Abstract

Introduction: Diverticulosis is a condition commonly seen (50% of patients above the age of 60 years) in the United States. Diverticulitis, a possible complication of diverticulosis, has many complications of its own. Some of these, such as colovesical or colocutaneous fistulas are more commonly reported while other, more rare presentations, are infrequently documented in literature. We report on a case of sigmoid diverticulitis complicated by perforation and fistula formation with adnexa effectively presenting as pelvic inflammatory disease in a 55-year-old female.

Case Description:  The patient is a 55-year-old white female with a 6-month history of diverticulitis previously treated medically without complications, who experienced a recurrent episode 10 days prior to her current presentation. The patient was seen at another facility during which CT scan performed showed sigmoid diverticulitis with localized, primarily contained perforation. The patient was managed conservatively with IV antibiotics and discharged 4 days later, on oral antibiotics. The patient then presented to clinic with worsening left lower quadrant pain, nausea, and vomiting stating that she initially began to feel better following discharge but a couple of days later, the pain worsened, and she was now having low grade fevers at home. The patient also reported new left flank pain and “bubbles in her urine.” Patient was instructed to go to the emergency department (ED) for admission to hospital and further evaluation and treatment. On presentation to ED, vital signs showed a heart rate of 104 beats per minute and a blood pressure of 90/58 mmHg. Physical examination was positive only for a moderate, diffusely tender, abdomen with some voluntary guarding but no rebound, rigidity, or abdominal masses. Repeat CT abdomen/pelvis showed sigmoid diverticulitis with post-inflammatory fistulous tract between the sigmoid colon and left adnexa with air-fluid level/abscess formation around the left adnexa, and extension into the intrauterine cavity without any pelvic free fluid.  On admission, surgery and gynecology were consulted and the patient was eventually taken to the OR for sigmoid colectomy and left salpingo-oophorectomy with possible hysterectomy.

Discussion: Colovaginal fistula, specifically in the absence of hysterectomy, is extremely uncommon. In people with a uterus, the uterus is usually protective against the spread of perforated diverticulitis, most commonly to the bladder, however this patient’s abscess spread through the left adnexa and lateral abdominal wall to involve the left ovary, fallopian tube, and the uterus. A history of previously uncomplicated, medically treated episodes of diverticulitis combined with a mild initial presentation with ‘walled-off’ perforation led to failed conservative management with resulting spread of infection into the reproductive organs. Treatment of diverticulitis has long been debated and investigated. While somewhat still controversial due to individualized presentations and outcomes, clinical and radiological guidelines have been recommended to make the best decision for each individual patient.