The Eurasian
Journal of Medicine
EAJM 2013; 45:68-70
Case Report
•IC
Transverse Colon Divertículítís with Calcified Fecalith Kalsifiye Fekalitin YolAçtigi Transvers Kolon Divertiküliti Aynur Solak\ llhami Solak^ Berhan Genç',Neslin Sahin', Seyhan Yalaz^ 'Department of Radiology, Sifa Hospital, Izmir, Turkey ^Department of General Surgery, Scool of Medicine Ege University, Izmir, Turkey 'Department of General Surgery, Sifa Hospital, Izmir, Turkey
Abstract
Özet
Left colonie diverticula are common in Western populations, whereas right colonie diverticulosis primarily occurs in Oriental populations. Diverticulitis of the transverse colon is very rare, with very few cases reported in the literature. Herein, we report a case of transverse colon diverticulitis caused by a calcified stone in a 69-year-old female. This was a solitary diverticulum. The signs and symptoms of the disease are similar to acute pancreatitis. To the best of our knowledge, this is the first report describing the MRI findings of a patient with transverse colon diverticulitis caused by a calcified stone. Keywords: Diverticulitis, Fecalith, Transverse colon
Divertiküller siklikla batí üikelerinde sol kolonda dogu üikelerinde sag kolonda yerlejirler. Transvers kolonda divertikülit son derece nadirdir ve literatürde cok az olguda bildirilmijtir. Biz burada 69 yajindaki bayan hastada kalsifiye fekalitin yol açtigi transvers kolon divertikülitini sunuyoruz.Lezyon soliterdir. Hastaligm bulgulan akut pankreatite benzemektedir. Bildigimiz kadariyla, bu olgu sunumu, kalsifiye fekalitin yol açtigi transvers kolon divertikülitinin MR bulgularinin tanimlandigi ilk yazidir.
Introduction Diverticular colon disease is very common in Western countries.The incidence rates are 5-10% in populations over 45 years of age and increase to 80% in populations over 85 years of age. The disease is commonly asymptomatic, with only 10% of cases developing diverticulitis. There are two primary reasons for the progression of diverticulitis: an increase in intraluminal pressure and weakening of the colon walls. The greatest contributing factor in the development of colon diverticulitis is a low-fiber diet, which speeds up colon passage time resulting in an increase in the intraluminal pressure [1,2]. Diverticula are most frequently located in the left colon. Rarely, when situated in the cecum and right colon, the clinical symptoms mimic those of appendicitis, and when situated in the transverse colon, the symptoms mimic those of pancreatitis [1]. In our study, we present the radiological findings of a patient with transverse colon diverticulitis who was difficult to diagnose due to the rare diverticula location.
Anahtar Kelimeler: Divertikülit, Fekalit,Transvers kolon
Case Report A 69-year-old female was admitted with clinically suspected acute pancreatitis. She complained of a four-day history of severe epigastric pain, anorexia and vomiting. Her white blood cell (WBC) count was elevated to 16,000 cells/ mcL. Her blood amylase and lypase levels were within normal limits (amylase: 69 Ü/L, lipase: 53 U/L). A physical examination identified a painful epigastric mass. The patient had previously undergone a cholecystectomy, and the epigastric fat planes were heterogeneous on ultrasonographic images. An ultrasonographic evaluation of the entire pancreas was hampered by the superposition of intestinal gas. Pancreatitis was suspected due to a choledoch stone. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) were ordered for further evaluation. MRI demonstrated thickening of the transverse colon wall, contrast enhancement and disseminated edema in the anterior pericolonic adipose tissue. In the center of the edematous
Received: July 23, 2012 / Accepted: October 29, 2012 Correspondence to: Aynur Solak, Sifa Hospital, Radiology Department, Fevzipasa Boulvard, 172/2,35240, Basmane, Izmir, Turkey Pilone: +90 232 446 08 80 Fax: +90 232 446 07 70 e-mail: [email protected] doi:10.5152/eajm.2013.14
EAJM 2013; 45:68-70
Solak et al. Diverticulitis of Transverse Colon by Calcified Fecalith
69
was insufficient distention of the neighboring transverse colon. Upon a second evaluation, a diverticulum with a calcified fecalith in the middle and an opaque air level inside and its connection with the colonie lumen were observed. The peridiverticular fat planes were thickened, and contrast material leakage was not observed outside of the lumen. The patient was diagnosed with transverse colon diverticulitis, and treatment with antibiotherapy was initiated. The endoscopie removal of the calcified fecalith was suggested, but the patient did not accept. After antibiotherapy, the patient was healthy. The patient is currently observed regularly at a follow-up outpatient clinic.
