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What's in Her Pocket: Worsening Diverticulitis

  • Lauren M. Bleich
    Correspondence
    Requests for reprints should be addressed to Lauren M. Bleich, MD, MPH, Section of Gastroenterology, Department of Medicine, 267 Grant Street, Bridgeport, CT 06610.
    Affiliations
    Section of Gastroenterology, Department of Medicine, Bridgeport Hospital, Yale New Haven Health, Bridgeport, Conn
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      Presentation

      Contrast concealed the culprit when a 54-year-old woman presented with a 5-day history of pain in the left lower quadrant of the abdomen and subjective fevers. Her white blood cell count on admission was elevated at 19.1 x 103 cells/mm3. Her medical history included diverticulosis. A computed tomography (CT) scan of the abdomen with intravenous (IV) and oral contrast revealed an area of fat stranding adjacent to diverticulosis of the proximal sigmoid colon. This finding was consistent with acute diverticulitis.
      The patient began a regimen of IV ciprofloxacin and IV metronidazole. Yet, during the next 4 days, her pain worsened, and she required increasing amounts of pain medication.

      Assessment

      Another CT scan of the abdomen was obtained; this time without contrast. Again, the study disclosed an area of fat stranding adjacent to the diverticulosis of the proximal sigmoid colon. In addition, curvilinear dense calcifications within the sigmoid colon lumen were evident, raising concern for a foreign body (Figure 1). Tiny flecks of extraluminal air were noted within the region. No abscess or fluid collection was identified.
      Figure thumbnail gr1
      Figure 1A computed tomography scan of the abdomen showed a curvilinear dense calcification within the sigmoid colon lumen.

      Diagnosis

      Flexible sigmoidoscopy was performed to further investigate the imaging results. Multiple large-mouthed diverticula were seen within the sigmoid colon. One of these diverticula held a chicken bone, which measured approximately 1.5 inches and protruded outward into the colonic lumen.

      Management

      Endoscopic removal of the chicken bone was accomplished with a rat-toothed forceps and snare (Figure 2). Because the bone end had produced a pinpoint hole within the diverticulum, a clip was placed over this area for closure of the mucosa.
      Figure thumbnail gr2
      Figure 2Endoscopy revealed a chicken bone in the diverticulum.
      The patient's abdominal pain improved significantly within the 24 hours following the flexible sigmoidoscopy, and her pain medication requirements decreased. She tolerated a low-residue diet and was discharged home the following day with instructions to complete a 10-day course of oral antibiotics.
      In a retrospective review of the initial CT scan, a linear high-density area was identified at the same location within the sigmoid colon. This had not been clearly recognized due to the presence of oral contrast within the colon and slice selection.