminology: ' s o l i t a r y air cyst', ' g i a n t air cyst', ' g i a n t gas cyst', ' g i a n t s i g m o i d d i v e r t i c u l u m ' a n d 'giant gas filled cyst o f the s i g m o i d c o l o n ' . Nevertheless, three distinct p a t h o l o g i c entities o f the c o l o n have been included under these terms: giant p s e u d o d i v e r t i c u l a (five cases), i n f l a m m a t o r y g i a n t diverticula ( a b o u t 60 cases), a n d true giant diverticula (12 cases) ( M c N u t t et al., 1988). W e r e p o r t the u n u s u a l case o f two giant p s e u d o d i v e r t i c u l a both o r i g i n a t i n g on the mesenteric b o r d e r o f the sigmoid. CASE REPORT An 80-year-old white man was admitted to our hospital with abdominal pain and a mass in the right lower quadrant (RLQ) of the abdomen of 3 days duration. He also complained of alternating periods of diarrhoea and constipation, with a 10 kg weight loss over the 3 months prior to admission. Physical examination revealed a soft, tender, mobile mass in the RLQ, approximately 10 cm in size. A supine radiograph of the abdomen revealed two round, smooth air collections, one located in the RLQ, with a maximum diameter of 11.5 cm, and the other of 6.5 cm projected against the sacrum (Fig. 1). A barium enema revealed sigmoid diverticulosis and showed the two air cysts communicating with the sigmoid colon and filled with barium (Fig. 2). Laparotomy confirmed the presence of diverticulosis predominating on the mesenteric border of the sigmoid. Two large diverticula with multiple adhesions were situated in the interior of the mesosigma. Both could be deflated manually and communicated with the sigmoid lumen through small orifices (Fig. 3). The affected sigmoid was resected. Pathologic examination of both diverticula revealed an intact serosal wall and a mucosal lining with scattered focal ulceration, deposits of fibrin and acute inflammatory changes (Fig. 4). There was no evidence of smooth muscle or nervous tissue in the wall. Post-operative recovery was uneventful.
DISCUSSION M c N u t t et al. (1988) clearly distinguished for the first time three types o f g i a n t colonic d i v e r t i c u l u m ( G C D ) c o r r e s p o n d i n g to three distinct entities with different etiology a n d h i s t o l o g y b u t having similar clinical a n d r a d i o l o g i c a l presentations. Correspondence to: Dr Dario J. Casas, Department of Radiology, Hospital Germans Trias y Pujol, Carretera de Canyet s/n, Ap. Correus 72, Badalona, Spain.
Fig. 1 Abdominal film showing a round, smooth margined radiolucency in the right lower quadrant (arrowheads) and an oval, smooth air collection within the true pelvis (arrows).
1 Giant pseudodiverticulum (Bergeron a n d Hanley, 1965; F o s t e r and Ross, 1977; K r i k u n et al., 1980; M u h t e t a l e r et al., 1981; M c N u t t et al., 1988). This is p r o d u c e d by g r a d u a l e n l a r g e m e n t o f a pre-existing pulsion p s e u d o d i v e r t i c u l u m w i t h o u t a n y evidence o f p e r f o r a t i o n . S o m e a u t h o r s have suggested t h a t i n f l a m m a t o r y changes cause n a r r o w i n g o f the neck o f the p s e u d o d i v e r t i c u l u m p r o d u c ing a ball-valve m e c h a n i s m t h a t allows colonic air to enter the p s e u d o d i v e r t i c u l u m , w h e n i n t r a l u m i n a l pressure increases, b u t n o t to exit f r o m it ( K e m p c z i n s k i a n d Ferrucci, 1974). Histologically, the true colonic m u s c u l a r -
126
CLINICALRADIOLOGY
Fig. 4 Sectionof a diverticulum with partially well preserved mucosa and areas of ulceration. Pronounced underlying fibrosis. Note the absence of smooth muscle (H&E x 100). Fig. 2 Barium enema. Post-evacuation film shows a partially filled GCD in the proximal sigmoid, a completelyfilled GCD (arrows) in the distal sigmoid, and associated diverticular disease of the sigmoid.
mucosal lining (Krikun et al., 1980; Foster and Ross, 1977).
2 Giant inflammatory diverticulum (Sibson and Edwards, 1972; Foster and Ross, 1977; Gallagher and Welch, 1979; Arianoffet al., 1979; Krikun et al., 1980; Muhletaler et al., 1981; Wallers, 1981). Its wall is composed of reactive scar tissue without any intestinal layers. It results from a focal perforation o f the mucosa and submucosa with the subsequent development of a contained cavity which remains in communication at least intermittently with the colonic lumen allowing the cavity to enlarge by some mechanism for which various theories have been proposed. Sibson and Edwards (1972) have suggested that bacteria play some part in the etiology of the gas in the cavity. Other authors have postulated a gradual enlargement of the cavity by a ball-valve effect, at least initially, that could be followed by recurring infections with intraluminal drainage of the abscess, with the possibility that peridiverticular adhesions would impede the reduction in size of the cavity (Kempczinski and Ferrucci, 1974; Gallagher and Welch, 1979; Muhletaler et al., 1981).