Discussion A normal colon is strong and relatively smooth. Small pouches or sacs, called diverticula, can form along the inner lining of the intestine. The presence of these pouches on the colon wall is termed diverticulosis. Although diverticuFigure 1. A Tl -weighted coronai image showing that the hypointense losis can occur anywhere in the colon, it is most commonly focus is in close proximity to the colonie wall (arrow). observed in the lower portion of the colon (rectosigmoid region) because the colon is narrowest and the inner pressure is highest in this location [1, 3]. In developed countries, a diet low in fiber increases the risk of diverticulum formation and subsequent diverticulitis. In those countries, diverticula are frequently retained in the left and distal colon, while in Eastern countries, they are more frequently retained in the right colon. There are very few cases with a transverse colon diverticulum in the literature. Thus, our case is very unique with respect to the lesion location [1, 2,4]. Most patients suffering from diverticulitis are elderly, making it difficult to interpret the symptoms and delaying the diagnosis. Diverticula do not possess a muscle layer on their walls, and if not treated, the wall of the diverticulum will gradually thin and may become perforated due to inflammation. After perforation, the lesion might spread to the peritoneal cavity and lead to generalized peritonitis. Occasionally, Figure 2. An axial post-contrast fat-suppressed image showing contrast enhancement around the hypointense fecailth (arrow) and thickening repeated diverticulitis attacks may lead to fistulization in adjacent to the intestinai mucosai waii. colon structures and other intestinal segments. Therefore, early diagnosis and treatment is critical for a favorable outregion, all sequences had a persisting 12 mm formation come [2, 3]. In the acute phase of diverticulitis, barium colowithout a signal (Figure 1, 2). An MRCP examination demonnography and endoscopie examinations are contraindicated strated a normally sized ductus choledochus, and no stone due to the risk of perforation [5]. Tomography is the gold formation was observed. The other intra- and extrahepatic standard for diagnosis because it shows mucosai defects bile ducts were normal. To better evaluate this signal-less forand inflammation in the adjacent fat planes and displays mation with suspected calcifications, the patient underwent the extramural components of the disease. Oral contrast CT (computed tomography). In the tomographic sections, a tomography eannot ereate adequate intestinal distention, so hyperdensity similar to an ectopic gallstone and surrounding the divertieulum lumen may not be filled with the contrast lipoid tissue heterogeneity were detected in the epigastrium material. Moreover, when administered orally, the contrast (Figure 3). To evaluate the colonie mucosa, contrast material material requires at least two hours to fill the colon [6]. Kireher et al. [7] used a reetal eontrast material instead of an oral or was rectally introduced, and BT was repeated because there
70
Solak et al. Diverticulitis of Transverse Colon by Calcified Fecalith
EAJM 2013; 45:68-70
Figure 3. A) CTofthe abdomen with orai and intravenous contrast materiai reveáis thickening and stranding of the anterior epigastric fatpianes. The white arrow indicates a hyperdense fecaiith mimicking the peripheraiiy calcified ectopic gaiistone. B) CT after the contrast materiai was administered through the coion. A coronaiiy reformatted image shov^ing the en tire iumen and communication with the transverse coion of the diverticuium. The caicified fecaiith and barium are isodense, and the caicified fecaiith is therefore indistinguishabie.
intravenous contrast material in 312 patients and reported 99% sensitivity and specificity in their study. Thickening of the intestinal mueosa and fat stranding are the most specific symptoms of diverticulitis [8]. In our study, we also used rectal contrast tomography to evaluate the diverticuium lumen and its relationship with the colon lumen in a patient who could not be evaluated using oral contrast tomography. To our knowledge, only two studies in the literature have shown that fecaiith may result in diverticulitis and become calcified and visible [6, 7]. In our patient, the fecaiith became calcified and visible, and we were therefore able to make an appropriate diagnosis. We performed abdominal MRI due to the suspicion of potential pancreatitis as a result of choledoch stones and observed the calcified fecaiith. Similar to the findings in BT, thickening of the colonie mueosa, contrast enhancement of the colonie and divertieular wall, thiekening and stranding in the perieolonie fat planes and edemas were observed using MRI. One should eonsider a ealeified feealith when a hypointense lesion is observed in heterogeneous thiek perieolonie fat tissue in eases similar to the one described above.
