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Giant sigmoid diverticulum—radiological findings
European Journal of Radiology Extra 53 (2005) 107–109
Giant sigmoid diverticulum—radiological findings Salem Zguem a, ∗ , Khaled Bouza¨ıdi a , B´eatrice Santoro b , Fr´ed´erique DeBroucker a , Idir Moali b , Marguerite Grossin c , Marc Levesque a a
Department of Radiology, Louis Mourier University Hospital, 178 Rue des Renouillers, Colombes 92700, France Department of Surgery, Louis Mourier University Hospital, 178 Rue des Renouillers, Colombes 92700, France c Department of Pathology, Louis Mourier University Hospital, 178 Rue des Renouillers, Colombes 92700, France b
Received 14 October 2004; received in revised form 18 January 2005; accepted 20 January 2005
Abstract Giant diverticulum of the colon is a rare complication of the colonic diverticulosis. However, it requires early elective surgical treatment because of the high complication rate. We describe a case of giant sigmoid diverticulum in a 53-year-old woman, perforated 24 h after diagnosis. The pathogenesis, pathology, radiological features and complications of this disease are discussed. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Giant diverticulum; Colon; Diverticulosis; Complication; Radiological features
1. Introduction Giant sigmoid diverticulum is a rare disease. Since the first case described by Bonvin and Bonte in 1946 in French literature and by Hughes and Greene in English literature in 1953, about 135 cases have been reported in the literature [1–3]. It is defined as a large colonic diverticulum, 4 cm in size or larger [4] and it is characterised by a high rate of complications. We describe a case of giant sigmoid diverticulum in a 53year-old woman, perforated 24 h after diagnosis.
2. Case report A 53-year-old woman presented, during her hospitalisation for brain tumor, left abdominal pain. Physical examination revealed a moderately distended and tympanic abdomen in the left lower quadrant and a temperature of 37.4 ◦ C. The white cell count was 12 × 109 l−1 and CRP was 42 mg dl−1 . The diagnosis of diverticulitis was proposed and an abdominal CT (5-mm collimation, 1.5 pitch) was ∗
Corresponding author. Fax: +33 1 47 60 62 79. E-mail address: khaled [email protected] (K. Bouza¨ıdi).
1571-4675/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2005.01.003
obtained. Intravenous contrast material was given and dilute rectal contrast medium was administered before examination. It showed a thin-walled, air-filled cavity in the left lower quadrant, intimately adherent to the sigmoid and compressing onto it (Fig. 1), but without filling of the cavity with orally or intravenously given contrast medium. Sparse smaller diverticula were associated without evidence of inflammation nor intraperitoneal soiling. The diagnosis of a giant sigmoid diverticulum was proposed. Within 1 day, patient presented diffuse peritoneal irritation. CT revealed free abdominal air. The air-filled cavity was less distended (Fig. 2). At emergency laparotomy, an enormous diverticulum originating from the sigmoid colon was excised with a partial sigmoid resection. The postoperative course was uneventful. Pathologic examination revealed an aspecific chronic inflammation. Some smaller diverticula were found in the resected sigmoid portion.
3. Discussion Although diverticular disease of the colon is common, giant colonic diverticulum is rare. This term includes three distinct pathologic entities:
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S. Zguem et al. / European Journal of Radiology Extra 53 (2005) 107–109
Fig. 1. CT scan of the pelvis demonstrates the giant diverticulum and its mass effect on the sigmoid colon.
