|Year : 2019 | Volume
| Issue : 1 | Page : 20-23
Giant solitary cecal diverticulum
Ipseet Mishra1, Rohan Kumar2, Washim Mollah3, Arup Kumar Dutta4
1 Department of Surgical Oncology, Saroj Gupta Cancer Centre and Research Institute, Kolkata, India
2 Department of General Surgery, Calcutta National Medical College and Hospital, Kolkata, India
3 Department of General Surgery, Islampur Superspeciality Hospital, Islampur, India
4 Department of General Surgery, Raiganj Super Specialty Hospital, Raiganj, West Bengal, India
|Date of Submission||15-Jul-2019|
|Date of Decision||27-Oct-2019|
|Date of Acceptance||03-May-2020|
|Date of Web Publication||30-May-2020|
T33/7G, Genexx Valley, Joka, Kolkata - 700 104, West Bengal
Source of Support: None, Conflict of Interest: None
Right iliac fossa (RIF) mass is a common case scenario in surgical practice with a wide range of differentials. Colon carcinoma, appendicular lump, ileocecal tuberculosis, and tubo-ovarian mass are among the common diagnoses. Diverticulosis of the colon presents as an abdominal mass when complicated by perforation, abscess formation, obstruction, or giant transformation. This report describes the case of a giant colonic diverticulum at cecum in a 30-year-old male presenting as a huge RIF mass.
Keywords: Cecal diverticulum, giant colonic diverticulum, giant diverticulum, right iliac fossa mass
|How to cite this article:|
Mishra I, Kumar R, Mollah W, Dutta AK. Giant solitary cecal diverticulum. Indian J Colo-Rectal Surg 2019;2:20-3
| Introduction|| |
Right iliac fossa (RIF) mass is a common case scenario in surgical practice with a wide range of differentials. Colon carcinoma, appendicular lump, ileocecal tuberculosis, and tuboovarian mass are among the common differential diagnoses. The common complications of diverticulosis of the colon include perforation, abscess formation, and at times formation of a lump. It seldom undergoes giant transformation. Diverticulosis commonly occurs on the left side and very rarely involves the cecum. Although the literature reports of giant colonic diverticulum (GCD) involving the sigmoid colon (80%), there are few (<5) cases reported involving the cecum as well. The present case report describes a case of GCD of the cecum presenting as a RIF mass.
| Case Report|| |
A 30-year-old male patient presented to our emergency department with a 3-day history of pain and gradual distension of the lower right abdomen. The pain was dull aching, continuous, and nonradiating. There were no complaints of nausea or vomiting, fever, alteration in bowel or bladder habit, and episodes of bleeding per rectum. There was no history of similar episodes in the past. He was a nonaddict, and his family history was not contributory. On general examination, his vitals were normal. On local examination, there was tenderness in the RIF, with no guarding and rigidity. A lump was palpable in the RIF, which was 10 cm × 8 cm in size, extending up to the hypogastrium and right lumbar region [Figure 1]. It was firm in consistency and immobile. Peristaltic sounds were audible.
|Figure 1: Patient's preoperative photograph showing the right iliac fossa mass|
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Per rectal examination revealed a firm, unyielding mass palpable in the pouch of Douglas; the rectal mucosa and lumen were, however, normal. Routine blood investigations were normal except for leukocytosis (16,800/cm) with 96% neutrophils and C-reactive protein level – 68 mg/L. Abdominal X-ray was not remarkable. Contrast-enhanced computed tomography (CECT) of the abdomen unveiled a focal, minimally enhancing 136.7 mm × 80.5 mm SOL in the RIF-containing fluid, pockets of air density, and tiny hyperdensities – likely a focally distended colonic diverticulum [Figure 2] and [Figure 3]. Acknowledging the possibility of impending colonic rupture, a decision of performing emergency laparotomy was taken without performing any further investigations and after proper counseling and informed consent.
|Figure 2: Computed tomography scan – axial section showing 136.7 mm × 80.5 mm cystic space occupying lesion (SOL) containing air, fluid, and focal hyperdensities with a thin-unenhanced smooth wall|
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|Figure 3: Computed tomography scan – coronal section showing air-filled colonic SOL in right iliac fossa that has filled the pelvic cavity and compressed the urinary bladder|
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On exploration, the cecum was found to be hugely dilated with impacted fecal matter and colonic gas while the rest of the bowel loops, including appendix, were normal [Figure 4]. There were no ascites, peritoneal disease, or lymph node involvement. A diagnosis of giant solitary diverticulum of the cecum was made, and limited colectomy with ileoascending anastomosis was performed. On cutting open the specimen, no mucosal abnormality or focal wall thickness was found [Figure 5]. The patient had a good postoperative recovery and was discharged on the 7th postoperative day. Histopathology showed a cecal diverticulum lined with colonic mucosa and muscular layer and with focal areas of ulceration and inflammatory exudates. The appendix was normal in histology, and there were no signs of malignancy. The patient was followed up with a full colonoscopy 2 months later, which was unremarkable.
