S2240 Uncommon Presentation of Acute Diverticulitis Complicated by Colovesical Fistula

Abstract

Introduction: Acute Diverticulitis primarily occurs in elderly men, with incidence increasing with increasing age. However, the incidence of diverticulitis in men aged 18 to 44 years is increasing. The most common presenting symptoms of acute diverticulitis are Abdominal Pain, Fever, Chills, Constipation, Diarrhea, and Nausea. Complications include abscess, obstruction, perforation, and fistula formation. Here we present an unusual case of a young male, who presented to our hospital with symptoms of UTI and was subsequently found to have a colovesical fistula secondary to acute diverticulitis. Treating physicians should be aware of the rare presentation of acute diverticulitis and should have a high index of suspicion when treating similar cases. Case Description/Methods: A 31-year-old Hispanic Male with a history of colonic diverticulosis and one episode of diverticulitis 4 years ago was presented to the hospital with the chief complaint of dysuria, increased urinary frequency, and urgency. His Vitals and Laboratory findings on presentation are shown in the table below. The physical exam did not show abdominal tenderness. He was clinically diagnosed with UTI and was started on appropriate antibiotics. He continued to have fever spikes and also developed passage of brown particles along with the passage of air in his urine. During his hospital stay, he did not have any abdominal pain, nausea, vomiting, diarrhea, or constipation. Based on the above history, an abdominal CT with contrast was obtained that showed acute diverticulitis of the sigmoid colon with colovesical fistula. The patient underwent robotic sigmoidectomy with excision of the fistula with improvement in his symptoms (Figure, Table). Discussion: A diverticulum is a sac-like protrusion of the colonic wall, developing at well-defined points of weakness where the vasa recta penetrate the circular muscle of the colon. Approximately 4% of patients with diverticulosis develop acute diverticulitis and very few of them develop complications. Fistula formation is more common in men, as the uterus and the broad ligaments are thought to protect the bladder from the inflamed sigmoid colon. Colovesical fistulas should be suspected in any patient who presents with pneumaturia or fecaluria or a male with UTI symptoms and a history of diverticulosis. Diverticular fistulas do not close spontaneously and require surgical management that involves identification and division of the fistula, resection of the involved portion of the colon, and bladder repair if necessary.Figure 1.: Sigmoid Diverticulitis with Colovesical Fistula. Table 1. - Significant Lab Values Temperature on presentation 102.6 WBC count 7500 Hemoglobin 14.9 Blood Urea Nitrogen 19 Creatinine 0.98 Urine Appearance Cloudy Urine Analysis Large Leukocyte Esterase positive Urine Microscopy WBC clumps and Large Blood Lactic Acid trend 2.2 > 0.9 Blood Cultures No growth