A Clinical Trial of Submucosal Saline Injection in Inverted Colonic Diverticula

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A Clinical Trial of Submucosal Saline Injection in Inverted Colonic Diverticula

Inverted colonic diverticula (ICD) are a relatively rare finding in colonoscopy, occurring in about 0.7% of procedures. They often resemble colon polyps, which can lead to misdiagnosis and potential complications such as bowel perforation during biopsy or endoscopic resection. This article presents a clinical trial using submucosal saline injection to distinguish ICD from colon polyps.

Introduction

Colonic diverticulosis is a common colon disorder worldwide. In Asian patients, it is mostly observed in the right colon, unlike in Western patients. ICD, a less common variant, can be challenging to diagnose. Previously described colonoscopy maneuvers like the radiating pillow sign, air insufflation, water jet, and forceps reversion have limitations. Aurora rings, a more recent finding, can help but may not always be reliable. This trial explores the use of submucosal saline injection.

Case Presentation

A 69-year-old woman with intermittent right lower quadrant abdominal pain presented. She had no significant medical history and no prior screening colonoscopy. Physical examination and laboratory tests were normal. Abdominal computed tomography showed diverticula in the cecum and ascending colon. Colonoscopy revealed several diverticula and an 8-mm polypoid lesion in the ascending colon. The lesion’s surface was shiny pink mucosa similar to the surrounding normal mucosa, and the Aurora rings sign was ambiguous. After submucosal injection, the lesion became flat with central dimpling.

Diagnostic Challenges and Previous Methods

ICD vs. Colon Polyps

Diagnosing ICD is difficult as it resembles colon polyps. Colonoscopy is useful for identifying diverticula and complications, but endoscopists need to differentiate to prevent post-biopsy or polypectomy complications.

Previous Maneuvers

  • Radiating Pillow Sign: Central dimple with radiating folds by repeated forceps probing. Helps distinguish ICD from soft subepithelial lesions like lipoma but not always reliable for larger ICD.
  • Air Insufflation and Water Jet: Attempt to revert and deform the lesion. However, air insufflation may be inefficient due to air leakage into the colon, and a negative finding doesn’t exclude ICD.
  • Forceps Revision: Can help diagnose but placement in the correct position is difficult for larger lesions.

Aurora Rings

Concentric pale rings surrounding the lesion, enhanced with narrow-band imaging and indigo carmine dye. But not always effective, especially for smaller ICD or poor bowel preparation. Standard white light colonoscopy may not show them well.

Submucosal Saline Injection

Mechanism

Only the submucosa around the ICD rises and flattens or shows a central dimple after injection. This is because the colon diverticulum is a pseudo-diverticulum that doesn’t contain all bowel layers.

Reliability

Reliable for both small and large ICD. However, a negative finding doesn’t exclude ICD due to varying shapes and locations. Using indigo carmine dye with submucosal saline injection can confirm Aurora rings and better identify ICD.

Conclusion

Submucosal saline injection with indigo carmine dye is a promising new colonoscopic method. It overcomes some limitations of previous maneuvers and can help distinguish ICD from colon polyps more effectively. This method has the potential to improve the accuracy of ICD diagnosis and reduce the risk of complications associated with misdiagnosis.

References

  1. Share MD, Avila A, Dry SM, Share EJ. Aurora rings: a novel endoscopic finding to distinguish inverted colonic diverticula from colon polyps. Gastrointest Endosc 2013;77:308–312. doi: 10.1016/j.gie.2012.09.004
  2. Shah AN, Mazza BR. The detection of an inverted diverticulum by colonoscopy. Gastrointest Endosc 1982;28:188–189. doi: 10.1016/s0016-5107(82)73052-4
  3. Yusuf SI, Grant C. Inverted colonic diverticulum: a rare finding in a common condition? Gastrointest Endosc 2000;52:111–115. doi: 10.1067/mge.2000.106539
  4. Cappell MS. The water jet deformation sign: a novel provocative colonoscopic maneuver to help diagnose an inverted colonic diverticulum. South Med J 2009;102:295–298. doi: 10.1097/SMJ.0b013e318198697f

This article was originally published in the Chinese Medical Journal in 2021 by Jeonghun Lee (Department of Internal Medicine, Ye Hospital, Anyang, Korea) and Youngsun Kim (Department of Obstetrics and Gynecology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea). The DOI is 10.1097/CM9.0000000000001485.

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