Fig. 3- Surgical specimen of resected sigmoid is opened on the antimesenteric border showingthe two GCD and the smallcommunication of the sigmoidlumen with one of them.
is ends abruptly at the neck of the pseudodiverticulum and there is no evidence of smooth muscle in the wall. Remnants of muscle may be found but these correspond to muscularis mucosae (Krikun et al., 1980). It is often lined by chronic granulation tissue interspersed with colonic mucosa and only rarely has a completely intact
3 True giant diverticulum (Melamed and Pantone, 1960; Sutorius and Bossert, 1974). This congenital diverticulum is caused by anomalous embryological development. It possesses all colonic layers and may therefore be considered to be a communicating partial duplication previously asymptomatic that, on developing complications, is described as GCD. Its histological examination reveals inflammatory cells and destruction of colonic layers in ratio to gravity and evolution of the inflammatory process. The age of patients at the time of diagnosis ranged from 38 to 89 years, with a maximum incidence over 70 years. Patients with a true diverticulum tend to be the youngest. The sex distribution is equal. Three clinical presentations have been described: asymptomatic abdominal mass, recurrent vague abdominal pain, and acute symptoms of
GIANT COLONIC DIVERTICULA
diverticulitis. Complications occur in about 12% of cases. A volvulus o f a GCD, an adenocarcinoma within a GCD, small bowel obstruction caused by adherence to a GCD, and different forms of perforation (including pneumoperitoneum, fistula and abscess) have been reported (Sutorius and Bossert, 1974; Krikun et al., 1980). In literature review we found only seven cases of patients with two giant colonic diverticula: a case with pseudodiverticula, a patient with inflammatory diverticula and two others with true diverticula (Melamed and Pantone, 1960; Sutorius and Bossert, 1974; Gallagher and Welch, 1979; Muhletaler et al., 1981). The histology of the other cases is not described (Bonvin and Bonte, 1946; Silberman and Thorner, 1961; Kempczinski and Ferrucci, 1974). Ninety-four per cent of G C D are located in the sigmoid, originating on the antimesenteric Side (Foster and Ross, 1977; Krikun et al., 1980). On our patient the G C D arose on the mesenteric border of the sigmoid. Only six other cases have been reported originating on the mesenteric side of the colon: two pseudodiverticula, three inflammatory diverticula and one true diverticulum (Bergeron and Hanley, 1965; Sibson and Edwards, 1972; Sutorius and Bossert, 1974; Arianoffet al., 1979; Muhlertaler et al., 1981; Wallets, 1981), The plain film, barium enema and CT findings in patients with G C D have been described (Foster and Ross, 1977; Krikun et al., 1980; McNutt et al., 1988). Plain abdominal radiography reveals a round, smooth margined radiolucency in the lower or mid abdomen, varying in diameter from 6 cm to 29 cm. An air-fluid level in the GCD is found in 25% of cases. During a barium enema the G C D remains in close apposition to the colon on all views. The G C D is filled with barium in nearly 60% of cases, showing a smooth internal wall. When irregular or lobulated, the possibility of an additional inflammatory or neoplastic process should be considered. A bilocular diverticulum has been reported (Schenken and Cochran , 1972). Small diverticula nearly always exist near the GCD. The adjacent colon is often irritated and oedematous and may be compressed by the GCD.
127
The causes of a large radiolucent lesion adjacent to the colon on an abdominal radiograph are multiple but the differential diagnosis of G C D is basically limited to an abdominal abscess adjacent to the colon, a necrotic turnout communicating with the intestinal lumen, and air in the urinary bladder.
REFERENCES
Arianoff, AA, Vielle, C, Arianoff, V & Nouzaradan, J (1979). Diverticule g6ant du sigmoi'de. Acta Chirurgiea Belgica, 78, 223-229. Bergeron, RB & Hanley, PH (1965). Giant sigmoid diverticulum. American Journal of Surgery, 109, 660 662. Bonvin, P & Bonte, G (1946). Diverticules g6ants du sigmo~de. Archives Maladies Appareil Digestive, 35, 353-355. Foster, DR & Ross, B (1977). Giant sigmoid diverticulum: clinical and radiological features. Gut, 18, 1051 1053. Gatlagher, JJ & Welch, JP (1979). Giant diverticula of the sigmoid colon: a review of differential diagnosis and operative management. Archives of Surgery, 114, 1079-1083. Kempczinski, RF & Ferrucci, JT Jr (1974). Giant sigmoid diverticula: a review. Annals of Surgery, 180, 864-867. Kricun, R, Stasik, J J, Reither, RD & Dex, WJ (1980). Giant colonic diverticulum. American Journal of Roentgenology, 135, 507-512. Melamed, M & Pantone, A (1960). Giant diverticula of the colon. Archives of Surgery, 81, 723 725. Muhletaler, CA, Berger, JL & Robinette, CL Jr (1981). Pathogenesis of giant colonic diverticula. Gastrointestinal Radiology, 6, 217-222. McNutt, R, Schmitt, D & Schulte, W (1988). Giant colonic diverticula Three distinct entities. Report of a case. Diseases of the Colon and Rectum, 31, 624-628. Schenken, JR & Cochran, R (1972). An intestinal-gas cyst, a rare complication of diverticulitis: report of a case. Diseases of the Colon and Rectum, 15, 448-452. Sibson, DE & Edwards, AJ (1972). Giant gas-filled cyst of sigmoid colon: report of a case and review of the literature. Postgraduate Medical Journal, 48, 180 184. Silberman, EL & Thorner, MC (1961). Volvulus of giant sigmoidal diverticulum. Journal of American Medical Association, 177, 782 785. Sutorius, DJ & Bossert, JE (1974). Giant sigmoid diverticulum with perforation. American Journal of Surgery, 127, 745-748. Wallers, KJ (1981). Giant diverticulum arising from the transverse colon of a patient with diverticulosis. British Journal of Radiology, 54, 683-684.