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.

Multi-slice spiral computed tomography diagnosis of juxta-papillary duodenal diverticulum and its relationship with biliopancreatic diseases.

BACKGROUND: Juxta-papillary duodenal diverticula (JPDD) are common but are usually asymptomatic, and they are often diagnosed by coincidence. OBJECTIVE: To analyse the anatomy and classification of JPDD and its relationship with biliary and pancreatic disorders, and to explore the diagnostic value of multi-slice spiral computed tomography (MSCT) in patients with JPDD. METHODS: The imaging data of patients with JPDD, which was obtained via abdominal computed tomography examination and confirmed via gastroscopy and/or upper gastrointestinal barium enema, in our hospital from 1 January 2019 to 31 December 2020 were retrospectively analysed. All patients were scanned using MSCT, and the imaging findings, classification and grading were analysed. RESULTS: A total of 119 duodenal diverticula were detected in 96 patients, including 73 single diverticula and 23 multiple diverticula. The imaging findings were mainly cystic lesions of the inner wall of the duodenum protruding to the outside of the cavity. The thin layer showed a narrow neck connected with the duodenal cavity, and the shape and size of the diverticula were different: 67 central-type cases and 29 peripheral-type cases. There were 50 cases of type I, 33 cases of type II, 19 cases of type III and six cases of type IV. Furthermore, there were seven small, 87 medium and 14 large diverticula. The differences in the location and size of the JPDD in MSCT grading were statistically significant (P< 0.05). CONCLUSION: The MSCT method has an important diagnostic value for the classification of JPDD, and MSCT images are helpful in the clinical evaluation of patients with JPDD and the selection of treatment options.

Gastrointestinal stromal tumour in a jejunal diverticulum: The eighth reported case worldwide with a brief review of the literature.

Jejunal diverticulosis is uncommon and so are gastrointestinal stromal tumours (GIST) arising in the jejunum. GIST arising in a jejunal diverticulum is a rarity and to date there are only 7 cases in the English literature. Our case of GIST occurring in a jejunal diverticulum of a 48-year-old lady would be the first reported in Malaysia and the 8th in the world. As in most cases, the clinical presentation and radiological findings of this patient were non-specific. With a history of acute abdominal pain, vomiting and fever, the patient was provisionally diagnosed as a case of twisted ovarian cyst and subjected to laparotomy. An intact roundish jejunal diverticulum 5.0 cm x 5.0 cm, about 50 cm distal to the duodeno-jejunal junction was found and resected with a segment of small intestine. Microscopic examination showed a tumour of the cut open diverticular wall, with epithelioid to spindled cells, demonstrating a mitotic rate of 1-2 per 5 mm2, confined to, while infiltrating the wall of the diverticulum. The immunohistochemical profile of positive staining for CD117, DOG-1, smooth muscle actin and CD34, and negative expression of desmin and S100 protein, clinched the diagnosis of GIST. Based on the AFIP Criteria for risk stratification,1 the patient was categorised as having moderate risk for disease progression, and was not offered further targeted imatinib as an immediate measure. The patient has remained well at the time of writing i.e. 8 months following excision, and continues on active surveillance by the surgical and oncological teams, with the option of imatinib, should the necessity arise. This case is presented not merely for the sake of documenting its rarity, but as a reminder to stay alert for uncommon conditions in histopathology practice.

Tip-in endoscopic papillectomy for ampullary adenoma near diverticulum to minimize complications.

Toyonaga and colleagues present a novel "tip-in endoscopic papillectomy" approach for resecting ampullary tumors, aiming to minimize complications like perforation and residual tumor by adapting the colonic polyp endoscopic mucosal resection tip-in method. The technique is described with accompanying video in a case of ampullary tumor near a diverticulum.

Detailed Courses and Pathological Findings of Colonic Perforation without Diverticula in Sisters with Musculocontractural Ehlers-Danlos Syndrome Caused by Pathogenic Variant in CHST14 (mcEDS-CHST14).

