Solitary Rectal Diverticulum: a Case Report

Home , Rectal prolapse, Stapled hemorrhoidopexy

506JCEI / 2013; 4 (4): 506-508 Journal of Clinical and Experimental Investigations doi: 10.5799/ahinjs.01.2013.04.0334 CASE REPORT / OLGU SUNUMU

Solitary rectal diverticulum: A case report

Soliter rektal divertikül: Olgu sunumu Kemal Peker1, İsmail Demiryılmaz2, Mehmet Seyhan Kalkan3, İsmayil Yılmaz1

ABSTRACT ÖZET Rectal diverticulas are very rare and most of patients with Rektal divertiküller çok nadirdir. Hastaların tanısı çoğun- rectal diverticula are diagnosed incidentally. Inflamma- lukta tesadüfen ve inflamatuar bir süreci takiben konur. tory processes may have developed at the time of the Çalışmada; Stapler ile transanal rezeksiyon sonrası rektal diagnosis. Here we report a case of rectal diverticulum divertikül gelişen bir hasta taktim ettik. Abdominal Manye- which was developed after stapled transanal rectal resec- tik Rezonans görüntüleme’de rektumda büyük bir diverti- tion procedure. Abdominal magnetic resonance imaging kül tespit edildi. Yapılan rektosigmoidoskopide; rektumda revealed a giant diverticulum of the rectum. A fecaloma dar bir ağzı olan ve fekaloidle dolu rektal divertikül tespit is removed from rectum endoscopically. J Clin Exp Invest edildi. Endoskop eşliğinde, tespit edilen fekalom parçala- 2013; 4 (4): 506-508 narak rektumdan dışarıya alındı. Key words: Magnetic resonance imaging, rectal diver- Anahtar kelimeler: Manyetik rezonans görüntüleme, ticulum, stapled hemorrhoidopexy rektal divertikül, stapled hemoroidektomi

INTRODUCTION than 1 year. In rectal examination a mass, nearly 4x4 cm diameter was determined on posterior Diverticulum disease is the most common pathol- rectum wall. Magnetic resonance imaging (MRI) ogy, which affects large intestine and is common in showed rectal diverticulum 5x4 cm in diameter on society [1]. Frequency of the disease increases by rectum posterior wall of pelvic (Figure 1). On rec- age and its incidence is 30% in population over the tosigmoidoscopy, rectal diverticulum with a narrow age of 60 years [2]. Rectal diverticulum is a rarely opening, which is full with fecaloma was determined encountered disease and generally its diagnosis is on proximal of Linea Dentata of rectum (Figure 2). established incidentally [3]. Stapled Hemorrhoido- A fecaloma is removed from rectum endoscopically. pexy includes concurrent excision and stapling of circumferential column of the mucosa and submu- cosa in the insensitive area above the dentate line, which results in reduction of mucosal prolapse [4]. Recently, rectal diverticula have been reported as surgical complication after the stapled transanal rectal resection (STARR) procedure [5]. In this pa- per, our purpose is to introduce a rectal diverticulum case, which was developed long after Stapled Hem- orrhoidopexy.

CASE REPORT Stapled Hemorrhoidopexy was performed to a 55-year-old male patient who has Hemorrhoid com- plaints for 5 years and pain and tenesmus com- plaints as well as constipation complaint for more Figure 1. Double lumen view can be seen on MRI incision

1 Erzincan University Department of General Surgery, Erzincan, Turkey 2 İbni Sina Hospital Department of General Surgery, Kayseri, Turkey 3 Red Crescent Hospital Department of General Surgery, Kayseri, Turkey Correspondence: Kemal Peker, Mengücek Gazi Eğitim ve Araştırma Hastanesi, Türkiye Email: [email protected] Received: 31.05.2013, Accepted: 24.06.2013 Copyright © JCEI / Journal of Clinical and Experimental Investigations 2013, All rights reserved Peker et al. Solitary rectal diverticulum 507