|Figure 4: Operative illustration showing giant cecal diverticulum at laparotomy|
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|Figure 5: Illustration showing cut section of the diverticulum with distal ileum probed by artery forceps (arrowhead indicates the neck of giant colonic diverticulum that communicates with the colonic lumen)|
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| Discussion|| |
A solitary cecal diverticulum is an uncommon presentation of diverticular disease with a prevalence in the general population estimated to be around 1/1,000,000. Such cases may remain asymptomatic for years, being diagnosed when complicated by the inflammation, perforation, or hemorrhage. Notably, a rare complication is the formation of a giant diverticulum. GCD, also known as a giant gas cyst, air cyst, or phantom tumor had been cited in the sigmoid colon (80%) in the majority of cases. GCD of the cecum as such has not been categorized in the literature, though few (<5) cases were found to be reported.,,
A GCD is defined as a cystic diverticulum of the colon, which is more than 4 cm in diameter. Although exact etiology is unknown, it is believed to be gradually distended by a ball-valve mechanism. Faecoliths obstructing the diverticular opening in the colonic lumen allow for ingress of air but does not allow the air to escape. This trapped air with colonic gas production enlarges the diverticulum to attain an enormous size. Presentation is variable – abdominal pain being the most common symptom (69%) followed by constipation and abdominal mass (17% each). Majority of GCD cases (85%) have associated diverticulosis. Perforation and abscess formation are the common complications with sporadic cases of peritonitis, volvulus, obstruction, bleeding, and lymphoma or adenocarcinoma also being reported.
CECT is the most sensitive investigation as it allows an accurate diagnosis in nearly all cases; it can identify the communication between the cyst and gut lumen and can provide information on the number of GCD's as well as associated complications., The diverticulum, when enlarged, appears as a cavity filled with gas and stool/fluid with no contrast enhancement. The amount of gas is greater in GCD than in abscesses due to communication between the colonic lumen and GCD. Duplication cysts are a rare differential diagnosis which are congenital fluid-filled cysts on the mesenteric side of the bowel, generally not communicating with the colonic lumen. Colonoscopy and barium enema, though useful for imaging diverticulosis, are avoided in cases of giant transformation for the risk of perforation.
McNutt et al. had classified GCD into three types histologically. Type 1 or pseudodiverticulum is a preexisting pulsion diverticulum that enlarges progressively, without any perforation. It has remnants of the true muscularis mucosa at the colonic border of the diverticulum. Type 2 or inflammatory diverticulum is formed from a local perforation, leading to a walled-off abscess cavity that allows the diverticulum to enlarge by communicating with the bowel lumen through a one-way valve. It has no normal intestinal layer, instead is lined by the fibrous tissue. Type 3 or true diverticulum contains all layers of the normal bowel wall and is in continuity with the gut lumen. This particular type is considered congenital, with origin probably linked to anomalous embryologic development. Type 2 (66%) is the most commonly encountered form followed by Type 1 (22%) and Type 3 (12%), as cited by Steenvoorde et al.
Nigri et al. in an analysis of 166 GCD cases had reviewed that segmental colectomy with en bloc diverticular resection is the most preferred and frequently done procedure for GCD's, considering the risk of perforation and subsequent development of peritonitis and the probability of recurrence, if managed nonoperatively. There is also a risk of development of adenocarcinoma (2%) in untreated GCDs.
The following features make this case noteworthy:
- This was a Type 3 diverticulum with a short history of abdominal pain and RIF mass with no evidence of any complications
- No particular faecolith was found in this case. Probably, a hard fecal matter may have caused it but was dislodged during manipulation at the operation or during bowel preparation
- No associated diverticulosis was found during the operation or at follow-up colonoscopy.
This case report illustrates the necessity to consider a GCD of the cecum as a differential diagnosis for RIF mass. Although it is a difficult and rare diagnosis, cecal diverticulosis and its complications should be considered by the practitioners in cases of pathologies of the RIF.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank the Department of General Surgery and Pathology, Calcutta National Medical College and Hospital, Kolkata, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]