Uncommon Presentation of Xanthogranulomatous Cholecystitis in a True Gallbladder Diverticulum: A Case Report and Literature Review.

BACKGROUND The gallbladder develops from the hepatic diverticulum during the fourth week of gestation, which also give rise to the liver, extrahepatic biliary ducts, and ventral part of the pancreas. Infrequently, the gallbladder has malformation or disruption in embryogenesis, leading to congenital anomalies. There are various congenital anomalies that can arise in the gallbladder. True or congenital diverticulum of the gallbladder is a rare entity that accounts for only 0.06% of gallbladder congenital anomalies and 0.0008% of cholecystectomies at the Mayo Clinic. CASE REPORT Herein, we report a rare case of a 38-year-old woman who presented to Jubail General Hospital's surgery clinic with right upper-quadrant (RUQ) pain associated with vomiting after meals for 1 month. Laparoscopic cholecystectomy was done and gallbladder tissue was sent to histopathology. Gross examination revealed an outpouching mucosa within the wall that was proven to consist of muscularis and serosa layers under light microscope. Interestingly, xanthogranulomatous inflammation was confined to the diverticulum, unlike the chronic inflammation involving the remaining gallbladder. Based on the above findings, the diagnosis of congenital diverticulum with xanthogranulomatous cholecystitis was made. CONCLUSIONS Gallbladders associated with a true diverticulum are uncommonly found to be buried in the liver, leading to surgical difficulties during cholecystectomy. Therefore, background knowledge of occasional anomalies plays a crucial role in guiding the surgeon to choose the optimal method of management. We also discuss the associated complications that accompany these anomalies, such as non-specific prolonged ailments, acalculous cholecystitis, cholecystitis and cholelithiasis, recurrent cholangitis, and carcinoma of the gallbladder.

Huge congenital right ventricular diverticulum in tetralogy of Fallot with pulmonary atresia: A double trouble.

Congenital diverticulum is an uncommonly detected cardiac lesion, especially in infancy. However, its association with cyanotic congenital heart disease is extremely rare. In the current work, we report a case diagnosed in the neonatal period with tetralogy of Fallot and pulmonary valve atresia associated with a large congenital diverticulum originating from the right ventricle.

Jejunal Diverticulosis Causing Small Intestinal Volvulus and Closed Loop Obstruction.

BACKGROUND Jejunal diverticulosis are false diverticula of the small bowel that form from outpouching of the mucosa and submucosa. They are pulsion diverticula that are often asymptomatic and can be found incidentally during surgery. In some instances, jejunal diverticula could result in intestinal obstruction. Small intestinal volvulus is an uncommon cause of small bowel obstruction that results in a closed loop obstruction and is an indication for emergent surgical intervention. CASE REPORT We report a case of an 84-year-old man who presented to the Emergency Department with abdominal pain and generalized weakness. A preoperative computerized tomographic scan demonstrated a closed loop small bowel obstruction with mesenteric swirling. The patient was taken for a diagnostic laparoscopy, which revealed extensive proximal jejunal diverticulosis and a volvulus of the involved jejunum. An exploratory laparotomy was warranted for safe detorsion of the small bowel and resection of the diseased segment. The small bowel was successfully detorsed, with resection of the involved jejunum. Intestinal continuity was established by a primary side-to-side anastomosis. CONCLUSIONS Jejunal diverticula have been reported in the literature as a cause of small bowel obstructions, and very few reports exist of concurrent small bowel volvulus. In very rare instances, both of these conditions can coexist. There should be prompt surgical intervention in all cases of closed loop small bowel obstructions to prevent intestinal ischemia, perforation, and sepsis.

Digestive bleeding due to jejunal diverticula: diagnosis and management.

A jejunal diverticular haemorrhage is the second most common complication of jejunum diverticula. It can manifest clinically as acute upper gastrointestinal bleeding and is common to imitate acute rectal bleeding. Bleeding is usually associated with or without haemodynamic stability. Its diagnosis is challenging, requiring imaging examinations. Treatment is conservative management or surgery.

Clinical and urodynamics outcomes in pediatric primary bladder diverticula: a comparative study.

