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Colitis cystica profunda (CCP) is a rare, uncommon and nonneoplastic condition that can occur anywhere in gastrointestinal tract, but its main occurrence is in the rectum and sigmoid colon. It is characterized by the presence of mucin filled cysts, lined by benign epithelium, beneath the muscularis mucosae, usually confined to the submucosa, and it can clinically and radiologically mimic a neoplasm. Here we report a rare case of CCP in a patient with a 2-months history of abdominal pain and severe anemia, associated with diverticulosis. The knowledge of this entity and its differential diagnosis, in particular with the intestinal mucinous adenocarcinoma, is necessary, as it can be a clinically and histological mimic of a malignant neoplasm., (Copyright © 2024 Società Italiana di Anatomia Patologica e Citopatologia Diagnostica, Divisione Italiana della International Academy of Pathology.)

Background: Juxta-papillary duodenal diverticula (JPDD) are common but are usually asymptomatic, and they are often diagnosed by coincidence., Objective: To analyse the anatomy and classification of JPDD and its relationship with biliary and pancreatic disorders, and to explore the diagnostic value of multi-slice spiral computed tomography (MSCT) in patients with JPDD., Methods: The imaging data of patients with JPDD, which was obtained via abdominal computed tomography examination and confirmed via gastroscopy and/or upper gastrointestinal barium enema, in our hospital from 1 January 2019 to 31 December 2020 were retrospectively analysed. All patients were scanned using MSCT, and the imaging findings, classification and grading were analysed., Results: A total of 119 duodenal diverticula were detected in 96 patients, including 73 single diverticula and 23 multiple diverticula. The imaging findings were mainly cystic lesions of the inner wall of the duodenum protruding to the outside of the cavity. The thin layer showed a narrow neck connected with the duodenal cavity, and the shape and size of the diverticula were different: 67 central-type cases and 29 peripheral-type cases. There were 50 cases of type I, 33 cases of type II, 19 cases of type III and six cases of type IV. Furthermore, there were seven small, 87 medium and 14 large diverticula. The differences in the location and size of the JPDD in MSCT grading were statistically significant (P< 0.05)., Conclusion: The MSCT method has an important diagnostic value for the classification of JPDD, and MSCT images are helpful in the clinical evaluation of patients with JPDD and the selection of treatment options.

Jejunal diverticulosis is uncommon and so are gastrointestinal stromal tumours (GIST) arising in the jejunum. GIST arising in a jejunal diverticulum is a rarity and to date there are only 7 cases in the English literature. Our case of GIST occurring in a jejunal diverticulum of a 48-year-old lady would be the first reported in Malaysia and the 8th in the world. As in most cases, the clinical presentation and radiological findings of this patient were non-specific. With a history of acute abdominal pain, vomiting and fever, the patient was provisionally diagnosed as a case of twisted ovarian cyst and subjected to laparotomy. An intact roundish jejunal diverticulum 5.0 cm x 5.0 cm, about 50 cm distal to the duodeno-jejunal junction was found and resected with a segment of small intestine. Microscopic examination showed a tumour of the cut open diverticular wall, with epithelioid to spindled cells, demonstrating a mitotic rate of 1-2 per 5 mm2, confined to, while infiltrating the wall of the diverticulum. The immunohistochemical profile of positive staining for CD117, DOG-1, smooth muscle actin and CD34, and negative expression of desmin and S100 protein, clinched the diagnosis of GIST. Based on the AFIP Criteria for risk stratification, 1 the patient was categorised as having moderate risk for disease progression, and was not offered further targeted imatinib as an immediate measure. The patient has remained well at the time of writing i.e. 8 months following excision, and continues on active surveillance by the surgical and oncological teams, with the option of imatinib, should the necessity arise. This case is presented not merely for the sake of documenting its rarity, but as a reminder to stay alert for uncommon conditions in histopathology practice.

