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Resumen La enfermedad diverticular es la patología benigna más frecuente del colon. Se considera una entidad crónica con una variedad en su sintomatología abdominal cuya principal manifestación es la diverticulitis. Su prevalencia ha aumentado de forma significativa en los países occidentales en las últimas décadas y con ello el número de hospitalizaciones y valoraciones quirúrgicas, ya que pueden desembocar en complicaciones como la hemorragia, el absceso, la obstrucción y la perforación intestinal. La forma más frecuente de presentación es la diverticulitis sigmoidea en un contexto inmunológico normal, cuyas guías terapéuticas están bien definidas diferenciando entre diverticulitis complicadas y no complicadas. Sin embargo el propósito de este artículo es la revisión de todas aquellas diverticulitis menos usuales que pueden considerarse circunstancias especiales y en cuyo tratamiento no existe un protocolo tan establecido. Estas circunstancias serían la enfermedad multifocal, el divertículo colónico gigante, la diverticulitis del lado derecho y por último la diverticulitis en pacientes con inmunosupresión.

Cases of diverticulosis of the colon continue to increase, especially in the Western countries. In these countries, two-thirds of the population older than 70 years of age are considered to experience this disease. Medical and surgical treatment for diverticulosis actually begun for the complications of diverticulitis and lower gastrointestinal hemorrhage. The first evaluation of complicated diverticular disease is based on patient’s history, physical examination, and laboratory data. But all these exams and data can be inaccurate and are often questionable in the diagnoses of many features of the disease. To describe the position, severity, and presence of complications of a detected diverticulum is crucial to its appropriate treatment. The greater part of the patients have mild disease and can be successfully cured medically. Only a small number of patients admit with acute diverticulitis and need urgent surgical intervention. Determining these patients early is crucial to morbidity and mortality reduction. Radiologic examination is important for exact evaluation of the extent of the course of the disease over the last three decades. This article aims to chart the place of the Computed Tomography (CT) imaging procedure in the assessment of acute complicated diverticular disease.

Background: Although duodenal diverticula are associated with less frequent pathology than the colonic diverticula in the large intestine, their periampullary position may have significant clinical implications. The aim of the study was to identify any possible correlation between the type of localisation of the major duodenal papilla, duodenal diverticula, and some particular clinical issues. Materials and methods: In total, 628 patients (408 females and 220 males; aged 21–91 years), who underwent endoscopic retrograde cholangiopancreatography were included in this study. The patients were divided into two groups: a study group comprising 66 (10.5%) patients with periampullary position of diverticula (group A), and a control group comprising 562 (89.5%) patients without diverticula (group B). Results: A duodenal diverticulum was diagnosed in the periampullary position in 66/628 (10.5%) patients: 41 women (aged 52–91 years) and 25 men (aged 54–83 years). Conclusions: Three types of localisation were observed for the major duodenal papilla with regard to the diverticula, with the most common type being next to each other (type III). In patients with diverticula, similar frequencies of gallstone occurrence are observed in men and women. Patients with papilla in the diverticulum who underwent cholecystectomy are more prone to develop lithiasis.

BACKGROUND Fecal impaction is defined as a large mass of compacted feces in the colon and has the potential to induce a serious medical condition in elderly individuals. Fecal impaction is generally preventable, and early recognition of the typical radiological findings is important for making an early diagnosis. The factors that lead to fecal impaction are usually similar to those causing constipation. Few cases with fecal impaction associated with a diverticulum have been reported. CASE SUMMARY We present the case of a 62-year-old woman who suffered from abdominal pain and vomiting, had a medical history of repeated acute abdomen and was diagnosed with fecal impaction in the descending colon based on X-ray and computed tomography (CT) imaging. After examination by gastrografin-enhanced colonography following colonoscopy and CT colonography, the fecalith was suspected to have been produced at the site of a large diverticulum in the transverse colon. The fecalith was surgically resected, and a histological diagnosis of pseudodiverticulum was made. There was no recurrence during 33 mo of follow-up. CONCLUSION This case highlights the importance of accurate identification and treatment of a fecal impaction. This case indicated that the endoscopic evacuation and subsequent colonography were effective for identifying a diverticulum that might have caused fecal impaction. A fecal impaction was associated with the diverticulum. Consequently, the planned diverticulectomy was performed. Appropriate emergency medical treatment and maintenance treatments should be selected in such cases to prevent recurrence.

