Endoscopic removal of inverted sigmoid diverticulum--is it a dangerous procedure?

Inverted colonic diverticulum (ICD): report of two cases and literature review of a not that unusual endoscopic challenge

Inverted colonic diverticulum (ICD) is a rare intraluminal lesion occurring in about 0.7-1.7% of people, often endoscopically indistinguishable from polyps. Some unspecific endoscopic features may assist to distinguish polypoid ICD from true polyps. This differentiation bears relevance for the therapeutic approach, as colonic polyps require snare polypectomy, a practice which may be associated with colonic perforation in case of true ICD. The endoscopist, therefore, should be aware of the likelihood of detecting these lesions during colonoscopy. A close inspection and a gentle probing could assist in a correct diagnosis and avoid risky procedures such as biopsy or polypectomy. Rarely, a neoplasm arising over an ICD and its treatment has been described. We reported two cases, one of which with dysplasia, and their treatment, and reviewed all the ICD endoscopic cases so far reported in the literature, remarking the possibility of finding pedunculated ICDs or neoplasm arising over an ICD.

Inverted colonic diverticulum: An endoscopic examination and presentation

OBJECTIVE

We aimed to determine the frequency, morphological features, differential diagnosis, possible adverse events of inverted colonic diverticulum (ICD), which may be misdiagnosed as polyps.

METHODS

In all, 810 patients who underwent a colonoscopy between April 2016 and November 2019 were included in the study, and their data were evaluated retrospectively. Colonoscopic procedures were performed at a single center by the same endoscopist.

RESULTS

Among all the 810 patients, the prevalence of diverticulum was 29.58% (121/409) in men and 25.19% (n = 101/401) in women, respectively. ICD was observed in 1.73% (n = 14) of all patients, including 11 (78.57%) men (aged 63.2 ± 12.95 years [range 47-90 years]) and three women (60.3 ± 4.04 years [range 58-65 years]). Most (63.16% [12/19]) ICD lesions were localized in the sigmoid colon. And the diagnosis was confirmed by eversion using biopsy forceps in 78.95% of them. One patient developed perforation after polypectomy with hot biopsy forceps and was treated by surgical operation.

CONCLUSIONS

ICD is a common lesion that may lead to serious adverse events if misdiagnosed as polyps. Differential diagnosis of ICD is crucial during the colonoscopy.

Look out before polypectomy in patients with diverticular disease--a case of a large, inverted diverticulum of the colon resembling a pedunculated polyp

Diverticular disease of the colon may be responsible for abdominal symptoms requiring colonoscopy, which may reveal the presence of concomitant polyps. A polyp found during colonoscopy in patients with colonic diverticular disease may be removed by endoscopic polypectomy with electrosurgical snare, a procedure associated with an incidence of perforation of less than 0.05%. The risk of such a complication may be higher in the event of an inverted colonic diverticulum, which may be misinterpreted as a polypoid lesion at colonoscopy. To date, fewer than 20 cases of inverted colonic diverticula, diagnosed at colonoscopy or following air contrast barium enema, have been reported in the literature. The present report describes a 68-year-old woman who underwent a screening colonoscopy, which revealed a voluminous pedunculated polyp that was recognized to be an inverted giant colonic diverticulum before endoscopic polypectomy.

The water jet deformation sign: a novel provocative colonoscopic maneuver to help diagnose an inverted colonic diverticulum

Colonoscopic differentiation of an inverted colonic diverticulum from a true colonic polyp is important because a true colonic polyp usually requires colonoscopic snare polypectomy or at least biopsy, whereas these maneuvers are contraindicated for an inverted diverticulum due to the risk of colonic perforation. Previously described diagnostic maneuvers to evert an inverted diverticulum include probing it with a closed biopsy forceps or intraluminal air insufflation during colonoscopy. On colonoscopy, a 59-year-old female had two intraluminal colonic projections. Probing these projections and using air insufflation failed to indent or evert them. Spraying these lesions with a water jet, however, flattened or partly everted them. This novel maneuver provided conclusive evidence that these intraluminal projections represented inverted diverticula. The proposed pathophysiology is that water pressure causes an inverted diverticulum to indent or evert due to its thin wall. The currently reported maneuver may be easier and safer than probing an inverted diverticulum with biopsy forceps and may prove a more reliable diagnostic maneuver than air insufflation.

Reducing the incidence and mortality of colon cancer: mass screening and colonoscopic polypectomy

Most colon cancers arise from conventional adenomatous polyps (conventional adenoma-to-carcinoma sequence), while some colon cancers appear to arise from the recently recognized serrated adenomatous polyp (serrated adenoma-to-carcinoma theory). Because conventional adenomas and serrated adenomas are usually asymptomatic, mass screening of asymptomatic patients has become the cornerstone for detecting and eliminating these precursor lesions to reduce the risk of colon cancer. Colonoscopy has become the primary screening test because of its high sensitivity and specificity, and the ability to perform polypectomy. Other screening tests include guaiac tests or fecal immunochemical tests (FIT) for fecal occult blood, and flexible sigmoidoscopy. A minimal colonoscopic withdrawal time of 6 minutes is important to maximize polyp detection at colonoscopy. Chromoendoscopy is an experimental technique used to highlight abnormal colonic areas to identify neoplastic tissue and to potentially determine the histology of colonic polyps at colonoscopy based on superficial pit anatomy.

Dilemma of an inverted cecal diverticulum simulating a pedunculated polyp: CT appearance

The computed tomographic (CT) appearance of an intussuscepting cecal diverticulum is described. Some features on CT suggest that the term "inverted" may not be accurate.