Sigmoid–Sigmoid Colon Fistula Caused by Diverticulitis

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Sigmoid–Sigmoid Colon Fistula Caused by Diverticulitis: A Rare Case and Insights

Diverticular disease is a common condition worldwide, and its incidence rises with age. Complicated diverticulitis, which can involve abscess, fistula, obstruction, and peritonitis, is a serious matter. Surgical treatment is often recommended for patients with symptomatic complications. Among these complications, colocolic fistula due to diverticulitis is rare, and sigmoid–sigmoid fistula is an extremely rare one. In this article, we’ll explore a case of sigmoid–sigmoid colon fistula caused by diverticulitis and discuss its implications.

The Case Presentation

A 71-year-old woman with hypertension came to the hospital. She had been experiencing intermittent abdominal pain in her left lower quadrant for a year, and the pain had worsened in the past few days. Physical examination showed abdominal tenderness, but otherwise, there were no remarkable findings.

Diagnostic Tests

  • Abdominal Pelvic Computed Tomography (CT): It showed a suspicious fistula between the proximal and distal sigmoid colon. In the axial view image (Figure 1A), the suspicious area was noted (arrows), but it wasn’t clear in the coronal view (not shown).
  • Colonoscopy Examination: Revealed a small fistula in the proximal sigmoid colon beside a small diverticulum. Through the fistula, twinkling points on the shaft of the colonoscope could be seen. The wire couldn’t be inserted anymore and was twisted out because of the shaft of the colonoscope in the distal sigmoid colon (Figure 1B).
  • Enema with Meglumine Diatrizoate: This revealed a connection between the proximal and distal sigmoid colon without evidence of leakage (Figure 1C). Based on these findings, sigmoid–sigmoid colon fistula caused by diverticulitis was finally diagnosed.

Management and Outcome

The medical team consulted with other departments, including the department of general surgery for multidisciplinary management. Although the standard treatment for complicated diverticulitis with fistula is surgery, the patient refused surgical treatment. So, she had conservative treatment, such as bowel rest, intravenous fluids, and intravenous antibiotics. Unfortunately, she was discharged from the hospital and eventually died of complicated diverticulitis a few months later.

Understanding Diverticular Disease and Fistula Complications

Diverticular Formation and Pathogenesis

Diverticular formation and the pathogenesis of diverticular disease are multifactorial and still not fully understood.

Fistula as a Complication

Fistula is one of the complications of diverticulitis. Colovesical fistula is the most common type, followed by colovaginal fistula. Colocolic fistula is rare, accounting for about 2% [1].

Management Strategies

Multidisciplinary Management

The management of diverticular disease is often individualized. Currently, multidisciplinary management of complicated diverticulitis is considered the best practice strategy [2]. This approach involves different medical specialties working together to provide comprehensive care.

Surgical Treatment as the Standard

However, for complicated diverticulitis with fistula, surgical treatment is the standard [3,4]. CT is recommended as the first diagnostic modality in diverticulitis. But when there’s a fistula, the diagnosis might not be clear. So, when colonoscopy shows a fistula in the sigmoid colon, physicians should consider the complication of diverticulitis. It’s important to note that multiple fistulas can be either internal or external, although this is rare.

In the case we presented, the patient’s refusal of surgery led to a tragic outcome. This emphasizes the importance of strongly recommending multidisciplinary management and surgical treatment for complicated diverticulitis with fistula.

Conclusion

This case of sigmoid–sigmoid colon fistula caused by diverticulitis highlights the rarity and seriousness of such a complication. It also underscores the need for physicians to be vigilant in diagnosing and managing complicated diverticulitis. Multidisciplinary management and surgical treatment, when appropriate, are crucial for improving patient outcomes. As our understanding of diverticular disease continues to evolve, sharing such cases helps in better recognition and management of these complex conditions.

References

  1. Strati TM, Sapalidis K, Koimtzis GD, Pavlidis E, Atmatzidis S, Liavas L, et al. Sigmoido – cecal fistula: a rare case of complicated recurrent diverticulitis and a review of the literature. Am J Case Rep 2018;19:1386–1392. doi: 10.12659/AJCR.911790.
  2. Lambrichts DPV, Birindelli A, Tonini V, Cirocchi R, Cervellera M, Lange JF, et al. The multidisciplinary management of acute complicated diverticulitis. Inflamm Intest Dis 2018;3:80–90. doi: 10.1159/000486677.
  3. Schultz JK, Azhar N, Binda GA, Barbara G, Biondo S, Boermeester MA, et al. European society of coloproctology: guidelines for the management of diverticular disease of the colon. Colorectal Dis 2020;22 Suppl 2:5–28. doi: 10.1111/codi.15140.
  4. Cirocchi R, Fearnhead N, Vettoretto N, Cassini D, Popivanov G, Henry BM, et al. The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: a systematic review and meta – analysis. Surgeon 2019;17:360–369. doi: 10.1016/j.surge.2018.08.010.

doi.org/10.1097/CM9.0000000000001753

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