las of the colon. It is suggested that the probability that they take place at areas of focal weakness in the rectal wall brought about by congenital or acquired origin [12]. Most patients who have rectal diverticula are diagnosed incidentally and they are also asymp- tomatic. But, rectal diverticula may become inflated with impacted feces and progress to abscess and perforation. Several complications that are con- nected to rectal diverticula contain perforation and abscess, a prolapsed rectum from an inverted rectal diverticulum, rectal stenosis, rectovesical fistula and misdiagnosis as carcinoma [13]. Drainage of the abscess, diverting colostomy, resection of the diverticular mass or abdominal perineal resection Figure 2. Endoscopic appearance of the rectal diverticulum of the rectum constitutes surgical treatment of the complicated rectal diverticula [14]. In conclusion, rectal diverticulum is a rare dis- DISCUSSION ease with unknown etiology. However, it is not pos- Diverticular disease is usually first determined on sible to claim that stapling hemorrhoidectomy is an sigmoid colon and following this process, it is also etiological reason for acquired diverticulum. Hence, be observed on ascending colon and cecum. How- multicenter studies that are composed of long se- ever, rectal diverticulum is scarce and frequency ries are necessary for this issue. of the disease is less than 1% [4, 6]. Scarcity of rectal diverticulum is associated with two theories. REFERENCES Firstly, the muscle fibers of the taenia coli spread outward. Hence, they surround the rectum and for- 1. Place RJ, Simmang CL. Diverticular disease. Best Pract Res Clin Gastroenterol 2002;16:135-148. tify it against intraluminal pressures. Secondly, in comparison with the sigmoid colon [7], accumulated 2. Young-Fadoc TM, Roberts PL, Spencer MP, Wolf BG. Colonic diverticular disease. Curr Probl Surg feces and a lower peristaltic activity exert lesser 2000;37:457-514. constant internal pressure on the rectum. 3. Jung SH, Kim JH. A case of solitary rectal diverticu- The factors, which contribute to rectal divertic- lum presenting with a retrorectal mass Gut Liver ula formation are not totally comprehended. Proba- 2010;4:394-397. ble predisposing factors involve congenital anoma- 4. Athar A, Chawla T, Turab P. Stapled hemorrhoidopexy. lies such as weakness in the circumferential muscle The Aga Khan University Hospital experience. Saudi surrounding the rectum, primary muscle atrophy or J Gastroenterol 2009;15:163-166. the absence of supporting structures like the coc- 5. Alabiso ME, Grassi R, Fioroni C, Marano I. Iatrogenic cyx. Relaxed rectal-vaginal septum, recurrent fecal rectal diverticulum in patients treated with transanal impactions exerting pressure and causing disten- stapled techniques. Radiol Med 2008;113:887–894. tion of the rectum and pelvic trauma or infections 6. Chen CW, Jao SW, Lai HJ, et al. Isolated rectal di- that result in the weakening of the rectal wall con- verticulum complicating with rectal prolapse and out- let obstruction: case report. World J Gastroenterol stitute other acquired reasons [8, 9].Furthermore, 2005;11:7697-7699. Plavsic et al.[10] reported that 2 of 27 patients who 7. Piercy KT, Timaran C, Akin H. Rectal diverticula: report have scleroderma had rectal diverticulosis without of a case and review of the literature. Dis Colon Rec- other diverticula in the rest of the colon. Loss of co- tum 2002;45:1116-1117. lonic haustrations has been reported in scleroderma 8. Weston SD, Schlachter IS.Diverticulum of the rectum. and probably results in the development of colonic Dis Colon Rectum 1959;2:458-464. diverticula [11]. Rectal diverticulas are typically lo- 9. Damron JR, Lieber A, Simmons T. Rectal diverticula. cated along the lateral aspects of the rectum as the Radiology 1975;115:599-601. total longitudinal muscular layer of the rectum is 10. Plavsic BM, Raider L, Drnovsek VH, Kogutt MS. As- thicker anteriorly and posteriorly in comparison with sociation of rectal diverticula and scleroderma. Acta the lateral aspects of the wall [9]. Moreover, most Radiol 1995;36:96-99. rectal diverticulas described so far involve all layers of the colonic wall in opposition to pseudo diverticu- J Clin Exp Invest www.jceionline.org Vol 4, No 4, December 2013 508 Peker et al. Solitary rectal diverticulum

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