Perforated Diverticular Disease Research Articles

PATIENT CASE STUDY: REBUILDING A PATIENT’S LIFE NOT JUST THEIR ABDOMINAL WALL – EXPERIENCE FROM A TERTIARY HERNIA CENTRE ON THE IMPACT OF ABDOMINAL WALL RECONSTRUCTION ON QUALITY OF LIFE

Abstract Introduction Abdominal wall reconstruction is a transformative intervention, significantly improving the quality of life for individuals with complex defects. This paper focuses on sharing a patient's experience post-surgery. Case Presentation The patient presented with a complex incisional hernia following a laparotomy, Hartmann’s procedure and splenectomy for perforated diverticular disease. Their CT scan showed a 16.5 × 17.5 cm defect, with a separate component involving their colostomy and lateral displacement of their muscle complexes. The hernia significantly impacted the patient's quality of life, manifesting as daily moderate pain that hindered routine activities. They required daily dressings and antibiotics due to skin changes over the hernia. Furthermore, dissatisfaction with the cosmetic appearance of the hernia contributed to the overall burden on the patient. Management and Outcomes The patient underwent pre-operative botulinum toxin injections six weeks prior to their abdominal wall reconstruction. They received 200 units divided equally between internal and external obliques. During their surgery they required a left sided transversus abdominus release and an >5cm mesh overlap was achieved in all directions. A post-operative CT scan conducted ten days after the surgery revealed no complications. The patient's recovery progressed well, leading to their discharge 12 days post-surgery. Discussion The patient was reviewed nine months post-surgery. Expressing high satisfaction with the surgical outcome, they conveyed a profound positive impact on their quality of life. The patient's newfound confidence in the improved cosmesis of their hernia was evident. Overall, the surgery proved transformative, liberating the patient from the burdens of frequent medical appointments and instilling a renewed sense of self-assurance.

SP1.12 Laparoscopic Hartmann’s procedure for diverticular perforation reduces length of stay and mortality

Abstract Introduction Hartmann's procedure for perforated diverticular disease is a common emergency abdominal operation; with a mean length of stay of over 2 weeks and a mortality of 8%. This study looks at whether the laparoscopic approach is feasible and might lead to improved outcomes. Methods The national NELA dataset was interrogated to find patients undergoing Hartmann's procedure for diverticular disease. Data were analysed according to surgical approach, length of stay and 30-day mortality. Results Over a 4-year period, 4061 patients underwent Hartmann's procedure for diverticular disease; 459 (11%) were started laparoscopically, and 162 (4%) were completed laparoscopically. 30 of 176 acute hospitals performed over half of laparoscopic cases, and 139 of 176 hospitals performed fewer than 1 each year. Mean length of stay was 17 days after open Hartmann's versus 11 days after the laparoscopic approach. Mortality in the open group was 8.2% versus 5.2% if surgery was started laparoscopically, and 1.3% if surgery was completed laparoscopically. This relationship remained when only patients with a predicted NELA mortality of less than 10% were considered (2.5% versus 1.4%). Observed versus expected mortality in the open group was 0.95, versus 0.63 in those undergoing laparoscopic surgery. Conclusions The laparoscopic approach to Hartmann's procedure for diverticulitis is associated with shorter hospital stay and reduced mortality. There is undoubtedly bias from patient selection, but some hospitals offer laparoscopy in over 50% of cases, which at least gives them the option of performing a laparoscopic Hartmann's if necessary and possible.

SP8.2.8 Resection and primary anastomosis is safe in selected patients with perforated diverticulitis; a cohort study