Musculocontractural Ehlers-Danlos syndrome (mcEDS) is a heritable connective tissue disorder characterized by multiple congenital malformations and progressive connective-tissue-fragility-related manifestations in the cutaneous, skeletal, cardiovascular, visceral, ocular, and gastrointestinal systems. It is caused by pathogenic variants in the carbohydrate sulfotransferase 14 gene (mcEDS-CHST14) or in the dermatan sulfate epimerase gene (mcEDS-DSE). As gastrointestinal complications of mcEDS-CHST14, diverticula in the colon, small intestine, or stomach have been reported, which may lead to gastrointestinal perforation, here, we describe sisters with mcEDS-CHST14, who developed colonic perforation with no evidence of diverticula and were successfully treated through surgery (a resection of perforation site and colostomy) and careful postoperative care. A pathological investigation did not show specific abnormalities of the colon at the perforation site. Patients with mcEDS-CHST14 aged from the teens to the 30s should undergo not only abdominal X-ray photography but also abdominal computed tomography when they experience abdominal pain.

Fibromyxoid Nephrogenic Adenoma: A Series of 43 Cases Reassessing Predisposing Conditions, Clinical Presentation, and Morphology.

Nephrogenic adenoma is a benign epithelial lesion of the genitourinary tract that arises from the reimplantation and proliferation of shed renal tubular cells in areas of urothelial injury and denudation. Fibromyxoid nephrogenic adenoma is a rare variant that consists of compressed spindle-shaped renal epithelial cells in a fibromyxoid background. Only 14 observations of this variant are reported in the literature. We performed a retrospective analysis of fibromyxoid nephrogenic adenomas from 3 large reference centers. We identified 43 lesions in 6 women and 36 men (2 in 1 man) with a median age of 72 years (range, 31 to 94 y). Median lesion size was 0.7 cm (range, 0.2 to 5 cm). Nephrogenic adenomas were in the bladder (n=15), prostate/prostatic urethra (n=14), kidney (n=7), ureter (n=3), penile urethra (n=3), and urethral diverticulum (n=1). One of the kidney lesions developed in an end-stage kidney and radiologically mimicked cancer. Of 37 patients with information, 36 had predisposing conditions including prior biopsy, transurethral resection of bladder tumor, resection, Foley catheter, BCG treatment, urinary stones, (chemo)radiation, or diverticulum. Only 4/37 (10.8%) had a history of prior irradiation. Fifteen lesions had pure fibromyxoid morphology and 28 were admixed classic and fibromyxoid patterns. Three nephrogenic adenomas involved prostatic stroma, 3 renal sinus fat, 2 muscularis propria (1 bladder, 1 renal pelvis), 1 perinephric fat, and 1 corpus spongiosum. Ten fibromyxoid nephrogenic adenomas were intermixed with urothelial carcinoma, 1 with prostate adenocarcinoma, and 1 with malignant melanoma. By immunohistochemistry, PAX8 was positive in all the examined lesions (n=31). Napsin A was negative in all examined fibromyxoid nephrogenic adenomas (n=30). Twenty of them had classic nephrogenic adenoma component which was positive for napsin A. Similar to classic nephrogenic adenoma, fibromyxoid nephrogenic adenoma can occur anywhere along the urinary tract and is associated with a prior history that causes urothelial injury. In nearly a quarter of the cases, fibromyxoid nephrogenic adenoma extended beyond the lamina propria. Unlike previously suggested, fibromyxoid nephrogenic adenoma is not specifically related to prior radiation therapy. Awareness of this variant is important to avoid misdiagnosis and overtreatment.

Type 2 calyceal diverticulum with an unusual appearance in the lower pole of the kidney.

A 45-year-old woman presented to our clinic with intermittent left flank pain. The family physician referred her for renal cystic mass with a calcified appearance. The non-contrast spiral abdominal computed tomographic (CT) scan demonstrated the mass-like cystic lesion with a densely calcified lesion in the lower pole of the kidney. A detailed history revealed that she underwent shock wave lithotripsy (SWL) for the lower pole renal stone one year ago. After SWL, the stone fragments migrated to the dependent diverticulum region and produced the misleading appearance of a Bosniak type III lesion. Contrast-enhanced computed tomography (CT) scan was done for further evaluation, and finally, the diagnosis of the calyceal diverticulum was confirmed in the lower pole of the kidney. Calyceal diverticula are the outpouching of the pyelocalyceal system lined by non-secretory transitional epithelium. It is a rare condition that occurs in less than 0.5% of the population. Most patients are asymptomatic and have been discovered incidentally in routine imaging modalities. As most of the patients are asymptomatic, many do not need intervention. However, in some instances, patients present with flank pain, hematuria, urinary tract infection, and stone formation in the diverticulum. They are in the differential diagnosis of renal cystic lesions such as simple renal cyst, renal cortical abscess, and parapelvic cyst. In renal cystic lesion besides of simple renal cyst or renal cystic mass, we should keep the differential diagnosis of the calyceal diverticulum type 2, especially in patients that underwent SWL for renal stones; the fragmented residual stone may have migrated to this dilated region and produce the deceptive appearance of a Bosniak type III lesion.

