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CASE REPORT Table of Contents   
Year : 2007  |  Volume : 13  |  Issue : 4  |  Page : 194-196
Perforated diverticulum of the transverse colon


1 Department of Surgery, NKP Salve Institute of Medical Sciences and Research Centre, Digdoh Hills, Hingna, Nagpur, India
2 Department of Pathology, NKP Salve Institute of Medical Sciences and Research Centre, Digdoh Hills, Hingna, Nagpur, India

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Date of Submission05-Feb-2007
Date of Acceptance07-Apr-2007
 

   Abstract 

Diverticula on the left side of the colon, especially in the sigmoid colon are a common occurrence in the West. However, right-sided diverticula are less common, being reported from Asian countries like China, Hong Kong, Japan, Singapore and India. Diverticula of the transverse colon are very rare with very few cases reported in literature. We report a case of perforated true diverticulum of the transverse colon in a sixty-two year-old lady.

Keywords: Perforation, transverse colon, true diverticulum

How to cite this article:
Wilkinson TR, Wilkinson AR. Perforated diverticulum of the transverse colon. Saudi J Gastroenterol 2007;13:194-6

How to cite this URL:
Wilkinson TR, Wilkinson AR. Perforated diverticulum of the transverse colon. Saudi J Gastroenterol [serial online] 2007 [cited 2019 May 25];13:194-6. Available from: http://www.saudijgastro.com/text.asp?2007/13/4/194/36753


Diverticular disease usually involves the left side of the colon in patients from Western countries, whereas the right side of the colon is involved more frequently in patients from Eastern countries. [1],[2] Diverticulitis of the transverse colon is very rare with very few cases reported in English medical literature. [3],[4],[5] Rarely, these diverticula of the transverse colon may perforate. [5],[6] The cause of diverticula at this site is unclear and their clinical presentation resembles that of right-sided diverticula. [6]


   Case Report Top


A sixty-two year-old lady presented with complaints of severe pain in the epigastrium and vomiting of one day's duration. She was a known case of hypertension and ischemic heart disease. There was no history of chronic constipation, melena, acid peptic disease or intake of nonsteroidal, antiinflammatory drugs.

Examination showed that she had a blood pressure of 160/100 mm Hg and a pulse rate of 110/min. The abdomen had marked tenderness all over with a board-like rigidity. Baseline investigations: Haemoglobin: 12 g/dL, total leukocyte count: 14,000/mm 3 , differential leukocyte count: neutrophils: 80%, lymphocytes: 16%, monocytes: 2%, eosinophils: 2%.

Plain X-ray of the abdomen showed air under the diaphragm (pneumoperitoneum). The chest X-ray was normal. Ultrasonography of the abdomen showed free fluid in the abdomen. Based on the history and investigations, a clinical diagnosis of hollow viscus perforation was made and she was taken up for exploratory laparotomy under general anesthesia after stabilizing her blood pressure.

Minimal pus was present intraoperatively in the paracolic gutters. The omentum was found to be adherent to the transverse colon, which on separation revealed a diverticulum in the midportion of the transverse colon with perforation at the tip [Figure - 1]. Inspection of the entire length of the colon did not reveal any other visible diverticula or area of thickening.

The rest of the abdominal viscera were normal. Since the base of the single diverticulum was healthy, a wedge-shaped incision was made at the base of the diverticulum and the diverticulum was excised. The defect in the transverse colon was closed with silk sutures. After a thorough peritoneal lavage, the abdomen was closed in layers. A postoperative diagnosis of a perforated diverticulum of the transverse colon was made.

Gross examination of the resected specimen showed a diverticulum measuring 4.5 x 3.5 x 2.5 cm in size with the presence of faecolith in the lumen.

Microscopically, it showed all four layers of the intestine namely colonic mucosa, submucosa [Figure - 2], muscle layer and serosa. Chronic inflammatory infiltrate composed of lymphocytes and histiocytes was seen in the wall. A histopathological diagnosis of true diverticulum of the colon with diverticulitis was given. The patient had an uneventful postoperative period and is being followed up in the outpatient department. No further investigations were done and she remains asymptomatic.


   Discussion Top


Diverticula of the colon are mostly pseudodiverticula, although true diverticula [demonstrating all the four layers of the intestine] have been described. Giant colonic diverticula are large diverticula, 4 cm in size or larger. [7] When inflammation occurs in a diverticulum, it is called diverticulitis. Diverticula may be asymptomatic or may cause symptoms like abdominal pain, fever or altered bowel habits. High fiber diet and antibiotics can help in treating uncomplicated cases, whereas surgical intervention is required for complications like abscess formation and perforation. The clinical presentations of transverse colon diverticula resemble that of right-sided diverticula.

