Diverticular Disease of the Gastrointestinal Tract

Non-Meckel Ileal Diverticulum Incarcerated Within a Strangulated Inguinal Hernia: A Case Report

Non-Meckel small bowel diverticula, particularly ileal diverticula, are rare, especially when incarcerated within an inguinal hernia sac. This case involves an 80-year-old man who presented with a newly noticed tender, irreducible lump in his left groin, accompanied by symptoms of bowel obstruction such as inability to pass flatus and vomiting. His medical history included a previous right inguinal hernia repair. Physical examination and laboratory tests indicated a strangulated hernia, which was confirmed by a contrast-enhanced computed tomography scan showing small bowel obstruction at the neck of the left inguinal hernia. The patient underwent a laparoscopic mesh repair, during which a non-Meckel ileal diverticulum was discovered within the hernia sac alongside a bruised but viable segment of the small bowel. The incarcerated diverticulum was gently reduced, and the hernia was successfully repaired using a mesh. The patient had an uneventful recovery and was discharged in a stable condition. This case highlights the importance of considering rare causes of small bowel obstruction in elderly patients presenting with hernias. Prompt imaging and surgical intervention are crucial to prevent serious complications such as bowel ischemia and perforation. The successful laparoscopic approach demonstrated minimal invasiveness and facilitated a swift postoperative recovery, underscoring its effectiveness in managing such uncommon clinical scenarios.

Histology of IBD and related colitides in the elderly

Inflammatory bowel disease (IBD) are chronic relapsing diseases, affecting both children and adults with a life-long duration. An increased co-morbidity gives raise to fragility in the elderly. In this regard it should consider that several non-IBD colitides may mimic both ulcerative colitis and Crohn's disease. Moreover, chronic diseases represent a clinical challenge, mostly about treatment effectiveness. Finally, it is worth noting that patients with long-standing diseases - and elderly patients among them - have an increased malignancy risk when compared to general (non-IBD) population. Our paper aims to review the three main histological topics that play a role in the clinical management of IBD in the elderly, namely differential diagnosis, mucosal healing and IBD-associated dysplasia.

A rare case report of diverticulum of the buccal mucosa

We report a case of diverticulum of the buccal mucosa. A 56-year-old man had a small pouch-shaped lesion behind the parotid papilla that caused pain and food impaction. After resection, the lesion was histopathologically diagnosed as diverticulum without buccal muscle tear. There has been no recurrence during 1 year postoperatively.

Evolving field of third-space endoscopy: Derivatives of peroral endoscopic myotomy

Third-space endoscopy, also known as submucosal endoscopy, allows for a wide range of therapeutic interventions within the submucosal layer and even into the muscular or subserosal layers of the gastrointestinal lumen. The technical development of peroral endoscopic myotomy (POEM) for achalasia has revolutionized the field of therapeutic endoscopy and the method has been continuously refined and modified. Although POEM has been applied to treat primary achalasia, it shows a favorable clinical response in other esophageal motility disorders and as a salvage treatment after previously failed intervention. Gastroesophageal reflux after POEM has drawn considerable attention and there have been major advancements in its prevention and management. POEM has led to advantageous derivatives such as peroral endoscopic tumor resection or submucosal tunneling endoscopic resection for resection of subepithelial lesions, Zenker POEM for hypopharyngeal diverticula, diverticular POEM for epiphrenic esophageal diverticula, and gastric POEM for refractory gastroparesis. These techniques have a similar concept, which constitutes submucosal tunneling with a mucosal flap valve and secure mucosal incision closure. The submucosal tunneling technique is widely accepted and continues to evolve. This study aimed to review in detail the indications, outcomes, and technical variations in POEM and explore several emerging submucosal tunneling procedures. This review will benefit future studies by providing a summary of recent developments in this field.

Acute abdomen following axial torsion of a Giant Meckel's diverticulum in a young male: A case report

INTRODUCTION AND IMPORTANCE

Among Meckel's diverticulum (MD), the 'Giant' category is relatively rare. Most Giant MDs lead to complications such as torsion and diverticulitis.

PRESENTATION OF CASE

A 20-year-old South Asian male presented with a three-day history of vomiting and left-sided abdominal pain. X-ray and ultrasound scan of the abdomen illustrated features of small bowel obstruction. He underwent laparotomy under general anaesthesia. A gangrenous, axially torsed 25-cm Giant MD with concurrent ileal compression by a mesodiverticular band was detected and diverticulectomy and segmental resection with end-to-end anastomosis of the ileum was performed. Histology revealed ectopic gastric and pancreatic tissue. He had an uneventful postoperative stay and was devoid of any surgery-related complications at one-year follow-up.

CLINICAL DISCUSSION

Adults mainly present with bowel obstruction following complicated MDs. Multiple mechanisms have been elaborated as causalities of bowel obstruction where the presence of bands of congenital or inflammatory origin, intussusception, and enteroliths are relatively common. The presence of ectopic tissue in MDs is associated with increased complications. Symptomatic MDs need resection to abate future complications such as haemorrhage and obstruction.

CONCLUSION

Despite the low diagnostic potential of clinical examination and radiological studies, a high degree of suspicion is warranted in cases of probable MD-resultant complications, where more common aetiologies have been ruled out, as delay in diagnosis and definitive surgical therapy are invariably associated with worsened morbidity and mortality. It is high time to elucidate related demographics and clinical data on Giant MDs to identify high-risk categories and develop safer follow-up protocols.