The Aortic Ductus Diverticulum-Innocent Bystander or Potential Source of Thromboembolic Stroke?

OBJECTIVE: Due to reversal blood flow in the diastolic phase, outpouchings at the aortic isthmus may carry the risk of thrombus formation and subsequent thromboembolism. The objective was to evaluate the association between aortic ductus diverticula (ADDs) and ischemic brain alterations in cerebral magnetic resonance imaging. METHODS: A retrospective analysis of 218 patients who received both a dedicated computed tomography angiography of the thoracic aorta and a brain magnetic resonance imaging was performed. Two radiologists independently reviewed all examinations for the presence of ADD as well as ischemic alterations of the brain. The association between this anatomical variant and ischemic brain alterations was evaluated by univariate and bivariate logistic regression analyses. RESULTS: ADDs were identified/present in 35 of 218 patients (16%). Ischemic brain alterations were found in 57% of patients (20/35) with an ADD and in 42% of the control group (77/183, P = 0.1). The presence of an ADD did not prove to be an independent risk factor for ischemic brain alterations after multivariate adjustment (odds ratio = 1.7, 95% confidence interval = 0.72-3.96, P = 0.225). CONCLUSIONS: In the present study, ADDs were not significantly associated with ischemic brain alterations. Therefore, ADDs seem to be an innocent bystander with respect to the pathogenesis of ischemic brain alterations.

Male urethral diverticulum squamous cell carcinoma containing a calculus: a rare entity.

Male urethral diverticula with calculi have a low incidence. It is extremely rare when the diverticulum accompanied with carcinoma. We report a case of diverticulum of the male urethra containing giant calculi which developed into squamous cell carcinoma. The patient initially presented with lower urinary tract symptoms and a hard, painless perineal mass. We believe that the process of diagnosis and treatment is of great significance in clinical practice.

Ultrastructural Features of the Aortic Wall in a Patient with Kommerell Diverticulum.

We report on the ultrastructural features of the aortic wall in a patient with Kommerell diverticulum. A 70-year-old woman with a right aortic arch, aberrant left subclavian artery, and Kommerell diverticulum underwent a successful total arch replacement plus the frozen elephant trunk procedure with anatomical left subclavian artery reconstruction. Small pieces of the ascending aorta, distal arch, right common carotid artery, and left subclavian artery were investigated ultrastructurally. In the ascending aortic wall, multiple cystic cavities were observed in the subintimal region of the media by scanning electron microscopy. Changes in organelles, including mild dilation of rough-surfaced endoplasmic reticulum and mitochondrial swelling and degrading, were also observed in all specimens by transmission electron microscopy. These ultrastructural features may indicate the fragility or stress of the aortic wall and are useful when considering the early surgical intervention of a patient with Kommerell diverticulum.

Enlarged uterine fibroid forming uterine diverticulum during pregnancy: a case report.

BACKGROUND: Although uterine fibroids are a common gynecologic neoplasm, uterine diverticulum accompanied by a uterine fibroid is unique. In addition, pregnancy complicated with uterine diverticulum is extremely rare. We experienced a case of a uterine fibroid that was associated with a uterine diverticulum that enlarged during pregnancy and puerperium. CASE PRESENTATION: A 25-year-old nulligravida woman had an abnormal uterine cavity surrounded by myomatous mass. After natural conception, the mass and pouch had enlarged during pregnancy. Six months after elective cesarean delivery, she underwent laparotomy because of abdominal pain caused by the myomatous mass and the fluid inside. The tumor was connected to the midline of the posterior wall of the normal uterus. The resected tumor was pathologically diagnosed as leiomyoma and diverticulum. CONCLUSIONS: Pregnancy can stimulate uterine fibroids to form uterine diverticula. Resection of the diverticulum and fibroid is a useful option for symptomatic patients with desired future fertility.

