Management of diverticulitis of the ascending colon. 10 years' experience

Right-Sided Colonic Diverticulitis: Clinical Features, Sonographic Appearances, and Management

PURPOSE

This study aims to evaluate patients with right-sided colonic diverticulitis detected at ultrasonography (US).

METHODS

We retrospectively analyzed 14 patients. Demographic data, clinical features, and US images were documented.

RESULTS

In the 14 patients, clinical manifestations included right lower abdominal tenderness (93%), leukocytosis (57.1%), and fever (28.6%). Diverticulitis occurred in cecum and ascending colon with a similar frequency (35.7%). US features included diverticular wall thickening (50%), surrounding echogenic fat (50%), intradiverticular echogenic material (50%), adjacent lymph node enlargement (21.4%), intradiverticularor peridiverticular fluid collection (28.6%), and color flow signals on or surrounding the diverticula (14.3%). Two (14.2%) patients suffered from recurrence. Two (14.3%) patients had abscess formation, and one (7.1%) patient had diverticulum perforation. Most (85.7%) patients received conservative treatment only. One (7.1%) patient received computed tomography-guided drainage due to diverticulum perforation and pocket of abscess formation. One patient underwent surgery due to recurrent diverticulitis-related fistula.

CONCLUSION

Common US features of diverticulitis include diverticular wall thickening, surrounding echogenic fat, and intradiverticular echogenic material. Proper recognizing of these features helps in differentiating diverticulitis from appendicitis and may obviate an unnecessary emergent 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.

Laparoscopic and Open Surgery for Right Colonic Diverticulitis

The purpose of this study is to evaluate the safety and effectiveness of laparoscopic surgery by comparing laparoscopic and conventional surgery of right colonic diverticulitis (RCD). Among 124 patients who were treated for RCD from January 1997 to July 2007, we enrolled 54 patients who received resection therapy of RCD. Patients were divided into two groups: laparoscopic (LAP; n = 19) and conventional (CON; n = 35) surgery groups according to the respective surgical modality. The diverticulectomy (DIV; n = 46) and right colectomy (COL; n = 8) groups were also compared according to operative methods. There were significant differences between preoperative diagnosis and selection of the operative method and between RCD type and selection of operative method. However, there were no significant differences between preoperative diagnosis and selection of laparoscopic surgery and between RCD type and selection of laparoscopic surgery. The Kaplan-Meier estimated recurrence risk for all patients also showed no significant differences between LAP and CON and DIV and COL ( P = 0.413). The Kaplan-Meier-estimated RCD-free period after surgery was 92.7 months (limited to 100 months). Laparoscopic surgery of RCD is an effective and safety method as a result of no differences in clinical data between conventional and laparoscopic surgery.

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.

Decision making in right-sided diverticulitis

AIM: To evaluate systematically our nine-year experience in treating right-sided diverticulitis of the colon, and to explore its clinical and radiological relationship.

METHODS: The clinical and radiological data of 40 patients with colonic diverticulitis treated in Mackay Memorial Hospital, Taipei, from 1993 through 2002 were reviewed retrospectively.

RESULTS: The average age of the patients with right-sided diverticulitis was 53.1 years, which was 11.6 years younger than that of the patients with left-sided diverticulitis. The preoperative diagnosis of appendicitis was made in 8 of 13 right-sided diverticulitis patients. Nine (69%) had right lower quadrant abdominal pain for more than 48 hours, and ten patients (77%) presented with fever. CT findings suggesting acute right-sided diverticulitis including thickening of the intestinal wall and pericolonic inflammation were present in five patients.

CONCLUSION: Right-sided diverticulitis is easily confused with acute appendicitis because it occurs at a somewhat younger age than that in left-sided diverticulitis. Barium enema and CT are helpful for the early diagnosis of right-sided diverticulitis. While clearly not required in the majority of patients with right lower quadrant abdominal pain, barium enema and CT may be helpful in making the decision with a clinical history or physical examinations atypical of acute appendicitis.

Aggressive resection is indicated for cecal diverticulitis

BACKGROUND

Because of the difficulties in preoperative diagnosis and controversies in the management, cecal diverticulitis has received much discussion in the literature. There, however, are still many questions that remain unanswered.

METHODS

During a 5-year period, 112 patients with a clinical diagnosis of cecal diverticulitis were treated. Twenty-seven patients were excluded because of uncertainty in diagnosis or incomplete data collection, leaving 85 patients as the study group. The diagnosis of cecal diverticulitis was made by pathology, surgical findings, or image study.

