Acute Perforating Diverticulitis Associated with Active Ulcerative Colitis: Yes, It Does Occur

Abstract

A 79-year-old female with a past medical history of UC presented with persistent watery diarrhea, abdominal pain, nausea, vomiting, and low-grade fever. She had originally presented 1.5 years prior with persistent hematochezia prompting colonoscopy which revealed congestion, erosions, erythema, friability, granularity and loss of vascularity extending in a continuous and circumferential pattern from the anus to the sigmoid colon. Numerous small and large-mouthed diverticula were found in the sigmoid colon and in the descending colon. Rectosigmoid biopsy revealed crypt distortion with increased lymphoplasmacytic and neutrophilic inflammatory infiltrate in the lamina propria and associated cryptitis, crypt abscesses, and reactive epithelial cell changes consistent with a diagnosis of UC. Over the next 1.5 years she intermittently tolerated combinations of 5-aminosalicylic acid preparations (5-ASA) and steroid suppositories and enemas with concomitant oral 5-ASA therapies. However she eventually developed steroid-dependent UC. Given persistent side effects of chronic steroid therapy biologic therapy with infliximab was started approximately one week prior to presentation. On admission to hospital, she was started on broad-spectrum antibiotics and intravenous steroids. With a negative infectious workup, she was continued on an accelerated infliximab program. This was complicated by the development of Clostridium Difficile colitis, requiring oral vancomycin therapy. She subsequently developed worsening abdominal pain prompting computed-tomography evaluation which revealed colitis with increased wall thickening and pericolonic inflammation along the descending colon with an associated droplet of extraluminal air and rim-enhancing fluid in the left paracolic gutter compatible with perforation. She underwent emergent exploratory laparotomy with identification of a descending colonic perforation resulting in subtotal colectomy with end ileostomy. Her post-op course was complicated by multiple pelvic fluid collections documented on serial imaging requiring drainage and growth of Vancomycin-Resistant Enteroccocus. Microscopic surgical pathology showed chronic UC associated with extensive colonic diverticulosis with acute perforative diverticulitis, subserosal abscesses and acute purulent serositis. The inflammation of UC was limited to the deep submucosa. There was no dysplasia, granulomata, or viral inclusions present.