Conflict of interest statement: The authors declare that they have no conflict of interest to the publication of this article. References 1.
2. 3. 4. 5. 6.
7.
8.
:
'. i
Golder M, Ster IC, Babu P, Sharma A, Bayat M, Farah A. Demographic determinants of risk, colon distribution and density scores of divertieular disease. World J Gastroenterol 2011; 178: 1009-17. FerzocoLB, RaptopoulousV, SilenW. Acute Diverticulitis. Current Concepts 1998; 338: 1521-6. Weizman AV, Nguyen GC. Divertieular disease: Epidemiology and management. Can J Gastroenterol 2011; 25: 385-9. Martin ST, Stocchi L. New and emerging tratmentsforthe prevention of recurrent diverticulitis. Clin Exp Gastroenterol 2011 ; 2:203-12. Flosch CL. Diagnosis and management of acute diverticulitis. J Clin Gastroenterol 2006; 3:136-44. Sheiman L, Levine MS, Levine AA, et al. Chronic diverticulitis: clinical, radiographie, and pathologic findings. AJR Am J Roentgenol 2008; 191: 522-8. Kireher M F, Rhea J T, Kihiezak D, Novelline RA. Frequency, sensitivity, and speeifieity of individual signs of divertieulitis on thinseetion helieal CT with eolonie eontrast material: experienee with 312eases. Am J Roentgenol 2002; 178:1313-8. Jeong HJ, Lee HL, Kim JO, et al. Correlation between eomplieated divertieulitis and viseeral fat. J Korean Med Sei 2011 ; 26:1339-43.
Copyright of Eurasian Journal of Medicine is the property of Aves Yayincilik Ltd. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Journal of Medicine
EAJM 2013; 45:68-70
Case Report
•IC
Transverse Colon Divertículítís with Calcified Fecalith Kalsifiye Fekalitin YolAçtigi Transvers Kolon Divertiküliti Aynur Solak\ llhami Solak^ Berhan Genç',Neslin Sahin', Seyhan Yalaz^ 'Department of Radiology, Sifa Hospital, Izmir, Turkey ^Department of General Surgery, Scool of Medicine Ege University, Izmir, Turkey 'Department of General Surgery, Sifa Hospital, Izmir, Turkey
Abstract
Özet
Left colonie diverticula are common in Western populations, whereas right colonie diverticulosis primarily occurs in Oriental populations. Diverticulitis of the transverse colon is very rare, with very few cases reported in the literature. Herein, we report a case of transverse colon diverticulitis caused by a calcified stone in a 69-year-old female. This was a solitary diverticulum. The signs and symptoms of the disease are similar to acute pancreatitis. To the best of our knowledge, this is the first report describing the MRI findings of a patient with transverse colon diverticulitis caused by a calcified stone. Keywords: Diverticulitis, Fecalith, Transverse colon
Divertiküller siklikla batí üikelerinde sol kolonda dogu üikelerinde sag kolonda yerlejirler. Transvers kolonda divertikülit son derece nadirdir ve literatürde cok az olguda bildirilmijtir. Biz burada 69 yajindaki bayan hastada kalsifiye fekalitin yol açtigi transvers kolon divertikülitini sunuyoruz.Lezyon soliterdir. Hastaligm bulgulan akut pankreatite benzemektedir. Bildigimiz kadariyla, bu olgu sunumu, kalsifiye fekalitin yol açtigi transvers kolon divertikülitinin MR bulgularinin tanimlandigi ilk yazidir.