Right-sided diverticulosis is an independent risk factor for bleeding in patients admitted for diverticular disease.

BACKGROUND: Diverticular bleeding is the main cause of lower gastrointestinal bleeding in both Eastern and Western countries. Several risk factors have been identified, such as comorbidities and concomitant medications. In Eastern population, the prevalence of right-side diverticulosis is higher than in Western one, and some Authors identified bilateral diverticulosis as a risk factor for bleeding. AIMS: To identify risk factors for diverticular bleeding in patients admitted for diverticular disease (DD). METHODS: All patients admitted for DD from January 2017 to December 2018 were retrieved from the hospital Information System. For each patient, age, gender, clinical presentation and concomitant medication were recorded. All patient underwent imaging assessment (computed tomography, ultrasound or MRI) and colonoscopy during hospitalization or within one month. RESULTS: Among 1248 patients discharged with a diagnosis of DD during the study period, 293 (52.2% male, median age 75 years) were finally analyzed; of them, 105 (35.8%) for diverticular bleeding. On multivariate analysis, male gender (OR 4.27), age (OR 1.12), anti-thrombotic medications (OR 2.60) and right-sided DD (OR 5.70) were independently correlated to diverticular bleeding. CONCLUSION: Our study provides evidence that, together with age, male gender and concomitant anti-thrombotic treatment, right-sided DD represents an independent risk factor for bleeding.

A Case of Duodenal Tumor Adjacent to the Diverticulum That Was Resected by the Technique of Partial Submucosal Injection Combined with Underwater Endoscopic Mucosal Resection.

A 66-year-old male was referred to our hospital for treatment of duodenal tumor. The most difficult part was that the lesion was adjacent to duodenal diverticulum. Endoscopic mucosal resection (EMR) was difficult because submucosal injection spread broadly and quickly and makes it difficult to visualize the diverticulum edge of the lesion. Simple underwater EMR (UEMR) had risk for perforation at the diverticulum part because duodenal diverticulum is spurious diverticulum that defects the proper muscle layer. Therefore, to make sufficient distance between diverticulum and the lesion, we performed partial submucosal injection into only the diverticulum side of the lesion combined with simple UEMR. The lesion was resected en bloc without any adverse events. Histopathological diagnosis was tubular adenoma with moderate atypia and surgical margin negative. Partial submucosal injection combined with simple UEMR might be useful for duodenal tumor that has any technical difficulties as in this case.

Macroscopic and microscopic characteristics of low grade appendiceal mucinous neoplasms (LAMN) on appendectomy specimens and correlations with pseudomyxoma peritonei development risk.

Low grade appendiceal mucinous neoplasm (LAMN) is the primary source of pseudomyxoma peritonei (PMP). PMP may develop after seemingly complete resection of primary tumor by appendectomy, which is unpredictable due to lack of reliable prognostic indicators. We retrospectively reviewed 154 surgically resected LAMNs to explore if any of the macroscopic and microscopic characteristics may be associated with increasing risk of PMP development. Our major findings include: (1) As compared to those without PMP, the cases that developed PMP were more frequent to have (a) smaller luminal diameter (<1 cm) and thicker wall, separate mucin aggregations, and microscopic perforation/rupture, all suggestive of luminal mucin leakage; (b) microscopic acellular mucin presenting on serosal surface and not being confined to mucosa; and (c) neoplastic epithelium dissecting outward beyond mucosa, however, with similar frequency of neoplastic cells being present in muscularis propria. (2) Involvement of neoplastic cells or/and acellular mucin at surgical margin did not necessarily lead to tumor recurrence or subsequent PMP, and clear margin did not absolutely prevent PMP development. (3) Coexisting diverticulum, resulted from neoplastic or non-neoplastic mucosa being herniated through muscle-lacking vascular hiatus of appendiceal wall, was seen in a quarter of LAMN cases, regardless of PMP. The diverticular portion of tumor involvement was often the weakest point where rupture occurred. In conclusion, proper evaluation of surgical specimens with search for mucin and neoplastic cells on serosa and for microscopic perforation, which are of prognostic significance, should be emphasized.

