REV ARGENT COLOPROCT | 2024 | VOL. 35, N

2 CASE REPORT

GIANT DIVERTICULUM WITH COMPLICATED ACUTE DIVERTICULITIS Riquoir Altamirano C.

Giant diverticulum with complicated acute diverticulitis

resolved by laparoscopic treatment

Christophe Riquoir A.

, Ismael Vial L.

, Sebastián López N.

1 Division of Surgey, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.

2 Coloproctology Team, Division of Surgey, Hospital San Juan de Dios, San Fernando, Chile.

3 Coloproctology Team, Division of Surgey, Hospital Dra. Eloísa Díaz, La Florida, Chile

ABSTRACT

Introduction: Giant diverticulum (GD) is a rare presentation in

diverticular disease with few cases reported in Chile and nearly 200

worldwide.

Aim: To update knowledge on this topic and discuss its manage-

ment from a complicated case.

Material and methods: A 34-year-old patient with a history of a

Hinchey Ia complicated acute diverticulitis episode of a GD found

on a computed tomography. Five years later, the patient presents

with a new Hinchey IV complicated episode. A laparoscopic sig-

moidectomy with primary anastomosis without protective ileostomy

is performed.

Results and discussion: The suggested treatment for all cases

facing diagnosis is en bloc resection of the diverticulum and the

diseased colonic segment given the risk of complications and

underlying neoplasia. In complicated cases, there are no particular

recommendations for DG, but it is possible to apply the same

current treatment recommended for acute diverticulitis. This implies

the possibility of the laparoscopic approach and primary anastomo-

sis with or without diverting ileostomy, depending on the case.

Diverticulectomy is not recommended and in the case of surgical

contraindication, percutaneous drainage, stent or antibiotics only

are valid alternatives.

Key words: giant diverticulum, acute diverticulitis, primary anasto-

mosis, protective ileostomy, Chile.

INTRODUCTION

Diverticular disease has a high prevalence worldwide,

affecting 65% of the population over 65 years of age and

increasing by 10% every 10 years from that age onwards.

Diverticula are usually multiple, a few millimeters in diame-

ter, and predominantly affect the sigmoid colon in the

Western population. Eighty percent present asymptomatical-

ly (diverticulosis) and 20% with some complication.

The giant diverticulum (GD) is a rare finding in the context

of diverticular disease; it was first described in France in

1946 and to date only around 200 cases have been reported

worldwide. It is defined as one that measures 4 or more cm

in diameter. It tends to be single and is preferentially (81%)

located in the sigmoid colon.

2,3

In Chile, three articles with

a total of 6 cases have been published on this condition,

2,4,5

the most relevant, for describing its surgical management at

the local level, was published in 2009 by Bannura et al.

The aim of this publication is to present a case of a compli-

cated GD, update the knowledge on this topic and discuss its

management with the available evidence.

CASE

A 34-year-old obese man, with a history of multiple previ-

ous consultations for recurrent hypogastric abdominal pain,

presents with an episode of complicated acute diverticulitis

Hinchey Ia of the Sartelli classification,

with fever (40°C),

C-reactive protein (CRP) 3 mg/dL and leukocytosis (15.000

cells/mm3). Computed tomography (CT) showed that the

origin of the condition was a giant diverticulum measuring

11.1 x 5.9 cm with calcified stercoraceous content (Fig. 1).

He progressed favorably with antibiotic treatment and was

discharged. Five years later he consulted again for a new

episode of acute diverticulitis, afebrile, with CRP of 2.5

mg/dL and leukocytosis (12.500 cells/mm3). The CT scan

described findings similar to the previous episode, without

collections, free fluid or pneumoperitoneum (Fig. 2). De-

spite four days of antibiotic therapy, he presented increased

abdominal pain with signs of peritoneal irritation, fever up

to 38°C and increased inflammatory parameters (CRP 39

mg/dL, WBC 13.000 cells/mm3). A new CT scan showed

increased signs of diverticulitis in relation to the giant

diverticulum, with pneumoperitoneum, pneumoretroperito-

neum, mild ascites and signs of pelviperitonitis (Fig. 3).

In the context of complicated acute Hinchey IV diverticuli-

tis, it was decided to perform laparoscopic sigmoidectomy.

Intraoperatively, a large diverticular mass formed by the

distal sigmoid colon adhered to the mesentery of the distal

ileum made dissection difficult. The resection of the dis-

eased sigmoid segment was completed with adequate de-

scent of the healthy colon, allowing a stapled descending

rectal anastomosis to be performed with a negative pneu-

matic test. Diverting ileostomy was not perform since there

were no risk factors for anastomotic leak. The patient had a

favorable postoperative outcome and was discharged after

nine days of hospitalization and five days of surgery.

Pathology reported diverticular disease without underlying

neoplasia, with a single 5 x 5 cm diverticulum and a 1 cm

hole in the mucosa, compatible with a pseudodiverticulum

(type I) of McNutt classification

(Fig. 4).