Abstract Aims Historically, the preferred procedure for perforated diverticular disease is Hartmann's procedure (HP). Although reliably achieving source control, it's associated with a high rate of post-operative complications and a stoma which often becomes permanent. We reviewed our experience of patients undergoing HP vs primary anastomosis (PA) for perforated diverticulitis. Methods All patients undergoing emergency resectional surgery for perforated diverticulitis between March 2015 and Jan 2021 were identified from the Hospital Episode Statistics (HES) data. Demographics were collected and the patient groups were case matched for age and Charleson Comorbidity Index (CCI), Computed Tomography (CT) appearance and intraoperative contamination data. Post-operative morbidity/mortality data was compared. Results 105 patients were included. 15 patients had PA (without diversion) and 90 HP. In the PA cohort were 10 males, median age 52 (range 27–76). There were no anastomotic leaks. 30-day morbidities were superficial wound dehiscence (1) and early incisional hernia (1). Median post-operative stay was 9 days (range 5–25). HP control group (age below 76, Charlson score 10 and below, Hinchey 1–3 intraoperatively). Included 58 patients, 26 males, median age 60.5 (range 30–76). Median post-operative stay was 10.5 days (range 5–227). 2 patients required re-operation. 5 patients developed wound infections. At the time of the study 18 patients have undergone reversal, 6 are on active waiting-list for reversal. There was a single 30-day mortality (post-discharge). Conclusion We have shown that PA is safe in selected cohort of patients and have identified that over 50% of patients undergoing HP could have been considered for PA.

Hartmann’s operation 100 years later: Time to think and stop?

When Henri Hartmann invented his operation in 1921, his intent was not for use in benign disease but as an alternative for Miles’ abdominoperineal resection which, at that period, had a high mortality rate. With advancements in medicine, Hartmann’s procedure was replaced by abdominoperineal resection which had a significant drop in mortality. In the 1980s to the 1990s, however, there was a renewed interest in Hartmann’s procedure as an alternative management for perforated diverticular disease leading to the formation of guidelines that advocated its use. Since then, resection with primary anastomosis has replaced Hartmann’s as the standard of care and with the alternative operations available for colorectal cancers, the place for Hartmann’s operation in medicine should be clearly defined.

Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience.

The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O2 therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.

Colonic diverticulosis - diagnostic and therapeutic difficulties

Objectives. The objectives of this study are to highlight the diagnostic and therapeutic difficulties in patients with complicated acute colonic diverticulosis. Methods. The study group comprised 40 patients hospitalized to the Second Surgical Clinic of the Emergency County Hospital in Craiova, Romania, through the emergency service between 2015 and 2021. Regarding the sex distribution of the patients with colonic diverticular disease studied, there was a predominance of males. The distribution of patients was as follows: 22 patients with acute colonic diverticulitis, out of whom 21 patients suffered from left acute colonic diverticulitis and 1 patient suffered from right acute colonic diverticulitis. Results. The diagnosis of acute colonic diverticulitis was made by corroborating the data obtained on the objective clinical examination with the data obtained by exploring the abdomen by means of computed tomography, which revealed a thickening of the colon wall (acute sigmoid diverticulitis predominated). The treatment applied to patients with acute diverticulitis was conservative and in patients with acute perforated colonic diverticulitis, the treatment of choice was the surgical one. Mortality was 7.5% of all the cases. Conclusions. In patients with perforated colonic diverticular disease, the administered treatment consisted in Hartmann segmental colectomy, wound care, peritoneal drainage. The reintegration of the colon in the digestive transit was performed after 3-6 months.

EP.TU.809Challenges in management of acute diverticulitis within a district general hospital

Abstract Aim Incidence of perforated sigmoid diverticular disease is estimated at 3.4 to 4.5 per 100,000. Perforation may be the first manifestation of complicated diverticulitis with a range of 50% to 70%. We aim to review management of systemically unwell patients with acute diverticulitis in a district general hospital against the 2019 NICE guidelines. Methods 29 patients presenting septic with acute diverticulitis, M:F ratio 12:17, median age 55 (range 24-82), median ASA 2 (range 0-3) were retrospectively reviewed over a 6-month period. Results Mean time to antibiotics was 3.96 hours (range 0-23.11). Of the 7 with perforated diverticulitis severity classification included: Hinchey I – n = 1, 3.4%; Hinchey IIa – 5 (17.2%), and; Hinchey IIb – 1 (3.4%). Time to CT abdomen pelvis was 3.38 hours (range 0-16.4 hours). Two pericolic abscesses met NICE drainage criteria at 3.7 cm and 3.9 cm respectively. The 3.7 cm abscess was drained radiologically at 7 days post-admission and was re-admitted 6 days later requiring further radiological drainage. The patient with a 3.9 cm abscess received a Hartmann’s procedure and had multiple re-admissions requiring a hospital stay of 34 days. There was 0% mortality at 30 days. Conclusion Management of acute diverticulitis continues to present a unique challenge. For systemically unwell patients, timely administration of antibiotics within an hour of sepsis recognition is encouraged to optimise outcomes. Timely cross-sectional imaging is pivotal in disease classification and decision-making regarding acute management. Interventional drainage and surgical resection remain important therapeutic strategies for unwell patients with Hinchey grade II diverticulitis.

