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Giant diverticulum of the sigmoid colon is rarely seen. The arbitrary definition of a giant diverticulum is based on a length of 4 cm or more. The treatment of giant diverticuli differs from the treatment strategy for simple diverticular disease. Here we present two cases of giant sigmoid diverticuli and review pertinent literature.
Case 1
A 63-year-old male patient presented with fever of 15 days duration. There were no abdominal or respiratory symptoms. Routine ultrasound abdomen showed thickened bowel wall with a bowel mass in the suprapubic region. Computed tomography scan showed sigmoid diverticulitis with pericolic abscess along with presence of thick walled giant sigmoid diverticulum (Figure 1).
Laparotomy revealed multiple diverticulae in the small and large bowel and an approximately 10 cm x 10 cm diverticulum in the sigmoid colon (Figure 2). The diverticulum had a hard, indurated base and was free from the surrounding structures. Sigmoid resection with end-to-side colorectal anastomosis was performed. Postoperatively, the patient had a smooth recovery and was discharged on the fourth day. Histopathology showed a thick walled giant sigmoid diverticulum with acute on chronic diverticulitis.
Case 2
A 73-year-old male patient presented with two episodes of lower gastrointestinal bleed. Colonoscopy showed presence of multiple diverticuli throughout the colon. Computed tomography scan revealed colonic diverticulitis with presence of a thick-walled giant sigmoid diverticulum. Laparotomy revealed a 7 cm x 8 cm diverticulum in sigmoid colon with multiple small diverticulae in the remaining colon. A subtotal colectomy with ileorectal anastomosis was performed. The postoperative period was uneventful and the patient was discharged on seventh postoperative day.
Discussion
Giant sigmoid diverticulum (GSD) is a rare entity.[1] Since its first description in the literature in 1953 by Hughes and Green,[2] approximately 135 cases have been reported.[3] The aetiology of the giant diverticulum is not clear, but three theories have been proposed.[4] The most commonly accepted belief is that these diverticuli arise from the out-pouching of the mucosa and submucosa through the circular muscle of bowel wall at the site of entry of blood vessels on the mesenteric border. A ball-valve mechanism occurs at the neck and the diverticlum increases in size. There may be infection with gas-producing organisms which may add up to further enlargement. The second hypothesis considers the GSD an abscess cavity secondary to focal perforation which has drained into the lumen. The third hypothesis of GSD formation is the occurrence of a true diverticulum of congenital origin. It is in the form of a communicating bowel duplication cyst and all four layers of the colonic wall.
The clinical manifestation of sigmoid GSD may vary from an asymptomatic abdominal mass or an incidental finding on radiological investigations as was seen in one of our patients or it may include symptoms like abdominal pain, fever, abdominal distension, change in bowel movement or gastrointestinal bleed etc.
A plain abdominal x-ray usually shows a translucent gas shadow in the lower abdomen and can suggest diagnosis of GSD in most cases. The CT scan demonstrates a thick-walled, air-filled cavity close to the colon.[5] CT is the most sensitive investigation, and can also help in identifying the communication between the cyst and the colon. Barium enema can show the communication in about two-thirds of cases but the risk of perforation does not support its routine use.[3] Colonoscopy is also not helpful for diagnosis, but GSD may be an incidental finding on colonoscopy.[6]
A high complication rate including perforation, abscess formation, fistula formation, and urinary obstruction is reported in the literature varying from 12 – 28%.[5] A 2% incidence of development of adenocarcinoma has also been reported. In view of the high complication rate and the low mortality associated with surgical treatment, elective surgical therapy with resection of the affected segment has been recommended.[7] This is in contrast to simple diverticular disease where treatment is recommended only for the complicated disease or after multiple attacks of diverticulitis. Elective sigmoid resection for even incidentally diagnosed GSD has been recommended.[8]
References
1. Choong CK, Frizelle FA. Giant colonic diverticulum: report of four cases and review of the literature. Dis Colon Rectum. 1998;41:1178–85.
2. Hughes WL, Green RC: Solitary air cyst in the peritoneal cavity. Arch Surg. 1953;67:931–96.
3. Steenvoorde P, Vogelaar FJ, Oskam J, Tollenaar RA. Giant colonic diverticula, review of diagnostic and therapeutic options. Dig Surg. 2004;21:1–6.
4. Mcnutt R, Schmitt D, Schulte W. Giant colonic diverticula – three distinct entities: report of a case. Dis Colon Rectum. 1988;31:624–8.
5. 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.
6. De Oliveira NC, Welch JP. Giant diverticula the colon: a clinical assessment. Am J Gastroenterol. 1997;92:1092–6.
7. Naber A, Sliutz AM, Freitas H. Giant diverticulum of sigmoid colon. Br J Surg. 1995;82:985.
8. Custer TJ, Blevins DV, Vara TM. Giant Colonic Diverticulum: A Rare Manifestation of a Common Disease. J Gastrointest Surg. 1999;3:543–8