A rare case of Hepatic Flexure Diverticulitis after pelvic laparoscopy and review of literature for management.

Aniket K Sakharpe, MD, MPH, Jakub Wilhelm, MD, Nida Mumtaz, BS, Abdul Badr, MD, Robert Bloch, MD, FACS, Leopoldo Baccaro, MD, George Ibrahim, MD. Drexel University and Easton Hospital.

Diverticulosis commonly affects the geriatric patients, 10-15% of whom ultimately develop diverticulitis. Diverticulitis has many known complications, such as the formation of phlegmon, fistulas, bowel obstruction, bleeding, perforation and colonic abscess. Diverticulitis in the western world most commonly affects the sigmoid colon and presents as “left-sided appendicitis” in that location. A perforated sigmoid diverticulum is often recognized preoperatively. Diverticulosis involving the transverse colon, however, is a rare finding and a perforated diverticulum of thehepatic flexure is seldom considered in the differential diagnosis of acute abdomen. Right sided diverticulitis lacks the more specific signs and symptoms of sigmoid diverticulitis and is therefore a more difficult diagnosis based on clinical exam alone .We present a rare case of perforated hepatic flexure diverticulitis in a 57-year-old female who presented with free air in the abdomen after pelvic laproscopy.

The patient presented with a 5 day history of acute non-radiating right upper quadrant pain, which worsened with motion. A diagnostic laparoscopy done 5 days before for an ovarian cyst that was abandoned due to multiple intrabdominal adhesions in the pelvic area. Patient was tachycardic and febrile, the abdomen was soft, distended with rebound tenderness in the right upper quadrant. Laboratory studies revealed elevated white blood cell count of 15,000/ mL with 53% bands. We expected some iatrogenic injury to the lower colon but to our surprise noncontrast CT of the abdomen and pelvis revealed interloop bowel abscess with a lot of free air and thickening of the proximal transverse colon. On exploratory laparotomy patient was found to have a diverticular abscess due to perforated diverticula in the hepatic flexure and short segment of the proximal transverse colon. A partial transverse colectomy with end colostomy and distal mucus fistula was performed. The postoperative course was complicated by an intrabdominal abscess treated conservatively. The patient had reversal of the colostomy with colo-colonic anastomosis.

Diverticulitis frequently involves the sigmoid colon in Western populations and the right-sided colon in Asian populations.Extensive literature search indicates that 80% of patients with diverticulosis had diverticula in the descending and sigmoid colon, 10% in the transverse colon, 4% in the ascending and 2% in the cecum.Transverse colon diverticulitis can be managed with both medical and surgical interventions.

In conclusion transverse colon diverticulitis is a rare cause of acute abdomen and needs to be included in the differential diagnosis of our aging population

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