O23 Outcomes after non-operative management of perforated diverticular disease: a population based cohort study

Abstract Introduction The management of perforated diverticular disease has changed in the last 10 years with a move towards less surgical intervention. This population based cohort study aimed to define the risk of mortality and readmission following non-operative management of perforated diverticular disease (DD). Method Patients diagnosed with perforated DD and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case-fatality, re-admissions and surgery at re-admission. Result In total, 880 patients with perforated DD were managed without surgery, comprising of 523 females (59.4%). One year case-fatality was 33.2% (293/880). The majority of deaths occurred in the first 90 days following the index admission with a 90 day case-fatality of 28.8%. 90 day survival varied by age with 97.2% survival at 90 days in those under 65 years compared to 85.0% in those between 65–74 years and 51.5% in those over 75 years. Of 767 patients discharged from hospital, 250 (32.6%, 250/767) were re-admitted (47 elective(6.1%) and 203 emergency(26.5%)) during a median of 1.6 years of follow-up (iqr 0.1–3.9 years) with similar proportions in each age category. In the first year of follow-up only 5.1% of patients required surgery of whom 16/767 (2.1%) required elective and 23/767 (3.0%) emergency surgery. Conclusion Conservative management of perforated diverticulitis in those under 65 years is feasible and safe. A third of patients are readmitted during follow-up, however, re-intervention rates following conservative management were low across all age categories. Take-home Message In younger patients (<65yrs) conservative management of perforated diverticulitis is feasible and safe. A third of conservatively managed patients are readmitted during follow-up, however, need for surgery on readmission is rare.

AB223. SOH21AS253. The misguided catheter: a case report

: Critically ill patients in an intensive care unit (ICU) require venous catheters to maintain and monitor their physiology. Peripherally inserted central catheter (PICC) and central venous catheters (CVC) are placed by experienced physicians using a standardised Seldinger technique in an aseptic environment, they are also associated with a myriad of complications. It is standard practice to confirm the position of catheters and assess for complications on a chest x-ray (CXR) before use. Here we present a case where the position of a previously sited right sided PICC was altered by the insertion of a left internal jugular CVC. A 64-year-old gentleman 3 days post laparoscopic Hartmann’s procedure for perforated diverticular disease developed type 1 respiratory failure requiring ICU admission. His respiratory deterioration resulted from a combination of post-operative ileus, hospital acquired pneumonia, para-pneumonic effusion and PCR confirmed COVID-19 infection (Image1). He required intubation and placement of a left sided CVC. A post-procedural CXR revealed drastic displacement of his right sided PICC, the tip now residing in the left brachiocephalic vein. We hypothesised that while a standardised approach and sequence was followed: the blunted, ‘hook-like’ guidewire was the culprit in the dislodgement of the previously sited PICC. Curiously the PICC spontaneously returned to its optimal position in the SVC without intervention. This case illustrates an unusual and interesting complication of CVC insertion despite standardised technique and safety precautions.

Outcomes after non-operative management of perforated diverticular disease: a population-based cohort study.