Nephrogenic adenoma is a benign epithelial lesion of the genitourinary tract that arises from the reimplantation and proliferation of shed renal tubular cells in areas of urothelial injury and denudation. Fibromyxoid nephrogenic adenoma is a rare variant that consists of compressed spindle-shaped renal epithelial cells in a fibromyxoid background. Only 14 observations of this variant are reported in the literature. We performed a retrospective analysis of fibromyxoid nephrogenic adenomas from 3 large reference centers. We identified 43 lesions in 6 women and 36 men (2 in 1 man) with a median age of 72 years (range, 31 to 94 y). Median lesion size was 0.7 cm (range, 0.2 to 5 cm). Nephrogenic adenomas were in the bladder (n=15), prostate/prostatic urethra (n=14), kidney (n=7), ureter (n=3), penile urethra (n=3), and urethral diverticulum (n=1). One of the kidney lesions developed in an end-stage kidney and radiologically mimicked cancer. Of 37 patients with information, 36 had predisposing conditions including prior biopsy, transurethral resection of bladder tumor, resection, Foley catheter, BCG treatment, urinary stones, (chemo)radiation, or diverticulum. Only 4/37 (10.8%) had a history of prior irradiation. Fifteen lesions had pure fibromyxoid morphology and 28 were admixed classic and fibromyxoid patterns. Three nephrogenic adenomas involved prostatic stroma, 3 renal sinus fat, 2 muscularis propria (1 bladder, 1 renal pelvis), 1 perinephric fat, and 1 corpus spongiosum. Ten fibromyxoid nephrogenic adenomas were intermixed with urothelial carcinoma, 1 with prostate adenocarcinoma, and 1 with malignant melanoma. By immunohistochemistry, PAX8 was positive in all the examined lesions (n=31). Napsin A was negative in all examined fibromyxoid nephrogenic adenomas (n=30). Twenty of them had classic nephrogenic adenoma component which was positive for napsin A. Similar to classic nephrogenic adenoma, fibromyxoid nephrogenic adenoma can occur anywhere along the urinary tract and is associated with a prior history that causes urothelial injury. In nearly a quarter of the cases, fibromyxoid nephrogenic adenoma extended beyond the lamina propria. Unlike previously suggested, fibromyxoid nephrogenic adenoma is not specifically related to prior radiation therapy. Awareness of this variant is important to avoid misdiagnosis and overtreatment., Competing Interests: Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Due to reversal blood flow in the diastolic phase, outpouchings at the aortic isthmus may carry the risk of thrombus formation and subsequent thromboembolism. The objective was to evaluate the association between aortic ductus diverticula (ADDs) and ischemic brain alterations in cerebral magnetic resonance imaging., Methods: A retrospective analysis of 218 patients who received both a dedicated computed tomography angiography of the thoracic aorta and a brain magnetic resonance imaging was performed. Two radiologists independently reviewed all examinations for the presence of ADD as well as ischemic alterations of the brain. The association between this anatomical variant and ischemic brain alterations was evaluated by univariate and bivariate logistic regression analyses., Results: ADDs were identified/present in 35 of 218 patients (16%). Ischemic brain alterations were found in 57% of patients (20/35) with an ADD and in 42% of the control group (77/183, P = 0.1). The presence of an ADD did not prove to be an independent risk factor for ischemic brain alterations after multivariate adjustment (odds ratio = 1.7, 95% confidence interval = 0.72-3.96, P = 0.225)., Conclusions: In the present study, ADDs were not significantly associated with ischemic brain alterations. Therefore, ADDs seem to be an innocent bystander with respect to the pathogenesis of ischemic brain alterations., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Male urethral diverticula with calculi have a low incidence. It is extremely rare when the diverticulum accompanied with carcinoma. We report a case of diverticulum of the male urethra containing giant calculi which developed into squamous cell carcinoma. The patient initially presented with lower urinary tract symptoms and a hard, painless perineal mass. We believe that the process of diagnosis and treatment is of great significance in clinical practice.

Background: Diverticular bleeding is the main cause of lower gastrointestinal bleeding in both Eastern and Western countries. Several risk factors have been identified, such as comorbidities and concomitant medications. In Eastern population, the prevalence of right-side diverticulosis is higher than in Western one, and some Authors identified bilateral diverticulosis as a risk factor for bleeding., Aims: To identify risk factors for diverticular bleeding in patients admitted for diverticular disease (DD)., Methods: All patients admitted for DD from January 2017 to December 2018 were retrieved from the hospital Information System. For each patient, age, gender, clinical presentation and concomitant medication were recorded. All patient underwent imaging assessment (computed tomography, ultrasound or MRI) and colonoscopy during hospitalization or within one month., Results: Among 1248 patients discharged with a diagnosis of DD during the study period, 293 (52.2% male, median age 75 years) were finally analyzed; of them, 105 (35.8%) for diverticular bleeding. On multivariate analysis, male gender (OR 4.27), age (OR 1.12), anti-thrombotic medications (OR 2.60) and right-sided DD (OR 5.70) were independently correlated to diverticular bleeding., Conclusion: Our study provides evidence that, together with age, male gender and concomitant anti-thrombotic treatment, right-sided DD represents an independent risk factor for bleeding., Competing Interests: Declaration of Competing Interest The Authors declare no conflict of interest., (Copyright © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Although uterine fibroids are a common gynecologic neoplasm, uterine diverticulum accompanied by a uterine fibroid is unique. In addition, pregnancy complicated with uterine diverticulum is extremely rare. We experienced a case of a uterine fibroid that was associated with a uterine diverticulum that enlarged during pregnancy and puerperium., Case Presentation: A 25-year-old nulligravida woman had an abnormal uterine cavity surrounded by myomatous mass. After natural conception, the mass and pouch had enlarged during pregnancy. Six months after elective cesarean delivery, she underwent laparotomy because of abdominal pain caused by the myomatous mass and the fluid inside. The tumor was connected to the midline of the posterior wall of the normal uterus. The resected tumor was pathologically diagnosed as leiomyoma and diverticulum., Conclusions: Pregnancy can stimulate uterine fibroids to form uterine diverticula. Resection of the diverticulum and fibroid is a useful option for symptomatic patients with desired future fertility.

To study the influencing factors of scar diverticulum formation and its monitoring methods, 141 people with a history of cesarean section and kidney deficiency and blood stasis were selected as subjects. The transvaginal ultrasound technique was used to divide the case into the scar diverticulum case group and the complete group, and the clinical situation was analyzed. Transvaginal three-dimensional ultrasound combined with HD flow pattern was used to analyze the morphology of uterus scar diverticulum and the parameters of peripheral muscle blood flow. The relationship between the size of scar diverticulum and its influencing factors, the location of the uterus and the number of cesarean sections were studied. Studies have found that retroposition of the uterus or the number of cross-cutting will increase the possibility of uterus scar diverticulum formation. Therefore, transvaginal three-dimensional ultrasound combined with HD flow mode can identify and diagnose scar diverticulum., (Copyright © 2020. Published by Elsevier Ltd.)