Superficial colonic neoplasms sometimes extend into a diverticulum. Conventional endoscopic mucosal resection of these lesions is considered challenging because colonic diverticula do not have a muscularis propria and are deeply inverted. Even if the solution is carefully injected below the mucosa at the bottom of the diverticulum, the mucosa is rarely elevated from the diverticular orifice, and it is usually just narrowed. Although endoscopic submucosal dissection or full-thickness resection with an over-the-scope clip device enables the complete resection of these lesions, it is still challenging, time consuming and expensive. Underwater endoscopic mucosal resection without submucosal injection (UEMR) is an innovative technique enabling en bloc resection of superficial colon lesions. We report three patients with colon adenomas extending into a diverticulum treated with successful UEMR. UEMR enabled rapid and safe en bloc resection of colon lesions extending into a diverticulum.

Video Video 1 Endoscopic clipping with polyglycolic acid sheets for colonic diverticulum bleeding.

Video Video 1 Successful endoscopic submucosal dissection for a tumor completely located within a colonic diverticulum after inversion of the diverticulum using a traction device. After reconfirming that the diverticulum could be inverted into the lumen with forceps, the first endoclip grasping a ring-thread made of dental floss was fixed on the mucosa in the diverticulum. Immediately afterward, a second endoclip was used to grasp the ring-thread and fix it to the opposite colonic wall. By insufflating with air, the lesion within the inverted diverticulum was pulled out of the diverticulum into the colonic lumen, establishing a good field of view for dissection. After local injection of hyaluronic acid, a circumferential incision and dissection were performed using a DualKnife, and the lesion was promptly removed en bloc. The wound was completely closed with endoclips, along with the diverticulum. The total procedure time was 10 minutes, and there were no adverse events.

Colonic diverticulosis is pervasive in Western society, with over half of individuals over the age of 60 carrying the diagnosis. A Giant Colonic Diverticulum (GCD) is a rare presentation of diverticulosis, involving one or more colonic diverticula that measure 4 cm or greater. Less than 200 reports of GCD have been published in the literature. Almost all GCD patients present with symptoms, with abdominal pain being the most common. Diagnosis is usually made with CT imaging and recommended treatment is segmental colectomy. We present an atypical case of GCD with an asymptomatic presentation, initial diagnosis made during endoscopy and a minimally invasive resection of multiple GCD within the same patient.

A man in his 40's was admitted to the general surgery ward with multiple episodes of large amounts of painless bright red per rectal (PR) bleeding and passage of clots. Urgent outpatient colonoscopy revealed a diverticulum which was associated with a wide diameter blood vessel originating from its base which was not actively bleeding. The clinical picture presented by the colonoscopy is one of the first to clearly identify large caliber blood vessels emerging from a colonic diverticulum.

Constipation has been considered the key risk factor for diverticulosis occurrence, but the underlying mechanism is unclear. We investigated the factors associated with diverticulosis, focusing on the association of constipation severity with the localization and number of diverticula.We analyzed consecutive patients who underwent colonoscopy between March and December 2019. Chronic constipation was diagnosed as constipation meeting Rome IV criteria or as that requiring laxative therapy for more than 6 months. The degree of constipation was scored using the Constipation Scoring System (CSS).We assessed 1014 patients. Multivariate analysis revealed that age, alcohol consumption, and hypertension were positively associated with diverticulosis, whereas chronic constipation was negatively associated with diverticulosis (odds ratio [OR] = 0.74; 95% confidence interval [CI], 0.55-0.99). When assessed according to the location of diverticula, right-sided diverticula were significantly associated with a lower incidence of constipation (OR = 0.94; 95% CI, 0.89-0.98), whereas neither left-sided nor bilateral diverticula was associated with constipation. This negative association of diverticula with constipation was stronger in patients with a high CSS score. In stratified analysis, the number of diverticula decreased with increasing degree of constipation (Chronic constipation was negatively associated with colonic diverticulosis. The association increased with the degree of constipation and was strong only in cases with right-sided diverticula and those with ≥3 diverticula.

