Case reportGiant Colonic Diverticulum: An Unusual Abdominal Lump
Introduction
Diverticulosis is a common clinical entity affecting 35% of persons over the age of 60 years.1 Giant colonic diverticulum (GCD) is a rare complication of this disease, with only 121 cases described so far in the English literature. A case of GCD is described here, and the literature is reviewed regarding the origin, presentation, and management of this rare condition.
Section snippets
Case report
A 50-year-old Danish woman presented to the emergency department with a history of abdominal pain over the left iliac fossa and associated bowel disturbance for about a week’s duration. A day before presentation, she noticed a lump in her abdomen at the site of the pain. She was on holiday in the United Kingdom and found that her pain increased rapidly during her flight to London along with an increase in the size of the lump and vomiting. This reaction forced her to seek medical help
Discussion
Colonic diverticulosis has its highest incidence in Western industrialized nations. The decreased intake of dietary fiber is considered to be the major etiologic factor. The resultant diminished stool volume facilitates the development of segmental high-pressure regions most frequently in the sigmoid colon because of its smaller radius. Over a period of time, pseudodiverticula is produced, resulting in diverticular changes.
Approximately 20% of these pseudodiverticula become symptomatic with the
Origin
Various theories have been proposed to explain the mode of formation of these cysts, as follows6:
- 1
Ball-Valve Mechanism: The colonic bowel diverticulum begins as an outpouching of mucosa and submucosa herniating through the circular muscle of the bowel wall. An unidirectional ball-valve mechanism through a tiny communicating ostium causes gas-entrapment, allowing air to enter but not to exit, with progressive enlargement and consequent GCD.
- 2
Inflammatory Mechanism: This mechanism is secondary to a
Clinical features
Most patients present after the sixth decade of life with mean age being 65 years. No significant gender predilection exists.12 The clinical presentation is variable and can be divided into 4 distinct groups:
- 1
Acute Presentation (30% to 35%): These present acutely, with abdominal pain being the most common symptom (70%). A palpable abdominal mass is found in two thirds of this group.12 Most patients are febrile and may have other symptoms suggestive of acute diverticulitis or peritoneal
Investigations
A plain abdominal radiograph demonstrates a large gas-filled cyst (Balloon sign).17
An air fluid level can be observed in 25% of cases.1 The size can vary, with the largest described being 40 cm.3 The wall of the cyst is typically smooth and regular, but if irregular or lobulated, then the possibility of an additional inflammatory or neoplastic process should be considered.1 A contrast enema demonstrates the relation of the mass to the bowel, and nearly 70% of cases demonstrate communication
Treatment
The aim of treatment is to alleviate symptoms and prevent complications. Excision of the cyst with segmental resection of the colon should be performed to reduce the possibility of recurrence and other diverticular complications.3 In most cases, surgery will be a sigmoid colectomy as this region is most commonly affected. Diverticulectomy without colonic resection has been described when the colon adjacent to the base is healthy and without any significant inflammation or marked diverticular
Conclusion
Giant colonic diverticulum is a rare complication of diverticular disease and can have variable clinical presentation. The cyst size can fluctuate and can be influenced by various factors. It is important to be aware of this condition in order to both correctly diagnose and manage it. The diagnosis is confirmed by radiological studies, with plain abdominal x-ray, CT scan, and Barium enema being the most commonly used. Surgical treatment is advised in all cases because of the high risk of
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Cited by (15)
Clinical features of colorectal duplication in children: A study of 25 cases
2022, Journal of Pediatric SurgeryCitation Excerpt :Furthermore, symptoms of cystic lesions located at the rectum (below the peritoneum reflection) were more atypical, such as anus prolapse, perianal infection, constipation and abnormal anus, which required surgeons to make a careful differential diagnosis [20–22]. Although the embryological mechanism for diverticular lesions originating from the sigmoid colon is unclear and needs further study, the results of our study may be helpful for the differential diagnosis of sigmoid colon lesions in children [23–25]. Moreover, our study found that perineum abnormalities, such as anus prolapse, perianal infection, and anorectal malformation, were more common in colorectal duplications involving the rectum (rectal duplication and total colon duplication).
A gas-filled abdominal cyst in an elderly woman: A giant colonic diverticulum case report
2016, International Journal of Surgery Case ReportsCitation Excerpt :Presentation with complications: secondary to perforation, abscess formation, volvulus, acute bowel and urinary obstruction, infarction, fistula formation, and extremely rare development of carcinoma inside the GCD. Asymptomatic cases: where a abdominal an abdominal mass is detected during physical examination or an air-filled cystic formation observed in an imaging procedure [2,14]. In a review study of 166 reported cases, Nigri et al., observed abdominal pain as the most common symptom (69% of the cases), followed by constipation (17%), sensation of an abdominal mass (17%), vomiting (12%), diarrhea (11%), rectal bleeding (9%), fever (20%) [12].
Giant colon diverticulum: Clinical and imaging findings in 17 patients with emphasis on CT criteria
2013, Clinical ImagingCitation Excerpt :A GCD is a rare presentation of diverticular disease of the colon defined as a diverticulum of 4 cm in size or larger [1,2,10]. The condition was first described in the French literature in 1946 and in the English literature in 1953 [10]. Many different names describing GCD have been previously reported: giant sigmoid diverticulum (GSD), giant gas cyst, giant air cyst, and giant colon cyst.
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