OBJECTIVE: This study aimed to compare the effects of bladder diverticula smaller than 30 (SD) mm and larger than 30 mm (LD) on bladder functions and urodynamics. MATERIALS AND METHODS: Our retrospective analysis involved a cohort of 40 pediatric patients diagnosed with primary bladder diverticula. RESULTS: The predicted mean bladder capacity (MBC) was 197.7 ± 95.8 mL, whereas the observed MBC was lower at an average of 170.1 ± 79.6 mL. This indicates that the observed MBC was 88.2 ± 12.9% of the predicted value (percentage). The mean diverticula diameter recorded was 33 ± 19.5 mm, and the diverticula to MBC ratio were calculated to be 0.25 ± 0.18. The distribution of urinary tract infections (UTIs) differed significantly between the groups (p < 0.001). Upper UT dilatation was significantly more common in the LD group (60%, n = 12) than in the SD group (15%, n = 3) (p = 0.003). The mean detrusor pressure (P[detrusor]) was significantly higher in the LD group (137.2 ± 24.1 cm H2O) than in the SD group (63.9 ± 5.8 cm H2O) (p = 0.001). In addition, the mean peak flow rate (Qmax) was significantly higher in the SD group (20.7 ± 7.9 mL/s) compared to the LD group (12.7 ± 3.8 mL/s) (p < 0.001). CONCLUSION: Bladder diverticula size is a significant factor in the clinical presentation and management of primary bladder diverticula in pediatric patients.

OBJETIVO: Este estudio tuvo como objetivo comparar los efectos de los divertículos vesicales menores 30 mm (SD), mayores 30 mm (LD) en las funciones y urodinámica de vejiga. MATERIALES Y MÉTODOS: Nuestro análisis retrospectivo involucró una cohorte de 40 pacientes pediátricos diagnosticados con divertículos vesicales primarios. RESULTADOS: Capacidad vesical media predicha (MBC) fue de 197.7 ± 95.8 mL, mientras que MBC observada fue menor con promedio de 170.1 ± 79.6 mL. Esto indica que MBC observada fue del 88.2 ± 12.9% del valor predicho (porcentaje). Diámetro medio de divertículos registrados fue de 33 ± 19.5 mm, y se calculó que relación entre los divertículos y la MBC era de 0.25 ± 0.18. Distribución de infecciones del tracto urinario (ITU) difirió significativamente entre grupos (p < 0.001). Dilatación del tracto urinario superior (UT) fue significativamente más común en grupo LD (60%, n = 12) que en grupo SD (15%, n = 3) (p = 0.003). Presión media del detrusor (P[detrusor]) fue significativamente mayor en grupo LD (137.2 ± 24.1 cm H2O) que en grupo SD (63.9 ± 5.8 cm H2O) (p = 0.001). Además, tasa de flujo máximo promedio (Qmax) fue significativamente mayor en grupo SD (20.7 ± 7.9 mL/seg) en comparación con grupo LD (12.7±3.8 mL/seg) (p < 0.001). CONCLUSIONES: Tamaño de divertículos vesicales es factor significativo en presentación clínica, manejo de divertículos vesicales primarios en pacientes pediátricos.

Efficacy of flexible ureterorenoscopy with holmium laser in the management of calyceal diverticular calculi.

The purpose of this study was to evaluate the efficacy and safety of flexible ureteroscopy with holmium laser lithotripsy in the management of calyceal diverticular calculi. In this study, we retrospectively analyzed the clinical data of 27 patients with calyceal diverticular calculi admitted to the Department of Urology of the Zigong First People's Hospital from May 2018 to May 2021. Intraoperatively, the diverticular neck was found in all 27 patients, but flexible ureterorenoscopy lithotripsy was not performed in 2 cases because of the slender diverticular neck, and the success rate of the operation was 92.6%. Of the 25 patients with successful lithotripsy, the mean operative time was 76.9 ± 35.5 (43-200) min. There were no serious intraoperative complications such as ureteral perforation, mucosal avulsion, or hemorrhage. Postoperative minor complications (Clavien classification I-II) occurred in 4 (16%) patients. The mean hospital stay was 4.4 ± 1.7 (3-12) days. The stone-free rate was 80% at the 1-month postoperative follow-up. After the second-stage treatment, the stone-free rate was 88%. In 22 cases with complete stone clearance, no stone recurrence was observed at 5.3 ± 2.6 (3-12) months follow-up. This retrospective study demonstrated that flexible ureterorenoscopy with holmium laser is a safe and effective choice for the treatment of calyceal diverticular calculi, because it utilizes the natural lumen of the human body and has the advantages of less trauma, fewer complications, and a higher stone-free rate.

Potential arrhythmic substrate of atrial fibrillation at the left atrial diverticulum.

