Rare symptom of left inguinal abscess secondary to a retroperitoneal perforation of diverticulitis of the sigmoid colon: A case report.

RATIONALE: Complicated colorectal diverticulitis could be fatal, and an abscess caused by this complication is usually formed at the pericolic, mesenteric, or pelvic abscess. Therefore, we report a rare case of sigmoid colon diverticulitis that developed a large inguinal abscess. PATIENT CONCERNS: A woman in her 70s was admitted to our hospital with a chief complaint of left inguinal swelling and tenderness 1 week before admission. Physical examination showed swelling, induration, and tenderness in the left inguinal region. Blood tests revealed elevated inflammatory reaction with C-reactive protein of 11.85 mg/dL and white blood cells of 10,300/µL. Contrast-enhanced computed tomography showed multiple colorectal diverticula in the sigmoid colon, edematous wall thickening with surrounding fatty tissue opacity, and abscess formation with gas in the left inguinal region extending from the left retroperitoneum. DIAGNOSES: The diagnosis was sigmoid colon diverticulitis with large abscess formation in the left inguinal region. INTERVENTIONS: Immediate percutaneous drainage of the left inguinal region was performed, as no sign of panperitonitis was observed. Intravenous piperacillin-tazobactam of 4.5 g was administered every 6 hours for 14 days. OUTCOMES: The inflammatory response improved, with C-reactive protein of 1.11 mg/dL and white blood cell of 5600/µL. Computed tomography of the abdomen confirmed the disappearance of the abscess in the left inguinal region, and complete epithelialization of the wound was achieved 60 days after the drainage. The patient is under observation without recurrence of diverticulitis. LESSONS: We report a rare case of sigmoid colon diverticulitis that developed a large inguinal abscess, which was immediately improved by percutaneous drainage and appropriate antibiotics administration.

Chronic lower abdominal pain in an elderly female patient: a case report about sigmoid colon fistula and pelvic abdominal infection.

An elderly woman patient presented with a history of recurrent right lower abdominal pain accompanied by fever and abnormal vaginal discharge for 36 years worse for two weeks. Conservative medical treatment was ineffective, by laparoscopic exploration combined with intraoperative colonoscopy, the presence of a sigmoid colon fistula and pelvic abdominal infection with foreign bodies were confirmed. It was hypothesized that the occurrence of recurrent right lower abdominal pain and intestinal fistula may be potentially associated with tubal injection sterilization performed 36 years ago.

Colo-salpingeal fistula: a rare gynecologic manifestation of diverticular disease.

INTRODUCTION: Diverticulitis can be complicated by fistulas between the colon and neighboring structures, which predispose to significant morbidity and mortality. Fistulas involving the female urogenital tract often present with urogynecologic symptoms, such as vaginal discharge or recurrent urinary tract infections. While colo-vaginal fistulas, a more common variant, often present with vaginal flatulence, colo-salpingeal fistulas are exceedingly rare and have not been reported with this symptomatology. We describe a case of colo-saplingeal fistula presenting with vaginal flatulence, requiring multidisciplinary collaboration for diagnosis and management. CASE: A 63-year-old woman presented with vaginal flatulence in the setting of persistent diverticulitis. Computed tomography (CT) scan revealed sigmoid diverticulitis, a submucosal abscess abutting the uterus, and air within the endometrial cavity, raising suspicion for a colo-uterine fistula. Following transient symptomatic relief with medical management and antibiotics, recurrence of symptoms prompted surgical intervention. Laparoscopic exploration allowed diagnosis of the colo-salpingeal fistula. Sigmoid colectomy and left salpingo-oophorectomy were performed with a minimally invasive surgical approach, resulting in an uncomplicated recovery with remission of symptoms. DISCUSSION: This rare case highlights novel gynecologic symptoms for a colo-salpingeal fistula, contrasted with reported presentations through a comprehensive literature review. This case underscores the importance of recognizing gynecologic symptoms related to diverticular disease, which may be subtle, but provide important considerations for prognosis and treatment. A multidisciplinary approach to care from diagnosis through surgery allowed for successful recognition and minimally invasive treatment of this anomalous condition before further complications could arise. Ultimately, surgical approaches to diverticulitis-associated gynecologic fistulas should be individualized.