1. Giant pseudodiverticulum begins as an outpouching of mucosa and submucosa herniating through the circular muscle of bowel wall, at the side of penetrating blood vessels in the mesenteric border. Histologically, it is often lined by chronic granulation tissue interspersed with colonic mucosa and there is no evidence of smooth muscle in the wall [2,5]. It probably results from a complication of colonic diverticular disease [4]. 2. Inflammatory giant diverticulum secondary to a focal subserosal perforation which leads to a walled-off abscess cavity. It is lined by fibrous scar tissue without any intestinal layer. It remains in communication with colonic lumen allowing cavity to enlarge [2,6]. 3. True giant diverticulum possessing all layers of the colonic wall and suggesting congenital origin. It is probably a variant of communicating cystic bowel duplication. The mechanism of formation of giant diverticulum is unclear. Some theories have been postulated, but none is
conclusive. The first theory suggests that inflammatory changes cause norrowing of the neck of the diverticulum yielding a ball-valve effect that allows colonic air to enter but not to exit from the diverticulum. The second theory is that the lesion might be the product of gas-forming micro-organisms which distend diverticulum after its stalk has become obliterated [5]. Giant colonic diverticula generally involves the sigmoid colon (90–94%) [3,7,8,9]. It is often associated with diverticular disease [10]. It can be encountered in patients 32–90 years old, with a maximum incidence over 70 years [1,5,6]. Clinical presentation is variable, from an asymptomatic abdominal mass or radiological finding to an acute abdomen [9]. Abdominal pain is the most common symptom (70%) [4,7] and abdominal mass is the most usual physical finding [4]. Abdominal discomfort, nausea, vomiting, fever, dysuria, meteorism have equally been reported [3]. Diagnosis is easy with radiological help. Abdominal radiographs can show in the lower abdomen a round, balloonlike, smooth margined, gas-filled cyst, varying in size from 4 to 25 cm [8]. An air-fluid level is found in 25% of cases [3]. Lack of haustral folds and location in the lower abdomen should help distinguish this condition from sigmoid or caecal volvulus. Barium enema confirms the diagnosis by filling of the diverticulum with contrast. However, only 50–60% of cases are opacified because of probable inflammation of the neck of the diverticulum [6,5,11]. It also shows the associated diverticular disease. Because of the risk of perforation of the diverticulum carried by barium enema, CT is considered more appropriate. It confirms the diagnosis of air-filled cavity and gives additionnal information on the presence of complications not seen on abdominal X-ray or barium enema (pericolic inflammation, collections). Endoscopy seems to be of lesser diagnostical importance [2]. Complications can occur in 15–28% of cases [2]. Diverticulitis, perforation, pneumoperitoneum, gas dissection into the mesentery, volvulus, small bowel obstruction, adhesions with bowel or bladder, carcinoma within the giant diverticulum, chronic anemia, and colonic hemorrhage have been reported [5,6,9]. The treatment usually involves surgical resection of the diverticulum with adjacent colon and a primary end-to-end anastomosis [5,9]. Only in complicated cases is a protective colostomy or Hartmann’s procedure justified. Postoperative morbidity and mortality are low and no recurrence was reported [2,5]. 4. Conclusion
Fig. 2. Follow-up CT after 36 h shows the perforated giant diverticulum which is less distended.
Giant diverticulum of the colon is a rare complication of the colonic diverticulosis which high risk rate of complications provides a strong reason for operating on patients soon after diagnosis which is easy with radiological help. CT is the most useful adjunct to the evaluation of this condition.
S. Zguem et al. / European Journal of Radiology Extra 53 (2005) 107–109
References [1] Roger T, Rommens J, Bailly JM, Vollont GH, Belva P, Delcour C. Giant colonic diverticulum: presentation of one case and review of the literature. Abdom Imag 1996;21:530– 3. [2] Steenvoorde P, Vogelaar FJ, Oskam J, Tollenaar RAEM. Giant colonic diverticula. Review of diagnostic and therapeutic options. Dig Surg 2004;21:1–6. [3] Matthyssens LE, Van Hee R, Van Osselaer GE, Lemmens L. Giant diverticulum of the colon: report of two new cases and review of the literature. Int Surg 2003;88:34–40. [4] Choong CK, Frizelle FA. Giant colonic diverticulum: report of four cases and review of the literature. Dis Colon Rectum 1998;91: 952–5.
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[5] Roth T, Demartines N, Gavelli A, Huguet C. Les diverticules g´eants du colon. A propos de deux cas. Chirurgie 1999;124:307–12. [6] Casas DJ, Tenesa M, Alastrue A, Hidalgo F, Barranco LC, Olazabal A. Uncommon radiological and pathological features of giant colonic diverticula. Clin Radiol 1991;44:125–7. [7] Bechade D, Baranger B, Desrame J, et al. Diverticule g´eant du cˆolon. Gastroenterol Clin Biol 2001;25:1032–4. [8] Grover H, Nair S, Hertan H. Giant true diverticulum of sigmoid colon. Am J Gastroenterol 1998;93:2267–8. [9] Baton O, Meyrat L, Eggenspieler P, et al. Diverticule g´eant du cˆolon. Ann Chir 2001;126:587–8. [10] Naber A, Sliutz AM, Freitas H. Giant diverticulum of the sigmoid colon. Int J Colorect Dis 1995;10:169–72. [11] Naing T, Ray S, Loughran CF. Giant sigmoid diverticulum: a report of three cases. Clin Radiol 1999;54:179–81.
