Diverticular disease is a common disease with increasing incidence in the aging population and Western countries. It varies widely by geographic location but the rate of hospitalizations has consistently increased over time in all age groups and in both sexes [3].

Diverticular disease consists of diverticulosis and diverticulitis, both of which were present in the patient. Diverticular disease is diverticulosis of the colon, which are small pockets from the colonic lumen caused by herniation of the mucosa through the weakened colonic wall, while chronic diverticulitis is characterized by frequent abdominal pain and chronic obstructive symptoms [4,5]. Around 80% of people with diverticular disease are asymptomatic but could become symptomatic in about 10-20% of cases, with resultant complications such as obstruction, perforation, abscess, and colonic stricture [6]. Colonic stricture caused by fibrosis or chronic inflammation of the colonic wall is most commonly caused by chronic diverticulitis with a high rate of bowel resection to relieve the obstructive symptoms [7].

The strictures commonly occur in the descending and sigmoid colon, but most especially at the sigmoid colon which is the narrowest part of the large intestine and with the highest intersegmental peristaltic pressure [8]. The resultant dilatation of the proximal colon and intraluminal stasis leads to overgrowth of intestinal flora, which in turn leads to translocation of the bacteria across the bowel wall with stool formation within the small bowel [9]. This is known as fecalization or small bowel feces sign, as seen in this patient. Fecalization of small intestines, which is a non-specific sign on contrast Computerized Tomography (CT) can also be seen in inflammation, ischemia, ileus, obstruction, and infection. Smoking, as in this patient, obesity, and a low fiber diet is believed to be some of the risk factors for symptomatic diverticular disease.

The diagnosis of diverticulosis and chronic diverticulitis is usually made by the characteristic clinical symptoms and radiographic findings [5]. Emesis, as seen in this patient, usually leads to electrolyte derangement due to loss of gastric hydrogen, chloride, and potassium which leads to metabolic alkalosis, but ironically, this patient had an abnormally elevated chloride level [9]. Colonoscopy has been considered in uncertain diagnosis and to rule out malignant obstruction, however, increased difficulty of diagnostic colonoscopy due to narrow lumen, colon spasms, and difficulty with angulations has limited its use [10]. Contrast CT is of great importance in the assessment of colonic abnormalities, as in addition to delineating the degree of bowel wall affectation, it provides extraluminal information that could impact treatment and prognosis, as well as, in exclusion of malignancy [8,11]. Another imaging modality which has been explored is the use of magnetic resonance imaging (MRI) which has been found to provide similar level of diagnostic accuracy in patients with diverticular disease [12].

Surgery is the definitive treatment of obstruction caused by colonic strictures in most cases. Acute surgical interventions are usually indicated when the colonic obstruction is not amenable to medical interventions and to completely exclude malignancies [13]. One-stage colorectal resection and primary end-to-end anastomosis are generally preferred [14]. Of great note, is the fact that this patient has had a total abdominal hysterectomy and a provisional diagnosis of intestinal obstruction secondary to adhesive bands could have been entertained before the diagnosis was confirmed to be colonic stricture due to diverticular disease after the surgery.