1553 A Phantom of the Large Bowel!

Abstract

INTRODUCTION: Giant colonic diverticulum (GCD), referred to as giant colon cyst or “phantom tumor,” is a diverticulum that commonly arises from sigmoid colon and is larger than 4 cm in diameter. This occurs mostly in individuals older than 60 years and its pathogenesis is not well understood. Two theories have been proposed that could co-exist: A one-way valve mechanism at the transition point between the bowel lumen and diverticulum permitting air entry and progressive increase in intraluminal pressure with subsequent enlargement of the diverticulum. Alternatively, gas forming bacteria encased within a cyst of the colon contributing to chronic inflammation and consequent gradual distention of a diverticulum. Patients are mostly asymptomatic, otherwise common clinical manifestations range from a soft palpable abdominal mass to lower abdominal pain, constipation or rectal bleeding. However, it is uncommon for GCD to present as acute diverticulitis, and to our knowledge, this is a rare case to be reported in the literature. Herein we report a case of an elderly male who presented with sepsis due to acute diverticulitis as an initial presentation of a GCD. CASE DESCRIPTION/METHODS: A 63-year-old bed-bound male with a history of multiple sclerosis and major depression presented to our hospital with generalized abdominal pain of one-day duration. The patient was febrile at 101 F, and physical exam was remarkable for lower abdominal tenderness without guarding. He was septic with evidence of leukocytosis of 23,400/mm3, neutrophilia and lactate of 3 mmol/L (normal range: 0.5–2.2 mmol/L). A CT of the abdomen with contrast demonstrated an isolated 4.5 cm diverticulum at the sigmoid colon with evidence of acute diverticulitis. There was no evidence of a focal drainable abscess, free air or diverticulosis in other colon segments. He was considered high risk for surgery due to his sedentary status and was conservatively managed with parenteral antibiotics. His symptoms resolved and discharged three days later, without any further complications. DISCUSSION: GCD is a rare manifestation of diverticular disease and can present with a myriad of symptoms. Acute diverticulitis should be considered in those with evidence of sepsis and at risk of developing GCD. The gold standard treatment of en-bloc resection of the GCD with primary anastomosis is not always ideal for the management of this entity and a more conservative approach can be taken in high-risk surgical candidates as in our patient and may lead to a favorable outcome.