At 60 days of follow-up there was no further discomfort or

new episodes of diverticulitis.

The authors declare no conflicts of interest or financial support. Christophe Riquoir Altamirano: cfriquoir@uc.cl

Christophe Riquoir Altamirano: ORCID ID: 0000-0001-7462-2708, Ismael Vial L: ORCID ID: 0000-0003-2577-1760

REV ARGENT COLOPROCT | 2024 | VOL. 35, N

2 CASE REPORT

GIANT DIVERTICULUM WITH COMPLICATED ACUTE DIVERTICULITIS Riquoir Altamirano C.

Figure 1. Computed tomography. Large diverticulum of the sigmoid

colon with calcified stercoraceous content and gas inside in trans-

verse (A) and coronal (B) sections, Inflammatory changes of the wall

and adjacent adipose tissue are observed (arrow).

Figure 2. Computed tomography. Large diverticular image with

fecal content inside, thickened wall and surrounding peripheral

inflammatory changes are shown (arrows).

Figure 3. Computed tomography. Increased signs of diverticulitis in

relation to the giant diverticulum of the sigmoid colon (circle), with

the appearance of pneumoperitoneum and pneumoretroperitoneum

(arrows) in transverse (A) and coronal (B) sections.

DISCUSSION

The pathophysiology of GD is the persistent entry of gas

into the diverticulum through a valve mechanism, causing

that in most cases no contrast medium is observed in the

diverticulum.

McNutt in 1988 described the classification

of GD: pseudodiverticulum (type I) composed only of

muscularis mucosa (22% of cases), inflammatory diverticu-

lum (type II) composed of scar tissue arising from perfora-

tion and abscess formation (66%) and true diverticulum

(type III) composed of all muscle layers and the myenteric

plexus (12%).

The most common symptoms are abdominal pain (69%) and

constipation (17%) and in 47% of cases a mass can be

palpated. Only 10% are asymptomatic and 28% present

some complication, such as perforation.

The age at presen-

tation is between 60 and 79 years, and the size of the diver-

ticulum is between 4 and 9 cm.

Perioperative mortality is

classically described as around 5%, however, in the last 12

years no associated mortality has been reported.

Historically, diagnosis has been made with a barium enema,

which is less sensitive and associated with a higher risk of

perforation than computed tomography, the current stand-

ard.

3,8

Colonoscopy is not useful for diagnosis because in up

to 83% of cases the diverticulum is not found due to a very

small ostium. Furthermore, in complicated cases it has a

greater risk of perforation. The literature is not clear about

the benefit of colonoscopy in the absence of a contraindica-

tion.

The treatment of choice for asymptomatic and uncomplicat-

ed cases is en bloc resection of the diverticulum and the

diseased segment of the colon with primary anastomosis,

with or without diverting ileostomy. This treatment has

reported zero mortality and minimal morbidity. For compli-

cated cases, the evidence is insufficient to make a particular

recommendation, so our suggestion is to follow the current

evidence that suggests that this same treatment is safe in

complicated acute diverticulitis.

In 2% of the cases described in the literature, a carcinoma is

found within the GD, so we recommend performing the

surgery following oncological criteria.

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GIANT DIVERTICULUM WITH COMPLICATED ACUTE DIVERTICULITIS Riquoir Altamirano C.

Laparoscopic resolution is described in only 5% of GDs,

despite the fact that it has been reported to be safe.

10-12

seems that surgeons consider the open approach safer due to

the risk of GD perforation and associated peritoneal fecal

contamination. At the moment it is recommended as long as

the surgeon has the adequate skills and equipment.

Non-

surgical treatment is not recommended due to the substantial

risk of complications and development of carcinoma.

In the present case, since it was a young patient with no

major comorbidities, the laparoscopic approach and primary

anastomosis without diverting ileostomy was preferred, with

favorable results. It should be noted that the diagnosis had

been made five years earlier when the presentation was not

complicated, at which time elective surgery would have

been more timely.

Regarding other therapeutic alternatives, diverticulectomy is

not recommended due to its greater risk of recurrence due to

dehiscence, explained by the adjacent inflammatory tissue.

In the case of patients with very high surgical risk or who

reject surgery, percutaneous drainage, occlusion of the

diverticular lumen with a stent or simply antibiotic treatment

can be performed, ideally with subsequent elective resec-

tion.

Figure 4. Operational sample. A. Calcified stercoraceous content

with at least 5 years of evolution was found inside the diverticulum.

B. The mucosal defect towards the diverticulum can be observed

from the lumen of the colon. C. Complete segment of descending

sigmoid colon with the perforation site where the giant diverticulum

was located.

CONCLUSION

GD is a rare presentation of acute diverticulitis. There are

few reports in Chile. Given its high rate of complications,

elective treatment is recommended over diagnosis. Laparo-

scopic excision with primary anastomosis and without

diverting stoma is a valid alternative in selected patients.

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