S1917 Complicated Diverticulitis of the Sigmoid Flexure in a Patient with Left Nephrolithiasis

Abstract

Introduction: Complicated diverticulitis is defined as diverticular inflammation associated with hemorrhage, abscess, phlegmon, perforation or obstruction. There are currently no reported cases of complicated diverticulitis occurring secondary to obstructive nephrolithiasis. We report a patient admitted for a left ureteral stone, whose significant perinephric inflammation was suspected to play a role in the development of complicated diverticulitis. Case description/methods: A 76 year old woman with history of recurrent nephrolithiasis presented with acute left flank pain. On arrival, she was mildly tachycardic. Physical exam was notable for left costovertebral angle tenderness. Labs were notable for an elevated blood urea nitrogen of 25 mg/dL. Computed tomography (CT) abdomen showed a 6 mm obstructing calculus within the left proximal ureter causing moderate hydronephrosis and significant peri-nephric inflammation. The patient was started on ceftriaxone. The next day, she had a worsening leukocytosis and an acute kidney injury, so she was taken urgently for left ureteral stent placement. Postoperatively, she had significant abdominal pain, so a repeat CT abdomen was obtained. It revealed inflamed diverticulum at the splenic flexure with an associated abscess abutting the spleen, consistent with complicated diverticulitis. She was managed supportively with nasogastric tube decompression, pain control, and broadened antibiotics. On hospital day 8, her abdominal pain worsened. Repeat CT abdomen showed enlargement of the perisplenic abscess and multiple new small abscesses anterior to the spleen. The patient was taken for laparoscopic splenectomy, which was complicated by iatrogenic perforation of the stomach, peritonitis, and septic shock. After a prolonged and complicated hospital stay in the surgical intensive care unit, the patient was discharged to a long term care facility. Discussion: Our patient's complicated diverticulitis was suspected to be secondary to her left ureteral stone. While most cases of diverticulitis occur at the sigmoid colon, our patient’s was at the splenic flexure, in close proximity to the left renal fossa where significant inflammation was noted on initial imaging. It is also possible that her diverticulitis was a consequence of iatrogenic ureteral injury during cystoscopy. Clinicians should be aware that complicated diverticulitis may occur in relation to nephrolithiasis.Figure 1.: a: Synaptophysin positive tumor cells b: Chromogranin A positive tumor cells c: Colonoscopy showing 2 cm mass at Hepatic flexure. d: High grade adenocarcinoma arising in a background of sessile serrated adenoma e: CK7 positive immunohistochemical staining.