University of Texas Health San Antonio San Antonio, TX
Shuhaib Ali, DO1, Brenda M. Briones, MD2, Andrew Han, MD3 1University of Texas Health San Antonio, San Antonio, TX; 2University of Texas Health Science Center, San Antonio, TX; 3UT Health San Antonio, San Antonio, TX
Introduction: Diverticulitis occurs when there is inflammation and microperforation to the outpouching of colonic mucosa and submucosa. One of the most common complications of diverticulitis is an abscess. Computed Tomography of the abdomen and pelvis is the imaging of choice to diagnose diverticulitis and its complications. Statistically the sensitivity, specificity, positive and negative predictive values are greater than 95%. However, in certain situations CT with a complex clinical history can skew one’s perception in diagnosing that could potentially lead to a delay in treatment. We present a case of a diverticular abscess masked as a colonic mass.
Case Description/Methods: 58-year-old Afro-American male with hypertension and tobacco use presented to the emergency department with 3 weeks of abdominal pain, bloating, constipation and a 12-pound weight loss. A colonoscopy 3 months’ prior had shown a 10 mm cecal polyp, ascending and sigmoid colon diverticulosis. Initial labs were significant for a hemoglobin of 11.2 g/dL and hematocrit of 33.2%. CT abdomen and pelvis (Fig. 1) showed a 4.9 x 3.9 cm peripherally enhancing hypodense exophytic mass at the splenic flexure concerning for colon malignancy. A colonoscopy was pursued revealing narrowed and congested erythematous mucosa in the sigmoid colon near a diverticulum with spontaneous drainage of pus (Fig. 2). Sigmoid biopsies showed focal cryptitis. Patient was started on antibiotics and 2 days after a repeat CT of the abdomen demonstrated interval resolution of the collection with residual inflammation (Fig. 3). Patient was discharged with 10 days of antibiotics and was later seen by his primary care physician for a follow up where he admitted to resolution of his symptoms.
Discussion: In this case a diverticular abscess was initially thought to be a colon mass delaying appropriate treatment with antibiotics and possibly drainage, highlighting the importance of keeping a broad differential even in those with imaging and symptoms suggestive of malignancy. Complicated diverticulitis with abscess formation occurs in 16-40% of patients who present with sigmoid diverticulitis but in some rare cases abscess formation has also been associated with colon cancer in up to 0.3 to 4% of patients that can lead to even more diagnostic challenges. In these situations, reviewing the imaging with your Radiologist might be helpful to further strengthen your diagnosis and to possibly avoid a colonoscopy that can have an increased risk of perforation in acute diverticulitis.
Figure: A.) Coronal view of splenic flexure exophytic mass B.) Sigmoid area with congestion, erythema and drainage of pus C.) Transverse view of residual splenic flexure mass
Disclosures:
Shuhaib Ali indicated no relevant financial relationships.
Brenda Briones indicated no relevant financial relationships.
Andrew Han indicated no relevant financial relationships.
Shuhaib Ali, DO1, Brenda M. Briones, MD2, Andrew Han, MD3. A0107 - A Colon Mass: Don't Always Believe What You See, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
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