Introduction Diverticular colon disease is very common in Western countries.The incidence rates are 5-10% in populations over 45 years of age and increase to 80% in populations over 85 years of age. The disease is commonly asymptomatic, with only 10% of cases developing diverticulitis. There are two primary reasons for the progression of diverticulitis: an increase in intraluminal pressure and weakening of the colon walls. The greatest contributing factor in the development of colon diverticulitis is a low-fiber diet, which speeds up colon passage time resulting in an increase in the intraluminal pressure [1,2]. Diverticula are most frequently located in the left colon. Rarely, when situated in the cecum and right colon, the clinical symptoms mimic those of appendicitis, and when situated in the transverse colon, the symptoms mimic those of pancreatitis [1]. In our study, we present the radiological findings of a patient with transverse colon diverticulitis who was difficult to diagnose due to the rare diverticula location.
Anahtar Kelimeler: Divertikülit, Fekalit,Transvers kolon
Case Report A 69-year-old female was admitted with clinically suspected acute pancreatitis. She complained of a four-day history of severe epigastric pain, anorexia and vomiting. Her white blood cell (WBC) count was elevated to 16,000 cells/ mcL. Her blood amylase and lypase levels were within normal limits (amylase: 69 Ü/L, lipase: 53 U/L). A physical examination identified a painful epigastric mass. The patient had previously undergone a cholecystectomy, and the epigastric fat planes were heterogeneous on ultrasonographic images. An ultrasonographic evaluation of the entire pancreas was hampered by the superposition of intestinal gas. Pancreatitis was suspected due to a choledoch stone. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) were ordered for further evaluation. MRI demonstrated thickening of the transverse colon wall, contrast enhancement and disseminated edema in the anterior pericolonic adipose tissue. In the center of the edematous
Received: July 23, 2012 / Accepted: October 29, 2012 Correspondence to: Aynur Solak, Sifa Hospital, Radiology Department, Fevzipasa Boulvard, 172/2,35240, Basmane, Izmir, Turkey Pilone: +90 232 446 08 80 Fax: +90 232 446 07 70 e-mail: [email protected] doi:10.5152/eajm.2013.14
EAJM 2013; 45:68-70
Solak et al. Diverticulitis of Transverse Colon by Calcified Fecalith
69
was insufficient distention of the neighboring transverse colon. Upon a second evaluation, a diverticulum with a calcified fecalith in the middle and an opaque air level inside and its connection with the colonie lumen were observed. The peridiverticular fat planes were thickened, and contrast material leakage was not observed outside of the lumen. The patient was diagnosed with transverse colon diverticulitis, and treatment with antibiotherapy was initiated. The endoscopie removal of the calcified fecalith was suggested, but the patient did not accept. After antibiotherapy, the patient was healthy. The patient is currently observed regularly at a follow-up outpatient clinic.
Discussion A normal colon is strong and relatively smooth. Small pouches or sacs, called diverticula, can form along the inner lining of the intestine. The presence of these pouches on the colon wall is termed diverticulosis. Although diverticuFigure 1. A Tl -weighted coronai image showing that the hypointense losis can occur anywhere in the colon, it is most commonly focus is in close proximity to the colonie wall (arrow). observed in the lower portion of the colon (rectosigmoid region) because the colon is narrowest and the inner pressure is highest in this location [1, 3]. In developed countries, a diet low in fiber increases the risk of diverticulum formation and subsequent diverticulitis. In those countries, diverticula are frequently retained in the left and distal colon, while in Eastern countries, they are more frequently retained in the right colon. There are very few cases with a transverse colon diverticulum in the literature. Thus, our case is very unique with respect to the lesion location [1, 2,4]. Most patients suffering from diverticulitis are elderly, making it difficult to interpret the symptoms and delaying the diagnosis. Diverticula do not possess a muscle layer on their walls, and if not treated, the wall of the diverticulum will gradually thin and may become perforated due to inflammation. After perforation, the lesion might spread to the peritoneal cavity and lead to generalized peritonitis. Occasionally, Figure 2. An axial post-contrast fat-suppressed image showing contrast enhancement around the hypointense fecailth (arrow) and thickening repeated diverticulitis attacks may lead to fistulization in adjacent