Novel endoscopic management for acute diverticulitis with localized abscess

The clinical spectrum of acute diverticulitis ranges from a phlegmon to limited abscesses, to free perforation with purulent or contaminated peritonitis [1]. While there is little debate about the optimal treatment for mild or very severe situations, uncertainty remains about the optimal strategy for acute diverticulitis with localized abscesses. Here, we report a successful endoscopic diverticulotomy for limited septic diverticulitis caused by a fecal stone.

A 44-year-old man experienced sudden abdominal pain 1 week earlier and computed tomography scan at a local hospital showed a high density shadow in the colon ([Fig. 1] a). Colonoscopy showed a mucosal defect in the ascending colon ([Fig. 1] b). However, after 3 days of antibiotic treatment, the patient’s abdominal pain worsened. Blood tests showed a threefold increase in C-reaction protein to 36 mg/L and a twofold increase in white blood cell counts to 18 × 10⁹/L. The patient was then referred to our endoscopy center and underwent colonoscopy.

Fig. 1 Limited septic diverticulitis caused by an embedded fecal stone. a Computed tomography showed a high density shadow (arrow) in the colon. b A mucosal defect was seen in the ascending colon. c The diverticular opening was congested and edematous. d X-ray showed an approximately 1-cm diverticulum (arrow). e Photograph of the yellow fecal stone.

Septic diverticulitis was considered first. The diverticular opening was congested and edematous ([Fig. 1] c), and white pus could be drawn. X-ray showed an approximately 1-cm diverticulum with inflammatory exudates, fortunately without perforation ([Fig. 1] d). Inspired by endoscopic septum division for esophageal diverticulum [2], the diverticular septum was incised carefully and a yellow fecal stone, about 0.6 cm in diameter, slipped out ([Fig. 1] e, [Video 1]). The bottom and the opening of the diverticulum were treated with electrocoagulation and closed by endoloop-assisted clip closure. Following this treatment and 3 days of antibiotic therapy, the patient’s abdominal pain resolved and blood test results returned to the normal range.

Endoscopic diverticulotomy with stone extraction for limited septic diverticulitis.Video 1

This patient was diagnosed with a diverticular abscess caused by an embedded fecal stone in the diverticulum. Antibiotic therapy alone for septic diverticulitis is accompanied by a high risk of recurrence owing to the persistence of the etiology [3]. In this case, we endoscopically removed the fecal stone, drained the pus, destroyed the diverticulum, and sutured with endoloop-assisted clip closure, thus avoiding the need for surgery. During a 1 year follow-up period, the patient had no further acute diverticulitis. This case demonstrates novel endoscopic management for acute diverticulitis with localized abscesses.

Endoscopy_UCTN_Code_TTT_1AQ_2AJ

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We thank the endoscopy nurses for their superb collaboration in the procedure.

• References

• 1 Sartelli M, Weber DG, Kluger Y. et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 2020; 15: 32
• 2 Zhang DF, Chen WF, Wang Y. et al. Submucosal tunneling endoscopic septum division for esophageal diverticulum with a median follow-up of 39 months: a multicenter cohort study. Gastrointest Endosc 2022; 96: 612-619
• 3 Wong WD, Wexner SD, Lowry A. et al. Practice parameters for the treatment of sigmoid diverticulitis – supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000; 43: 290-297

Publication History

Article published online:
05 June 2024