Catheter ablation therapy for persistent atrial fibrillation (PeAF) is both difficult and has limited outcomes. The mechanisms underlying the development and persistence of atrial fibrillation (AF) are not fully understood; therefore, ablation strategies are diverse. A 45-year-old man was referred to our hospital for persistent atrial fibrillation to undergo radiofrequency catheter insertion (RFCA). In the first session we conducted pulmonary vein isolation and additional linear ablation, including that of the roof line and posterior inferior line (posterior box lesion) as the stepwise ablation. However, AF was recurred in six months, therefore he was readmitted for second session ablation preoperative 3D computed tomography (CT) scan for drug-refractory PeAF was performed. The additional isolation of the left superior pulmonary vein and potential drivers of AF by mapping wavefront propagation using multipolar catheters by CARTOFINDER (Biosense Webster, Inc, Diamond Bar, CA, USA) was conducted. However, AF did not terminate. Tomography revealed that the left atrial (LA) diverticulum (LAD) was found uniquely. Electrophysiological findings showed focal firing of the myocardial sleeve and LA diverticulum by an approach for defragmented potentials by re-visiting in interval confidence level (ICL) mode included in the electroanatomical mapping system (CARTO 3, Biosense Webster, Inc, Diamond Bar, CA, USA) and the ablation by encircling this site finally made AF terminate. The AF has not recurred for more than 12 months without the use of antiarrhythmic drugs. This case report suggests that additional ablation around substrates in LAD may be effective for treating refractory AF.

Urinary catheter placement and adverse urinary outcomes with a focus on elevated risk in men with indwelling Foley catheters.

BACKGROUND: Prior studies indicated a link between urinary catheter use and urinary complications, highlighting the need for comprehensive, gender-specific investigations. This study explored the association through a national retrospective cohort, emphasizing gender disparities and long-term outcomes. METHODS: Our study utilized data from the entire population covered by Taiwan's National Health Insurance Research Database from 2000 to 2017. We included 148,304 patients who had undergone Foley catheter placement and their propensity-scores matched controls in the study. We evaluated urinary complications, which encompassed urinary tract cancer, urolithiasis, urethral stricture, obstructive uropathy, reflux uropathy, fistula, diverticulum, caruncle, false passage, prolapsed urethral mucosa, urinary tract rupture, and urinary tract infection. These were assessed using the Fine and Gray sub-distribution proportional hazards model to compare between the Foley and non-Foley groups. Sensitivity analyses were conducted with different matching ratios. RESULTS: In the study, the non-Foley group presented a marginally higher mean age (75.24 ± 10.47 years) than the Foley group (74.09 ± 10.47 years). The mean duration of Foley catheterization was 6.1 ± 4.19 years. Men with Foley catheterization exhibited the highest adjusted sub-distribution hazard ratios for urinary tract cancer (6.57, 95% CI: 5.85-7.37), followed by women with Foley catheterization (4.48, 95% CI: 3.98-5.05), and men without catheterization (1.58, 95% CI: 1.39-1.8) in comparison with women without the procedure. Furthermore, men with Foley catheterization were found to be at the greatest risk for complications such as urolithiasis, urethral stricture, obstructive and reflux uropathy, fistula, diverticulum, caruncle, false passage, prolapsed urethral mucosa, and urinary tract rupture. Conversely, women with urinary catheterization were most susceptible to urinary tract infections. CONCLUSIONS: The evidence confirms that urinary catheterization significantly increases urinary complications, particularly among men. Our study underscores the crucial need for healthcare providers to carefully evaluate the necessity of catheterization, aim to shorten its duration whenever feasible, and strictly adhere to established protocols to minimize complications.

Colonic Diverticulosis at Colonoscopy in Africa: A Systematic Review and Meta-Analysis of Pooled Estimates.

INTRODUCTION: There is need to ascertain any epidemiologic shift of diverticulosis among Africans with traditionally high fiber diet consumption patterns and rare diverticulosis prevalence. METHODS: We systematically searched PubMed, Scopus, Cochrane Library, African Journal Online (AJOL), and Google Scholar. Eligibility criteria included full-text observational and experimental human colonoscopy studies on asymptomatic and symptomatic African population from 1985 to 2022. Case reports, conference abstracts, dissertations, systematic reviews, and studies lacking colonoscopy findings were excluded. NIH quality assessment tool for observational cohort and cross-sectional studies was used to assess risk of bias. Meta-analysis was performed using the random-effect model. Heterogeneity was assessed using inconsistency (I2) statistics. RESULTS: Thirty studies were included. Pooled prevalence rate of colonic diverticulosis in the last decade (2012-2022) has increased to 9.7% (95% CI 6.5-13.4; I2 = 97.3%) from 3.5% (95% CI 1.4-6.4; I2 = 62.7%). The highest regional prevalence rate was in West African studies at 11.3% (95% CI 7.6-14.9; I2 = 96.2%). Proportion of individuals with diverticulosis ≥50 years and male sex were 86.9% (95% CI 80.5-92.1) and 65.2% (95% CI 55.0-74.8), respectively. The left colon had the highest diverticulosis frequency (37% [148/400]). Bleeding/inflammation complications were sparingly detected (OR 0.2 [95% CI 0.03-0.75; p < 0.0001]). CONCLUSION: An increasing utilization of colonoscopy revealed approximately a threefold increase in the prevalence rate of colonic diverticulosis in Africa. This pathology was most common in males aged >50. Left colon was predominantly affected. Further studies are needed to demonstrate the effect of westernization of diet.

