EP405 - First Episode Of Acute Diverticulitis Presenting With Stricture And Large Bowel Obstruction: A Report Of Two Cases

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Purpose/Background: The incidence of diverticulitis has increased dramatically over the last 3 decades. It accounts for over 340,000 emergency department visits and over $2.2 billion per year. Complicated diverticulitis represents about 12% of this. Stricture is a well known complication of diverticulitis that typically occurs after prolonged inflammation and usually repeated episodes. We report two patients presenting with acute large bowel obstruction (LBO) requiring emergent sigmoidectomy as a result of a first episode of diverticulitis without any history of abdominal pain or gastrointestinal signs or symptoms. To date, there is no other literature describing LBO as initial presentation of diverticulitis. The aim of this discussion is to educate providers regarding aberrant presentation of a common GI malady, to increase awareness about virulent diverticulitis, and to generate discussion about screening and management of complicated diverticulitis.

Methods/Interventions: This is a case series describing LBO/stricture as the initial presentation of diverticulitis and its management.

Patient A: 48 year old man with abdominal pain and constipation for 5 days. Abdominal pain was sudden onset and steadily increased prompting evaluation. No prior abdominal pain, episodes of similar nature, history of diverticulitis, weight loss, diarrhea, melena, hematochezia or change in stool caliber or quality. No previous colonoscopy. Abdominal computed tomography (CT) revealed an obstructing mass in the sigmoid colon with proximal large bowel dilation, cecum measuring 13 cm and cecal pneumatosis (Figure 1a).

Patient B: 59 year old woman with lower abdominal pain and constipation for 2 days. Increasing pain and lack of response to laxatives prompted evaluation. No prior abdominal complaints. Colonoscopy performed 1 year prior was significant for diverticulosis. Labs were significant for lactic acidosis and leukocytosis. Abdominal CT demonstrated large bowel obstruction secondary to sigmoid diverticulitis (Figure 1b).

Results/Outcomes: Both patients were emergently taken to the operating room upon diagnosis. A fibrotic, mass-like stricture with proximal dilation was confirmed intra-operatively in both patients.

Patient A underwent a low anterior resection (LAR) and small bowel resection with end colostomy. Post-operative course was complicated by septic shock, acute kidney injury requiring dialysis, and complicated soft tissue infection requiring debridement and drain placement. Final pathology demonstrated diverticular disease and diverticulitis with abscess formation, fibrosis, and stricture.

Patient B underwent LAR with primary anastomosis and diverting loop ileostomy. Hospital course was uncomplicated. Final pathology demonstrated diverticulitis, fibrosis, and focal perforation.

Conclusion/Discussion: The incidence of diverticulitis in the US has been increasing over the last 3 decades. Stricture represents a known complication of diverticulitis, but this typically presents after recurrent or prolonged episodes. This case describes an atypical presentation of LBO, a surgical emergency, upon first presentation of diverticulitis supporting a particularly aggressive form of diverticulitis. With the rise in incidence of diverticulitis, providers should be familiar with atypical presentations. It may be helpful in the future to develop screening mechanisms to attempt to identify patients with aggressive forms of diverticulitis to decrease morbidity and improve outcomes associated with complicated diverticulitis.