P1663 - Kissing Area: A Rare Report of Sigmoido - Cecal Fistula

Nirali Sheth, DO¹, Anastasia Novikov, MD², Maliyat M. Matin, MD³, Genanew Bedanie, MD⁴, Vennis Lourdusamy, MD⁵, Raghav Bansal, MD⁶, Krishna Gurram, MD⁷, Aaron Walfish, MD⁵, Joshua Aron, MD⁷, Joel Baum, MD^8
1Icahn School of Medicine Mount Sinai - Elmhurst Hospital Center, Rego Park, NY; ²Elmhurst Hospital Center/ Icahn School of Medicine at Mount Sinai, Elmhurst, NY; ³Icahn School of Medicine Mount Sinai - Elmhurst Hospital Center, Elmhurst, NY; ⁴Icahn School of Medicine at Mount Sinai, New York, NY; ⁵Elmhurst Hospital Center/ Icahn School of Medicine, Elmhurst, NY; ⁶Elmhurst Hospital Center, Elmhurst, NY; ⁷Icahn School of Medicine at Mount Sinai, NYC Health + Hospitals/Elmhurst, Queens, NY; ⁸Icahn School of Medicine at Mount Sinai - Elmhurst Hospital, Queens, NY

Introduction: While Diverticular disease is well reported and common in developed countries, the incidence of complications including obstruction, fistula, abscess, or perforation is low. We report a rare case of sigmoido – cecal fistula complicated by diverticulitis and abscess formation with initial presentation concerning for malignancy or colonic tuberculosis.

Case Description/Methods: This is a 70 year old female with no history presenting with abdominal pain for 2 weeks. No prior episodes, no associated fevers, diarrhea, or weight loss. She reports night sweats & cough. Labs consistent with leukocytosis, CA 125 elevated at 152 U/mL, CEA elevated at 53.7 ng/ml, AFP sputum positive x 2. Computed tomography (CT) notable for multilocular soft tissue and fluid collection adjacent to the uterus and inseparable from bowel concerning for malignancy [Figure 1A]. There was also thickening of the sigmoid with multiple diverticula suggestive of diverticulitis as well as multifocal nodular infiltrate in bilateral lungs consistent with granulomatous infection. A colonoscopy was performed to evaluate for malignancy. A large, advanced polyp was found at the cecum with pus at the appendiceal orifice suggestive of possible fistulous tract [Figure 1B]. No masses identified. Subsequent Magnetic resonance imaging notable for fluid collection in the right hemipelvis with fistulation from the cecum to the sigmoid colon [Figure 1C]. Patient underwent exploration laparoscopy, found to have sigmoido – cecal fistula with no other findings.

Discussion: Intra-abdominal fistulas are a known complication of diverticulitis, but colo- colonic fistulas, especially sigmoido – cecal are very rare with few reported cases in literature. Such cases involved recurrent diverticulitis and obstruction which were not seen in our patient. Given mass like appearance on imaging and elevated tumor markers, patient was initially thought to have a malignancy. Despite positive AFP and imaging consistent with granulomatous disease, colonic mucosa appeared healthy without ulcerations, therefore colonic tuberculosis was not suspected. While CT is the recommended diagnostic modality in diverticulitis, complicated diverticulitis with fistula may be unclear as seen with our patient. Colonoscopy should be considered in aiding in the diagnosis. This case highlights that in atypical presentations of diverticulitis multidisciplinary management is vital to not delay the diagnosis of sigmoido- cecal fistula or the individualized management that is required.



Disclosures:


Nirali Sheth, DO¹, Anastasia Novikov, MD², Maliyat M. Matin, MD³, Genanew Bedanie, MD⁴, Vennis Lourdusamy, MD⁵, Raghav Bansal, MD⁶, Krishna Gurram, MD⁷, Aaron Walfish, MD⁵, Joshua Aron, MD⁷, Joel Baum, MD⁸. P1663 - Kissing Area: A Rare Report of Sigmoido - Cecal Fistula, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.