Surgical outcomes in ileal Crohn's disease complicated by ileosigmoid fistula.

BACKGROUND: The management of Crohn's disease (CD) complicated by ileosigmoid fistula (ISF) remains a challenge, and Australian outcomes have not previously been reported. METHODS: A retrospective review of a tertiary colorectal inflammatory bowel disease unit, across public and private sites, from 2005 to 2023 to identify adult patients having undergone operative management of ISF. RESULTS: Twenty-nine patients underwent surgery for ISF in the study period. Seventeen were male and the median age was 40 years. The pre-operative diagnosis of ISF was made in 76%, and patients were more likely to undergo resectional surgery if the pre-operative diagnosis was made endoscopically. Sixty-nine percent of cases were performed electively, with 76% completed laparoscopically with an 18.5% conversion rate to an open approach. The ISF was oversewn in three patients, repaired primarily in 14 patients, managed with segmental wedge resection in eight patients and resected via an anterior resection in four patients. The rate of stoma formation at the index procedure was 20.7% overall and 22% in patients being acutely managed with steroids. Emergent cases were more likely to be defunctioned with a stoma. Morbidity was 17.2% with a single anastomotic leak. CONCLUSION: ISF in CD remains difficult to diagnose pre-operatively, but can be safely managed laparoscopically without formal resection, and with limited use of diverting stoma formation. The specific surgical approach to the sigmoid in ISF is difficult to pre-determine and often requires decisions to be made intra-operatively.

Outcomes for sigmoid volvulus managed with and without early definitive surgery: 20-year experience in a tertiary referral centre.

BACKGROUND: Sigmoid volvulus is rare in Western countries. Patients at risk of sigmoid volvulus are often older with significant co-morbidity. Without sigmoid colectomy there is a high recurrence rate, but indications for surgery are controversial. METHODS: A retrospective observational study was conducted by reviewing clinical records of patients admitted to Waikato Hospital 1 January 2000 to 1 January 2020 with a diagnosis of sigmoid volvulus. Patient characteristics, clinical features, investigations, management, and outcomes were recorded. RESULTS: One hundred and thirty-two patients (87 male) were included with 203 volvulus episodes. Median age 76 years, median Charlson co-morbidity index (CCI) 4. Median follow-up 11 years. 44/132 (33.3%) had surgery during the index admission, two had elective surgery and the remainder had planned non-operative management. 73/132 (55.3%) had surgery at any stage. 42/86 (48.8%) patients managed non-operatively recurred; 66.7% of recurrences were within 6 months. Forty-three (32.6%) died within 12 months of index admission; 28 (21.2%) died during an admission for volvulus. On univariate analysis higher age and abnormal vital signs were associated with inpatient and 12-month mortality; higher CCI was associated with 12-month mortality. On multi-variate analysis increasing age in years was associated with increased risk of death (HR 1.089 [1.052-1.128, P < 0.001]). Normal vital signs at presentation were associated with decreased risk of death (HR 0.147 [0.065-0.334, P < 0.001]). CONCLUSION: Sigmoid colectomy should be considered at index presentation with sigmoid volvulus. Half of patients managed non-operatively recurred, with two-thirds recurring within 6 months. The mortality rate remains high for subsequent volvulus episodes.

Eosinophilic Myenteric Ganglionitis Presenting as Sigmoid Volvulus: A Brief Report.

Eosinophilic myenteric ganglionitis (EMG) is a rare pathologic finding within the Auerbach myenteric plexus characterized by eosinophilic infiltration on light microscopy. The plexus's ultimate obliteration results in chronic intestinal pseudo-obstruction (CIPO). EMG is almost exclusively seen in the pediatric population. The diagnosis of EMG is made through full-thickness rectal biopsy and EMG is not detectable through routine screening measures such as imaging or colonoscopy. The current treatment modality for this disorder is not standardized, and has often been treated with systemic steroids given its eosinophilic involvement. This case presents a 73-year-old male with chronic constipation presenting with new obstipation in the setting of recent orthopedic intervention requiring outpatient opioids. Admission radiographs were consistent with sigmoid volvulus. Following endoscopic detorsion, exploratory laparotomy revealed diffuse colonic dilation and distal ischemia requiring a Hartmann's procedure. Surgical pathology revealed EMG, increasing the complexity of subsequent surgical decision-making after his urgent operation.