to the intestinai mucosai waii. colon structures and other intestinal segments. Therefore, early diagnosis and treatment is critical for a favorable outregion, all sequences had a persisting 12 mm formation come [2, 3]. In the acute phase of diverticulitis, barium colowithout a signal (Figure 1, 2). An MRCP examination demonnography and endoscopie examinations are contraindicated strated a normally sized ductus choledochus, and no stone due to the risk of perforation [5]. Tomography is the gold formation was observed. The other intra- and extrahepatic standard for diagnosis because it shows mucosai defects bile ducts were normal. To better evaluate this signal-less forand inflammation in the adjacent fat planes and displays mation with suspected calcifications, the patient underwent the extramural components of the disease. Oral contrast CT (computed tomography). In the tomographic sections, a tomography eannot ereate adequate intestinal distention, so hyperdensity similar to an ectopic gallstone and surrounding the divertieulum lumen may not be filled with the contrast lipoid tissue heterogeneity were detected in the epigastrium material. Moreover, when administered orally, the contrast (Figure 3). To evaluate the colonie mucosa, contrast material material requires at least two hours to fill the colon [6]. Kireher et al. [7] used a reetal eontrast material instead of an oral or was rectally introduced, and BT was repeated because there
70
Solak et al. Diverticulitis of Transverse Colon by Calcified Fecalith
EAJM 2013; 45:68-70
Figure 3. A) CTofthe abdomen with orai and intravenous contrast materiai reveáis thickening and stranding of the anterior epigastric fatpianes. The white arrow indicates a hyperdense fecaiith mimicking the peripheraiiy calcified ectopic gaiistone. B) CT after the contrast materiai was administered through the coion. A coronaiiy reformatted image shov^ing the en tire iumen and communication with the transverse coion of the diverticuium. The caicified fecaiith and barium are isodense, and the caicified fecaiith is therefore indistinguishabie.
intravenous contrast material in 312 patients and reported 99% sensitivity and specificity in their study. Thickening of the intestinal mueosa and fat stranding are the most specific symptoms of diverticulitis [8]. In our study, we also used rectal contrast tomography to evaluate the diverticuium lumen and its relationship with the colon lumen in a patient who could not be evaluated using oral contrast tomography. To our knowledge, only two studies in the literature have shown that fecaiith may result in diverticulitis and become calcified and visible [6, 7]. In our patient, the fecaiith became calcified and visible, and we were therefore able to make an appropriate diagnosis. We performed abdominal MRI due to the suspicion of potential pancreatitis as a result of choledoch stones and observed the calcified fecaiith. Similar to the findings in BT, thickening of the colonie mueosa, contrast enhancement of the colonie and divertieular wall, thiekening and stranding in the perieolonie fat planes and edemas were observed using MRI. One should eonsider a ealeified feealith when a hypointense lesion is observed in heterogeneous thiek perieolonie fat tissue in eases similar to the one described above.
Conflict of interest statement: The authors declare that they have no conflict of interest to the publication of this article. References 1.
2. 3. 4. 5. 6.
7.
8.
:
'. i
Golder M, Ster IC, Babu P, Sharma A, Bayat M, Farah A. Demographic determinants of risk, colon distribution and density scores of divertieular disease. World J Gastroenterol 2011; 178: 1009-17. FerzocoLB, RaptopoulousV, SilenW. Acute Diverticulitis. Current Concepts 1998; 338: 1521-6. Weizman AV, Nguyen GC. Divertieular disease: Epidemiology and management. Can J Gastroenterol 2011; 25: 385-9. Martin ST, Stocchi L. New and emerging tratmentsforthe prevention of recurrent diverticulitis. Clin Exp Gastroenterol 2011 ; 2:203-12. Flosch CL. Diagnosis and management of acute diverticulitis. J Clin Gastroenterol 2006; 3:136-44. Sheiman L, Levine MS, Levine AA, et al. Chronic diverticulitis: clinical, radiographie, and pathologic findings. AJR Am J Roentgenol 2008; 191: 522-8. Kireher M F, Rhea J T, Kihiezak D, Novelline RA. Frequency, sensitivity, and speeifieity of individual signs of divertieulitis on thinseetion helieal CT with eolonie eontrast material: experienee with 312eases. Am J Roentgenol 2002; 178:1313-8. Jeong HJ, Lee HL, Kim JO, et al. Correlation between eomplieated divertieulitis and viseeral fat. J Korean Med Sei 2011 ; 26:1339-43.
Copyright of Eurasian Journal of Medicine is the property of Aves Yayincilik Ltd. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
