Complicated diverticulitis mimicking colonic carcinoma: combined approach with endoscopy and budesonide

Abstract

Complicated diverticulitis is an uncommon endoscopic finding. We report an unusual case of complicated diverticulitis in a 53-year-old man suffering from chronic constipation, abdominal pain and a recent episode of subocclusion. He underwent to colonoscopy that showed left-sided diverticulosis and a 3 cm irregular mass in the sigmoid. During biopsy sampling due to the suspect of colonic carcinoma, pus and bleeding came out from the lesion. After lavage, a large diverticulum with visible vessel at the bottom was found, which was clipped with stopping bleeding. After a short course of in-hospital treatment, at discharging the patient was treated with budesonide MMX9 mg/day for 8 weeks. At that time, colonoscopy did not show sign of diverticular inflammation, and inflammatory indexes were normal. This case demonstrates that the use of a topical steroid, combined with an endoscopic approach, may easily resolve an unusual endoscopic complication in patients suffering from complicated diverticular disease.

Background

Colonic diverticulosis is the most frequent anatomic alteration in the western population, especially in older people,¹ and it is also the most frequent endoscopic finding detected during colonoscopy.² We can find signs of acute diverticular inflammation in about 1%–3% of people having diverticulosis and undergoing to colonoscopy, often without any clinical sign of acute diverticulitis.^{3 4} Endoscopic finding of the colon having diverticulosis may be used as predictors on the outcome of the disease,⁵ and colonoscopy is mandatory in order to differentiate between diverticular disease and colorectal cancer.⁶

Case presentation

A 53-year-old man, with history of 2-year chronic constipation, underwent to outpatient colonoscopy due to a 1 month history of abdominal pain, located mainly in left lower quadrant, bloating and worsening of constipation (<1 evacuation/week). He suffered from hypertension, under treatment with lisinopril 20 mg/day, and diabetes mellitus, under treatment with metformin 500 mg three times/day. His general practitioner tried to control constipation by using macrogol, without any significant efficacy. Thus, he required colonoscopy due to suspected colonic disease.

Investigations

Colonoscopy showed diffuse diverticulosis of the left colon, with sign of inflammation of some sigmoid diverticula (score 2 according to Diverticular Inflammation and Complication Assessment (DICA) classification).⁷ A 3 cm irregular mass located in the sigmoid was also detected (figure 1), no limiting colonic exploration with standard colonoscope.

Figure 1.

Endoscopic appearance of a large mass in sigmoid colon, suspected for colonic carcinoma, after the first biopsy sampling.

Differential diagnosis

Large sigmoid polyp

It can be sometimes large and may fill the colonic lumen.

Sigmoid colorectal cancer

A large and irregular mass is the typical endoscopic appearance of the colonic colorectal cancer, often filling the colonic lumen.

Inflammatory bowel diseases

Although the endoscopic findings of acute diverticulitis generally differ from that of inflammatory bowel diseases, these diseases may sometimes share the same endoscopic signs of severity (as ulcers or spontaneous bleeding).

Treatment

During biopsy sampling due to the suspected colonic carcinoma, pus and bleeding came out from the lesion. After lavage, a large diverticulum with visible vessel was found at the bottom of the diverticulum, which was clipped with stopping bleeding (figure 2).

Figure 2.

Endoscopic appearance at the bottom of the diverticulum, with some clip placed on visible vessel.

The patients was therefore hospitalised. At admission, no leucocytosis was found, Erythro-Sedimentation Rate (ESR) was 80 mm/hour (normal value (n.v.) ≤10 mm/hour), C-Reactive Protein (CRP) was 64 mg/L (n.v. ≤5 mg/L) and faecal calprotectin was 320 mg/kg (n.v. ≤50 mg/kg). An abdominal CT scan was also performed, with detection of thickening of the colonic wall in the sigmoid-descending colon, with perisigmoid fat standing but without abscesses (figure 3). He was treated with mesalazine 2.4 g/day and metronidazole 1.5 g/day with rapid resolution of abdominal pain and discharging after 4 days.

Figure 3.

Abdominal CT showing thickening of the sigmoid colon with fat stranding but without abscesses. This finding, together with the endoscopic findings, permits to exclude the diagnosis of colonic carcinoma or segmental colitis associated with diverticulosis.