Sigmoid volvulus: Evaluating identification strategies and contemporary multicenter outcomes.

BACKGROUND: There is limited epidemiologic data on sigmoid volvulus (SV) from non-endemic regions. Therefore, we performed a multicenter study to report contemporary outcomes and appraise literature-based methods that pair diagnostic and procedural codes to identify SV. METHOD: Using an automated search for patients with 'volvulus' in our system from 2011 to 2021, we reviewed electronic charts to clarify the diagnosis, automatically replicate three strategies to identify SV, and retrieved 6-month outcomes. RESULTS: Of 895 patients, 109 had SV. Literature-based strategies poorly identified SV. At the index admission, patients underwent endoscopic reduction alone (33%), emergent (16.5%), semi-elective (34%), or elective (16.5%) surgery. Endoscopic reduction alone had high recurrence rates and delayed surgery was associated with worse outcomes. CONCLUSION: Literature-based strategies to identify SV suffer from misclassification bias which affects patient counseling. In this large series, one-third of patients do not undergo during their index admission despite improved outcomes with earlier surgery.

Successful gallstone ileus treatment by endoscopy.

We present the case of a 73-year-old woman who was admitted to hospital with a 6-day history of complete constipation, abdominal pain and vomiting. An abdominal CT scan is performed that shows a large colonic dilatation. In the sigmoid colon identifying a 43x20mm gallstone impaction and a solution of continuity between the gallbladder and the hepatic flexure with pneumobilia associated. Because the obstruction is located at the sigmoid colon, it was decided to perform an urgent colonoscopy. During the endoscopy, the gallstone was observed, which was successfully extracted using a Roth Net. The surrounding mucosa showed signs of mucosal damage and an extensive decubitus ulcer. After endoscopy, the patient presented resolution of the obstructive condition. During her admission, surgery was performed to resection the cholecystocolic fistula, cholecystectomy, and primary closure of the colon. However, the patient presented a torpid evolution with ascending colon perforation and necrotizing fasciitis in the surgical wound, finally dying of abdominal septic shock.

Factors precipitating volvulus formation in sigmoid volvulus.

BACKGROUND: Sigmoid volvulus (SV), the wrapping of the sigmoid colon around itself, is a rare intestinal obstruction form world-wide. For this reason, the physiopathology of SV, particularly the precipitating factors, are not clearly identified. The aim of this study is to evaluate the precipitating factors in SV. METHODS: The clinical records of consecutive 416 patients with SV were reviewed prospectively from January 1986 to July 2020. As a control, the records of consecutive 100 patients with non-volvulus intestinal obstruction were reviewed prospectively in the past 24 months. The premorbid symptoms including acute diarrhea, sudden and excessive body motions, overeating after a prolonged starvation, coughing spell, and labor was evaluated. RESULTS: Among the premorbid symptoms, 1-5-day interval of diarrhea (42 patients, 10.1%, p<0.05), harvesting activation (35 patients, 8.4%, p<0.05), and overeating after Ramadan fasting (31 patients, 7.5%, p<0.05) were found to be statistically significant precipitating factors in SV. CONCLUSION: Although there are few studies about the precipitating factors of SV in the literature, increased bowel motility, excessive body motions, and overeating following a prolonged starvation look like the precipitating factors in the development of SV.

Prognostic factors in the decision-making process for sigmoid volvulus: results of a single-centre retrospective cohort study.

BACKGROUND: Sigmoid volvulus is a common cause of emergency surgical admission. Those patients are often treated conservatively with a high rate of recurrence. We wondered if a more aggressive management might be indicated. METHODS: We have reviewed data of patients diagnosed with acute sigmoid volvulus over a 2-year period. The primary endpoint was patient survival. RESULTS: We analysed 332 admissions of 78 patients. 39.7% underwent resection. Survival was 54.9 ± 8.8 months from the first hospitalization, irrespective of the treatment. Long-term survival was positively influenced by being female, having a low "social score", a younger age and surgery. Multivariate analysis showed that only being female and surgery were independently associated with better survival. CONCLUSION: Early surgery may be the best approach in patients with recurrent sigmoid volvulus, as it ensures longer survival with a better quality of life, regardless of the patient's social and functional condition.