Esophageal intramural pseudodiverticulosis.

Esophageal intramural pseudodiverticulosis (EIPD) is a disease of unknown pathogenesis characterized by usually systemic, cystic dilatation of the excretory ducts of esophageal submucosal glands. In this article, I review the epidemiology, clinical manifestations, endoscopic findings, esophagographic findings, and histopathology of EIPD. I also discuss the etiology and possible pathogenesis of EIPD based on my experiences with this disease and a review of the literature. EIPD usually presents with dysphagia in middle-aged individuals. It is often complicated with secondary infections, most commonly candidiasis. On esophagography, EIPD is delineated as small, multiple, flask-shaped outward projections within the esophageal wall. In recent years, EIPD has been mainly diagnosed by endoscopic findings of multiple, localized, small mucosal depressions. The orifices of the "pseudodiverticula" periodically open and close, and excrete mucus onto the mucosal surface. On histopathological examination, the luminal surface of dilated ducts in EIPD is covered by multilayered, hyperplastic epithelial cells, but myoepithelial cells in the glandular acini are well preserved. Treatment of EIPD is usually symptomatic therapy, and prevention of the infectious complications is important. The etiology and pathogenesis of EIPD are largely unknown, but functional abnormalities of autonomic nerve fibers innervating the esophageal glands likely play an important role, since the structures of the glands are basically preserved in this disease.

Small Bowel Diverticulosis and COVID-19: Awareness Is the Key: A Case Series and Review of the Literature.

Small bowel non-Meckelian diverticulosis is a rare condition with only a few published cases despite being described over 200 years ago. In the midst of the COVID-19 pandemic, studies suggested that many patients may experience gastrointestinal manifestations. Intestinal symptoms could worsen the inflammation and infection associated with small bowel diverticulitis. Here we present three cases: one with inflammation and rupture in a COVID-19 patient and another as an asymptomatic detection. The third case involved recurrence after the first laparoscopic lavage approach. Furthermore, we provide a mini-review of the literature to emphasize the importance of considering this entity in the differential diagnosis of an acute abdomen. In the majority of cases involving small bowel diverticula, conservative management is the preferred approach. However, when complications arise, surgical intervention, including enteroctomy and primary anastomosis, may be necessary to achieve optimal outcomes.

Diverticulosis and risk of diverticulitis in 10 years; a Swedish retrospective observational study.

BACKGROUND: Diverticulosis is a common condition and is thought to be increasing in the Western population. Several studies have attempted to estimate the prevalence of diverticulosis and it's inflamed state, diverticulitis, with results varying depending on study population and methodology, The aim of this study was to investigate the prevalence of diverticulosis in patients undergoing colonoscopy at a Swedish academic referral centre and to study the incidence of diverticulitis in a 10-year follow-up. METHODS: All patients who had undergone colonoscopy at the Endoscopy unit, Skåne University Hospital, Sweden, during 01 January 2010 through 31 December 2011 were identified. The colonoscopy referrals, colonoscopy reports, and medical records until 14 June 2022 were reviewed. RESULTS: In all, 2648 patients were included in the study, whereof 910 patients had reported diverticulosis (34.4%). During the 10-year follow-up, the overall incidence of computed tomography verified diverticulitis was 4.4%, and 0.6% for patients with and without diverticulosis at index colonoscopy, respectively. Of the 50 patients that developed diverticulitis, 21 were complicated and 29 uncomplicated. CONCLUSION: Diverticulosis is a common condition in the population, although most patients will not develop diverticulitis.

Reproductive outcomes after in vitro fertilization in women with cesarean section scar diverticulum: A retrospective study.

