Air in the Middle of the Abdomen

A 66-year-old man presented with a 20-day history of constipation, lower abdominal and back pain, and fever. Two days before admission, his symptoms worsened, with nausea and passing flatus but not stool. The patient's medical history included acute diverticulitis that was managed conservatively. The abdomen was soft and slightly distended, with mild tenderness in the lower quadrants. The laboratory results showed leukocytosis (white-cell count, 10,890 per cubic millimeter). Plain radiography showed a large air bubble (>10 cm in diameter) centrally located in the abdomen (Panel A). Urgent abdominal computed tomography (CT), without the use of contrast medium, suggested that the midabdominal air bubble was a large diverticulum, at least 10 cm in diameter, located adjacent to the duodenum (Panel B, arrows) and inferior mesenteric artery (Panel B, arrowheads). There were no signs of perforation, inflammation, or free fluid. The CT images also revealed possible communication between the diverticulum sack and the sigmoid colon, through a narrow diverticular neck (Panel C, arrows). Laparotomy confirmed a colonic diverticulum extending from the level of the duodenojejunal junction to the aortic bifurcation. The diverticulum was resected and Hartmann's procedure was performed. The pathology report confirmed diffuse colonic diverticular disease and a giant sigmoid diverticulum with a maximum diameter of 17 cm, with signs of acute inflammation, localized perforation, and fibrinopurulent peritonitis. Five months later, the patient underwent colostomy reversal. Colocolic anastomosis was performed, and the postoperative course and follow-up were uneventful.

N Engl J Med 2010; 363:e28 October 28,2010