British Journal of Radiology (2007) 80, e201-e204
© 2007 British Institute of Radiology
doi: 10.1259/bjr/23274345
Complicated giant diverticulum of the transverse colon accompanied by right inguinal hernia of the greater omentum
S E Yoon, MD
1
Y-H Lee, MD
1
K-H Yoon, MD
1
E-A Kim, MD
1
S S Choi, MD
1
S K Juhng, MD
1
K J Yun, MD
2 and
W C Park, MD
3
Departments of 1 Radiology, 2 Pathology and 3 Surgery, Wonkwang University School of Medicine, 344-2 Sinyong-dong, Iksan, Jeonbuk 570-711, Korea
Correspondence: Seong Eon Yoon, Department of Radiology, Wonkwang University School of Medicine, 344-2 Sinyong-dong, Iksan, Jeonbuk 570-711, Korea. E-mail: radiology{at}paran.com
 |
Abstract
|
|---|
Giant colonic diverticulum is a very rare entity in colonic diverticular disease and is characterized by a high rate of complications such as perforation, abscess formation and even carcinoma. We report a case of a complicated giant diverticulum of the transverse colon accompanied by a right inguinal hernia of the greater omentum in a 52-year-old man, as demonstrated on CT.
|
Introduction
|
|---|
A 52-year-old man presented to our emergency department with increasing periumbilical pain of 3 h duration. Physical examination showed a tender mass in the right groin of 20 cm maximum dimension. The patient had a 10 year history of an intermittent right inguinal hernia with self-manual reduction. His vital signs were stable and the laboratory findings were non-specific.
Abdominal radiography showed increased opacity in the right inguinal area, which was presumed to be an inguinal hernia. A downward displacement of the transverse colon with a large faeces-filled cavity was noted in the mid-portion of the pelvic cavity, which suggested that the transverse colon was not herniated through the right inguinal canal (Figure 1
). The right groin mass was treated by manual reduction. Even after manual reduction of the right groin mass, the patient's periumblical pain continued to accelerate.
View larger version (136K):
[in this window]
[in a new window]
|
Figure 1. Abdominal radiograph shows increased opacity in the right inguinal area(open arrows) and a downward displacement of the transverse colon (arrows) with a faeces-filled giant diverticulum (arrowheads) in the mid-portion of the pelvic cavity.
|
|
He eventually underwent CT, which revealed a bulky greater omentum lying just above the right inguinal canal (Figure 2a). We assessed that the initial right groin mass before reduction contained only the greater omentum. The CT scan showed a faeces-filled giant diverticulum of the transverse colon with contrast enhancement of the diverticular wall and haemorrhagic strands with engorged middle colic vessels adjacent to the diverticulum (Figure 2b). An oblique coronal multiplanar reformatted CT scan showed a downward displacement of the transverse colon with the giant diverticulum and a stretched, engorged middle colic vessel along the transverse mesocolon (Figure 3). Finally, we concluded that the patient had a complicated giant diverticulum of the transverse colon accompanied by a right inguinal hernia of the greater omentum.
View larger version (57K):
[in this window]
[in a new window]
|
Figure 2. (a) Contrast-enhanced axial CT scan depicts a bulky greater omentum occupying the right anterior pelvic cavity (asterisk). (b) CT shows a contrast enhancement of the wall of the giant colonic diverticulum (GCD; arrowhead). Note the communication between the GCD and the transverse colonic lumen. Also, haemorrhagic strands are seen adjacent to the GCD (arrow).
|
|
View larger version (159K):
[in this window]
[in a new window]
|
Figure 3. Oblique coronal multiplanar reformatted CT scan demonstrates a downward displacement of the transverse colon(thin arrows) with giant colonic diverticulum (thick arrows) and the stretched, engorged middle colic vessel (GCD; arrowhead) in the transverse mesocolon. Note a bulky greater omentum (asterisks) lying just above the right inguinal canal (open arrowhead), lateral to the inferior epigastric vessel.
|
|
Laparoscopic surgery revealed a large, paper-thin diverticulum on the mesenteric side of the transverse colon. Segmental resection of the transverse colon with the large diverticulum was carried out. The resected specimen was a 6x4 cm diverticulum on the mesenteric border of the transverse colon (Figure 4a). Microscopic examination revealed that the giant colonic diverticulum (GCD) contained all four layers of normal bowel wall, i.e. mucosa, submucosa, muscularis and serosa, as well as transmural infiltration of inflammatory cells through the wall of the GCD (Figure 4b). Histopathologically, an incarcerated, inflammatory giant true diverticulum of the transverse colon was diagnosed. The patient was discharged 1 week after surgery without having experienced any complications.
View larger version (72K):
[in this window]
[in a new window]
|
Figure 4. (a) The resected specimen shows a 6x4 cm giant diverticulum on the mesenteric side of the transverse colon. Note the iatrogenic perforation of the giant colonic diverticulum (GCD), which occurred during the laparoscopic surgery. (b) Microscopic examination (x100, haematoxylin and eosin stain) reveals transmural infiltration of inflammatory cells through the true GCD wall, which contains all four colonic layers.
|
|
|
Discussion
|
|---|
GCD, defined as a diverticulum larger than 4 cm in maximum dimension, is a rare condition in colonic diverticular disease [1, 2]. Since Hughes and Greene [3] first described a "solitary air cyst" in the literature it has been referred to by several names, e.g. "giant air cyst" and "giant cyst", but the recent preference is for the term GCD [2]. To date, 136 cases of GCD have been reported in the literature and more than 90% of reported GCDs have been encountered in the sigmoid colon [2, 4]. Our research of the literature reveals only two case reports of GCD found in the transverse colon [5, 6]. These two cases were diagnosed by barium enema, which was not accompanied by any complications. We believe that our case is the first complicated GCD of the transverse colon demonstrated by CT in the literature. In addition, to the best of our knowledge, the coexistence of GCD of the transverse colon and inguinal hernia of the greater omentum has never been reported.