Recurrence after Zenker's peroral endoscopic myotomy despite complete septotomy: how far to go with myotomy on the esophageal side

Video 1A case of recurrence after Z-POEM because of incomplete myotomy on the esophageal side.

Treatment of Giant Esophageal Epiphrenic Diverticulum Using Robotic-Assisted Surgery

Epiphrenic diverticulum is a rare condition associated with esophageal motor disorder, and it is often asymptomatic, with a well-established surgical indication. The present study aims to report a case of a giant epiphrenic diverticulum in a 68-year-old male patient who, due to the symptoms, opted for surgical treatment using the daVinci® system. Robotic surgery consisting of esophageal diverticulectomy with cardiomyotomy was performed. The patient had an excellent recovery with an abbreviated hospitalization, return to food, and satisfactory routine activity.

Diverticular per oral endoscopic myotomy (DPOEM) for esophageal diverticular disease: a systematic review and meta-analysis

The traditional way to tackle Zenker's diverticulum (ZD) has been flexible endoscopic septum division (FESD). Recently, the concept of per oral endoscopic myotomy has been found useful for managing diverticular diseases of the esophagus and has been termed DPOEM. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of D-POEM in diverticular disease of the esophagus and to compare it with FESD. We systematically searched PubMed and Embase, for studies reporting clinical success, technical success and adverse events in D-POEM alone or D-POEM comparing with FESD. We computed pooled prevalence for D-POEM alone and risk ratio for D-POEM vs FESD using random effect method with inverse variance approach. Subgroup analysis for ZD, non-ZD and mixed diverticulum was conducted. Totally 19 studies including 341 patients were identified reporting on D-POEM. The pooled clinical, technical success and adverse event rates for D-POEM were 87.07%, 95.19% and 10.22%, respectively. The clinical success was significantly better than FESD while the technical success, adverse event rate, procedure time and length of hospital stay were comparable with FESD. The recurrence rate was negligible for D-POEM compared to FESD. On subgroup analysis by dividing into three groups of ZD, non-ZD and mixed, there was no difference between clinical, technical success and adverse event rate among the three groups. D-POEM is an effective and safe technique among both ZD and non-ZD patients and has better clinical success than FESD.

[Diverticula in the gastrointestinal tract]

The prevalence of diverticula varies depending on the location within the gastrointestinal tract. Diverticula of the esophagus, stomach and small intestine are rare, more frequent are peripapillary diverticula and colonic diverticula. Meckel diverticula can also be of relevance in adults. Diverticula have to be differentiated from intramural pseudodiverticulosis of the esophagus and bile duct cysts. An endoscopic and radiological diagnostic work-up is only necessary for symptomatic diverticula or complications. In some cases additional functional diagnostic tests, such as high-resolution esophageal manometry to detect underlying motility disorders (Zenker's diverticulum, epiphrenic diverticulum) or the hydrogen breath test to detect bacterial overgrowth in the small intestine (diverticula of the small intestine) are mandatory. Effective treatment requires the close interdisciplinary cooperation between different specialist disciplines. Therapeutic modalities include pharmacotherapy, endoscopy and surgical methods.

Oral diverticulum

Oral diverticulum .

Early colonoscopy in patients with acute diverticular bleeding is associated with improvement in healthcare-resource utilization

Background

Diverticular bleeding (DB) is the most common cause of severe acute lower gastrointestinal bleeding (GIB) in developed countries. The role of early colonoscopy (<24 hours) continues to remain controversial and data on early colonoscopy in acute DB are scant. We aimed to evaluate the effect of timing of colonoscopy on outcomes in patients with acute DB using a nationwide inpatient sample.

Methods

Data from the nationwide inpatient sample from 2012 to 2014 were used. The ninth version of the International Classification of Diseases coding system ICD 9 was used for patient selection. We included discharges with the primary and secondary inpatient diagnosis of diverticulosis with bleeding and diverticulitis with bleeding. Discharges with no primary or secondary diagnosis of diverticulosis with bleeding, diverticulitis with bleeding, patients who were less than 18 years old and those who did not undergo colonoscopy during the admission were excluded. The primary outcomes were length of stay (LOS) and total hospitalization costs.

Results

A total of 88 600 patients were included in our analysis, amongst whom 45 020 (50.8%) had colonoscopy within 24 hours of admission (early colonoscopy), while 43 580 (49.2%) patients had colonoscopy after 24 hours of admission (late colonoscopy). LOS was significantly lower in patients with early colonoscopy as compared to those with late colonoscopy (3.7 vs 5.6 days, P < 0.0001). Total hospitalization costs were also significantly lower in patients with early colonoscopy ($9317 vs $11 767, P < 0.0001). There was no difference in mortality between both groups (0.7 vs 0.8%). After adjusting for potential confounders, the differences in LOS and total hospitalization costs between early and late colonoscopy remained statistically significant.

Conclusions

Early colonoscopy in acute DB significantly reduced LOS and total hospitalization costs. There was no significant difference in mortality observed. Performance of early colonoscopy in the appropriate patients presenting with acute DB can have potential cost-saving implications. Further research is needed to identify which patients would benefit from early colonoscopy in DB.