Low grade appendiceal mucinous neoplasm (LAMN) is the primary source of pseudomyxoma peritonei (PMP). PMP may develop after seemingly complete resection of primary tumor by appendectomy, which is unpredictable due to lack of reliable prognostic indicators. We retrospectively reviewed 154 surgically resected LAMNs to explore if any of the macroscopic and microscopic characteristics may be associated with increasing risk of PMP development. Our major findings include: (1) As compared to those without PMP, the cases that developed PMP were more frequent to have (a) smaller luminal diameter (<1 cm) and thicker wall, separate mucin aggregations, and microscopic perforation/rupture, all suggestive of luminal mucin leakage; (b) microscopic acellular mucin presenting on serosal surface and not being confined to mucosa; and (c) neoplastic epithelium dissecting outward beyond mucosa, however, with similar frequency of neoplastic cells being present in muscularis propria. (2) Involvement of neoplastic cells or/and acellular mucin at surgical margin did not necessarily lead to tumor recurrence or subsequent PMP, and clear margin did not absolutely prevent PMP development. (3) Coexisting diverticulum, resulted from neoplastic or non-neoplastic mucosa being herniated through muscle-lacking vascular hiatus of appendiceal wall, was seen in a quarter of LAMN cases, regardless of PMP. The diverticular portion of tumor involvement was often the weakest point where rupture occurred. In conclusion, proper evaluation of surgical specimens with search for mucin and neoplastic cells on serosa and for microscopic perforation, which are of prognostic significance, should be emphasized., Competing Interests: Declaration of competing interest All authors declare no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

A 53-year-old man was found to have a giant 16 × 6-cm hemorrhagic and cystic mass centered on the pancreas and duodenum. Initially diagnosed as a pancreatic pseudocyst at the time of autopsy, the cystic mass was later determined by histologic examination to be a true diverticulum of the duodenum as microscopic examination of the wall revealed 2 layers of muscle, as well as a neutrophilic infiltrate. While the cause of death of the individual was certified as methamphetamine toxicity, cardiomegaly and probable dehydration associated with a giant duodenal diverticulum were listed as contributory conditions. While duodenal diverticula in general are relatively uncommon findings, an extramural, true, giant duodenal diverticulum that is inflamed is a rare clinical or autopsy finding, with only 2 case reports identified in the clinical medical literature and none in the forensic literature.

Rationale: Intermittent combined pancreaticobiliary obstruction may lead to multiple episodes of ascending cholangitis and pancreatitis, usually due to choledocholithiasis or periampullary mass. However, one of the rare causes is periampullary or juxtapapillary duodenal diverticulum. Although duodenal diverticula are relatively common in the general population, the overwhelming majority are asymptomatic. Duodenal diverticula can cause combined pancreaticobiliary obstruction through multiple mechanisms such as stasis-induced primary choledocholithiasis, stasis-induced intradiverticular enterolith, or longstanding diverticulitis, causing stenosing fibrosing papillitis or a combination of more than one of these mechanisms. Herein, I report a case of Lemmel syndrome due to a combination of multiple mechanisms and review the available literature on the epidemiology, pathogenesis, clinical presentation, diagnostic work-up, and management of juxtapapillary duodenal diverticulum., Patient Concerns: Multiple episodes of abdominal pain, jaundice, anorexia, fever, and significant unintentional weight loss., Diagnoses and Interventions: Primary choledocholithiasis, recurrent ascending cholangitis, recurrent acute pancreatitis, and pancreatic atrophy due to giant juxtapapillary duodenal diverticulum, with unsuccessful endoscopic retrograde cholangiopancreatography that was completely resolved after open transduodenal sphincteroplasty and septoplasty, transampullary and transcystic common bile duct exploration and stone extraction, and duodenal diverticular inversion., Outcome: Complete resolution of combined pancreaticobiliary obstruction without recurrence for 2 years after surgery., Lessons: Surgeons should be aware of such rare syndromes to avoid misdiagnosis and delayed or inappropriate management. Furthermore, they should understand the different available operative options for cases that are refractory to endoscopic approach.

Diverticular pouch in the oral cavity is a rare disease, and its etiology is unclear. The authors present a rare case of diverticular pouch in the buccal mucosa. A 79-year-old man visited our hospital with a chief complaint of food impaction in the right buccal mucosa. Intraoral examination revealed a pouch just inferior to the parotid papilla. Histopathological examination after excisional biopsy showed that the epithelial cells lining the pouch were continuous with the mucous membrane and a diagnosis was made of diverticular pouch of the buccal mucosa. Twenty-five months after the patient's initial visit no recurrence has been noted. Further clinico-pathological studies are required to understand diverticular disease in the buccal mucosa. This case might help dentists to become more aware of these lesions and collect data for further investigations.

Background: Gastrointestinal stromal tumors (GISTs) generally form well-defined mass lesions. However, some cases of the flatly distributed and muscularis propria-replacing GISTs have been reported so far. We experienced an additional case of planar-type GIST of the sigmoid colon accompanied by a diverticulum with perforation., Case Presentation: A 68-year-old Japanese male with sudden onset of abdominal pain was clinically diagnosed with gastrointestinal perforation, and an emergency abdominal operation was performed. A diverticulum with rupture was found in the sigmoid colon, but no apparent tumor was observed. Histological examination revealed bland spindle cells flatly proliferating and diffusely replacing the muscularis propria at the diverticular structure. The spindle cells were positive for KIT, DOG1, and CD34. Mutational analysis of the c-kit gene revealed that the lesion had a heterozygous deletion of 2 amino acids at codons 557 and 558 of exon 11. The mutation was not observed in the normal mucosa of the surrounding tissue., Conclusion: We diagnosed this case as an unusual planar-type GIST. Some similar cases have been reported in the sigmoid colon and other sites. We discuss the mechanism of development of the planar-type GISTs associated with the diverticulum.