Recurrent ascending cholangitis with acute pancreatitis and pancreatic atrophy caused by a juxtapapillary duodenal diverticulum: A case report and literature review.

RATIONALE: Intermittent combined pancreaticobiliary obstruction may lead to multiple episodes of ascending cholangitis and pancreatitis, usually due to choledocholithiasis or periampullary mass. However, one of the rare causes is periampullary or juxtapapillary duodenal diverticulum. Although duodenal diverticula are relatively common in the general population, the overwhelming majority are asymptomatic. Duodenal diverticula can cause combined pancreaticobiliary obstruction through multiple mechanisms such as stasis-induced primary choledocholithiasis, stasis-induced intradiverticular enterolith, or longstanding diverticulitis, causing stenosing fibrosing papillitis or a combination of more than one of these mechanisms. Herein, I report a case of Lemmel syndrome due to a combination of multiple mechanisms and review the available literature on the epidemiology, pathogenesis, clinical presentation, diagnostic work-up, and management of juxtapapillary duodenal diverticulum. PATIENT CONCERNS: Multiple episodes of abdominal pain, jaundice, anorexia, fever, and significant unintentional weight loss. DIAGNOSES AND INTERVENTIONS: Primary choledocholithiasis, recurrent ascending cholangitis, recurrent acute pancreatitis, and pancreatic atrophy due to giant juxtapapillary duodenal diverticulum, with unsuccessful endoscopic retrograde cholangiopancreatography that was completely resolved after open transduodenal sphincteroplasty and septoplasty, transampullary and transcystic common bile duct exploration and stone extraction, and duodenal diverticular inversion. OUTCOME: Complete resolution of combined pancreaticobiliary obstruction without recurrence for 2 years after surgery. LESSONS: Surgeons should be aware of such rare syndromes to avoid misdiagnosis and delayed or inappropriate management. Furthermore, they should understand the different available operative options for cases that are refractory to endoscopic approach.

An Inflamed, Giant, True, Extramural Duodenal Diverticulum: A Rare Autopsy Finding.

A 53-year-old man was found to have a giant 16 × 6-cm hemorrhagic and cystic mass centered on the pancreas and duodenum. Initially diagnosed as a pancreatic pseudocyst at the time of autopsy, the cystic mass was later determined by histologic examination to be a true diverticulum of the duodenum as microscopic examination of the wall revealed 2 layers of muscle, as well as a neutrophilic infiltrate. While the cause of death of the individual was certified as methamphetamine toxicity, cardiomegaly and probable dehydration associated with a giant duodenal diverticulum were listed as contributory conditions. While duodenal diverticula in general are relatively uncommon findings, an extramural, true, giant duodenal diverticulum that is inflamed is a rare clinical or autopsy finding, with only 2 case reports identified in the clinical medical literature and none in the forensic literature.

Appendiceal neurofibroma and diverticula in a neurofibromatosis type 1 patient with chronic right lower quadrant pain.

Neurofibromatosis type 1 (NF1, Von Recklinghausen disease) is an autosomal dominant disease with a birth incidence of 1/2500-3000. The most common presentations of NF1 are cutaneous presentations like café-au-lait spots and neurofibromas. 5%-25% of patients with NF1 have gastrointestinal manifestations of the disease. Appendiceal neurofibroma are extremely rare and only a few cases are described in literature. An appendectomy is indicated because of high risk of appendicitis and malignant transformation. We report the case of a 74-year-old male patient with a history of NF1 with chronic right lower quadrant pain. Successive imaging scans showed suspicion of chronic appendicitis. A diagnostic laparoscopy, resulting in a laparoscopic appendectomy was performed without complications. Histopathology showed appendiceal neurofibroma and diverticula. The postoperative course was uneventful. In patients with NF1 with right lower quadrant pain benign appendiceal neurofibroma should be included in the differential diagnosis. A diagnostic laparoscopy should be performed followed by an appendectomy.