Mature cystic teratoma is the most common form of ovarian germ cell tumor. Mature cystic teratoma is a benign tumor, mainly diagnosed in young women, with non-specific symptoms. However, the risk of malignant transformation exists (1-2%). Squamous cell carcinoma is the most frequently encountered histological form. Giant colonic diverticulum is a rare complication of diverticular disease, characterized by a diverticulum larger than 4 cm which can sometimes be confused with other digestive pathologies (appendicitis, small bowel perforation ...). We report a case of an ovarian squamous cell carcinoma arising from a mature cystic teratoma, presenting like a sigmoid fistula, with an initial doubt with the diagnosis of a giant colonic diverticulum. A 68-year-old woman was admitted for chronic hypogastric abdominal pain with a doubt concerning the diagnosis between a mature cystic teratoma and a giant colonic diverticulum. A computed tomography scan was performed revealing a perisigmoid cyst with hydro-aeric level in favor of a giant colonic diverticulum. The pelvic MRI rather suggested a left ovarian cyst, fistulated in the sigmoid colon. Finally, the colonoscopy confirmed this hypothesis with the visualization of a sigmoid fistula located 15cm from the anal margin in connection with a cavity containing hairs. Biopsies revealed a squamous cell carcinoma. After a negative extension assessment, a posterior pelvectomy was performed with pelvic and lumbo-aortic lymph node dissection. The pathological diagnosis was an ovarian pT4N1R0 squamous cell carcinoma. An adjuvant chemotherapy is still in progress.

Aims: To demonstrate the prevalence, accompanying pathologies, imaging and follow up findings of Duodenal Diverticula (DD) with Multidetector Computed Tomography (MDCT). Materials and Methods: Consecutive 2910 abdominal MDCTs were retrospectively reviewed on axial, coronal and sagittal planes. DD were evaluated for prevalence, location, number, size, contents, diverticular neck, accompanying pancreaticobiliary pathologies, jejunal and colonic diverticula, respectively. Results: DD were diagnosed in 157 cases (5.4%) and found mostly in the second part of the duodenum. Juxta-ampullary DD was the most common type (78.3%) and mostly located ventral (n:86, 69.9%) to the ampulla of Vater. DD was solitary in 123 patients (78.3%) and more than one in 34 patients (21.7%). The median diameter of DD was 2.5 cm (range 1.5-3.6 cm) in the long-axis. The lumen of DD contains air and contrast agent (n:96, 61.1%); air, contrast agent and debris (n:42, 26.7%) in most cases. Colonic diverticula (n:36, 22.9%), cholelithiasis (n:32, 20.4%), choledocholithiasis (n:7, 4.4%), and biliary dilatation (n:8, 5.1%) were the most common additional findings. Median follow-up time was 23 months (range 11 to 41 months). In three cases, new findings (cholelithiasis, n:3, choledocholithiasis, n:1) were detected. Conclusion: Accompanying pathologies with DD diagnosis are valuable for physicians in order to manage the patients. Following clinical and radiological features of well-diagnosed DD might reduce the possible complications.

Purpose: To evaluate the effectiveness of a therapeutic barium enema as a treatment for colonic diverticulum bleeding, by using a standard concentration as a diagnostic examination. Methods: We retrospectively analyzed 68 cases of the patients admitted to our hospital with colonic diverticular bleeding between October 2012 and September 2017. We evaluated the following items: (1) the presence/absence of a previous history of diverticular bleeding, (2) the use of medications (anticoagulants, nonsteroidal anti-inflammatory drugs, and antiplatelet drugs), (3) the location of bleeding, (4) the presence/absence of previous treatment and the result, (5) the time between bleeding and the beginning of the barium enema, (6) procedural success, (7) the clinical success of the initial hemostasis, (8) the clinical success of preventing recurrence, and (9) complications such as perforation and diverticulitis associated with this procedure. Results: Four patients (three men and one woman; age range 60–85 years; median age 76 years) who underwent therapeutic barium enema with a concentration equivalent for diagnostic purpose (78 w/v%) were included. The follow-up period ranged from 11 to 12 months (median 12 months). All three patients who received a barium enema for initial hemostasis were successfully treated. All four patients remained free from recurrence during the follow-up period. There was no complication due to barium in this series. Conclusion: Although we had no statistical evidence, a therapeutic barium enema with a standard concentration as a diagnostic examination may be effective for both the initial hemostasis and preventing the recurrence of colonic diverticular bleeding without complications. Keywords: Barium enema, Gastrointestinal tract, Bleeding, Diverticulum

BACKGROUND Computed tomography colonography (CTC) may be superior to colonoscopy and barium enema for detecting diverticula. However, few studies have used CTC to diagnose diverticula. AIM To evaluate the current prevalence and distribution of colonic diverticula in Japan using CTC. METHODS This study was conducted as part of the Japanese National Computed Tomographic Colonography Trial, which included 1181 participants from 14 hospitals in Japan. We analyzed the prevalence and distribution of colonic diverticula and their relationships with age and sex. The relationship between the diverticula and the length of the large intestine was also analyzed. RESULTS Diverticulosis was present in 48.1% of the participants. The prevalence of diverticulosis was higher in the older participants (P < 0.001 for trend). The diverticula seen in younger participants were predominantly located in the right-sided colon. Older participants had a higher frequency of bilateral type (located in the right- and left-sided colon) diverticulosis (P < 0.001 for trend). The length of the large intestine with multiple diverticula in the sigmoid colon was significantly shorter in those without diverticula (P < 0.001). CONCLUSION The prevalence of colonic diverticulosis in Japan is higher than that previously reported. The prevalence was higher, and the distribution tended to be bilateral in older participants.

