Case History

In July 2010, a 22-year-old woman was admitted with a history of constipation and meterorism that were longstanding from childhood. The loss of weight and anorexia secondary to restricted diet appeared several years ago. She underwent appendectomy at the age of 1 year. She had been previously diagnosed in other departments, and based on colonoscopy, dolichocolon had been suggested. Physical examination revealed a large abdominal mass and cachexia (BMI = 15.5 kg/m2). A plain abdominal X-ray showed a round radiolucent air-filled cyst. Barium enema revealed a single, large diverticulum of the transverse colon (Fig. 1). Laparotomy showed a giant diverticulum originating from the proximal part of the transverse colon that was 40 cm long, 10–15 cm wide at the bottom and 4–5 cm wide at the gate (Fig. 2). The right half of the colon was dilated and had flabby walls. An extended right hemicolectomy with primary end-to-end anastomosis was performed. Histopathology revealed that the giant diverticulum contained all four layers of the normal bowel wall (Fig. 3). The postoperative course was uneventful, and she was discharged in 1 week without any complications.

Fig. 1
figure 1

Barium enema showing a giant diverticulum of the transverse colon

Full size image
Fig. 2
figure 2

Intraoperative image demonstrating a giant diverticulum of the transverse colon

Full size image
Fig. 3
figure 3

Histopatological examination—a giant diverticulum contains all four layers of the normal bowel wall

Full size image

Discussion

A giant colonic diverticulum (GCD) is defined as a colonic diverticulum measuring 4 cm or larger.1,2 It is a very rare condition, and most frequently, it is associated with colonic diverticular disease. More than 90% of giant colonic diverticula are found in the sigmoid colon. GCD was described first in 1953 by Hughes and Greene,3 primarily as a “solitary air cyst”. Different names (“giant air cyst” or “giant cyst”) have been used to describe this condition. According to Steenvoorde et al.,2 the term “giant colonic diverticulum” is preferred. Pathologically, GCD is divided into three types: type I (22%), pseudodiverticulum composed of granulation and fibrous tissue, with chronic inflammatory cells and remnants of muscularis mucosa; type II (66%), inflammatory diverticulum arising from local perforation and communicating with an abscess cavity and type III (12%), true diverticulum that contains all the layers of normal bowel wall and being in continuity with the gut lumen.2,4 Giant diverticulum located in the transverse colon is extremely rare.5–7 Only one case of a true giant diverticulum of the transverse colon that was accompanied by a right inguinal hernia of the greater omentum has been reported in the literature.5

We present the unique case of an uncomplicated true giant diverticulum of the transverse colon. Because symptoms have been remaining from patient’s childhood, we believe that this pathology can be congenital due to an intestinal duplication.

GCD may be asymptomatic or presents with nonspecific symptoms, such as vague abdominal pain, constipation, rectal bleeding, nausea and vomiting, abdominal distension, diarrhoea and abdominal mass.2 In 28% of patients, complications such as inflammation, perforation, intraabdominal abscess formation and wall infarction occur. A 2% risk of carcinoma developing inside diverticulum has been reported in the literature. 4 A plain supine abdominal X-ray is the radiological investigation of choice for GCD diagnosis.2 Preoperative diagnosis may also include barium enema, CT scan or MRI.5,8

Diverticulectomy in selected cases or partial colectomy with the diverticulum is the preferred method of treatment in uncomplicated GCD. In complicated cases, a two-stage resection with Hartmann procedure is necessary.8