Neurofibromatosis type 1 (NF1, Von Recklinghausen disease) is an autosomal dominant disease with a birth incidence of 1/2500-3000. The most common presentations of NF1 are cutaneous presentations like café-au-lait spots and neurofibromas. 5%-25% of patients with NF1 have gastrointestinal manifestations of the disease. Appendiceal neurofibroma are extremely rare and only a few cases are described in literature. An appendectomy is indicated because of high risk of appendicitis and malignant transformation. We report the case of a 74-year-old male patient with a history of NF1 with chronic right lower quadrant pain. Successive imaging scans showed suspicion of chronic appendicitis. A diagnostic laparoscopy, resulting in a laparoscopic appendectomy was performed without complications. Histopathology showed appendiceal neurofibroma and diverticula. The postoperative course was uneventful. In patients with NF1 with right lower quadrant pain benign appendiceal neurofibroma should be included in the differential diagnosis. A diagnostic laparoscopy should be performed followed by an appendectomy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Different types of periampullary diverticulum (PAD) may differentially affect the success of endoscopic retrograde cholangiopancreatography (ERCP) cannulation, but the clinical significance of the two current PAD classifications for cannulation is limited., Aim: To verify the clinical value of our newly proposed PAD classification., Methods: A new PAD classification (Li-Tanaka classification) was proposed at our center. All PAD patients with native papillae who underwent ERCP from January 2012 to December 2017 were classified according to three classification systems, and the effects of various types of PAD on ERCP cannulation were compared., Results: A total of 3564 patients with native papillae were enrolled, including 967 (27.13%) PAD patients and 2597 (72.87%) non-PAD patients. In the Li-Tanaka classification, type I PAD patients exhibited the highest difficult cannulation rate (23.1%, P = 0.01), and type II and IV patients had the highest cannulation success rates (99.4% in type II and 99.3% in type IV, P < 0.001). In a multivariable-adjusted logistic model, the overall successful cannulation rate in PAD patients was higher than that in non-PAD patients [odds ratio (OR) = 1.87, 95% confidence interval (CI): 1.04-3037, P = 0.037]. In addition, compared to the non-PAD group, the difficulty of cannulation in the type I PAD group according to the Li-Tanaka classification was greater (OR = 2.04, 95%CI: 1.13-3.68, P = 0.004), and the successful cannulation rate was lower (OR = 0.27, 95%CI: 0.11-0.66, P < 0.001), while it was higher in the type II PAD group (OR = 4.44, 95%CI: 1.61-12.29, P < 0.01)., Conclusion: Among the three PAD classifications, the Li-Tanaka classification has an obvious clinical advantage for ERCP cannulation, and it is helpful for evaluating potentially difficult and successful cannulation cases among different types of PAD patients., Competing Interests: Conflict-of-interest statement: The authors declare that they have no conflicts of interest to disclose., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objectives: Prenatal ventricular outpouchings (VOs), which include congenital ventricular aneurysms (CAs) and congenital ventricular diverticula (CD), are very rare. We describe the features and outcomes of prenatal VOs diagnosed over a 4-year period., Methods: Retrospective cohort study of cases of prenatal diagnoses of CAs and CD at our center between June 2014 and January 2018. The prenatal and postnatal echocardiogram data were reviewed, and telephone follow-up was conducted of liveborn cases., Results: A total of 25 VOs were identified. Two were lost to follow-up, 15 chose termination of pregnancy, and eight resulted in livebirths. Only two cases underwent autopsy: Histopathology showed that the CA wall was substituted by collagen fibers. At follow-up, none of the eight liveborn babies experienced adverse events, and three VOs near the tricuspid annulus almost disappeared, though one was extremely large., Conclusions: In our center, all liveborn babies with VO had good prognoses. We hypothesize that VOs located near the right ventricular annulus may be caused by prenatally unbalanced pressure, given their decrease in size after birth when the right heart pressure declines., (© 2020 John Wiley & Sons, Ltd.)

Aim: There is currently no universally accepted method for typing of cesarean scar pregnancy (CSP) to guide the choice of treatment approach. We introduce a new method for typing CSP and investigate its clinical significance., Method: Clinical data of 198 patients with CSP were collected and analyzed. The patients were divided into three types according to the size of their cesarean scar diverticula (CSD), measured by magnetic resonance imaging: type I (size of CSD ≤40 mm), type II (40 mm < size of CSD ≤70 mm) and type III (size of CSD >70 mm)., Results: With increase in the type level, the risk of adverse events increased significantly (χ 2 = 36.345, P = 0.000). There was a significant difference in the choice of the treatment approaches in various types of the patients (χ 2 = 27.106, P = 0.000). With increase in the type level, the invasiveness level of the treatment approach increased significantly (R = 0.405, P = 0.000). Further analysis found two other factors that influenced treatment choice., Conclusion: Our study, for the first time, demonstrates the value of size of CSD in typing of CSP and, thereby supplements the CSP typing system with a novel quantitative indicator. This typing method is of significance for evaluation of risk of CSP and guiding the choice of treatment approach. This typing method, combined with the two features of cesarean scar thickness and lesions protruding outside the uterine contour, will improve the risk assessment of CSP and the rationale of treatment plan formulation for this condition., (© 2020 Japan Society of Obstetrics and Gynecology.)

