Diverticulitis or Cancer? That is the Question

Abstract

Purpose: Introduction: Isolated diverticulitis is often known to mimic an inflammatory polyp or malignancy. Our patient is a 68 year old man who was found to have a suspicious appearing lesion arising in a diverticular pouch. This case represents the risk of endoscopic removal and appropriate conservative management with antibiotic treatment and laparoscopic removal of the lesion. Case Presentation: During a screening colonoscopy, our patient was found to have a 1.5 cm erythematous fungating lesion located in the sigmoid colon, within a diverticular pouch. The lesion was surrounded by multiple diverticuli. The site was marked with Spot ink for presumptive diagnosis of malignancy. Biopsies showed inflammatory changes and negative for malignancy. He denies abdominal pain, blood in the stool, and change in bowel habits, weight loss or fever. He denies any family history of colon cancer or polyps. Physical exam was unremarkable. His hemoglobin and MCV were within normal limits. The patient was empirically treated for diverticulitis with oral ciprofloxacin and metronidazole for 2 weeks. A colonoscopy was repeated in 2 months. The previously marked location was identified and there was significant improvement in erythema. However, the mucosa appeared multilobulated and suspicious for malignancy. This area was located in a diverticular pouch making endoscopic removal of the lesion high risk. Patient underwent laparoscopic resection of the affected colonic segment, which showed polypoid granulation tissue/inflammatory pseudopolyp arising in an inflamed diverticulum. Discussion: The prevalence of diverticulosis increases with age. By age 85, 65% of the population has diverticulosis. Most patients are asymptomatic (70%), however 15 to 25 percent develop diverticulitis, and 5 to 15 percent develop diverticular bleeding. Up to 30 percent of patients with uncomplicated diverticulitis require surgical intervention during the initial attack. Surgery has generally been advised after a first attack of complicated diverticulitis or after two or more episodes of uncomplicated diverticulitis. When compared to open sigmoid resection, laparoscopic colonic resection is associated with shorter recovery time. A laparascopic approach appears to be best suited for patients in whom the episode of acute diverticulitis has resolved and in patients with Hinchey classification stage I or II disease. Inflammation of a diverticulum can have a similar appearance to an inflammatory polyp or malignancy. Endoscopic removal of such lesions can lead to bowel perforation. Antibiotic treatment with or without laparoscopic removal should be recommended.