Giant sigmoid diverticulum—radiological findings Salem Zguem a, ∗ , Khaled Bouza¨ıdi a , B´eatrice Santoro b , Fr´ed´erique DeBroucker a , Idir Moali b , Marguerite Grossin c , Marc Levesque a a
Department of Radiology, Louis Mourier University Hospital, 178 Rue des Renouillers, Colombes 92700, France Department of Surgery, Louis Mourier University Hospital, 178 Rue des Renouillers, Colombes 92700, France c Department of Pathology, Louis Mourier University Hospital, 178 Rue des Renouillers, Colombes 92700, France b
Received 14 October 2004; received in revised form 18 January 2005; accepted 20 January 2005
Abstract Giant diverticulum of the colon is a rare complication of the colonic diverticulosis. However, it requires early elective surgical treatment because of the high complication rate. We describe a case of giant sigmoid diverticulum in a 53-year-old woman, perforated 24 h after diagnosis. The pathogenesis, pathology, radiological features and complications of this disease are discussed. © 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Giant diverticulum; Colon; Diverticulosis; Complication; Radiological features
1. Introduction Giant sigmoid diverticulum is a rare disease. Since the first case described by Bonvin and Bonte in 1946 in French literature and by Hughes and Greene in English literature in 1953, about 135 cases have been reported in the literature [1–3]. It is defined as a large colonic diverticulum, 4 cm in size or larger [4] and it is characterised by a high rate of complications. We describe a case of giant sigmoid diverticulum in a 53year-old woman, perforated 24 h after diagnosis.
2. Case report A 53-year-old woman presented, during her hospitalisation for brain tumor, left abdominal pain. Physical examination revealed a moderately distended and tympanic abdomen in the left lower quadrant and a temperature of 37.4 ◦ C. The white cell count was 12 × 109 l−1 and CRP was 42 mg dl−1 . The diagnosis of diverticulitis was proposed and an abdominal CT (5-mm collimation, 1.5 pitch) was ∗
Corresponding author. Fax: +33 1 47 60 62 79. E-mail address: khaled [email protected] (K. Bouza¨ıdi).
1571-4675/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2005.01.003
obtained. Intravenous contrast material was given and dilute rectal contrast medium was administered before examination. It showed a thin-walled, air-filled cavity in the left lower quadrant, intimately adherent to the sigmoid and compressing onto it (Fig. 1), but without filling of the cavity with orally or intravenously given contrast medium. Sparse smaller diverticula were associated without evidence of inflammation nor intraperitoneal soiling. The diagnosis of a giant sigmoid diverticulum was proposed. Within 1 day, patient presented diffuse peritoneal irritation. CT revealed free abdominal air. The air-filled cavity was less distended (Fig. 2). At emergency laparotomy, an enormous diverticulum originating from the sigmoid colon was excised with a partial sigmoid resection. The postoperative course was uneventful. Pathologic examination revealed an aspecific chronic inflammation. Some smaller diverticula were found in the resected sigmoid portion.
3. Discussion Although diverticular disease of the colon is common, giant colonic diverticulum is rare. This term includes three distinct pathologic entities:
108
S. Zguem et al. / European Journal of Radiology Extra 53 (2005) 107–109
Fig. 1. CT scan of the pelvis demonstrates the giant diverticulum and its mass effect on the sigmoid colon.