BackgroundThe management of perforated diverticular disease has changed in the past 10 years with a move towards less surgical intervention. This population-based cohort study aimed to define the risk of death and readmission following non-operative management of perforated diverticular disease.MethodsPatients diagnosed with perforated diverticular disease and managed without surgery were identified from the linked Clinical Practice Research Datalink and Hospital Episode Statistics data from 2000 to 2013. The outcomes were 1-year case fatality, readmissions, and surgery at readmission.ResultsIn total, 880 patients with perforated diverticular disease were managed without surgery, comprising 523 women (59.4 per cent). The 1-year case fatality rate was 33.2 per cent (293 of 880). The majority of deaths occurred in the first 90 days after the index admission, with a 90-day case fatality rate of 28.8 per cent. The 90-day survival rate varied by age, and was 97.2 per cent among those aged less than 65 years, compared with 85.0 per cent for those aged between 65 and 74 years, and 47.7 per cent in those at least 75 years old. Of 767 patients discharged from hospital, 250 (32.6 per cent) were readmitted (47 elective, 6.1 per cent; 203 emergency, 26.5 per cent) during a median of 1.6 (i.q.r. 0.1–3.9) years of follow-up, with similar proportions in each age category. In the first year of follow-up, only 5.1 per cent of patients required surgery, of whom 16 of 767 (2.1 per cent) required elective and 23 (3.0 per cent) emergency operation.ConclusionNon-operative management of perforated diverticulitis in those aged less than 65 years is feasible and safe. Reintervention rates following conservative management were low across all age categories.

A shift in surgical management of perforated jejunal-ileal diverticulitis? Two case reports

Small bowel diverticular disease is usually asymptomatic, but complicated small bowel diverticular disease can present as an acute abdomen, manifesting as diverticulitis, perforation, abscess, obstruction or bleeding. Due to the rarity of the disease, very few studies have been conducted on complicated small bowel diverticular disease. Therefore, there are no clear guidelines on management. General peritonitis remains the best indication for surgical management due to its correlation with high mortality and prolonged hospital stay. Traditionally, perforated small bowel diverticular disease is managed with exploratory laparotomy, primary bowel resection and anastomosis regardless of acute presentation. However, more recent studies demonstrated a trend towards conservative or less invasive surgical management. Here, we report two perforated small bowel diverticulitis cases at our institution that underwent different management and had different outcomes.

Damage control surgery in perforated diverticulitis: ongoing peritonitis at second surgery predicts a worse outcome.

Damage control strategy (DCS) is a two-staged procedure for the treatment of perforated diverticular disease complicated by generalized peritonitis. The aim of this retrospective multicenter cohort study was to evaluate the prognostic impact of an ongoing peritonitis at the time of second surgery. Consecutive patients who underwent DCS for perforated diverticular disease of the sigmoid colon with generalized peritonitis at four surgical centers were included. Damage control strategy is a two-stage emergency procedure: limited resection of the diseased colonic segment, closure of oral and aboral colon, and application of a negative pressure assisted abdominal closure system at the initial surgery followed by second laparotomy 48h later. Therein, decision for definite reconstruction (anastomosis or Hartmann's procedure (HP)) is made. An ongoing peritonitis at second surgery was defined as presence of visible fibrinous, purulent, or fecal peritoneal fluid. Microbiologic findings from peritoneal smear at first surgery were collected and analyzed. Between 5/2011 and 7/2017, 74 patients underwent a DCS for perforated diverticular disease complicated by generalized peritonitis (female: 40, male: 34). At second surgery, 55% presented with ongoing peritonitis (OP). Patients with OP had higher rate of organ failure (32 vs. 9%, p= 0.024), higher Mannheim Peritonitis Index (25.2 vs. 18.9; p= 0.001), and increased operation time (105 vs. 84min., p= 0.008) at first surgery. An anastomosis was constructed in all patients with no OP (nOP) at second surgery as opposed to 71% in the OP group (p< 0.001). Complication rate (44 vs. 24%, p= 0.092), mortality (12 vs. 0%, p= 0.061), overall number of surgeries (3.4 vs. 2.4, p= 0.017), enterostomy rate (76 vs. 36%, p= 0.001), and length of hospital stay (25 vs. 18.8days, p= 0.03) were all increased in OP group. OP at second surgery occurred significantly more often in patients with Enterococcus infection (81 vs. 44%, p= 0.005) and with fungal infection (100 vs. 49%, p= 0.007). In a multivariate analysis, Enterococcus infection was associated with increased morbidity (67 vs. 21%, p< 0.001), enterostomy rate (81 vs. 48%, p= 0.017), and anastomotic leakage (29 vs. 6%, p= 0.042), whereas fungal peritonitis was associated with an increased mortality (43 vs. 4%, p= 0.014). Ongoing peritonitis after DCS is a predictor of a worse outcome in patients with perforated diverticulitis. Enterococcal and fungal infections have a negative impact on occurrence of OP and overall outcome.

