International Journal of Medical and Pharmaceutical Case Reports 6(1): 1-5, 2016; Article no.IJMPCR.22364 ISSN: 2394-109X, NLM ID: 101648033

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Are We Missing Any Other Components of Saint Triad?

Jayabal Pandiaraja 1* and Arumuguam Sathyaseelan 1

1SRM Medical College, Potheri, Kancheepuram, 603203, India.

Authors’ contributions

This work was carried out in collaboration between both authors. Author JP wrote the draft of the manuscript. Author JP managed the literature searches. Author AS designed the figures, managed literature searches and contributed to the correction of the draft. Author JP provided the case, the figures and supervised the work. Both authors read and approved the final manuscript.

Article Information

DOI: 10.9734/IJMPCR/2016/22364 Editor(s): (1) Erich Cosmi, Director of Maternal and Fetal Medicine Unit, Department of Woman and Child Health, University of Padua School of Medicine, Padua, Italy. (2) Jignesh G. Patel, Department of Pathology, University of Texas Medical Branch at Galveston, Texas, USA. Reviewers: (1) Aşkın Ender Topal, Dicle University, Turkey. (2) Eyo E. Ekpe, University of Uyo, Nigeria. (3) Ketan Vagholkar, D. Y. Patil University, School of Medicine, India. Complete Peer review History: http://sciencedomain.org/review-history/12062

Received 29 th September 2015 th Case Study Accepted 17 October 2015 Published 2nd November 2015

ABSTRACT

Saint triad consists of colonic diverticulosis, gall stone and hiatus hernia. But there are reports of colonic diverticulosis with cardiomyopathy. This is a case report of Saint Triad with dilated cardiomyopathy and duodenal diverticulosis. So all patients who fall under Saint Triad have to undergo upper gastro intestinal endoscopy to identify duodenal diverticulum apart from hiatus hernia and echo cardiography to identify cardiomyopathy as a part of screening.

Keywords: Saint triad; duodenal diverticulum; cardiomyopathy; pentad.

1. INTRODUCTION there are a structural abnormalities or abnormal colonic motility. As a conventional teaching any Colonic diverticulosis mostly occur in developed patient with colonic diverticulosis should be countries as a result of lack of fiber in their diet screened for Saint Triad to identify gall stone and [1]. Colonic diverticulosis mainly occurs when hiatus hernia as a part of triad. But there ______

*Corresponding author: E-mail: [email protected];

Pandiaraja and Sathyaseelan; IJMPCR, 6(1): 1-5, 2016; Article no.IJMPCR.22364

are reports of colonic diverticulosis with fundus of gall bladder [Fig. 4]. Patient treated cardiomyopathy. It raises the question whether to conservatively with blood transfusion and iron screen for cardiomyopathy when the patient fall supplementation. Patient condition improved under Saint Triad. during treatment.

2. CASE HISTORY 3. DISCUSSION

A 55 years old male patient who is known case of type 2 diabetes mellitus, systemic Saint triad consists of colonic diverticulosis, gall hypertension and dilated cardiomyopathy stone and hiatus hernia [2]. Saint triad is presented with complaint of recurrent episode of considered as a part of herniosis, that is systemic bleeding per rectum for 1 day. History of similar connective tissue disease known to cause episode before 4 years. No history of chest pain, diverticulosis and hernia [3]. There are reports palpitation and breathlessness. There was no of cardiomyopathy in patient with colonic history of haematemesis, melena and abdominal diverticulosis. One case reported by Pagano D. distension. On examination there was pallor with et al. [4] showed malignant diverticulosis dehydration. Cardiovascular examination showed associated with dilated cardiomyopathy and systolic murmur at 2 nd and 3 rd intercostal space another case reported by Elisa Palladino et al. [5] and apical impulse felt at 5 th intercostal space at showed association of hypertrophic cardiomyo- mid calvicular line. Abdominal examination was pathy with Diverticular disease. normal. Per rectal examination showed skin tag at 6’o position and blood clot. Patient treated with Both cardiomyopathy and diverticulosis share blood transfusion and fresh frozen plasma. same pathophysiology. 25-35% of the patient ECG showed biventricular hypertrophy and with dilated cardiomyopathy are associated with echo showed dilated cardiomyopathy with mutations of cytoskeletal proteins and proteins asymmetrical septal hypertrophy [Fig. 1]. No that involve in contraction [6]. The mutated genes evidence of left ventricular outflow tract predominately encode two major sub groups: obstruction. Colonoscopy showed diverticulosis Cytoskeletal protein includes dystrophin, desmin, present in entire colon starting from caecum to lamin and sarcoglycan. Sarcometric proteins sigmoid colon [Fig. 2]. Upper gastro intestinal includes ß- myosin heavy chain, myosin binding endoscopy showed hiatus hernia with duodenal protein and actin [7]. This may explain diverticulosis. Contrast enhancing CT showed association with hiatus hernia, diverticulosis and diverticulum at the 2 nd part of duodenum, dilated cardiomyopathy. Formation of gall stone ascending colon, transverse colon and or gall bladder disease may be as a part of descending colon [Fig. 3]. Contrast CT also dismotility or dilation that produces bile stasis showed a single 9 mm calculi present in the and gall stone formation.

