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Giant colonic diverticula are a rare manifestation of diverticular disease and there are fewer than 150 cases described in the literature. They may have an acute or chronic presentation or may remain asymptomatic and be found incidentally. As the majority (over 80%) of giant diverticula are located in the sigmoid colon, they usually present with left-sided symptoms but due to the variable location of the sigmoid loop, right-sided symptoms are possible. We describe the acute presentation of an inflamed giant sigmoid diverticulum with right iliac fossa pain. We discuss both the treatment options for this interesting condition and also the important role of computed tomography in the diagnosis and management of abdominal pain in elderly patients. case history A 70-year-old man presented to the acute general surgical take with a 24-hour history of worsening right iliac fossa pain. On examination he was found to have guarding and percussion tenderness in the right iliac fossa with pyrexia and tachycardia. A laboratory blood analysis showed a leukocytosis and an elevated C-reactive protein level. A diagnosis of acute appendicitis was suspected but in view of the age of the patient and his co-morbidity (ischaemic heart disease and type 2 diabetes) an urgent computed tomography (CT) of the abdomen and pelvis with oral contrast was arranged (Fig 1). The scan showed a 6.5cm-diameter giant sigmoid diverticulum in the mid-sigmoid to the right of the midline within an area of moderate diverticulosis. The giant diverticulum showed contrast enhancement indicating active inflammation. There was no evidence of a paracolic abscess, perforation or appendicitis and a diagnosis of acute giant sigmoid diverticulitis was made. Our patient was assessed as being at high risk for a laparotomy and was treated with intravenous broad-spectrum antibiotics with anaerobic cover. After 72 hours his symptoms had settled and he was well enough to be discharged. Ann R Coll Surg Engl

IntroductionNecrotizing fasciitis is a rare condition with a mortality rate of around 34%. It can be mono- or polymicrobial in origin. Monomicrobial infections are usually due to group A streptococcus and their incidence is on the rise. They normally occur in healthy individuals with a history of trauma, surgery or intravenous drug use. Post-operative necrotizing fasciitis is rare but accounts for 9 to 28% of all necrotizing fasciitis. The incidence of wound infection following saphenofemoral junction ligation and vein stripping is said to be less than 3%, although this complication is probably under-reported. We describe a case of group A streptococcus necrotizing fasciitis following saphenofemoral junction ligation and vein stripping.Case PresentationA 39-year-old woman presented three days following a left sided saphenofemoral junction ligation with long saphenous vein stripping at another institution. She had a three day history of fever, rigors and swelling of the left leg. She was pyrexial and shocked. She had a very tender, swollen left groin and thigh, with a small blister anteriorly and was in acute renal failure. She was prescribed intravenous penicillin and diagnosed with necrotizing fasciitis. She underwent extensive debridement of her left thigh and was commenced on clindamycin and imipenem. Post-operatively, she required ventilatory and inotropic support with continuous veno-venous haemofiltration. An examination 12 hours after surgery showed no requirement for further debridement. A group A streptococcus, sensitive to penicillin, was isolated from the debrided tissue. A vacuum assisted closure device was fitted to the clean thigh wound on day four and split-skin-grafting was performed on day eight. On day 13, a wound inspection revealed that more than 90% of the graft had taken. Antibiotics were stopped on day 20 and she was discharged on day 22.ConclusionNecrotizing fasciitis is a very serious complication for a relatively minor, elective procedure. To the best of our knowledge, this is the first report in the English-language literature of this complication arising from a standard saphenofemoral junction ligation and vein stripping. It highlights the need to be circumspect when offering patients surgery for non-life-threatening conditions.

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