Post-inflammatory mucosal hyperplasia and appendiceal diverticulosis simulate mucinous neoplasms, causing diagnostic confusion. Distinction between neoplasia and its mimics is particularly important since many authorities now consider all appendiceal mucinous neoplasms to be potentially malignant. The purpose of this study was to identify clinicopathologic and molecular features that may distinguish appendiceal mucinous neoplasms from non-neoplastic mimics. We retrospectively identified 92 mucinous lesions confined to the right lower quadrant, including 55 non-neoplastic examples of mucosal hyperplasia and/or diverticulosis and 37 low-grade neoplasms. Presenting symptoms, radiographic findings, appendiceal diameter, appearances of the lamina propria, non-neoplastic crypts, and epithelium, as well as mural changes were recorded. Twenty non-neoplastic lesions were subjected to KRAS mutational testing. Non-neoplastic appendices were smaller (p < 0.05) and more likely to present with symptoms of appendicitis (p < 0.05) than neoplasms. While post-inflammatory mucosal hyperplasia and diverticula often showed goblet cell-rich epithelium, extruded mucin pools, and patchy mural alterations with fibrosis, they always contained non-neoplastic crypts lined by mixed epithelial cell types and separated by lamina propria with predominantly preserved wall architecture. On the other hand, mucinous neoplasms lacked normal crypts (p < 0.05) and showed decreased lamina propria (p < 0.05) with diffusely thickened muscularis mucosae and lymphoid atrophy. Six (30%) non-neoplastic lesions contained KRAS mutations, particularly those containing goblet cell-rich hyperplastic epithelium. We conclude that distinction between neoplastic and non-neoplastic mucinous appendiceal lesions requires recognition of key morphologic features; KRAS mutational testing is an unreliable biomarker that cannot be used to assess biologic risk or confirm a diagnosis of neoplasia.

Purpose: The purpose of this study was to evaluate the prevalence, location, size and morphological characteristics of left atrial diverticula using electrocardiographically gated multi-detector computed tomography in patients with normal sinus rhythm., Methods: Electrocardiographically gated cardiac multi-detector computed tomography was performed in 93 patients with normal sinus rhythm. The prevalence, number, size, morphological characteristics and location of left atrial diverticula were recorded., Results: A total of 72 left atrial diverticula were diagnosed in 45 (48.4%) of the 93 patients in this study. Of these 72 diverticula, 66 (91.7%) were cystiform and 6 (8.3%) were tubiform. Anterosuperior wall, left lateral wall and septum were the most common locations of these left atrial diverticula (n = 42, 58.3%; n = 22, 15.3% and n = 7, 9.7%, respectively)., Conclusion: Diverticula are common variations. The discovery of these structures is relatively new and their clinical significance remains unclear. They are generally asymptomatic but although not supported by many studies, in some case reports they are claimed to be associated with arrhythmias and thromboembolism. In addition, it is theoretically reasonable to think that they may cause complications during interventional procedures. Better understanding of these structures has the potential to improve management strategies and reduce potential complications. Therefore, they should be reported during routine cardiac computed tomography.

Research conclusions differ on the impact of periampullary diverticulum (PAD) on endoscopic retrograde cholangiopancreatography (ERCP). An up-to-date meta-analysis evaluated the role of PAD in ERCP, especially in terms of cannulation failure and early complications. A comprehensive literature search was performed. All statistical analyses were carried out with the Review Manager 5.3 software. Horizontal lines represented a 95% confidence interval (CI) and the area of each square in forest plots. Twenty-six studies including 23 826 patients with or without PAD who underwent ERCP were evaluated. PAD was associated with an increase in the overall cannulation failure rate (RR=1.46, 95% CI: 1.27-1.67; p<.00001), but in the subgroup of studies performed post-2000, PAD was irrelevant to cannulation failure (RR=1.16, 95% CI: 0.96-1.41; p=0.12). In overall analyses, PAD was also associated with a high risk of ERCP-related pancreatitis (RR=1.32, 95% CI: 1.10-1.59; p=0.003), perforation (RR=1.73, 95% CI: 1.06-2.82; p=0.030), and bleeding (RR=1.48, 95% CI: 1.13-1.93; p=0.005). The presence of PAD increased the overall cannulation failure rate, but not the rate post-2000. PAD also affected the occurrence of early pancreatitis, perforation, and bleeding.

