• Colon
• Diverticulosis
• Submucosal tumor

• Abdominal mass
• Abdominal pain
• Case report
• Diverticular disease
• Giant colonic diverticulum
• Surgery

• Gastrointestinal surgery
• General surgery

• Humans
• Male
• Colon, Sigmoid/diagnostic imaging
• Colon, Sigmoid/surgery
• Colon, Sigmoid/pathology
• Sigmoid Diseases/surgery
• Sigmoid Diseases/diagnostic imaging
• Tomography, X-Ray Computed
• Diverticulum, Colon/surgery
• Diverticulum, Colon/diagnostic imaging
• Diverticulum, Colon/pathology
• Aged

• Case report
• Computed tomography
• Enhanced recovery
• Giant colonic diverticulum
• Robotic colectomy

• giant colonic diverticulum
• sigmoid colectomy
• sigmoid colon
• sigmoid diverticulitis
• sigmoid diverticulosis

Colonic diverticulosis is pervasive in Western society, with over half of individuals over the age of 60 carrying the diagnosis. A Giant Colonic Diverticulum (GCD) is a rare presentation of diverticulosis, involving one or more colonic diverticula that measure 4 cm or greater. Less than 200 reports of GCD have been published in the literature. Almost all GCD patients present with symptoms, with abdominal pain being the most common. Diagnosis is usually made with CT imaging and recommended treatment is segmental colectomy. We present an atypical case of GCD with an asymptomatic presentation, initial diagnosis made during endoscopy and a minimally invasive resection of multiple GCD within the same patient.

• colectomy
• colonic diverticulosis
• giant colonic diverticulum
• minimally-invasive surgery

• diverticulitis
• giant diverticulum
• immunosuppression
• multifocal disease
• right-sided diverticulitis

• Diverticular disease
• Giant colonic diverticulum
• Laparoscopic sigmoid resection
• Surgery

• Aged
• Diverticulum, Colon/complications
• Diverticulum, Colon/diagnostic imaging
• Diverticulum, Colon/surgery
• Female
• Humans
• Urinary Bladder/diagnostic imaging
• Urinary Bladder/surgery
• Urinary Bladder Neck Obstruction/diagnostic imaging
• Urinary Bladder Neck Obstruction/etiology
• Urinary Bladder Neck Obstruction/surgery

Intestinal duplications are rare congenital anomaly found in the pediatric age group. Although, the ileum is the most common site, there are cases of colonic duplications even in the adult. Colonoscopy is a good investigation tool for the diagnosis of colonic duplications; however, it may not be true in all cases. We report a case of 43 years woman presented with chronic constipation, intermittent colicky abdomen pain, and a cystic lump in the left abdomen diagnosed as tubular duplication cyst of descending colon. She was managed with left hemicolectomy and excision of the cyst with uneventful postoperative days. This case has been reported as it is a rare condition.

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

• Age Factors
• Colonoscopy
• Diagnostic Imaging
• Digestive System Surgical Procedures
• Disease Management
• Diverticulitis, Colonic/diagnosis
• Diverticulitis, Colonic/therapy
• Humans
• Risk Factors

• K23 DK118192 NIDDK NIH HHS

•

Giant colonic diverticulum is a rare complication of colonic diverticulosis that occurs when a single diverticulum enlarges to over 4 cm in diameter.

Giant colonic diverticulum is a rare complication of colonic diverticulosis that occurs when a single diverticulum enlarges to over 4 cm in diameter. There have been fewer than 200 cases reported worldwide since it was first described in 1946.

The author presents a rare case of a giant colonic diverticulum that presented as a sigmoid volvulus. The patient underwent emergency surgery with resection of the diverticulum and reduction of the volvulus.

Due to their propensity to cause complications and mechanical blockage from their large size, all authors recommend surgical resection of giant colonic diverticula. This has been documented to be safely done by diverticulectomy as was performed in this patient, but also by segmental colectomy, laparoscopic diverticulectomy, or laparoscopic colectomy.

Giant colonic diverticulum is a rare entity that tends to cause many intra-abdominal complications, including volvulus. Surgical resection is recommended once identified.

• Complications
• Diverticulosis
• Giant colonic diverticulum
• Sigmoid colon
• Volvulus

•

Giant colonic diverticulum is a rare complication of colon diverticulosis.

