Mit A. Chauhan, MD1, Khamoshi Patel, DO1, Siva Prasad Maruboyina, MD1, Heli Bhatt, DO2, Rewanth Katamreddy, MD1, Yatinder Bains, MD3 1Saint Michael's Medical Center, Newark, NJ; 2Texoma Medical Center, Denison, TX; 3Saint Michael's Medical Center, New York Medical College, Newark, NJ
Introduction: We present a case of diverticulitis complicated by a recto-sigmoid mass presumed to be malignancy due to alarming symptoms and lymphadenopathy, treated with surgical resection.
Case Description/Methods: 59-year-old female presents to the emergency department complaining of bright red blood per rectum associated with left-sided abdominal pain, 100-lb weight loss in 3 years, and reduced appetite. Patient was afebrile, HR 103 beats/min, RR 18 breaths/min, BP was 167/94 mmHg, with generalized abdominal tenderness on physical exam. CT scan shows chronic sigmoid diverticulitis with colocolic fistula and mild adjacent fat stranding. Colonoscopy was attempted but not completed due to the large infiltrative mass in the rectum extending to distal sigmoid colon, 3-5 inches in length, suspected to be a malignancy. Pathology showed hyperplastic changes. MRI showed T4N4 Tumor in the sigmoid colon 8 cm from the anal verge, with lymphadenopathy in the mesorectal fat. CT scan was negative for metastatic disease. CEA was 0.7. Patient underwent a repeat sigmoidoscopy for tissue biopsy, which again showed hyperplastic changes. Patient underwent surgical resection of the mass. Resected lymph nodes and rectosigmoid mass were sent to pathology which returned negative for malignancy. Lymph nodes were remarkable for acute diverticulosis with abscess formation, marked fibrosis, perforation of pericolic fibrous adhesions, and vascular congestion with recent hemorrhage.
Discussion: Our patient had many unusual complications such as fistulas, lymphadenopathy, and obstruction, which makes this case unique. Therefore, we emphasize the importance of keeping diverticular disease in the differential even afterward, until confirmed by pathology. Colonoscopy is generally avoided in acute diverticulitis in order to avoid perforations and is performed weeks after the resolution of diverticulitis (Hulknick et al). In this novel case, diagnostic colonoscopy was attempted multiple times, but unsuccessful due to the mass causing an obstruction, which prohibited safe navigation of the scope proximal to the rectosigmoid mass. As a result, our patient had to undergo laparotomy and tissue biopsy which eventually confirmed the diagnosis. Such patients in whom the rectum, Hartmann’s procedure is the procedure of choice (Schein et al.). Patients require further follow-up since 33% of procedures are never reversed (Belmont et.al), and patient that undergoes a surgical reversal of a procedure face poses significant morbidity and fatality.
Figure: Coronal view (Figure 1) and Saggital view (FIgure 2) of large rectosigmoid mass spanning sigmoid colon through the rectum inseparable from adjacent structures. Secondary Fistula (figure 3) between the colon and bladder.
Disclosures:
Mit Chauhan indicated no relevant financial relationships.
Khamoshi Patel indicated no relevant financial relationships.
Siva Prasad Maruboyina indicated no relevant financial relationships.
Heli Bhatt indicated no relevant financial relationships.
Rewanth Katamreddy indicated no relevant financial relationships.
Yatinder Bains indicated no relevant financial relationships.
Mit A. Chauhan, MD1, Khamoshi Patel, DO1, Siva Prasad Maruboyina, MD1, Heli Bhatt, DO2, Rewanth Katamreddy, MD1, Yatinder Bains, MD3. E0153 - An Unusual Case of Diverticulitis With Reactive Lymphadenopathy, Complete Obstruction, and Fistula, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