Spontaneous intracranial hypotension (SIH) is an under-diagnosed cause of headache in children and adolescents. SIH results from cerebrospinal fluid (CSF) leak due to breach in the dura mater and the etiology for dural breach is often diverse. We report an adolescent boy who presented with chronic episodic headache that later progressed to daily headache. There was a typical history of worsening of headache on upright position and relief of headache on lying down. He was treated with migraine prophylaxis in another hospital but there was no response. Marfanoid features and brisk deep tendon reflexes were observed on clinical examination. Brain magnetic resonance imaging (MRI) revealed sagging of the brain stem, pachymeningeal enhancement, and tonsillar herniation. MRI of spine myelogram confirmed multiple levels of CSF leak. He was initially managed with supportive measures and fluoroscopic-guided fibrin glue injection. Although child remained symptom-free for the next 6 months, he again developed headache. MRI and computed tomography spine myelogram revealed a meningeal diverticulum in the lumbar spine. He was managed with an autologous epidural blood patch and he has been well since then. In this report, we highlight the clinical and radiological pointers to the presence of SIH in children with recurrent headache., Competing Interests: The authors declare that they have no conflicts of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Studies have shown a high risk of tumor development within a bladder diverticulum (BD). We were interested in the relationship between BD and the development of bladder cancer. Herein, we attempted to investigate whether there exists an association between documented BD and subsequent risk of bladder cancer., Methods: We identified 10,662 hospitalized urology patients, including 2,134 documented BD patients (study cohort) and 8,528 non-BD subjects (comparison cohort) from Taiwan's National Health Insurance database. Only urology patients were enrolled in the study to minimize selection bias. The two cohorts were frequency-matched 1:4 by age, sex and index-year. Patients with less than one year of follow-up were excluded to avoid inverting cause and effect. Risks of developing bladder cancer were estimated using the Cox proportional hazard regression model., Results: There was an increased bladder cancer risk in the documented BD patients. The incidence of bladder cancer in documented BD patients was 2.60-fold higher than that in the comparison group, and the overall risk-factor-adjusted hazard ratio was 2.63 (95% CI, 1.74-3.97). Moreover, stratified analysis by sex also showed that documented BD patients were at higher risk of subsequent bladder cancer than the comparison cohort. The effect of BD on the risk of bladder cancer was higher in males than in females and was more profound in patients without comorbidities than in those with comorbidities., Conclusion: In this population-based longitudinal study, urology patients with documented BD might have an elevated risk of subsequent bladder cancer. Based on the limitations of the retrospective study design, further studies are required., Competing Interests: The authors have declared that no competing interests exist.

Objective: To present the results of the largest series of patients with bladder diverticula > 4 cm managed with an endoscopic approach and give tips about the execution of the procedure., Materials and Methods: Data of male patients undergone the endoscopic approach for an acquired bladder diverticula > 4 cm from December 2004 to August 2018 were prospectively collected and retrospectively analyzed. The description of the monopolar and bipolar techniques are provided. The success of the procedure was defined as the reduction of the diverticula for more of the 80% of its initial diameter documented at the 3- months follow-up imaging. Continuous variables with nonparametric distribution were compared using the Mann-Whitney test, while frequencies of categorical variables were compared between groups by Fisher's exact test with significance level set at 0.05., Results: Thirty-nine patients with a mean (+/- SD) age at surgery of 69.4 ± 8.8 years were enrolled, for an equal number of diverticula managed. The mean diverticular size was 75.1 ± 24.5 millimeters. The mean operative time was 65 ± 21.9 minutes including the prostate surgery. Twelve patients (30.8%) were managed with bipolar energy, the others with monopolar. The success of the procedure was achieved in 30 patients (76.9% - 7 bipolar and 23 monopolar - p = 0.66)., Conclusions: The endoscopic approach might be considered as a useful option for patients with a large bladder diverticulum who are at risk for major or laparoscopic procedure.

Aims: To research and identify how often complicated diverticular disease of the appendix [appendiceal diverticular disease (ADD)] shows histological mimicry of low-grade appendiceal mucinous neoplasms (LAMNs) and to provide guidance on the useful histopathological features that allow the appropriate diagnosis to be made., Methods and Results: Seventy-four cases of complicated appendiceal diverticular disease were identified from two specialist centres. Of the second opinion/consultation cases, 71% of the ADD cases had been diagnosed by referring pathologists as LAMNs. Salient pathological features were identified and agreed upon to reach the applicable diagnosis. For a diagnosis of complicated diverticulosis, particularly when associated with mucus cysts, the following morphological features were regarded as important: relative retention of the normal mucosal architecture with lamina propria and a maintained crypt architecture, crypts arranged in regular array, epithelial hyperplasia and a lack of nuclear abnormalities extending the length of the crypts. In a formal case-control study undertaken on 30 cases with each diagnosis, ADD and LAMN, loss of lamina propria, a filiform architecture and hypermucinosis were significantly associated with low-grade appendiceal mucinous neoplasms. Mucosal neuromas were significantly associated with diverticular disease of the appendix., Conclusions: To our knowledge, this study represents the largest series in the world literature and serves to highlight the important pathological features to distinguish complicated diverticular disease of the appendix from LAMNs, and emphasises the difficulties experienced by diagnostic pathologists in diagnosing complicated appendiceal diverticulosis. This is important, as LAMNs have a significant risk of transcoelomic spread, while complicated appendiceal diverticulosis has no such risk., (© 2019 John Wiley & Sons Ltd.)

The etiopathogenesis of Zenker's diverticulum (ZD) remains uncertain. Increased hypopharyngeal pressure due to a hypertonic upper esophageal sphincter results in herniation proximal to the sphincter producing a pulsion diverticulum. Gastroesophageal reflux, which is known to induce shortening of the injured esophagus, likely plays a prominent role in ZD formation by pulling the cricopharyngeus muscle (CPM) away from the anchored inferior constrictor muscle. This creates a "weak zone" encouraging herniation. A bilobed diverticulum may originate from continuation of the fibrous midline raphe inferiorly to developmentally include part of the CPM. We report using laser endoscopy to divide the inter-diverticular septum followed by transmucosal cricopharyngeus myotomy. Presentation of a rare, bilobed diverticulum emphasizes the importance of the midline prevertebral raphe in anchoring the pharyngeal constrictor muscles with respect to the CPM. This lends support to the hypothesis that the etiopathogenesis of ZD is multifactorial while guiding us to a unified understanding of ZD.