Outcome and follow-up

At discharge, patient was treated with metronidazole 1.5 g/day for further 6 days and with budesonide MMX 9 mg/day for 4 weeks, followed by budesonide MMX 9 mg/ every other day for further 4 weeks. At that time, ESR dropped to 18 mm/hour, CRP to 5 mg/L (n.v. ≤5 mg/L) and faecal calprotectin to 80 mg/kg (n.v. ≤50 mg/kg). Colonoscopy was performed again, showing no sign of diverticular inflammation.

At present, the patient is under treatment with mesalazine 2.4 g/day, rifaximin 800 mg/day for 10 days/month and with the probiotic mixture VSL#3 1 bag/day for 10 days/month, and he is still asymptomatic (no abdominal pain and regular bowel habit).

Discussion

Colonoscopy is generally contraindicated in complicated diverticulitis,⁶ and it could be a marginal chance just in well-selected patients.⁸ It is mandatory in patients with no clear differential diagnosis, in which early colonoscopy seems to be a significant tool to pose the correct diagnosis.⁹

Complicated diverticulitis may be the first appearance of the disease, and patients often do not report any significant symptom before complication.¹⁰ In this case, we found that diverticular abscess appeared as an irregular mass mimicking a colonic carcinoma, and leading to biopsy sampling to perform. The biopsy sampling of this lesion caused purulent outflow with bleeding, which was easily controlled by clipping, which is one of the best tool in managing diverticular bleeding.¹¹

Another interesting finding of this case is that budesonide MMX was able to reach a quick resolution of symptoms with significant dropping of faecal calprotectin. Budesonide, a second-generation corticosteroid, exerts a significant anti-inflammatory effect in the intestinal mucosa; it shows also low systemic bioavailability after oral administration because it is extensively metabolised (90%) in the liver at its first passing.¹² It has an high affinity for the glucocorticoid receptor, and combines an excellent solubility with a strong anti-inflammatory activity. Budesonide exerts its role through a significant downregulation of the inflammation pathways, downregulating several proinflammatory cytokines as tumour necrosis factor-α, IL-1 and 6 (IL-6), and nuclear factor kappa-B.^{13 14} Budesonide has also lower systemic adverse events when compared with systemic steroids, and the most common of them are Cushingoid face and hypokalemia (due to effects on the endocrine organs).¹⁵

Budesonide MMX is a new formulation of this steroid with low systemic bioavailability.¹⁶ Thanks to its availability to deliver the drug in the left colon, with the availability of the budesonide to cross the colonic wall together with very low adverse event rate,¹⁷ budesonide MMX could be considered an interesting therapeutic approach in treating diverticular disease. In fact, the inflammation in acute diverticulitis is transmural and similar to that occurring in Crohn’s disease,¹⁸ and it persistence could explain why symptoms may persist in those people after resolution of an episode of acute diverticulitis.¹⁹ The use of budesonide MMX, thanks to its availability to deliver the drug in the left colon and to cross the colonic wall, could speed up the resolution of the inflammation (and therefore of the symptoms), overcoming also the potential risk of infections linked to its use. In fact, budesonide has an excellent safety profile despite being a steroid, significantly better than other steroids.¹⁷ Moreover, a preliminary experience found budesonide effective in treating segmental colitis associated with diverticulosis,²⁰ that could be the first indication for budesonide treatment in patients having diverticulosis with inflammation. The use of budesonide was therefore intriguing also in patients with complicated diverticular disease: this case report seems to confirm completely this hypothesis, since we obtained the complete resolution of the inflammation using budesonide MMX, without any adverse events. Further studies are needed to identify the optimal dosage and the optimal duration of this treatment.

In conclusion, this case report well describes how complicated diverticulitis may mimic colonic carcinoma. In these patients, the combined approach between endoscopic treatment and budesonide MMX could be useful also in managing complicated diverticular disease, similar to that occurs in the management of inflammatory bowel diseases.

Patient’s perspective.

I had a positive experience about the management of my illness. Doctors resolved my ill and I feel really better.

Learning points.

• Colonoscopy is the gold standard to pose a correct differential diagnosis between diverticular disease and colorectal carcinoma.

• Complicated diverticulitis may be the first clinical expression of the disease.

• Budesonide MMX is a new formulation of this steroid with low systemic bioavailability and delivery in the left colon. Crossing the colonic wall, it could speed up the resolution of the inflammation (and therefore of the symptoms) also in complicated diverticular disease.

• Budesonide MMX could be effectively used in combination with endoscopic treatment to manage complicated diverticular disease.