Cecal diverticulitis: a diagnostic challenge

Caecal diverticulitis can be misdiagnosed as acute appendicitis: a systematic review of the literature

AIM

Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies among medical centres. The aim of this study was to review cases of patients with CD, to identify the factors differentiating CD from acute appendicitis and to provide a summary of existing diagnostic methods and therapeutic alternatives regarding its management.

METHODS

This systematic review was conducted in accordance with the PRISMA guidelines and the AMSTAR2 checklist. We searched MEDLINE and Embase from inception until 1 October 2018 for original publications reporting cases of CD.

RESULTS

Out of the 560 identified studies, 146 publications (988 patients) were included in the qualitative synthesis. Most frequent symptoms of CD were right iliac fossa pain (93.2%), nausea and/or vomiting (35.4%) and fever (26.9%). A total of 443 patients (44.8%) underwent radiological imaging, which reported CD in 225 patients (22.8%). For the other patients, the diagnosis was obtained by surgical exploration (73.9%). Among patients diagnosed with CD by imaging, 67 (29.8%) underwent surgery and 158 (70.2%) were treated conservatively. Among patients who underwent surgical exploration, treatment consisted most frequently of right hemi-colectomy (33%), appendectomy (18.8%) and diverticulectomy with appendectomy (16.3%).

CONCLUSION

CD can be misdiagnosed as acute appendicitis, therefore resulting in unnecessary surgical exploration. The review of the literature starting from 1930 highlights the critical role of medical imaging in supporting the clinician to diagnose this condition and administer adequate treatment.

Ileocecal thickening: Clinical approach to a common problem

Ileocecal thickening (ICT) is a common finding on radiological imaging. It can be caused by a variety of inflammatory, infectious, or neoplastic conditions, and evaluating a patient of ICT can be a challenging task. Intestinal tuberculosis (ITB), Crohn's disease (CD), and adenocarcinoma are the most common causes. Enteric bacterial infections, cytomegalovirus, histoplasmosis, amebiasis, systemic vasculitis, lymphoma, etc. should be suspected in appropriate clinical settings. However, it could often be a spurious or nonspecific finding. A thickness of more than 3 mm in a normally distended small bowel is usually considered abnormal. Detailed evaluation of imaging of the site and extent of thickening; the degree and pattern of thickening; and the associated findings, such as degree of fat stranding, fibrofatty proliferation, adjacent lymph nodes, and solid organ involvement, should be performed. Ileocolonoscopy is an important tool for diagnosing and obtaining samples for tissue diagnosis. Histopathology is usually the gold standard for diagnosis, although—not uncommonly—findings could be nonspecific, and reaching a definitive diagnosis is difficult. As such, a systematic approach with the integration of clinical, biochemical, radiological, endoscopic, histological, and other laboratory tests is the key to reaching a diagnosis. In this article, we review the causes of ICT and present a clinical approach for the management of ICT.

Uncommon Diverticular Disease

This article describes the epidemiology, pathogenesis, diagnosis, and treatment of three rare variants of diverticular disease: cecal and right-sided colonic diverticula, giant colonic diverticula, and small bowel diverticula.

Cecal diverticulitis is a challenging diagnosis: a report of 3 cases

Case series

Patient: Male, 44 • Female, 73 • Male, 63

Final Diagnosis: Cecal diverticulitis

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: Right hemicolectomy

Specialty: Surgery

Conservative treatment of right-sided colonic diverticulitis

BACKGROUND

Diverticulosis of the right colon occurs in a small percentage of patients in Western countries. Clinical presentation of right-sided colon diverticulitis is indistinguishable from that of acute appendicitis, and the majority of patients undergo surgical intervention for presumed appendicitis. The liberal use of diagnostic radiological modalities whenever appendicitis was suspected led to correct diagnosis and also to more preoperative diagnosis of right-sided diverticulitis, which consented conservative medical therapy in cases of uncomplicated right-sided diverticulitis. The aim of the study was to report the outcome in patients with right-sided diverticulitis diagnosed nonoperatively using computed tomography scanning and treated conservatively.