Occipital horn syndrome (OHS) is a rare connective tissue disorder caused by pathogenic variants in ATP7A, encoding a copper transporter. The main clinical features, including cutis laxa, bony exostoses, and bladder diverticula are attributed to a decreased activity of lysyl oxidase (LOX), a cupro-enzyme involved in collagen crosslinking. The absence of large case series and natural history studies precludes efficient diagnosis and management of OHS patients. This study describes the clinical and molecular characteristics of two new patients and 32 patients previously reported in the literature. We report on the need for long-term specialized care and follow-up, in which MR angiography, echocardiography and spirometry should be incorporated into standard follow-up guidelines for OHS patients, next to neurodevelopmental, orthopedic and urological follow-up. Furthermore, we report on ultrastructural abnormalities including increased collagen diameter, mild elastic fiber abnormalities and multiple autophagolysosomes reflecting the role of lysyl oxidase and defective ATP7A trafficking as pathomechanisms of OHS.

Jejunal diverticulosis is an underdiagnosed condition due to its relatively benign existence and uncharacteristic presentation. The complications can be very severe and, due to its often late diagnosis, patients may require urgent surgery. We present a woman who initially complained of non-specific abdominal symptoms but was diagnosed with a contained jejunal diverticular perforation relatively early. We managed her non-operatively with intravenous antibiotics from which she recovered well. She was discharged 2 days later and has remained completely well. Follow-up at 3 months showed no recurrence. Our case differs from most of the literature due to the early diagnosis and successful non-operative management of the patient. We conclude that, in cases of non-specific abdominal pain with diagnostic ambiguity, a diagnosis of small bowel diverticulosis should be considered. It should be managed non-operatively where possible., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Hypothesis: We hypothesize that internal auditory canal (IAC) diverticula occur independent of otosclerosis as demonstrated by temporal bone histopathology., Background: Diverticula at the anterior-inferior aspect of the IAC have been described histologically in the setting of cavitary otosclerosis. Recent radiographic studies show the prevalence of IAC diverticula that is higher than what can be accounted for by cavitary otosclerosis alone., Methods: We examined hematoxylin and eosin temporal bone histopathology slides with otosclerosis involving the IAC. We also examined bones from normal hearing subjects with normal histologic findings. Temporal bones were included if donors were more than 18 years of age at time of death and adequate horizontal cuts were available to evaluate the area of interest., Results: IAC diverticula were found in 33 of 47 (70%) temporal bones with IAC otosclerosis and in 5 of 20 (25%) normal temporal bones. The difference in mean pure tone averages (PTA) in the normal temporal bones with (PTA 7.3 ± 7) and without (PTA 8 ± 2) diverticula was not statistically significant (p = 0.86)., Conclusion: IAC diverticula which have been previously demonstrated to occur in the setting of cavitary otosclerosis can also occur independent from otosclerosis. Subjects with diverticula but without other temporal bone pathology have normal hearing thresholds.

Background/aims: Diverticulosis and colorectal neoplasia share epidemiological trends and risk factors which are common in Western countries and incidences increase with age. However, the data on an association between diverticulosis and colorectal neoplasia are conflicting. Thus, we performed a meta-analysis to evaluate whether diverticulosis is associated with colorectal neoplasia., Methods: A systematic literature search of PubMed, EMBASE, Cochrane Library, Web of Science, and SCOPUS was conducted to identify studies that investigated the association between diverticulosis and advanced colorectal neoplasia (advanced adenoma, colorectal cancer), adenomas, or polyps. The demographic characteristics of patients, including age, gender, indication for colonoscopy, confounding factors, and outcomes of colorectal neoplasia were assessed., Results: We identified 29 cross-sectional studies (N = 450,953) that investigated the association between diverticulosis and colorectal neoplasia. The meta-analysis found that diverticulosis was not associated with advanced colorectal neoplasia (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.63-1.50). Although there was a positive correlation between diverticulosis and adenomas (OR 1.47, 95% CI 1.18-1.84) and diverticulosis and polyps (OR 1.95, 95% CI 1.15-3.31), diverticulosis did not increase the risk of adenomas (OR 1.34, 95% CI 0.87-2.06) in patients who underwent screening colonoscopy. Moreover, all the increased risk of colorectal neoplasia in patients with diverticulosis was observed in published studies only, and not in unpublished ones., Conclusions: This meta-analysis demonstrated that diverticulosis is not associated with an increased risk of advanced colorectal neoplasia. Although diverticulosis was associated with a higher risk of polyps and adenomas, the risk was not increased in screening populations. Moreover, the increased risk of colorectal neoplasia in patients with diverticulosis was observed only in published studies and not in unpublished ones., Competing Interests: The authors have declared that no competing interests exist.