A Rare Case Of Sigmoid Colon Perforation With Subsequent Psoas Abscess Collection With Extensive Involvement Of The Sartorius Muscle

A middle-aged man was admitted with worsening hip pain, fevers and reduced mobility. These symptoms were preceded by a mechanical fall but despite regular analgesia, symptoms did not resolve. His...

Corticosteroid use and mortality risk in patients with perforated colonic diverticular disease: a population-based cohort study

BackgroundCorticosteroids are a potential risk factor for mortality in patients with perforated diverticular disease, due to blinding of disease severity, hampered wound healing or adrenal insufficiency. We examined mortality in...

A population-based case–control study on statin exposure and risk of acute diverticular disease

Objective: A reduced risk of perforated diverticular disease among individuals with current statin exposure has been reported. The aim of the present study was to investigate whether statins reduce the risk of acute diverticular disease. Material and methods: A nation-wide population-based case–control study was performed, including 13,127 cases hospitalised during 2006–2010 with a first-time diagnosis of colonic diverticular disease, and 128,442 control subjects (matched for sex, age, county of residence and calendar year). Emergency surgery, assumed to be a proxy for complicated diverticulitis, was performed on 906 of the cases during the index admission, with 8818 matched controls. Statin exposure was classified as “current” or “former” if a statin prescription was last dispensed ≤125 days or >125 days before index date, respectively. The association between statin exposure and acute diverticular disease was investigated by conditional logistic regression, including models adjusting for country of birth, educational level, marital status, comorbidities, nonsteroidal anti-inflammatory drug/steroid exposure and healthcare utilisation. Results: A total of 1959 cases (14.9%) and 16,456 controls (12.8%) were current statin users (crude OR 1.23 [95% CI 1.17–1.30]; fully adjusted OR 1.00 [0.94–1.06]). One hundred and thirty-two of the cases subjected to surgery (14.6%), and 1441 of the corresponding controls (16.3%) were current statin users (crude OR 0.89 [95% CI 0.73–1.08]; fully adjusted OR 0.70 [0.55–0.89]). Conclusions: The results do not indicate that statins affect the development of symptomatic diverticular disease in general. However, current statin use was associated with a reduced risk of emergency surgery for diverticular disease.

Brief Useful Comments on Laparoscopic Surgery in Acute Abdomen

The use of laparoscopic surgery tends to become more and more popular, nowadays. It has also been extended in the management of acute abdominal disease as a diagnostic and as a therapeutic tool. However, its therapeutic use requires special experience and appropriate instrumentation, in addition to a reliable definite diagnosis. Based on randomized, controlled trials, it can be postulated that laparoscopic surgery in acute abdomen is feasible, safe and effective in acute cholecystitis, acute appendicitis and gastroduodenal ulcer perforation. There are still conflicting aspects in perforated diverticular disease and small bowel obstruction. In case of purulent peritonitis attention must be paid in order to avoid residual abscess formation and sepsis by thorough irrigation of the peritoneal cavity and on time antibiotic therapy. The proper indication for each case under the certain emergency circumstances is crucial.

Laparoscopic peritoneal lavage: a definitive treatment for diverticular peritonitis or a "bridge" to elective laparoscopic sigmoidectomy?: a systematic review.

