Case Report

Sigmoid Diverticulitis in an Obese Pediatric Patient Without

Genetic Predisposition
*Megan Bartel, BS, †Christopher Burnett, MD, and ‡Danielle Barnes, MD

Abstract: Sigmoid diverticulitis has historically been a rare cause of abdomi-
nal pain in pediatrics, with minimal cases documented in the literature. The
patient studied is one of the first reported cases of acquired pediatric uncom-
plicated sigmoid diverticulitis in whom lifestyle was the main contributing
factor, as all associated known genetic risk factors were absent. Given the
rarity of the diagnosis, many pediatricians may not consider the diagnosis;
however, with the increasing incidence in younger patients, consideration of
diverticulitis on the differential diagnosis with lower abdominal pain, espe-
cially in patients predisposed to diverticular disease, is increasingly important
to avoid misdiagnosis and potential delays in appropriate treatment.
Key Words: abdominal pain, diverticulosis, obesity, pediatric
INTRODUCTION
Due to its rarity, diverticulitis, specifically of the sigmoid
colon, has not been well studied in the pediatric population. Most
studies that focus on the disease in the “young” refer to patients under
40 years old, with a majority falling aged between 30 and 40 years
old (1,2). In the United States, >50% of people over 60 years have
diverticulosis, while the prevalence of diverticulosis in those aged
<40 years is only 5% (3,4). Recently, the incidence of diverticulitis
has been increasing across all ages, with a 150% increase in hospi-
talization rates for 15- to 24-year-old patients specifically from 1998
to 2005 (3,5). Due to the increasing incidence in younger patients,
consideration of diverticulitis on the differential diagnosis for pedi-
atric patients presenting with lower abdominal pain is increasingly
important (3). We present a pediatric patient with sigmoid diverticu-
litis without any known genetic predisposition. The patient’s parent
provided consent for the publication of this case report.
significant for a similar episode 4 months prior with fever, nausea,
vomiting, anorexia, and abdominal pain, which resolved with oral
antibiotics, although no imaging was performed, and no diagnosis of
diverticulitis was considered. Upon initial presentation, the patient was
febrile and tachycardic with right lower quadrant tenderness and no
peritoneal signs. Initial laboratory analysis was significant for leuko-
cytosis (White blood cell count 19,400 cells/mm3) with leftward shift
(74% neutrophils), elevated inflammatory markers (erythrocyte sedi-
mentation rate 38 mm/h, C-reactive protein 15.51 mg/dL), and mild
transaminasemia (alanine aminotransferase 49 U/L, aspartate amino-
transferase 35 U/L). Abdominal computed tomography scan showed
a single sigmoid diverticulum with significant bowel wall thickening
and sigmoid colon edema, without evidence of concomitant appendi-
citis and an incidental finding of mild hepatomegaly (Figs. 1 and 2).
The patient was admitted for bowel rest, IV antibiotics (ceftriax-
one, metronidazole), and a consultation was obtained from pediatric
gastroenterology. An initial workup for inflammatory bowel disease
was undertaken and included fecal occult blood (negative), fecal
calprotectin (16 µg/g), complete metabolic panel (mild transamina-
semia, normal albumin), and complete blood count (no anemia). He
responded well to antibiotic therapy and tolerated a gradual reintro-
duction of a regular diet and transition to oral antibiotics (ciprofloxa-
cin, metronidazole). Due to transaminasemia, a workup to exclude
autoimmune, infectious, and metabolic liver disease was undertaken,
including liver-kidney microsomal antibody, smooth-muscle anti-
body, alpha-1 antitrypsin, antinuclear antibody, mitochondrial anti-
body, and ceruloplasmin, which were negative. The patient had no
other symptoms suggestive of underlying genetic syndromes such
as cystic fibrosis or Williams syndrome, thus further genetic test-
ing was not conducted. The patient’s hepatomegaly, fat infiltration

CASE PRESENTATION
The patient is a 15-year-old nondysmorphic male with autism
spectrum disorder, obesity (body mass index >99th percentile), and
functional constipation, who presented to the emergency department
with 1 day of lower abdominal pain and anorexia without nausea,
vomiting, or diarrhea. The patient’s mother reported chronic consti-
pation and straining with defecation. His past medical history was

Received January 14, 2021; accepted February 24, 2021.

