Metastatic Sigmoid Diverticulitis in the Era of Advanced Imaging and Health Care – A Case Report

Arunkumar Baskara, MRCS MD, Stefanie L Saunders, MS Medical Student, Prashanth Ramachandra, MD. Mercy Catholic Medical Center

Abstract :
Sigmoid diverticular disease is a common disorder and has been dubbed “the disease of Western civilization”. Morbidity and mortality associated with diverticular disease is primarily related to acute lower gastrointestinal bleeding, diverticulitis and perforated diverticulum. We present a case report of a patient who had unusual presentation of sigmoid diverticulitis. The clinical presentation and investigations were misleading for sigmoid colon mass with colo-vesical fistula, possible metastasis to the liver and brain. The patient was found to have metastatic sigmoid diverticulitis abscess. The patient made a full recovery after the brain abscess was drained and the sigmoid colon was resected
Our patient, a 54 years old gentleman, presented to the emergency room with acute onset of headache and weakness in the left upper extremity and passing stool in urine. On examination he had mild tenderness in the left lower quadrant with no signs of peritonitis. He was alert, awake and oriented to place, person and time with no focal neurological deficits. His lab investigations were unremarkable except for urine analysis which was positive for nitrite. CT scan of the head showed a cystic appearing lesion within the cortex and subcortical white matter in the right fronto-parietal region . Solid appearing lesions were found in the right centrum semiovale and right frontal white matter suggestive of metastatic tumor, lymphoma or infection.
CT abdomen and pelvis showed sigmoid colon mass colo-vesical fistula solitary liver lesion and thrombosis of right branch of the portal vein. CT chest showed chronic obstructive pulmonary disease. His carcinoembryonic antigen level was 2.6.
During the hospital stay, he had clonic-tonic seizure. The patient was started on intravenous (IV) anticonvulsants for seizures, IV steroids for brain edema, IV anticoagulation for portal venous thrombosis and IV antibiotics for urinary tract infection. MRI of the brain revealed multiple ring and solid enhancing lesions in the right frontal lobe and right centrum semi ovale.
Colonoscopy showed diverticular disease in the left colon, a 6 mm sessile polyp at 40 cm from the anal verge. Snare polypectomy was done using electrocautery and specimen was sent for histopathology. Rigid cystoscopy showed fistula tract with evidence of stool coming from the fistula. There were not tumors or stones in the bladder. Biopsies were taken around the fistula site.
In order to obtain tissue diagnosis, neurosurgeons took the patient to the operating room for image guided right parietal craniotomy. Intra-operatively the lesion was visible on the surface and contained purulent material surrounded by a relatively thick and well organized wall which was consistent with an abscess. The specimen was sent to microbiology for aerobic, anaerobic, fungal, tuberculous culture sensitivity. Four days later the patient was taken back to the operating room for resection of sigmoid colon, repair of colo-vesical fistula and end colostomy with hartmann’s pouch. The specimen was sent for histopathology.His pathology report for colon polyp was positive for tubular adenoma with no evidence of high-grade dysplasia and malignancy. The pathology result for resected sigmoid colon was positive for diverticular disease with no malignancy
 

View Poster