Giant colonic diverticulum.

CASE PRESENTATION A 58-year-old Hispanic man presented to the emergency department at Baylor University Medical Center complaining of a 1-year history of intermittent abdominal pain associated with occasional nausea and vomiting. He had been seen previously in another emergency department for this pain and had been treated with oral antibiotics and discharged home. However, he did not have a primary care physician and did not undergo routine screenings or colonoscopic surveillance. The patient was afebrile, and his vital signs were stable. His abdomen was mildly tender to palpation in the left upper quadrant but did not exhibit signs of peritonitis. He was also noted to have a nontender reducible epigastric hernia that was away from the area of his pain. Laboratory evaluations revealed a white blood cell count of 15.1 × 103/μL with no bandemia. A computed tomography scan of the abdomen and pelvis with Gastrografin and Omni-paque 350 revealed a 12.1 × 9.8-cm air-filled structure within the left upper quadrant (Figure). The structure exhibited mild wall thickening and appeared to contain a small volume of stool and liquid. It was surrounded by stranding inflammatory changes. The patient was admitted to the general ward, given orders to take nothing by mouth, and treated with intravenous fluid resuscitation and intravenous antibiotics, and a gentle bowel prep was started. At operation, a large inflammatory mass was found in the left upper quadrant with extremely dense adhesions. Careful dissection disclosed that the large air-filled mass was a perforated sigmoid diverticulum that had volvulized over the splenic flexure. An inflammatory rind held the sigmoid adherent to the transverse colon. After dissecting the sigmoid and the accompanying inflammatory mass free and mobilizing the splenic flexure, we performed a left hemicolectomy and sideto-side functional end-to-end anastomosis between the proximal transverse colon and rectum. Pathologic assessment of the specimen revealed that the diverticulum was contiguous with a GCD. The cystic portion was 12.5 × 12.5 × 12.0 cm, with a 0.2 cm diameter orifice. Surrounding inflammatory changes were present; two included lymph nodes were benign. The patient’s recovery was uneventful, and on the sixth postoperative day he was discharged home.