University of Maryland Medical Center Baltimore, MD, United States
Brandon Rodgers, MD1, Daniel G. Hwang, MD2, Peter Darwin, MD2 1University of Maryland Medical Center, Baltimore, MD; 2University of Maryland School of Medicine, Baltimore, MD
Introduction: Colorectal adenomas and diverticular disease are often found independently on screening colonoscopy. The presence of colorectal adenomas share common risk factors with diverticular disease, including advanced age, low fiber diet and obesity. Therefore it is not surprising that colorectal adenomas have been found within diverticuli although it is not common.
Case Description/Methods: A 61 year old woman with history of COPD initially presented for polypectomy after a 15 mm polyp was found on screening colonoscopy. Sigmoidoscopy revealed a 15 mm tubular adenomatous polyp in the sigmoid colon at the rim of a diverticulum (a). The polyp was injected with 5 mL ORISE for lesion assessment (b) and removed via a piecemeal manner with hot snare (c). Pathology revealed a tubulovillous adenoma with focal high grade dysplasia. Follow up sigmoidoscopy 10 months later showed recurrence of the lesion, now extending deep within the diverticulum (d), preventing polypectomy. The polyp was biopsied multiple times for evaluation of dysplasia or intramural carcinoma. Pathology showed tubulovillous adenoma, and a referral was made to colorectal surgery for risk assessment of laparoscopic resection.
Discussion: Adenomas found within diverticuli pose a challenge to be managed endoscopically. Due to the lack of a muscular layer within the diverticulum, endoscopic intervention of these adenomas carries a greater risk for colonic perforation. Both diverticuli and adenomas concurrently increase in prevalence with increasing age. It is important to examine diligently during colonoscopy since high grade lesions, as in this patient, can arise in locations difficult to visualize and resect. Furthermore, progression to colon cancer of these intradiverticular lesions in case reports have been shown to have challenging complications including fistula formation. Our case highlights the need for developing a safe and effective technique for endoscopic management, which will be paramount in helping patients avoid the need for surgical management
Figure: A: 15 mm tubular sigmoid adenomatous polyp at the rim of a diverticulum. B: Polyp injected with 5 mL ORISE for lesion assessment. C: Polyp after removal with hot snare. D: Recurrent sigmoid polyp extending deep within the diverticulum.
Brandon Rodgers indicated no relevant financial relationships.
Daniel Hwang indicated no relevant financial relationships.
Peter Darwin indicated no relevant financial relationships.
Brandon Rodgers, MD1, Daniel G. Hwang, MD2, Peter Darwin, MD2. P1259 - Tubulovillous Adenoma Within a Diverticulum, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.