Background: Complications of diverticular disease are increasingly common, possibly linked to increasing obesity. Visceral fat could contribute to the development of symptomatic diverticular disease through its pro-inflammatory effects., Objective: The study had 2 aims. A) to develop a semi-automated algorithm to measure abdominal adipose tissue from 2-echo magnetic resonance imaging (MRI) data; B) to use this to determine if visceral fat was associated with bowel symptoms and inflammatory markers in patients with symptomatic and asymptomatic diverticular disease., Design: An observational study measuring visceral fat using MRI together with serum adiponectin, leptin, stool calprotectin and patient-reported somatisation and bowel habit., Setting: Medical and imaging research centres of a university hospital., Participants: MRI scans were performed on 55 patients after an overnight fast measuring abdominal subcutaneous and visceral adipose tissue volumes together with small bowel water content (SBWC). Blood and stool samples were collected and patients kept a 2 week stool diary and completed a somatisation questionnaire., Main Outcome Measures: Difference in the volume of visceral fat between symptomatic and asymptomatic patients., Results: There were no significant differences in visceral (p = 0.98) or subcutaneous adipose (p = 0.60) tissue between symptomatic and asymptomatic patients. However measured fat volumes were associated with serum adipokines. Adiponectin showed an inverse correlation with visceral adipose tissue (VAT) (Spearman ρ = -0.5, p = 0.0003), which correlated negatively with SBWC (ρ = -0.3, p = 0.05). Leptin correlated positively with subcutaneous adipose tissue (ρ = 0.8, p < 0.0001). Overweight patients (BMI > 25 kgm-2) showed a moderate correlation between calprotectin and VAT (ρ = 0.3, p = 0.05). Somatization scores were significantly higher in symptomatic patients (p < 0.0003)., Conclusions: Increasing visceral fat is associated with lower serum adiponectin and increased faecal calprotectin suggesting a pro-inflammatory effect which may predispose to the development of complications of diverticulosis., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Low-grade chronic inflammation has been suggested to play a role in uncomplicated asymptomatic and symptomatic diverticular disease. However, population-based studies are lacking. We investigated whether community participants with diverticulosis, with or without symptoms, would have colonic inflammation on histology and serology., Methods: In a nested case-control study of 254 participants from the population-based colonoscopy (PopCol) study, colonic histological inflammatory markers and serological C-reactive protein levels were analyzed in cases with diverticulosis and controls without diverticulosis. Statistical methods included logistic and linear regression models., Results: Background variables including age (P = 0.92), sex (P = 1.00), body mass index (P = 0.71), smoking (P = 0.34), and recent antibiotic exposure (P = 0.68) were similar between cases and controls. Cases reported more abdominal pain (P = 0.04) and diarrhea symptoms (mushy and high-frequency stools) than controls (P = 0.01 and P = 0.03, respectively) but were otherwise similar. The median C-reactive protein levels were similar among cases and controls [1.05 mg/L (0.3, 2.7) vs 0.8 (0.4, 2.2), P = 0.53]. There was a trend of increased numbers of cecal lymphoid aggregates in cases vs controls (P = 0.07), but no other associations between diverticulosis and inflammatory markers on histology were found. Similarly, no serological or mucosal inflammation was associated with symptomatic cases of diarrhea or abdominal pain vs asymptomatic controls., Conclusions: In a general community sample, both asymptomatic and symptomatic diverticulosis are not associated with colonic mucosal inflammation. Other explanations for symptomatic colonic diverticulosis need to be identified.

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., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Female urethral diverticular cancer is a very rare entity with only around 100 cases reported so far in literature and accounts for <1% of all malignancies. In this article, we present a 47-year-old African American female with repeated hospital visits for urinary retention, hematuria, and urinary tract infections. Initial computed tomography imaging and cystoscopy was unremarkable except for a distended urinary bladder. Subsequent magnetic resonance imaging and corresponding cystoscopy eventually indicated the presence of a urethral diverticulum. She underwent urethral diverticulectomy and was found to have a mass arising from urethral diverticulum extending to vaginal walls. Her biopsy was suggestive of invasive adenocarcinoma in advanced stages, for which she subsequently underwent a total pelvic exenteration. Next-generation sequencing of the tumor showed CDKN2A/B loss, MSI-stable, and low TMB, thereby ruling out the options for targeted therapies. Extensive literature search and expert opinions were sought for her case since no consensus exists regarding the optimal therapeutic approach due to the rarity of this tumor. A final decision was made to treat her with platinum-based chemotherapy. Different treatment approaches including neoadjuvant chemoradiation followed by surgery, surgery followed by adjuvant chemotherapy, and surgery followed by chemoradiation have been tried. Platinum-based chemotherapy has generally been preferred based on an extensive literature search. Multimodality treatment approach seems to be the current approach to management for advanced stages for better overall survival. This case illustrates the challenges faced in making diagnosis and treatment decisions due to the rarity of this type of tumor and lack of consensus in the treatment approach.

Acquired outpouches of the intestinal tract are referred to as pseudodiverticula or false pulsion diverticula. In contrast to true diverticula, in which the wall contains all layers of the intestinal tract, the wall of pseudodiverticula lacks the tunica muscularis. Smooth muscle hypertrophy of the small intestine is commonly considered a cause of pseudodiverticulosis in animals due to increased intraluminal pressure. This study reports pseudodiverticula associated with idiopathic smooth muscle hypertrophy of the small intestine in lagomorphs. Four domestic rabbits had single or multiple (up to 200) pseudodiverticula of various size in the small intestine. In all cases the tunica muscularis was diffusely thickened, significantly exceeding reference thickness of 14 rabbits (mean, 112.3 µm; range, 26.3-389.0 µm). Clinical signs were considered to be caused by severe necrosis and inflammation of the wall of large pseudodiverticula, leading to perforation with subsequent peritonitis and mesenteric and omental abscess formation in 2 cases.