Giant colonic diverticulum (GCD), a rare complication of the diverticular disease, can present with a wide range of nonspecific symptoms as abdominal pain and bowel obstruction. Its diagnosis represents a challenge that mainly depends on imaging findings.

We report the case of a 79 year-old female patient that came to our emergency department complaining of 5-day history of hypogastric pain and constipation. Physical examination reveled a 15 cm hypogastric round, tender and tympanic mass. Enhanced abdominal CT scan showed a large air-filled cyst adjacent to a diverticular sigmoid colon without evidence of intra-abdominal free air or fluid. Based on the radiological features, GCD was suspected and surgical treatment performed. The mass and the sigmoid colon were resected. The postoperative course was uneventful. Histopathology confirmed the preoperative diagnosis.

GCD, defined as a diverticulum larger than 4 cm, represents a rare complication of the diverticular disease. Usually abdominal X-ray and computed tomography (CT) scan show a gas-filled structure, sometimes communicating with the adjacent colon. GCD resection and segmental colectomy are strongly recommended even in asymptomatic cases due to the high incidence and severity of complications.

Because of its rarity and variable and non-specific clinical presentation, the diagnosis of GCD depends mainly on imaging findings. The gold standard treatment is surgical resection of the GCD and the compromised colon with primary anastomosis when possible.

• Air-filled cyst
• Colonic diverticular disease
• Giant colonic diverticulum
• Giant sigmoid diverticulum

• Giant colonic diverticulum
• Giant sigmoid diverticulum

• Aged
• Colectomy/methods
• Colon, Sigmoid/diagnostic imaging
• Colon, Sigmoid/pathology
• Colon, Sigmoid/surgery
• Diverticulum, Colon/diagnostic imaging
• Diverticulum, Colon/pathology
• Diverticulum, Colon/surgery
• Humans
• Male
• Tomography, X-Ray Computed

• Colonic
• Diverticulum
• Giant
• Sigmoid
• Surgery

• Aged, 80 and over
• Colectomy
• Diverticulum, Colon/classification
• Diverticulum, Colon/complications
• Diverticulum, Colon/diagnosis
• Diverticulum, Colon/surgery
• Female
• Humans
• Predictive Value of Tests
• Tomography, X-Ray Computed
• Treatment Outcome

• Adult
• Anastomosis, Surgical/methods
• Colectomy/methods
• Colon, Sigmoid/abnormalities
• Colon, Sigmoid/surgery
• Colonic Diseases/congenital
• Colonic Diseases/diagnosis
• Colonic Diseases/surgery
• Diagnosis, Differential
• Female
• Humans
• Laparotomy
• Tomography, X-Ray Computed

Diverticular disease of the colon is a common disease, and its incidence is increasing gradually. A giant colonic diverticulum (GCD) is a rare entity and is defined as a diverticulum greater than 4 cm in size. It mainly arises from the sigmoid colon, and possible etiology is a ball-valve mechanism permitting progressive enlargement. A plain abdominal X-ray can be helpful to make a diagnosis initially, and a barium enema and abdominal computed tomography may confirm the diagnosis. Surgical intervention is a definite treatment for a GCD. We report a case of an ascending GCD presenting with intussusception in a young adult.

• Ascending colon
• Giant colonic diverticulum
• Intussusception
• Surgical intervention

• Adult
• Colon, Sigmoid/diagnostic imaging
• Diverticulum, Colon/diagnostic imaging
• Female
• Gases
• Humans
• Male
• Middle Aged
• Tomography, X-Ray Computed

• Aged
• Anastomosis, Surgical
• Diagnosis, Differential
• Diverticulum, Colon/diagnosis
• Diverticulum, Colon/surgery
• Female
• Humans
• Sigmoid Diseases/diagnosis
• Sigmoid Diseases/surgery

• giant colonic diverticulum
• transverse colon
• congenital duplication

• Colectomy/methods
• Colonoscopy/methods
• Diagnosis, Differential
• Diverticulum, Colon/diagnosis
• Diverticulum, Colon/surgery
• Female
• Humans
• Laparotomy
• Radiography, Abdominal/methods
• Young Adult

Giant diverticulum of the colon is a rare but clinically significant condition, usually regarded as a complication of an already existing colonic diverticular disease. This is the first report of a giant diverticulum of the colon with a co-existing rectal carcinoma.