Colonic diverticula are outpouchings of mucosa and submucosa through the large intestine wall. Inverted colonic diverticula can be confused with colonic adenoma. It is important to differentiate them. Here we report two cases of inverted diverticula that seem to like adenomas.

The objectives of the current case report are to describe and report the diagnostics and surgical treatment of colonic diverticulum in a dog. A 13-year-old intact male Labrador retriever, suffering from the inability to defecate for 10 days, was diagnosed with a mass between the colon and the urinary bladder, filled with faeces. The diagnosis of a colonic diverticulum was obtained using plain abdominal radiography, ultrasonography, cystography and irigography. Native and contrast abdominal radiography and ultrasonography detected an abdominal mass with a diameter of 9 cm, filled with faeces, connected to the descending colon, and an enlarged prostatic gland. The dog was treated surgically with orchiectomy, exploratory celiotomy, partial resection of the colonic diverticulum wall, followed by reconstruction of the colon using the wall of the colonic diverticulum as a flap. The dog defecated 24 hours after surgery. On the 5th postoperative day, a wound infection was observed (redness, serous discharge from the ventral midline wound). The functional outcome was satisfactory. To the best of our knowledge, such a case report has not been reported before., Cilj rada bio je prikazati dijagnostiku i kirurško liječenje divertikula debelog crijeva u psa. Mužjak u dobi od 13 godina pasmine labrador retriver, tijekom 10 dana nije mogao defecirati. Psu je dijagnosticirana tvorba između kolona i mokraćnog mjehura, ispunjena fecesom. Abdominalnom radiografijom, ultrazvukom, cistografijom i irigografijom postavljena je dijagnoza divertikula kolona. Nativna i kontrastna abdominalna radiografija i ultrazvuk otkrili su abdominalnu masu promjera 9 cm, ispunjenu fecesom i povezanu sa silaznim kolonom, kao i uvećanu prostatu. U psa je učinjena orhiektomija, eksploratorna celiotomija i parcijalna resekcija stijenke divertikula kolona, te rekonstrukcija debelog crijeva, upotrebom stijenke crijevnog divertikula kao preklopa. Nakon 24 sata pas je defecirao. Petog dana poslije kirurškog zahvata primijećena je infekcija rane (crvenilo, serozni iscjedak iz ventralnog srednjeg dijela rane). Funkcionalni ishod bio je zadovoljavajući. Prema nama dostupnim podacima ovakav slučaj dosad nije prikazan.

Giant colonic diverticulum, defined as a single diverticulum ≤ 4cm, is rarely encountered. Due to the high incidence of complications related to the disease, obtaining the correct diagnosis early in the disease course is essential. Diagnosis is usually reached by conventional and cross-sectional abdominal radiography. Treatment decisions should be ideally made by a multidisciplinary discussion among surgeons, interventional radiologists, and the patient. The treatment of choice is the surgical management by open or laparoscopic approach.

Objective The assessment of colonic diverticula with colon capsule endoscopy (CCE) in a Japanese population provided unclear results. In this study, we retrospectively reviewed a cohort of Japanese patients who had undergone CCE to assess its safety and usefulness in the diagnosis of colonic diverticula. Methods In this study, 175 consecutive Japanese patients who had their entire colon observed via CCE from November 2013 to July 2018 were included. Patients were retrospectively stratified according to age, gender, colonic segment, and symptoms involvement. A multivariable regression analysis was performed to investigate the presence of any correlation among variables. The safety of CCE was assessed in terms of the incidence of adverse events (AEs). Results Colonic diverticula were observed in 42.3% of all cases; of those; 36.5% were right-sided, 31.1% were left-sided, and 32.4% were bilateral. Moreover, one to two colonic diverticula were observed in 35.1%, while three or more diverticula were seen in 64.9%. Multivariable analysis showed that age (≥70 years) was positively associated with colonic diverticula, while male gender and the presence of colonic polyps were negatively associated with colonic diverticula. No correlation was found between colonic diverticula and symptoms. There was no significant difference between groups with and without colonic diverticula in the incidence of AEs. AEs were mild in severity, with no severe AE-related bowel preparation and capsule ingestion reported. Conclusion CCE was well-tolerated by the participants, and the incidence of colonic diverticula was 42.3%, with one to two and three or more diverticula being found in 35.1% and 64.9%, respectively. There was little difference in the frequency of colonic diverticula formation on the right side, left side, and on both sides. Age was a positive association factor, while male gender and the presence of colorectal polyps were negative association factors. No correlation was found between diverticula and symptoms.