Clinically, most GCDs present during the seventh and eighth decades of life and there is a 60% male predominance. In general, the symptoms include an abdominal mass and vague abdominal pain. Overall, 28% of patients with GCD present with complications including perforation, abscess formation and focal wall infarction; these symptoms are often clinically and preoperatively attributed to more common causes of acute abdomen such as acute appendicitis or acute cholecystitis [2, 7]. Moreover, it has been reported that there is a 2% risk of carcinoma developing inside the diverticulum in GCD. Because of its higher rate of complications, including carcinoma development, GCD should be treated by surgical resection [2].
Pathologically, GCD can be classified into three types: pseudodiverticulum, inflammatory diverticulum and true diverticulum [7, 8]. Pseudodiverticula, which account for 22% of all GCDs, consist of granulation tissue and remnants of muscularis mucosa and muscularis propria. Inflammatory diverticula, which account for 66% of all GCDs, consist of granulation tissue arising from a local perforation of the mucosa and communicating with an abscess cavity. True diverticula, which account for 12% of all GCDs, contain all layers of the colon. The pathogenesis of a true diverticulum has been suggested to be congenital. Our patient had a true diverticulum, which suggests that the GCD had been present for a long time before symptom development. The two previously reported giant diverticula of the transverse colon were a pseudodiverticulum and an inflammatory diverticulum [5, 6]. Therefore, our case may be the first report of a true giant diverticulum of the transverse colon in the literature.
Radiologically, there are several reports describing the CT findings of GCD [9, 10]. The CT scans show a large thin-walled air-containing cavity near the adjacent colon, which may or may not have a communication with the colonic lumen. When acute inflammation of the diverticulum develops, the wall may show contrast enhancement. In our case the CT scans demonstrated a GCD with a contrast-enhanced wall and an opening into the colonic lumen. In our patient it was necessary to differentiate the GCD from a communicating colonic duplication cyst, which primarily affects the younger population and is found near the rectum or the lateral colon but is extremely rare in the transverse colon [11]. Duplication cysts are usually located on the antimesenteric border of the colon and are fusiform in shape and fluid-filled in appearance, whereas GCD has a tendency to be located on the mesenteric or antimesenteric border of the colon and is oval and gas-filled [4, 7].
Interestingly, in our case the CT scans clearly suggest a relationship between the complicated GCD of the transverse colon and the right inguinal hernia of the greater omentum. First, based on the fact that the greater omentum attaches to the transverse colon, the right inguinal hernia of the greater omentum causes a downward displacement of the transverse colon. Next, the downward displacement of the transverse colon stretches the middle colic vessels. Consequently, the stretched, engorged middle colic vessels give rise to ischaemic, haemorrhagic changes of the GCD. We therefore assume that the right inguinal hernia of the greater omentum complicates the GCD of the transverse colon.
In conclusion, we report the first case of a complicated GCD in the transverse colon accompanied by a right inguinal hernia of the greater omentum. CT plays a major role not only in the diagnosis of such a rare GCD and its complications but also in providing an explanation for the relationship between the inguinal hernia of the greater omentum and the complicated GCD.
|
Acknowledgments
|
|---|
The authors thank Bonnie Hami, MA, Department of Radiology, University Hospitals Health System, Cleveland, Ohio, for her editorial assistance in preparing the manuscript. This paper was supported by Wonkwang University 2005.
Revision received February 11, 2006. Revision received April 3, 2006.
Accepted for publication April 21, 2006.
|
References
|
|---|
- Choong CK, Frizelle FA. Giant colonic diverticulum: report of four cases and review of the literature. Dis Colon Rectum 1998;41:1178–85.[CrossRef][Medline]
- Steenvoorde P, Vogelaar FJ, Oskam J, Tollenaar RA. Giant colonic diverticula. Review of diagnostic and therapeutic options. Dig Surg 2004;21:1–6.[CrossRef][Medline]
- Hughes WL, Greene RC. Solitary air cyst of peritoneal cavity. AMA Arch Surg 1953;67:931–6.[Abstract/Free Full Text]
- Altaf N, Geary S, Ahmed I. Giant colonic diverticulum. J R Soc Med 2005;98:169–70.[Free Full Text]
- Sagar S. Giant solitary diverticulum of the transverse colon with diverticulosis. Br J Clin Pract 1973;27:145–6.[Medline]
- Wallers KJ. Giant diverticulum arising from the transverse colon of a patient with diverticulosis. Br J Radiol 1981;54:683–8.[Abstract/Free Full Text]
- Custer TJ, Blevins DV, Vara TM. Giant colonic diverticulum: a rare manifestation of a common disease. J Gastrointest Surg 1999;3:543–8.[CrossRef][Medline]
- McNutt R, Schmitt D, Schulte W. Giant colonic diverticula – three distinct entities. Report of a case. Dis Colon Rectum 1988;31:624–8.[CrossRef][Medline]
- Roger T, Rommens J, Bailly J, Vollont GH, Belva P, Delcour C. Giant colonic diverticulum: presentation of one case and review of the literature. Abdom Imaging 1996;21:530–3.[CrossRef][Medline]
- Grover H, Nair S, Hertan H. Giant true diverticulum of sigmoid colon. Am J Gastroenterol 1998;93:2267–8.[CrossRef][Medline]
- Sugihara S, Fujii S, Kinoshita T, Ogawa T. Giant sigmoid colonic diverticulitis: case report. Abdom Imaging 2003;28:640–2.[CrossRef][Medline]
Top
Abstract
Introduction
