Giant colonic diverticulum
Giant colonic diverticula, also referred to as giant colonic pseudodiverticula, are an uncommon form of presentation of colonic diverticulosis and are characterized by large diverticular masses, usually filled with stool and gas, that communicate with the colonic lumen.
Although the great majority of cases are not true colonic diverticula (c.f. pseudodiverticula or chronic contained perforation of the colon), this article will follow the majority of publications and the way the condition is commonly referred to in daily practice, which means grouping all types under the umbrella term of giant colonic diverticula.
The most common presentation is abdominal pain. Other presenting symptoms include constipation, abdominal masses, vomiting, diarrhea, and rectal bleeding 5.
The majority (>90%) arise from the sigmoid colon 1,3, but they can occur in any part of the colon. They are divided into three different types 2,4,6:
- giant pseudodiverticula (or type I)
- the second most common type (~20% of cases)
- the mucosa herniates through the muscular wall and becomes progressively enlarged by colonic gas via a ball-valve type mechanism 4
- diverticula wall is made of remnants of both the muscularis mucosa and muscularis propria, which are permeated by chronic granulation tissue 4,6
- inflammatory giant colonic diverticula (or type II)
- majority of cases (~70% of cases)
- result from perforation and formation of a persistent abscess cavity that remains in communication with the colonic lumen 6
- it can also be understood as a chronic contained colonic perforation
- diverticula wall is made of dense fibrous tissue containing both chronic inflammatory cells and foreign body giant cells 4
- true giant colonic diverticula (or type III)
- rare (~10% of cases)
- contain all the colonic wall layers: serosa, muscularis, submucosa, and mucosa
- believed to represent a duplication cyst that has communication with the colonic lumen 4,
Imaging plays an important role in the diagnosis of giant colonic diverticula as they might not be identified on colonoscopy studies due to a small ostium 6.
Abdominal x-rays may show large gas-filled cysts with a gas-fluid level 5.
CT is the best imaging modality for diagnosis given that colonoscopies are rarely carried out due to the risk of perforation 2. CT shows the diverticulum as a gas, fluid or feces-filled cavity, sometimes with calcification in the case of chronic inflammation. There is usually no contrast enhancement unless there is active inflammation 2.
Treatment and prognosis
The definitive treatment for a giant diverticulum is surgery 2.
- common 6,8
- abscess formation
- less common
- intestinal volvulus
- intestinal obstruction
- lower gastrointestinal bleeding
- adenocarcinoma arising in the diverticulum
- 1. Custer TJ, Blevins DV, Vara TM. Giant colonic diverticulum: a rare manifestation of a common disease. J. Gastrointest. Surg. 2000;3 (5): 543-8. Pubmed citation
- 2. Thomas S, Peel RL, Evans LE et-al. Best cases from the AFIP: Giant colonic diverticulum. Radiographics. 2006;26 (6): 1869-72. doi:10.1148/rg.266065019 - Pubmed citation
- 3. McQuade KL, Foreman ML. Giant colonic diverticulum. Proc (Bayl Univ Med Cent). 2011;21 (1): 25-6. Free text at pubmed - Pubmed citation
- 4. Kempczinski RF, Ferrucci JT. Giant sigmoid diverticula: a review. (1974) Annals of surgery. 180 (6): 864-7. Pubmed
- 5. Nigri G, Petrucciani N, Giannini G, et al. Giant colonic diverticulum: Clinical presentation, diagnosis and treatment: Systematic review of 166 cases. World Journal of Gastroenterology : WJG. 2015;21(1):360-368. doi:10.3748/wjg.v21.i1.360. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4284356/
- 6. P. Steenvoorde, F.J. Vogelaar, J. Oskam, R.A.E.M. Tollenaar. Giant Colonic Diverticula. (2019) Digestive Surgery. 21 (1): 1. doi:10.1159/000074833 - Pubmed
- 7. Choong CK, Frizelle FA. Giant colonic diverticulum: report of four cases and review of the literature. (1998) Diseases of the colon and rectum. 41 (9): 1178-85; discussion 1185-6. Pubmed
- 8. Abdel-Rauf Zeina, Ahmad Mahamid, Alicia Nachtigal, Itamar Ashkenazi, Mika Shapira-Rootman. Giant colonic diverticulum: radiographic and MDCT characteristics. (2015) Insights into Imaging. 6 (6): 659. doi:10.1007/s13244-015-0433-x - Pubmed