Fawaz Spots in Segmental Colitis Associated With Diverticulosis Syndrome

Abstract

Introduction: The inflammatory complications of diverticulosis include the more common colonic diverticulitis and a rarer ‘segmental colitis associated diverticulosis' (SCAD). SCAD has a male gender predilection. We here describe a case of a 55-year-old man with complaints of abdominal pain and intermittent rectal bleeding whose colonoscopy revealed segmental colitis associated with diverticulosis and confirmed on histopathology. Case: A 55-year-old man presented from his primary care for evaluation of intermittent lower abdominal pain associated with few episodes of hematochezia. He denied fevers, diarrhea or weight loss. Physical examination was unremarkable. Laboratory results were normal for hemoglobin 14.7 gm/dl, and white cell count 6.5 K/cmm. Diagnostic colonoscopy revealed severe patchy erythematous mucosa in segments of the colon with diverticulosis which were in the sigmoid and descending colon (Figure 1); consistent with Fawaz spots seen in SCAD. Histopathology of biopsies taken showed colonic mucosa with chronic inactive colitis confirmatory for SCAD (Figure 2).Figure: Inflammatory changes with submucosal hemorrhages (Black arrows).Figure: H&E stain showing segmental colitis.Discussion: SCAD is recognized as a distinct clinical syndrome, separate from inflammatory bowel diseases of Crohn's disease and Ulcerative colitis. It is described as chronic inflammation affecting segments of diverticula, sparing the rectum and right colon. SCAD is common among males in their 6th decade of life and older. Prevalence has been reported to be between 1.5 - 11% of all patients with diverticulosis. Clinically, SCAD has been noted on endoscopic evaluation for occult colorectal malignancy, rectal bleeding, abdominal pain and/or diarrhea. Laboratory examination in SCAD usually yields normal findings unlike IBD. Stool studies for bacteria and parasites, and serological markers such as perinuclear neutrophil cytoplasmic antibodies (pANCA) and anti-Sacchromyces cerevisiae antibodies (ASCA) are negative in SCAD. On colonoscopy, the inflammatory process of SCAD is observed within the interdiverticular mucosa without involvement of the diverticular opening. Histopathologically, SCAD presents as nonspecific segments of non-granulomatous inflammation. SCAD is usually self-limiting and often resolves spontaneously. However in some cases of persistent symptoms or recurrence, a short course of 5-aminosalicylate, corticosteroids, infliximab and/or surgery may be required for disease resolution. Our patient was treated supportively with a favorable clinical outcome.