LAUSR

Isolated transverse colon diverticulitis is rare. It constitutes less than 1% of colonic diverticulitis and presentation as perforation is even more rare. We report a case of solitary perforated diverticulitis of the transverse colon of a young woman. A 20-year-old woman presented to the emergency department complaining of central abdominal pain for a duration of 1 month. The pain became acutely severe 1 h prior to presentation. The pain was associated with fever, anorexia, nausea and vomiting. On examination, her temperature was 36.8 C, blood pressure was 123/59 mmHg and pulse was 122 per minute. Abdominal examination revealed generalized tenderness although the abdomen was relatively soft and bowel sounds were normal. Blood investigations showed leukocytosis of 14.5 × 10/L and high C-reactive protein (178 mg/L). Erect chest X-ray showed significant amounts of air under the diaphragm (Fig. 1). Bedside ultrasound showed no intraperitoneal fluid. Exploratory laparotomy revealed free intraperitoneal air without fluid. The source of perforation was initially difficult to find. There were minor fibrin flakes on the left side of the transverse colon. The splenic flexure and transverse colon were mobilized. To our surprise, we found an inflamed diverticulum on the antimesenteric border of the transverse colon located between the right two-thirds and left one-third of the transverse colon measuring 3 × 2.5 cm which was perforated at the tip (Fig. 2). The colon was thoroughly examined and we could not find other diverticula or wall thickening. Other abdominal viscera were normal. The diverticulum was excised with a wedge resection. The defect was closed transversely in two layers using Vicryl 3/0 sutures (Johnson and Johnson, Antwerp, Belgium). Histopathology of the resected specimen showed a pseudo-diverticulum with areas of mucosal ulceration associated with acute inflammation. The muscular layer was missing from the diverticular wall (Fig. 3) indicating that this was a pseudo-diverticulum. The patient had smooth post-operative recovery. Gastrografin enema carried out 6 weeks after surgery was normal, showing no other colonic diverticula. The preoperative differential diagnosis in our patient included typhoid perforation, foreign body bowel perforation or fallopian tube air suction. We did not think of diverticulitis preoperatively, nor that this was likely to be a perforated duodenal ulcer, as among the 116 treated perforated duodenal ulcers in our hospital, only two were females (1.7%). Furthermore, the central abdominal pain was against duodenal perforation. Computed tomography (CT) scan was not performed because the patient was young and we wanted to avoid irradiation as we thought that it would not change our management of carrying out a laparotomy. It was difficult to define the cause of the perforation even with open laparotomy. We think that a diagnostic laparoscopy may have missed this lesion. Preoperative diagnosis of perforated diverticulum was extremely difficult in the era pre-CT scan. In retrospect, the relatively soft abdomen and large amount of air under the diaphragm should have raised our suspicion of colonic perforation. Performing a CT scan with contrast may have helped us in defining the source of perforation. Conservative management may have then been considered because our patient was haemodynamically stable although there was a high risk of failure because of the distant air location from the perforation site. Reported cases of transverse colon