PURPOSE: Some studies have suggested that cesarean section diverticulum may affect the pregnancy outcomes of assisted reproductive technology through a variety of mechanisms. This study aims to explore whether previous cesarean section and uterine scar diverticulum affect pregnancy outcomes after in vitro fertilization. METHODS: This retrospective study included 954 infertile women with only one previous delivery who had in vitro fertilization treatment and underwent fresh embryo transplantation for the first time at our center between 2015 and 2019. We first divided the women into two groups by previous vaginal delivery (n = 557) or cesarean section delivery (n = 397), and the latter group included 88 women with cesarean diverticulum and 309 women without cesarean diverticulum. Baseline characteristics were compared and analyzed, and logistic regression analyses were performed to explore the different pregnancy outcomes among the above groups. RESULTS: Although the live birth rate, clinical pregnancy rate, and mean embryo implantation rate after in vitro fertilization were significantly reduced in patients with previous cesarean section (live birth rate: 26.45% vs. 43.99%, adjusted OR: 0.602, CI: 0.447-0.810; clinical pregnancy rate: 35.26% vs. 49.91%, adjusted OR: 0.724, CI: 0.544-0.962; mean embryo implantation rate: 0.227 ± 0.378 vs. 0.243 ± 0.397, adjusted OR: 0.860, CI: 0.514-1.439), there were no significant differences in pregnancy outcomes between the women with cesarean diverticulum and without cesarean diverticulum (p > 0.05) or between the two groups at different ages. The live birth and clinical pregnancy rates in the women with residual muscle thickness ≤2.2 mm or prolonged menstruation were reduced, but the difference was not statistically significant (p > 0.05). CONCLUSION: This study showed reduced pregnancy and live birth rates after in vitro fertilization in patients with previous cesarean section, while uterine scarring did not adversely affect pregnancy and delivery outcomes after in vitro fertiliazation.

Surgical treatment for right-side aortic arch concomitant with Kommerell's diverticulum: techniques selection and follow-up results.

BACKGROUND: Right-side aortic arch concomitant with Kommerell's diverticulum (KD) is a rare and complex ailment, and there is no consensus on the optimal strategy to deal with this congenital anomaly. We retrospectively analyzed and summary of the cases treated in our center with individual treatment methods for different situations. METHODS: Between September 2018 and December 2021, 10 patients experienced surgical therapy at our institution who presented with a Kommerell's diverticulum arising from an aberrant subclavian artery from the right-side aortic arch. Four main surgical techniques were applied to those patients: 1. total arch replacement with frozen elephant trunk implantation (n = 2); 2. hybrid procedure combining open arch repair and endovascular intervention (n = 1); 3. total endovascular repair using thoracic endovascular aortic repair (TEVAR) with or without left subclavian artery (LSCA) revascularization (n = 6); 4. direct repair underwent endoaneurysmorrhaphy. Clinical characteristics and outcomes were collected. RESULTS: The mean age of these 10 patients was 56.5 years (range 29-79 years) and only 1 woman. The pathology includes aortic dissection (n = 6) and aneurysm (n = 4). The mean diverticulum size was 41.4 [24.2-56.8] mm. There were no in-hospital deaths, and the median hospital stay was 22 [15-43] days. During the follow-up period (21.4 months, 1-44 months), one died of an unknown cause and one died of esophageal fistula. Two patients underwent second-stage endovascular intervention for distal lesion. And none of the patients had endoleak during the follow-up period. CONCLUSIONS: Each of the procedures we have mentioned here has its advantages and disadvantages; individualized treatment should meet the appropriate indications. A single-branched stent graft is feasible and effective in the treatment of aortic disease combined with Kommerell's diverticulum.

A meta-analysis of the accessory left atrial appendage and the left atrial diverticulum.

Left atrial (LA) structures, including the accessory left atrial appendage (aLAA) and left atrial diverticulum, have been studied based on their prevalence, shape, and association with arrhythmia and thrombi formation. A pooled prevalence with morphometric data has not been determined in previous research. Our goal is to provide structured, clinically relevant information on said structures for clinical practitioners to use in their daily work. We propose that morphometric data of additional LA structures is necessary when considering the possible complications during cardiac interventions. We conducted a meta-analysis of all relevant studies which used electrocardiogram (ECG)-gated computed tomography (CT) imaging to determine the prevalence of LA structures and record their morphometric characteristics as well as the presence of thrombi. Data were extracted from 19 studies (n = 6643 hearts). The pooled prevalence estimate of left atrial diverticulum and/or aLAAs were reported from 14 studies and was 28.8%. The most common location noted was anterosuperior in the LA with 70.2% of structures found there. Data regarding thrombi presence in left atrial diverticulums or aLAAs were extracted from 11 studies and a thrombus was present in 0.2%. The prevalence rates of aLAAs and left atrial diverticulums are essential in performing uncomplicated cardiac interventions and reducing risk of electrophysiological procedures. Our findings show a considerable prevalence of LA structures in varying populations, provides information regarding the general characteristics of said structures, and does not support the previously theorized associated risk of thrombus formation in relation to LA structure presence.