We report a case of a 66-year-old Caucasian woman who presented with lower abdominal pain, chronic constipation and abdominal swelling. Preoperative abdominal computed tomography revealed a giant diverticulum of the colon with a coexisting rectal carcinoma and pulmonary metastasis revealed on a further thoracic computed tomography. An en bloc anterior resection of the rectum along with sigmoid colectomy, partial hysterectomy and right salpingoophorectomy was subsequently performed due to extensive adhesions.

This report shows that the presence of a co-existing distal colorectal cancer can potentially lead to progressive development of a colonic diverticulum to become a giant diverticulum by increasing colonic intra-luminal pressure and through the ball-valve mechanism. This may be of interest to practising surgeons and surgical trainees.

A 21-year-old male with developmental delay presented with abdominal pain of two days' duration. He was afebrile and his abdomen was soft with mild diffuse tenderness. There were no peritoneal signs. Plain x-ray demonstrated a large air-filled structure in the right upper quadrant. Computed tomography of the abdomen revealed a 9 × 8 cm structure adjacent to the hepatic flexure containing an air-fluid level. It did not contain oral contrast and had no apparent communication with the colon. At operation, the cystic lesion was identified as a duplication cyst of the sigmoid colon that was adherent to the right upper quadrant. The cyst was excised with a segment of the sigmoid colon and a stapled colo-colostomy was performed. Recovery was uneventful. Final pathology was consistent with a duplication cyst of the sigmoid colon. The cyst was attached to the colon but did not communicate with the lumen.

Diverticular disease of the colon is a common benign condition. The majority of patients with diverticular disease are asymptomatic and are managed non-operatively, however complications such as perforation, bleeding, fistulation and stricture formation can necessitate surgical intervention. A giant colonic diverticulum is defined as a diverticulum larger than 4 cm in diameter. Despite the increasing incidence of colonic diverticular disease, giant colonic diverticula remain a rare clinical entity.

This is the first reported case of laparoscopic-assisted resection of a giant colonic diverticulum. We discuss the symptoms and signs of this rare complication of diverticular disease and suggest investigations and management. Reflecting on this case and those reported in the literature to date, we highlight potential diagnostic difficulties and consider the differential diagnosis of intra-abdominal gas-filled cysts.

The presence of a giant colonic diverticulum carries substantial risk of complications. Diagnosis is based on history and examination supported by abdominal X-ray and computed tomography findings. In view of the chronic course of symptoms and potential for complications, elective surgical removal is recommended. Colonic resection is the treatment of choice for this condition and, where possible, should be performed laparoscopically.

Diverticulosis coli is the most common disease of the colon in Western countries. Giant colonic diverticulum, defined as a colonic diverticulum measuring 4 cm in size or larger, represents an unusual manifestation of this common clinical entity.

A 68-year-old Caucasian British woman with a history of intermittent lower abdominal mass, leg swelling and focal neurological symptoms underwent extensive non-diagnostic investigations over a significant period under a number of disciplines. The reason for a diagnosis being elusive in part related to the fact that the mass was never found on clinical and ultrasound examination. As a result, the patient's validity was questioned. Ultimately, this 'phantom-mass' was diagnosed as a giant colonic diverticulum causing intermittent compression of the iliac vein and obturator nerve.

Intermittent compression of the iliac vein and the obturator nerve by a colonic diverticulum has not previously been reported. A giant colonic diverticulum presenting as an intermittent mass is very rare. This case also illustrates two factors. First, the patient is often right. Second, the optimal mode of investigation for any proven or described abdominal mass with referred symptoms is cross-sectional imaging, typically a computed tomography scan, irrespective whether the mass or symptoms are constant or intermittent.

• Aged
• Colon, Sigmoid/pathology
• Colon, Sigmoid/surgery
• Diverticulum, Colon/complications
• Diverticulum, Colon/diagnosis
• Diverticulum, Colon/surgery
• Humans
• Male
• Sigmoid Diseases/complications
• Sigmoid Diseases/diagnosis
• Sigmoid Diseases/surgery

• Diverticulum/complications
• Hemoperitoneum/etiology
• Humans
• Male
• Middle Aged
• Sigmoid Diseases/complications