METHODS

Patients with clinical and radiological diagnosis of cecal or right colon diverticulitis treated conservatively between January 2005 and December 2007 were included. The demographic and clinical data were retrospectively analyzed.

RESULTS

Fifteen patients were included in this study. The median age was 52 years (range, 34-72 years) and the duration of symptoms was 4 days (range, 1-9 days) before the diagnosis. The median hospital stay was 5 days (range, 1-9 days). All patients were successfully treated with medical therapy. During a median follow-up of 32 months (range, 24-52 months) only one patient (6.6%) had a recurrent attack, and he was successfully treated again with medical therapy.

CONCLUSION

The routine use of the computed tomography scan for abdominal pain in the right lower quadrant, and whenever right-sided diverticulitis is suspected, improves diagnosis and reduces surgical interventions. The current study provides additional data in support of conservative therapy as the initial treatment in acute right-sided diverticulitis, even in cases of recurrence.

Acute inflammation of the true cecal diverticulum--case report

In this case report, we describe a rare event: acute inflammation of the true cecal diverticulum. Emergency surgery enabled proper diagnosis and management of this condition. Diagnostic approaches and the management of this disease are described in detail and based on literature review. In conclusion, pathologies of cecal diverticula should be considered in differential diagnosis of pain in the right iliac fossa.

Perforated caecal diverticulum as a content of inguinal hernia - report of a rare case

A tablet induced perforation of a caecal diverticulum into a hernial sac is a rare happening. The report discusses the presentation and outcome of a patient with such an unusual disease. A 55-year-old man presented with features of irreducible right sided indirect inguinal hernia. A hard swelling near upper pole of right testis was noted. Scrotal ultrasound revealed a normal testis. At operation caecum and proximal ascending colon were found in the hernial sac with the caecum adherent to the testis. As caecal malignancy could not be ruled out and enbloc Rt Haemicolectomy with Rt orchidectomy was performed. The patient had an uneventful recovery. Pathological examination of the specimen revealed a perforated caecal diverticulum with presence of multiple tablets in its lumen invaginating the upper pole of right testis without any evidence of malignancy. Tablet induced perforation of a caecal diverticulum into a hernial sac is a rare clinical entity. If malignancy cannot be negated at operation, a right haemicolectomy is a safe and feasible option.

Conservative Treatment for Patients with Acute Right Colonic Diverticulitis

Little is known about the natural history of right colonic diverticulitis treated with conservative management. The purpose of this study was to analyze the short-term outcome of a conservative approach to the treatment of patients with acute right colonic diverticulitis. A retrospective review of the clinical and radiological findings of 62 patients with acute right colonic diverticulitis was carried out. Conservative treatment was provided to 47 patients and surgical treatment to 15 patients with the diagnosis of acute right colonic diverticulitis. An initial ultrasound was performed in 45 of 62 patients (73%) and a CT was performed in 16 of 62 patients (26%). Diverticulitis was confirmed pretreatment diagnosis in 56 of 61 (91.8%) patients who had radiological evaluation. There were seven (11.3%) pericolic abscesses identified as a complication of the diverticulitis. All 47 patients who received conservative management were successfully treated and had improvement of symptoms with no sign of clinical deterioration. For the fifteen patients who had surgery: 5 had right hemicolectomies, 8 had appendectomies without diverticulectomy, 1 had an appendectomy with diverticulectomy, and 1 had diverticulectomy alone. During a median follow-up of 23.9 months, two of 55 (3.6%) patients who did not have surgical resection for inflamed diverticulum had recurrences one and ten months after the initial treatment; they were successfully treated again with bowel rest and antibiotics without complication. Conservative treatment should be considered as a safe and effective option for acute right colonic diverticulitis. In addition, a less aggressive approach may be more suitable for recurrent diverticulitis than extended surgical resection.

Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period

INTRODUCTION

In contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis.

OBJECTIVE

The aim of this study was to analyze surgical challenge in right-sided diverticulitis.

MATERIALS AND METHODS

All patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996-2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry.

