Correspondence

Giant Colonic Diverticulum

N Engl J Med 1995; 333:1645December 14, 1995

Article

To the Editor:

The legend to the Image in Clinical Medicine by Ueda and Hall showing a giant colonic diverticulum (July 27 issue)1 suggests that the patient's recurrent episodes of pain were causally related to the giant diverticulum of the sigmoid colon. Although that may be true, a noninflamed diverticulum that has not undergone torsion, even if it has enlarged, is unlikely to cause such acute episodes of pain.

The term “acute abdomen” used to describe the circumstances that led to an emergency operation is an unfortunate one, giving no clue to the cause of the pain. The barium enema shows an extremely redundant ascending colon and hepatic flexure, and a cecum and ileum high in the right abdomen, an anatomical precursor of so-called cecal volvulus. Did the surgeon assess this area at operation (although spontaneous detorsion may have occurred), and has the patient had further attacks of pain?

William Silen, M.D.
Robert G. Sheiman, M.D.
Beth Israel Hospital, Boston, MA 02215

1 References

1. 1

   Ueda P, Hall D. Giant colonic diverticulum. N Engl J Med 1995;333:228-228
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Ueda replies:

To the Editor: These questions present the opportunity to fill out this patient's history, which was quite interesting.

The patient told a curious story of a feeling of warmth in the pelvic area, with chills in the extremities, that had occurred four times over the previous year. The onset of these symptoms always followed a normal void, and the symptoms lasted two days and were accompanied by a temperature reaching 38.3°C. She also said that for six months she had felt as if she had a lump in her lower abdomen that seemed to move from side to side and was particularly noticeable with recumbency. She had long-standing constipation. The abdominal examination on this first visit did raise a question of a mass in the right lower quadrant, with tympany to percussion over this area. A pelvic examination was normal. Pelvic ultrasonography showed a hypoechoic uterine mass, probably representing a fibroid in the right adnexa.

Before further evaluation was undertaken, the patient presented at the end of a typical episode. She described a temperature of 38.9°C two days earlier, possibly with a rigor, and dysuria, crampy right-lower-quadrant and suprapubic pain, and one episode of vomiting. Her symptoms were relieved by acetaminophen. At the visit she was afebrile and had no other signs of systemic infection. Her examination was notable only for moderate tenderness in the right lower quadrant, with flatness to percussion and mild right costovertebral tenderness. An examination of urinary sediment was unremarkable (and a culture subsequently negative), and a complete blood count was normal.

At this point I asked whether the patient's symptoms could be explained simply by recurrent episodes of self-limited diverticulitis. A barium enema was performed in the hope of clarifying the situation, as well as to rule out more serious bowel disease. The finding of the giant diverticulum was frankly a surprise, but in retrospect it may indeed explain her symptoms. Specifically, the Valsalva maneuver involved in voiding may have forced additional colonic gas into an already enlarged diverticulum, with resulting acute distention and transient bacteremia.

At surgery, in addition to the giant diverticulum, moderate sigmoid diverticulosis was found. It is entirely possible that any of these diverticula may have accounted for previous symptomatic episodes. None were inflamed at laparotomy, and the colon was otherwise normal. The rectosigmoid was resected, along with the right fallopian tube and ovary, because the giant diverticulum adhered to these structures. Since her surgery, which occurred almost three years ago, the patient has had no further symptoms.

Peggy Ueda, M.D.
Massachusetts General Hospital, Boston, MA 02114

Citing Articles (1)

Citing Articles

1. 1

   Linmarie Ludeman, Bryan F. Warren, Neil A. Shepherd. (2002) The pathology of diverticular disease. Best Practice & Research Clinical Gastroenterology 16:4, 543-562
   CrossRef