Elsevier

Journal of Surgical Education

Volume 64, Issue 2, March–April 2007, Pages 97-100
Journal of Surgical Education

Case report
Giant Colonic Diverticulum: An Unusual Abdominal Lump

https://doi.org/10.1016/j.jsurg.2006.10.007Get rights and content

Giant colonic diverticulum is a rare complication of diverticular disease of the colon and is thought to result, in most cases, from a “ball-valve” effect. The presentation and clinical course can be variable and confusing. The most common symptoms are abdominal pain and a palpable abdominal lump, with many patients presenting acutely with complications such as perforation and peritonitis. Preoperative diagnosis requires a high degree of suspicion and needs to be differentiated from sigmoid volvulus, caecal volvulus, intestinal duplication cyst, pneumatosis cystoidis intestinalis, and similar conditions. A plain x-ray and computed tomography (CT) scan of the abdomen shows a huge air-filled cyst termed “balloon sign” and confirms the diagnosis. The barium enema shows a communication with the bowel in most cases. In view of the high incidence of complications, treatment is advised even in asymptomatic cases and consists of excision of the cyst with resection of the adjacent colon with primary anastomosis. This treatment would, in most cases, be a sigmoid colectomy. Percutaneous drainage and Hartmann’s procedure may be appropriate in some cases who present with a well-formed abscess or gross fecal peritonitis, respectively. A case is described, and the literature is reviewed.

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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