From the *Uniformed Services University, Bethesda, MD; †Department of Pedi-
atrics, Naval Medical Center San Diego, San Diego, CA; and ‡Division of
Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Naval
Medical Center San Diego, San Diego, CA.
Correspondence: Danielle Barnes, MD, 34800 Bob Wilson Dr, Building 2, San
Diego, CA 92134. E-mail: DaniMHBarnes@gmail.com
The authors report no funding and conflicts of interest.
The opinions and assertions expressed herein are those of the author(s) and do not
necessarily reflect the official policy or position of the Uniformed Services
University, the United States Navy, or the Department of Defense.
Written work prepared by employees of the Federal Government as part of their
official duties is, under the U.S. Copyright Act, a "work of the United States
Government" for which copyright protection under Title 17 of the United
States Code is not available. As such, copyright does not extend to the contri-
butions of employees of the Federal Government.
JPGN Reports (2021) 2:2(e078) FIGURE 1.  The arrow indicates the area of diverticulitis noted
ISSN: 2691-171X in this patient on a transverse abdominal CT scan. CT = com-
DOI: 10.1097/PG9.0000000000000078 puted tomography.

1
Case Report
FIGURE 2.  This abdominal CT coronal cross section shows
diffusely thickened sigmoid colon with surrounding inflam-
mation indicated by the arrow. CT = computed tomography.
on computed tomography images, and mild transaminasemia were
thus diagnosed as nonalcoholic fatty liver disease. His inflammatory
markers normalized, and the patient was discharged home on a regu-
lar diet with gastroenterology follow-up.
DISCUSSION
Characterizing the presentation of diverticulitis in younger
patients has been challenging, with studies presenting conflicting
results. The presentation can include abdominal pain, fever, leuko-
cytosis, constipation, and diarrhea (4). These presenting symptoms
are shared by a number of gastrointestinal pathologies, which makes
diagnosing diverticulitis in young patients difficult and could increase
the potential for an adverse outcome if the diagnosis were missed (6).
A number of studies have found diverticular disease in the young to
carry increased morbidity when compared with older patients based
on the need for surgery, and more advanced disease stage, complica-
tion rate, and likelihood of recurrence, although this remains contro-
versial (6,7). The potential increased severity of diverticular disease
in young patients may be due, in part, to diagnostic delays rather than
true age-related factors (6).
Younger patients typically present with right-sided diverticu-
lar disease, even in Western populations where left sided are more
common (8). The majority of published diverticulitis cases in those
under 18 years of age discuss genetic predisposing factors, such as
cystic fibrosis and connective tissue disorders like Marfan syndrome,
Ehlers Danlos syndrome, and Williams-Beuren syndrome (9). We
believe our patient is one of the first reported cases of acquired
2 www.jpgn.org
pediatric uncomplicated sigmoid diverticulitis in whom lifestyle was
the main contributing factor.
There are a number of lifestyle factors that are believed to
be important in the development of diverticulitis, including West-
ern diets (low fiber, high consumption of red meat, fat and refined
grains), low physical activity, obesity, smoking, low vitamin D lev-
els, and medications including nonsteroidal anti-inflammatory drugs,
opiates, and corticosteroids (3,4). These risk factors likely contribute
to diverticulitis in a variety of ways. Low dietary fiber intake, as seen
in Western diets, has been shown to play a role in the development of
diverticulosis (3). Both physical inactivity and low fiber intake can
contribute to obesity, and multiple studies have found obesity to be
significantly related to diverticular disease in the young (3,5). Obe-
sity and Western diets have been shown to decrease gut microbiota
diversity, and studies have found associations between altered gut
microbiota and diverticular disease (3). Diverticulitis has been asso-
ciated with chronic inflammation and shares risk factors, like obesity,
physical inactivity, and a Western diet, with other diseases, such as
cardiovascular disease and diabetes, that are believed to be caused, at
least in part, by chronic inflammation (3).
Pediatric sigmoid diverticulitis has historically been a rare
finding, but as with adult diverticulitis, the incidence is on the rise.
Further studies are needed to clarify the pathogenesis of diverticular
disease. We presented a patient with left sided, acquired diverticuli-
tis, highlighting that a high index of clinical suspicion is warranted
when evaluating pediatric patients with lifestyles, which may predis-
pose them to diverticular disease. It should be particularly considered
in the differential diagnosis for lower abdominal pain in patients with
risk factors such as obesity, low fiber diet, and physical inactivity.
Earlier diagnosis may allow for conservative management and a less
severe disease course.
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