To this day, the treatment of generalized peritonitis secondary to diverticular perforation is still controversial. Recently, in patients with acute sigmoid diverticulitis, laparoscopic lavage and drainage has gained a wide interest as an alternative to resection. Based on this backdrop, we decided to perform a systematic review of the literature to evaluate the safety, feasibility, and efficacy of peritoneal lavage in perforated diverticular disease.A bibliographic search was performed in PubMed for case series and comparative studies published between January 1992 and February 2014 describing laparoscopic peritoneal lavage in patients with perforated diverticulitis.A total of 19 articles consisting of 10 cohort studies, 8 case series, and 1 controlled clinical trial met the inclusion criteria and were reviewed. In total these studies analyzed data from 871 patients. The mean follow-up time ranged from 1.5 to 96 months when reported. In 11 studies, the success rate of laparoscopic peritoneal lavage, defined as patients alive without surgical treatment for a recurrent episode of diverticulitis, was 24.3%. In patients with Hinchey stage III diverticulitis, the incidence of laparotomy conversion was 1%, whereas in patients with stage IV it was 45%. The 30-day postoperative mortality rate was 2.9%. The 30-day postoperative reintervention rate was 4.9%, whereas 2% of patients required a percutaneous drainage. Readmission rate after the first hospitalization for recurrent diverticulitis was 6%. Most patients who were readmitted (69%) required redo surgery. A 2-stage laparoscopic intervention was performed in 18.3% of patients.Laparoscopic peritoneal lavage should be considered an effective and safe option for the treatment of patients with sigmoid diverticulitis with Hinchey stage III peritonitis; it can also be consider as a “bridge” surgical step combined with a delayed and elective laparoscopic sigmoidectomy in order to avoid a Hartmann procedure. This minimally invasive staged approach should be considered for patients without systemic toxicity and in centers experienced in minimally invasive surgery techniques. Further evidence is needed, and the ongoing RCTs will better define the role of the laparoscopic peritoneal lavage/drainage in the treatment of patients with complicated diverticulitis.

Management of acute diverticulitis and its complications.

Colonic diverticular disease is a common condition, and around a quarter of people affected by it will experience acute symptoms at some time. The most common presentation is uncomplicated acute diverticulitis that can be managed conservatively with bowel rest and antibiotics. However, some patients will present with diverticular abscesses or purulent or faeculent peritonitis due to perforated diverticular disease. Whilst most mesocolic abscesses can be managed with percutaneous drainage alone, pelvic abscesses are associated with a higher rate of future complications and usually require percutaneous drainage followed by interval sigmoid resection. Patients who require emergency surgery for complicated acute diverticulitis most commonly undergo a Hartmann's procedure, although resection with primary anastomosis and laparoscopic peritoneal lavage have emerged as alternative treatment options for patients with purulent peritonitis in recent years. However, robust evidence from randomized trials is lacking for these alternative procedures, and the studies that have reported good outcomes from them have included carefully selected patient groups. There has been a move away from recommending elective prophylactic colectomy after two episodes of acute diverticulitis in the light of evidence that most patients will not experience a significant recurrence of their symptoms; elective surgery is indicated for those with ongoing symptoms, pelvic abscesses, complications-such as fistulating disease, strictures or recurrent diverticular bleeding-and those who are at high risk of perforation during future episodes, for example, due to immunosuppression, chronic renal failure or collagen-vascular diseases.

PWE-049 Five Year Retrospective Morbidity and Mortality Figures for Colonoscopy in a District General Hospital

IntroductionBetween 1 July 2007 and 31 August 2012, 15284 colonoscopies were performed by Gastroenterologists, Colorectal Surgeons, Gastroenterology and Surgical trainees and Nurse Endoscopists. Over the 5 year period our unit...

Peri-diverticular pulse granulomas in the colon: a case report and review of the literature

<h3>Aim</h3> To describe the case of pulse granulomas (PG) found in a colonic resection from a 44-year-old female with a previous history of perforated diverticular disease, and to review the literature on extra-oral PGs. We also aimed to document the incidence of PG in our institution. <h3>Methods</h3> A sigmoid colectomy specimen was examined with H&E and histochemical stains. Computerised pathology files were searched for reports which included the terms ‘pulse granuloma' or ‘hyaline rings' over the past 5 years. <h3>Results</h3> Histologically typical PGs were found in the wall and subserosa of the colon, in close proximity to peri-diverticular in-inflammation. Our files found only three oral and four additional extra-oral PGs in the last 5 years. <h3>Discussion</h3> Extra-oral pulse granulomas are distinctly uncommon inflammatory lesions related to vegetable material. Most documented cases in the literature and in our files occurred in perianal areas, or were related to diverticular disease, fistulae or transrectal prostate biopsies.