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Thread: Diverticular Polyp Pictures - Atlas of Colon and Ileum

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    Default Diverticular Polyp Pictures - Atlas of Colon and Ileum

    Diverticular disease of the colon, a condition frequently observed in clinical practice, may be responsible for abdominal symptoms requiring colonoscopy. Colonoscopy may reveal the presence of polyps, often adenomas concomitant with diverticular disease , which may be removed by endoscopic polypectomy. This procedure has been estimated to account for approximately 50% of the cases of perforation reported during colonoscopy, the incidence of which has been reported to be less than 0.05% The risk of such a complication is higher in the event of an inverted colonic diverticulum, which may be misinterpreted as a polypoid lesion at colonoscopy. To date, fewer than 20 cases of inverted colonic diverticula, diagnosed at colonoscopy or following air contrast barium enema, have been reported in the literature .

    The present report describes a patient who underwent a screening colonoscopy, which revealed a voluminous, pedunculated polyp recognized to be an inverted giant colonic diverticulum before endoscopic polypectomy.

    CASE PRESENTATION
    A 68-year-old woman was referred to the Department of Internal Medicine, Tor Vergata University (Rome, Italy), for a gastroenterological consult on account of abdominal pain and constipation. The patient’s symptoms persisted for approximately three months, without other relevant conditions or clinical signs in her medical history for which she would have undergone any previous digestive tract investigations. Routine hematochemical tests, including inflammatory parameters (C-reactive protein and erythrocyte sedimentation rate) as well as complete blood count, were within normal ranges. Following a standard bowel cleansing consisting of gut lavage with 4 L of polyethylene glycol, a full colonoscopy was performed, which revealed a polypoid lesion in the distal sigmoid with a head approximately 2.5 cm in size and a peduncle approximately 3 cm in length. The mucosa covering the head showed hyperemia and mild granularity (Figure 1). Multiple diverticula were also present in the left colon and in the tract where the polypoid lesion was located. Because standard assessments of coagulation and complete blood counts were within the normal ranges, removal of the polypoid lesion by means of endoscopic polypectomy with diathermal coagulation was scheduled. However, when in contact and moved with biopsy forceps, the head of the polyp appeared soft and empty (Figure 2). When delicate pressure was applied, the polypoid lesion appeared reduced in size, as if it was pushed out beyond the colonic wall. Polypectomy was abandoned and three biopsy specimens were collected from the head of the lesion to define its nature. Histology revealed the presence of hyperplastic epithelium and mild inflammatory changes in the normal colonic mucosa – a finding consistent with a diagnosis of inverted diverticulum of the colon.
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    DISCUSSION
    The present report described endoscopic findings with regard to a colonic lesion, first diagnosed as a polyp, possibly an adenoma; however, based on macroscopic features and histological findings, the lesion was subsequently revealed to be an inverted diverticulum of the colon. The relevance of this condition seems to reside in the apparent difficulty in reaching an appropriate diagnosis in clinical practice because, to date, fewer than 20 cases have been reported in the literature Of these, six were correctly diagnosed on radiology and five at colonoscopy while the remaining eight were diagnosed following histological assessment of colonic specimens after surgery in five cases and following endoscopic polypectomy in three. These data have led to speculation that there is a high possibility of missing an inverted colonic diverticulum, or misdiagnosing this condition as a polyp at radiology and colonoscopy. This outcome appears more likely when the lesion is large, such as the one described in the present case (greater than 2 cm in size), and strongly resembles a pedunculated polyp. This latter morphology has previously been observed in only two large (3 cm) inverted colonic diverticulae , one of which appeared as a pedunculated polyp and is very different from most cases of inverted diverticulum described to date, which were only a few millimetres in size.

    Although little data regarding the incidence of complications associated with inverted colonic diverticulum have been reported in the literature, it is tempting to hypothesize that an incorrect diagnosis of this condition, especially when resembling a polyp, may be responsible for severe complications such as perforation following endoscopic polypectomy with electrosurgical snare. Therefore, prompt diagnosis of an inverted colonic diverticulum during colonoscopy appears to be crucial. To more easily define a differential diagnosis between an inverted colonic diverticulum and common true polyps, it may be worthwhile to attempt to induce eversion of the diverticulum by air insufflation, as observed during radiological examination or colonoscopy or by probing the lesion with biopsy forceps and gently pushing it outside the colonic wall, as suggested by Triadafilopoulos These manoeuvres seem to be more successful in cases of a small diverticulum, but may fail in cases of a large inverted colonic diverticulum as, in part, occurred in the present case. In these occurrences, collection of biopsy specimens may reveal a normal mucosa, a finding consistent with a diagnosis of diverticulum. Recognizing that the wall of a diverticulum consists only of mucosa, biopsies should be performed with considerable caution. Indeed, biopsy specimens in the present case were collected without complications, a finding consistent with other reportsColonic perforation following biopsy collection from an inverted colonic diverticulum has been described in only one case . Thus, the risk of colonic perforation following biopsy collection from a large, inverted colonic diverticulum appears to be low.

    Epidemiology
    Diverticulosis is very common in westernised countries and is typically found in older individuals. At 40 years of age, approximately 5% of the population have diverticula; at 60 approximately 30%, increasing to 50-80% by the age of 80
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    Pathology
    Colonic diverticula are almost all false diverticula: mucosa herniating through a defect in the muscularis and covered by overlying serosa (where present). This herniation typically occurs where nutrient arteries enter the colon 1, and therefore, are more common on the mesenteric side of the colon.

    They are thought to relate to increased intraluminal pressure which may be a result of low volume stool. The colon is shortened and hypertrophied (myochosis coli).

    There is also an increased incidence of diverticula amongst patients with connective tissue disorders, e.g. Ehlers-Danlos syndrome, Marfan syndrome, scleroderma

    Colonic diverticula are most common in the sigmoid colon and, to a lesser extent, in the descending colon. The entire colon can be affected however, with 15% of patients having right sided diverticula . In patients from Asia, right sided diverticula are more common, and can either be single or multiple

    Barium enema
    Both single and double contrast barium enemas are able to demonstrate diverticula as barium-filled out-pouchings.
    When seen en-face they can look similar to polyps but can be distinguished by the presence of pooling contrast within the diverticulum and forming a meniscus. Even if seen on a recumbent overhead film, the two can usually be separated. (see differential below)
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    References:
    Colonic diverticulosis | Radiology Reference Article | Radiopaedia.org
    Look out before polypectomy in patients with diverticular disease – a case of a large, inverted diverticulum of the colon resembling a pedunculated polyp











    Last edited by Medical Photos; 09-15-2015 at 09:10 PM.

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