Fig. 1. Echo showed dilated cardiomyopathy with asymmetrical septal hypertrophy

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Pandiaraja and Sathyaseelan; IJMPCR, 6(1): 1-5, 2016; Article no.IJMPCR.22364

Fig. 2. Colonoscopy showed diverticulosis present in entire colon starting from caecum to sigmoid colon

There are multiple proposed causes for and these patients are more prone to develop development of diverticulosis, but accepted colonic diverticulosis. causes are structural abnormalities of colon, abnormal colonic motility and lack of dietary fiber The importance of cardiac screening in colonic [8]. Marked thickening of circular muscle fibers diverticulosis is to determine the prognosis are seen in microscopic anatomy of colonic and plan for intervention. End stage of diverticulum. These thickenings of muscle fiber cardiomyopathy need cardiac transplantation. occur when there is abnormal cross linking of We must treat diverticulosis before administering collagen. This abnormal cross-linking of collagen immunosuppression for cardiac transplntation, produces excess deposition of elastin. Excess because there is a higher chance of malignant deposition of elastin cause increased contractility diverticulitis following immunosuppression [4]. As which in turn produces weakening of colonic wall a routine protocol, patient with Saint Triad has to and produces diverticulosis [9]. This factor better be screened for cardiomyopathy. Still further appreciated when connective tissue disorders studies are needed to validate importance of are associated with cardiac disease or echo cardiography in patient with diverticulosis aneurysmal disease as a component of disease when it occurs as a part of Saint Triad.

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Pandiaraja and Sathyaseelan; IJMPCR, 6(1): 1-5, 2016; Article no.IJMPCR.22364

Fig. 3. Contrast enhancing CT showed diverticulum at inferior aspect and medial aspect of 2 nd part of duodenum and multiple small diverticulums in ascending, transverse and descending colon

Fig. 4. A single 9 mm calculi present in the fundus of gall bladder with duodenal diverticulum

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Pandiaraja and Sathyaseelan; IJMPCR, 6(1): 1-5, 2016; Article no.IJMPCR.22364

4. CONCLUSION and case contribution. Minerva Med. 1987; 78(15):1183–7. All patients who fall under Saint Triad have to 3. Hauer-Jensen M, Bursac Z, Read RC. Is undergo upper gastro intestinal endoscopy to herniosis the single etiology of Saint’s identify duodenal diverticulum apart from hiatus triad? Hernia J Hernias Abdom Wall Surg. hernia and echo cardiography to identify 2009;13(1):29–34. cardiomyopathy as a part of screening. 4. Pagano D, Cintorino D, Gruttadauria S, Saint triad with duodenal diverticulum and Spada M, Echeverri G, Botrugno I, et al. cardiomyopathy can be considered as a pentad Malignant diverticulitis of the left colon in Saint Triad. complicating heart transplantation. Ann Transplant Q Pol Transplant Soc. 2010; CONSENT 15(3):71–4. 5. Palladino E, Cappiello A, Guarino V, All authors declare that ‘written informed consent Perrotta N, Loffredo D. Laparoscopic was obtained from the patient (or other approved colostomy for acute left colon obstruction parties) for publication of this case report and caused by diverticular disease in high risk accompanying images. patient: A case report. Int J Surg Case Rep. 2015;12:78–80. ETHICAL APPROVAL 6. McNally EM, Golbus JR, Puckelwartz MJ.

Genetic mutations and mechanisms in It is not applicable. dilated cardiomyopathy. J Clin Invest. COMPETING INTERESTS 2013;123(1):19–26. 7. Hazebroek M, Dennert R, Heymans S. Authors have declared that no competing Idiopathic dilated cardiomyopathy: interests exist. Possible triggers and treatment strategies. Neth Heart J Mon J Neth Soc Cardiol Neth REFERENCES Heart Found. 2012;20(7-8):332–5. 8. Simpson J, Scholefield JH, Spiller RC. 1. Matrana MR, Margolin DA. Epidemiology Pathogenesis of colonic diverticula. Br J and pathophysiology of diverticular Surg. 2002;89(5):546–54. disease. Clin Colon Rectal Surg. 2009; 9. von Rahden BH, Germer CT. 22(3):141–6. Pathogenesis of colonic diverticular 2. Scaggion G, Poletti G, Riggio S. Saint’s disease. Langenbecks Arch Surg Dtsch triad. Statistico-epidemiologic research Ges Für Chir. 2012;397(7):1025–33. ______© 2016 Pandiaraja and Sathyaseelan; This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Peer-review history: The peer review history for this paper can be accessed here: http://sciencedomain.org/review-history/12062

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