Diverticulosis involving the entire colon is rare in Western society. During a routine dissection of a 74-year-old Caucasian female cadaver, who died from vascular disease complications, diverticula were observed in the ascending, transverse, and descending colon. A total of 413 diverticula were manually counted. The majority of diverticula arose from the right and transverse colon, which is atypical of the disease in Western society. Histological examination of sections from sample diverticula reveals morphology consistent with pseudodiverticula, suggestive of acquired disease. Pancolonic diverticulosis may be associated with systemic diseases such as collagen disorders, vascular complications, and increased risk of recurrent diverticulitis. This case is an example of a rare manifestation of diverticular disease that is important for clinicians to recognize when evaluating and treating patients with gastrointestinal symptoms.

Introduction: Most lung transplant patients are older than 50 years. Complications from colonic diverticula are not uncommon, especially with chronic immunosuppression. However, limited data exist regarding the optimal management of these patients. We sought to investigate the incidence, risk factors, and outcomes of diverticulitis after lung transplant. Methods: We conducted a retrospective study to review patients undergoing lung transplant between 2007 and 2016 with posttransplant acute colonic diverticulitis. Patients were grouped based on medical or surgical management. Results: Of 512 transplant recipients, 17 (3.32%) developed 26 episodes of diverticulitis over a median follow-up of 39 months. Nine patients had documented diverticulosis on pretransplant colonoscopy. These patients had a higher incidence of surgical intervention for diverticulitis, were more likely to have recurrent diverticulitis, and had longer lengths of stay than patients without pretransplant diverticulosis. Six (35.3%) of 17 patients required surgery (ie, Hartmann procedure; 4 during the initial episode and 2 during their third and fourth episodes); 11 patients (64.7%) were managed with antibiotics alone. Patients in the surgical group presented earlier posttransplant ( P = .004) and were on higher doses of tacrolimus ( P = .03). Six (46.1%) of 13 patients with medically managed first episodes of diverticulitis experienced recurrence. No recurrence occurred after surgical management. No deaths were attributable to diverticulitis in either group. Conclusions: Patients with pretransplant diverticulosis experienced earlier, more complicated episodes of diverticulitis posttransplant than patients without. Surgical patients received higher doses of tacrolimus and presented earlier than medical patients. Uncomplicated diverticulitis in posttransplant patients can be managed medically, even in the case of recurrent, uncomplicated disease.

Adenomas or adenocarcinomas located within a colonic diverticulum are considered a rare phenomenon that has been described in the literature. These lesions are technically difficult to manage endoscopically and usually require surgical intervention for removal. There is also an increased risk of perforation upon endoscopic resection owing to the lack of a muscular layer within the diverticulum. We report a case and include a literature review to evaluate different endoscopic techniques and propose the most effective for management of adenomas within a diverticulum. This technique is potentially comprised of employing a combined approach using a suction banding device, an over-the-scope clip (OTSC; Ovesco Endoscopy AG, Tübingen, Germany) , and hyperthemic snare to successfully remove the polyp, ensure tissue retrieval, and reduce risk of iatrogenic colonic perforation.

Background and study aims Unsatisfactory detectability of a previously bleeding diverticulum by colonoscopy results from difficulty in precisely locating the target lesion, even with presence of an extravasation on contrast-enhanced computed tomography (CECT). This study aimed to evaluate the usefulness of the step-clipping method to overcome this limitation. Patients and methods Step-clipping was indicated for patients with colonic diverticular bleeding and presence of extravasation on CECT, but with absence of active bleeding on subsequent colonoscopy. The target diverticulum was identified by comparing computed tomography images before and after step clipping, which provided a positional relationship between each clip and the target lesion. Results Based on data from 21 consecutive cases meeting our inclusion criteria (14 men and 7 women; mean age, 73.2 years), the target diverticulum was endoscopically identified in 20 cases (95 %), in a median time of 5 minutes, and successfully treated. No adverse events were observed with the step-clipping method. Conclusion Step-clipping provided easy guidance to the target site for treatment in a short time, despite spontaneous cessation of bleeding at the diverticulum.