RESULTS

From a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens.

DISCUSSION

As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.

Surgical management of cecal diverticulitis: is diverticulectomy enough?

INTRODUCTION

Cecal diverticulitis is a rare condition in the western population. The optimal management of this condition is still controversial, ranging from conservative antibiotic treatment to aggressive resection. We present our experience of the surgical management of eight cases of cecal diverticulitis over a 25-year period.

PATIENTS AND METHODS

The mean age of the patients was 54.2 years. Five patients underwent diverticulectomy, 2 patients underwent ileocecal resection, and 1 patient underwent suture of the perforated diverticulum.

RESULTS

The postoperative course of all patients was uneventful. At long-term follow-up (mean 14.6 years, range 1-25 years) none of the patients who underwent diverticulectomy, mentioned any symptom or complication.

CONCLUSION

We conclude that diverticulectomy, if technically feasible, could be considered as adequate therapy for cecal diverticulitis. Aggressive resection should be considered in cases of extensive inflammatory changes.

[Right colon diverticulitis]

Diverticulitis involving the right colon is uncommon in the Occident; only one case for every 300 cases of appendicitis occurs in Western countries compared to a ratio of 1/40-1/180 in Asia. The preferential localization of diverticula in the right colon among Asiatics is probably due to genetic factors. In Asia as in the West, a right colon diverticulum is more likely to cause hemorrhage than diverticulitis. The peak age of symptoms is 40-45 years and the sex ratio is 1:1. The patient most commonly presents with symptoms suggestive of acute appendicitis, acute localized peritonitis, or, more rarely, a psoas abscess. Clinical exam reveals an inflammatory mass in the right lower quadrant in 30% of cases; diffuse peritonitis, large abscesses, and fistulae are rare. Helical CT scan is the best tool for establishing the diagnosis and also helps to rule out other possible etiologies in the differential diagnosis-particularly a perforated right colon cancer. In noncomplicated cases with convincing evidence for the diagnosis by CT scan, a conservative (non-surgical) treatment with antibiotics is possible; a later stage colonoscopy will rule out other colonic lesions. More commonly, the correct diagnosis is only made after embarking on an appendectomy via a McBurney incision; the surgical strategy thereafter depends on the level of suspicion regarding the diagnosis and the extent and complexity of the diverticulitis. Therapeutic options may be conservative (appendectomy), limited (diverticulectomy, or extensive (ileocecal resection or right hemicolectomy). For complicated disease (abscess, localized perforation), an aggressive surgical approach is warranted. Surgical strategies need to be validated, particularly in the light of the increasing use of the laparoscopic approach for suspected appendicitis.

It is not always appendicitis

BACKGROUND

Patients who are suspected of having acute appendicitis usually undergo surgery in order to avoid life-threatening complications such as perforation and peritonitis. However, acute appendicitis is difficult to distinguish from other sources of right-sided abdominal pain. The clinical picture is almost indistinguishable from appendiceal diverticulitis, which is a rare entity and remains a difficult diagnostic problem.

PATIENTS AND METHODS

We describe the case of a 39-year-old male with perforated appendiceal diverticulitis. The patient was admitted to our surgical unit with acute appendicitis-like symptoms and underwent surgery with a diagnosis of suspected acute appendicitis.

RESULTS

The patient was found to have perforated appendiceal diverticulitis and standard appendectomy with abdominal lavage was carried out.

DISCUSSION

Most patients presenting with acute right-sided peritonitic pain are diagnosed and managed as cases of acute appendicitis. Acute pain in the lower right side of the abdomen caused by appendiceal diverticulitis is very rare and clinically indistinguishable from acute appendicitis. Inflammatory complications of appendiceal diverticula mimic acute appendicitis.

CONCLUSION

Every surgeon should be aware of the possibility of diverticulitis of the appendix in the operating room, even if this does not change the operative management. As diverticula of the cecum can be found as solitary lesions, as multiple lesions confined to the right colon, or as part of a generalized disease of the entire colon, postoperative barium enema examination may be useful.