Diverticula are common in the sigmoid colon. Right-sided colonic diverticula are less common and mostly seen in the caecum and ascending colon. Very few cases of transverse colon diverticula have been reported [3],[5] and presentation with perforation is extremely rare. [5],[6] Transverse colon diverticula are mostly seen in adulthood with a rare case being reported in a thirteen year-old girl. [3]

Preoperatively, right-sided colonic diverticula may be sometimes confused with acute appendicitis. [6] A plain X-ray of the abdomen is useful in demonstrating giant colonic diverticula and pneumoperitoneum. [7] However, CT scans are the most useful in the diagnosis of colonic diverticula. [4],[8]

Intraoperatively, diverticula may be confused with carcinoma of the colon. [9] A case of transverse colon diverticulitis lodged in an incarcerated inguinal hernia has also been reported. [10]

Diverticular disease of the colon is more common in the West due to a low fiber diet, which causes constipation and increased intraluminal pressure in the bowel. A lower frequency of colonic diverticular disease is seen in the Indian subcontinent. [11] However, in developing countries, the lower frequency of diverticular disease is also attributed to underdiagnosis and hence, patients are more likely to present with complications. [12]

There is a 2% incidence of carcinoma reported in cases of giant colonic diverticula. [7] Hence, it is important to diagnose and treat diverticular disease promptly, to minimize complications like obstruction, abscess or fistula formation or free perforation.

Surgical treatment options for diverticular disease are variable depending on the presentation of the patient. Diverticulectomy or colectomy is done depending on the intraoperative findings. Management of perforated diverticulitis by laparoscopic lavage has also been reported. [13] However, we personally do not have any experience on this technique for the management of perforated diverticulitis.

A literature search of Medline databases revealed only 36 cases of transverse colon diverticula, thus demonstrating that this is a rare occurrence. Our case is even more significant in that this rare site of diverticular disease presented with a complication, which in itself is also rare.


   Acknowledgment Top


We thank Dr Lalit Lad, Consultant Pathologist, Nagpur for providing us the histopathology slides of this patient.

 
   References Top

1.Shyung LR, Lin SC, Shih SC, Kao CR, Chou SY. Decision making in right sided diverticulitis. World J Gastroenterol 2003;9:606-8.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Nakada I, Ubukata H, Goto Y, Watanabe Y, Sato S, Tabuchi T, et al. Diverticular disease of the colon at a regional general hospital in Japan. Dis Colon Rectum 1995;38:755-9.  Back to cited text no. 2  [PUBMED]  
3.Wilkinson S. Acute solitary diverticulitis of the transverse colon in a child. Report of a case. Dis Colon Rectum 1988;31:574-6.  Back to cited text no. 3    
4.Jasper DR, Weinstock LB, Balfe DM, Heiken J, Lyss CA, Silvermintz SD. Transverse colon diverticulitis: Successful nonoperative management in four patients. Report of four cases. Dis Colon Rectum 1999;42:955-8.  Back to cited text no. 4    
5.Yamamoto M, Okamura T, Tomokawa M, Kido Y, Shiraishu M, Kimura T et al. Perforated diverticulum of the transverse colon. Am J Gastroenterol 1997;92:1567-9.  Back to cited text no. 5    
6.McClure ET, Welch JP. Acute diverticulitis of the transverse colon with perforation: Report of three cases and review of the literature. Arch Surg 1979;114:1068-71.  Back to cited text no. 6  [PUBMED]  
7.Steenvoorde P, Vogelaar FJ, Oskam J, Tollenaar R. Giant Colonic Diverticula. Review of diagnostic and therapeutic options. Dig Surg 2004;21:1-6.  Back to cited text no. 7    
8.Strouk Perforation of a solitary diverticulum of the transverse colon. Contribution of preoperative R, Le Pape Y, Wilhelm JP, Domain B, Caramella JP, Deletang D. X-ray, computed tomography and echography. J Chir (Paris) 1988;125:104-6.  Back to cited text no. 8    
9.Shperber Y, Halavy A, Oland J orda R. Perforated diverticulitis of the transverse colon. Dis Colon Rectum 1986;29:466-8.  Back to cited text no. 9    
10.Yahchouchy-Chouillard EK, Aura TR, Lopez YN, Limot O, Fingerhut AL. Transverse colon diverticulitis simulating inguinal hernia strangulation: A first report. Dig Surg 2002;19:408-9.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Kang JY, Dhar A, Pollok R, Leicester RJ, Bensen MJ, Kumar D, et al. Diverticular disease of the colon: Ethnic differences in frequency. Aliment Pharmacol Ther 2004;19:765-9.  Back to cited text no. 11    
12.Kakodkar R, Gupta S, Nundy S Complicated colonic diverticulosis: Surgical perspective from an Indian Centre. Trop Gastroenterol 2005;26:152-5.  Back to cited text no. 12    
13.Taylor CJ, Layanai L, Ghusn MA, White SI. Perforated diverticulitis managed by laparoscopic lavage. ANZ J Surg 2006;76:962-5.  Back to cited text no. 13    

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Correspondence Address:
Triloksingh R.V Wilkinson
37, Chitnavis Layout, Byramji Town, Nagpur - 440 013, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.36753

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    Figures

  [Figure - 1], [Figure - 2]

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