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DIAGNOSTIC CHALLENGES IN COMPLICATED DIVERTICULITIS: A CASE REPORT
Srishti Kulshrestha
*, Rida Aziz, Andre Gabriel
Internal Medicine, Inspira Medical Center Mullica Hill, Mullica Hill, NJ
Introduction:The overlap in clinical and radiological features between diverticulitis and colorectal cancer can make diagnosis challenging. Persistant diverticulitis may mask malignancy, as seen in this case, emphasizing the need to consider cancer in patients with atypical symptoms or poor response to treatment.
Case Description: A 73-year-old woman with history of diverticulosis presented with 3 days of lower abdominal pain, constipation, and nausea. On arrival, she was hypertensive and tachypneic. Her lab results were significant for leukocytosis and mild normocytic anemia. CT imaging showed marked thickening of the sigmoid colon as well as an adjacent extraluminal air and fluid collected concerning for a walled-off perforated sigmoid diverticulitis. Conservative management was pursued as the collection was inaccessible for percutaneous drainage, and the patient was discharged on antibiotics. Two days later, she returned with new-onset vomiting and diarrhea and was admitted for concern of a small bowel obstruction secondary to a contained perforated diverticulitis with abscess. She was treated with a 3-week course of meropenem, after which her condition stabilized. A midline catheter was placed to facilitate outpatient ertapenem therapy under infectious disease follow-up. Despite treatment with more than 8-weeks of bread-spectrum antibiotics, the patient re-presented with complaints of worsening abdominal pain and distension. Repeat CT imaging showed a worsening distal bowel obstruction secondary to a 5.5cm soft tissue density encasing the proximal sigmoid colon (Figure 1), concerning for malignancy. Carcinoembryonic antigen (CEA) was elevated to 6 ng/mL. Exploratory laparotomy showed a rock-hard sigmoid mass adherent to the retroperitoneum, left ureter, and iliac bifurcation, precluding resection due to the risk of ureteral and vascular injury. A loop diverting colostomy was performed. A flexible sigmoidoscopy was attempted to obtain a biopsy of the mass. However, even a pediatric colonoscope was incapable of being advanced due to severe luminal narrowing to 20cm. The decision was made to wait for the post-operative swelling to subside and to follow closely with colorectal surgery, who may perform endoscopy via her ostomy site and pursue further workup of the colonic mass.
Discussion: Diverticulosis is common and typically benign, but progression to diverticulitis may obscure an underlying malignancy, as demonstrated in this case. Chronic inflammation or recurrent episodes of diverticulitis can mask the clinical signs of colorectal cancer. Physicians should maintain a high index of suspicion for malignancy in patients with atypical presentations, poor treatment response, or concerning imaging findings such as a fixed mass or bowel obstruction. Prompt biopsy and multidisciplinary care are essential to prevent diagnostic delays.
Abrupt decompression of the proximal sigmoid colon which is encased by a soft tissue mass measuring approximately 5.5 x 4.1 x 4.5 cm containing trace internal fluid/necrosis.
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