1. Giant pseudodiverticulum begins as an outpouching of mucosa and submucosa herniating through the circular muscle of bowel wall, at the side of penetrating blood vessels in the mesenteric border. Histologically, it is often lined by chronic granulation tissue interspersed with colonic mucosa and there is no evidence of smooth muscle in the wall [2,5]. It probably results from a complication of colonic diverticular disease [4]. 2. Inflammatory giant diverticulum secondary to a focal subserosal perforation which leads to a walled-off abscess cavity. It is lined by fibrous scar tissue without any intestinal layer. It remains in communication with colonic lumen allowing cavity to enlarge [2,6]. 3. True giant diverticulum possessing all layers of the colonic wall and suggesting congenital origin. It is probably a variant of communicating cystic bowel duplication. The mechanism of formation of giant diverticulum is unclear. Some theories have been postulated, but none is
conclusive. The first theory suggests that inflammatory changes cause norrowing of the neck of the diverticulum yielding a ball-valve effect that allows colonic air to enter but not to exit from the diverticulum. The second theory is that the lesion might be the product of gas-forming micro-organisms which distend diverticulum after its stalk has become obliterated [5]. Giant colonic diverticula generally involves the sigmoid colon (90–94%) [3,7,8,9]. It is often associated with diverticular disease [10]. It can be encountered in patients 32–90 years old, with a maximum incidence over 70 years [1,5,6]. Clinical presentation is variable, from an asymptomatic abdominal mass or radiological finding to an acute abdomen [9]. Abdominal pain is the most common symptom (70%) [4,7] and abdominal mass is the most usual physical finding [4]. Abdominal discomfort, nausea, vomiting, fever, dysuria, meteorism have equally been reported [3]. Diagnosis is easy with radiological help. Abdominal radiographs can show in the lower abdomen a round, balloonlike, smooth margined, gas-filled cyst, varying in size from 4 to 25 cm [8]. An air-fluid level is found in 25% of cases [3]. Lack of haustral folds and location in the lower abdomen should help distinguish this condition from sigmoid or caecal volvulus. Barium enema confirms the diagnosis by filling of the diverticulum with contrast. However, only 50–60% of cases are opacified because of probable inflammation of the neck of the diverticulum [6,5,11]. It also shows the associated diverticular disease. Because of the risk of perforation of the diverticulum carried by barium enema, CT is considered more appropriate. It confirms the diagnosis of air-filled cavity and gives additionnal information on the presence of complications not seen on abdominal X-ray or barium enema (pericolic inflammation, collections). Endoscopy seems to be of lesser diagnostical importance [2]. Complications can occur in 15–28% of cases [2]. Diverticulitis, perforation, pneumoperitoneum, gas dissection into the mesentery, volvulus, small bowel obstruction, adhesions with bowel or bladder, carcinoma within the giant diverticulum, chronic anemia, and colonic hemorrhage have been reported [5,6,9]. The treatment usually involves surgical resection of the diverticulum with adjacent colon and a primary end-to-end anastomosis [5,9]. Only in complicated cases is a protective colostomy or Hartmann’s procedure justified. Postoperative morbidity and mortality are low and no recurrence was reported [2,5]. 4. Conclusion
Fig. 2. Follow-up CT after 36 h shows the perforated giant diverticulum which is less distended.
Giant diverticulum of the colon is a rare complication of the colonic diverticulosis which high risk rate of complications provides a strong reason for operating on patients soon after diagnosis which is easy with radiological help. CT is the most useful adjunct to the evaluation of this condition.
S. Zguem et al. / European Journal of Radiology Extra 53 (2005) 107–109
References [1] Roger T, Rommens J, Bailly JM, Vollont GH, Belva P, Delcour C. Giant colonic diverticulum: presentation of one case and review of the literature. Abdom Imag 1996;21:530– 3. [2] Steenvoorde P, Vogelaar FJ, Oskam J, Tollenaar RAEM. Giant colonic diverticula. Review of diagnostic and therapeutic options. Dig Surg 2004;21:1–6. [3] Matthyssens LE, Van Hee R, Van Osselaer GE, Lemmens L. Giant diverticulum of the colon: report of two new cases and review of the literature. Int Surg 2003;88:34–40. [4] Choong CK, Frizelle FA. Giant colonic diverticulum: report of four cases and review of the literature. Dis Colon Rectum 1998;91: 952–5.
109
[5] Roth T, Demartines N, Gavelli A, Huguet C. Les diverticules g´eants du colon. A propos de deux cas. Chirurgie 1999;124:307–12. [6] Casas DJ, Tenesa M, Alastrue A, Hidalgo F, Barranco LC, Olazabal A. Uncommon radiological and pathological features of giant colonic diverticula. Clin Radiol 1991;44:125–7. [7] Bechade D, Baranger B, Desrame J, et al. Diverticule g´eant du cˆolon. Gastroenterol Clin Biol 2001;25:1032–4. [8] Grover H, Nair S, Hertan H. Giant true diverticulum of sigmoid colon. Am J Gastroenterol 1998;93:2267–8. [9] Baton O, Meyrat L, Eggenspieler P, et al. Diverticule g´eant du cˆolon. Ann Chir 2001;126:587–8. [10] Naber A, Sliutz AM, Freitas H. Giant diverticulum of the sigmoid colon. Int J Colorect Dis 1995;10:169–72. [11] Naing T, Ray S, Loughran CF. Giant sigmoid diverticulum: a report of three cases. Clin Radiol 1999;54:179–81.