RESULTS

Nonoperative management was applied to 18 patients initially. Three patients had recurrent diverticulitis during follow up. These patients responded satisfactorily to another course of medical treatment. Laparotomy was performed in 67 patients. Acute appendicitis was the preoperative diagnosis in 47 patients (70%). Of the other 20 patients, 6 received operation because of repeated attack of diverticulitis, 7 had preoperative computed tomography (CT) diagnosis of cecal diverticulitis with perforation, 5 had preoperative diagnosis of cecal tumor, and 2 had medical treatment failure. All these 20 patients received right hemicolectomy. In the 47 patients with a preoperative diagnosis of acute appendicitis, 24 received appendectomy, 9 received diverticulectomy, and 14 received right hemicolectomy. Overall, 34 patients received right hemicolectomy, 9 received diverticulectomy, and 24 received appendectomy only. In the right hemicolectomy group, there were 2 deaths with underlying diseases and 5 complications. In the appendectomy group, there was no postoperative mortality, but in 7 patients recurrent diverticulitis developed. Three of them required right hemicolectomy.

CONCLUSIONS

The natural history of cecal diverticulitis varies from benign and self-limiting to fulminant in the oriental population. Less than 40% (32 of 85) of patients were successfully treated with conservative methods initially and had no recurrence during the follow-up period. We recommend aggressive surgical resection for patients with a definite diagnosis. Adjuvant appendectomy without resection of the lesion should be considered only in uncomplicated patients whose diagnosis is in doubt.

Right-sided colonic diverticulitis: CT findings

Right-sided colonic diverticulitis is an uncommon but clinically significant condition as it closely mimics other common acute right-sided abdominal conditions like acute appendicitis and cholecystitis. CT can provide a rapid and accurate diagnosis of this condition and thereby prevent unnecessary laparotomy and surgical procedures since it is essentially a benign self-limiting condition requiring medical treatment. It is the aim of this pictorial essay to describe the CT findings and increase awareness among radiologists of this condition.

Acute diverticulitis of the cecum and ascending colon: the value of thin-section helical CT findings in excluding colonic carcinoma

OBJECTIVE

The purpose of this study was to assess the value of characteristic thin-section helical CT findings of acute diverticulitis involving the cecum and ascending colon in excluding colonic carcinoma.

MATERIALS AND METHODS

Thin-section helical CT scans (5-mm collimation) of 19 consecutive patients with proven diverticulitis and 21 consecutive patients with surgically proven carcinoma involving the cecum and ascending colon were reviewed retrospectively. Two radiologists independently analyzed these parameters: degree of pericolic infiltration, mesenteric fluid, vascular engorgement, arrowhead-shaped wall thickening, air-filled diverticula, inflamed diverticula, and preserved enhancement pattern of involved colonic wall. Inter-observer agreement was assessed with a kappa statistical analysis, and the features that most distinguished diverticulitis from colonic carcinoma were selected with a stepwise logistic-regression analysis.

RESULTS

The two CT findings of right-sided colonic diverticulitis that most distinguished it from colonic carcinoma were inflamed diverticula and the preservation of an enhancement pattern of the involved colonic wall. Excellent interobserver agreement (kappa > 0.60) was obtained for both findings. Inflamed diverticula (kappa = 0.80) had a mean sensitivity, specificity, and accuracy for diverticulitis of 86.8%, 92.9%, and 90.0%, respectively, in differentiating right-sided colonic diverticulitis from colonic carcinoma. Preserved wall enhancement pattern (kappa = 0.70) had a mean sensitivity, specificity, and accuracy of 89.5%, 95.3%, and 92.5%, respectively.

CONCLUSION

On thin-section helical CT, an inflamed diverticula and a preserved enhancement pattern of the thickened colonic wall were the two most statistically significant CT findings of acute diverticulitis involving the cecum and ascending colon that distinguished diverticulitis from colonic carcinoma.

Massive arterial haemorrhage from the lower gastrointestinal tract

We have studied the clinical, radiological and pathological features of three patients with recurrent massive lower gastrointestinal arterial haemorrhage. Case 1 was an example of Dieulafoy's vascular malformation within the proximal ascending colon in a 46-year-old woman. Cases 2 and 3 were men aged 81 and 83 years with arterial erosions contained within small mucosal diverticula in the hepatic flexure and descending colon, respectively. All three patients presented with recurrent acute episodes of massive lower gastrointestinal haemorrhage. Selective mesenteric angiography was performed in cases 1 and 3 to localize the bleeding point in both patients. The features were very different to those of angiodysplasia, lacking the tuft of abnormal vessels and the early venous filling phase commonly seen in the latter condition. The patients were all successfully treated by partial colectomy. The aetiology of Dieulafoy's vascular malformation remains unclear. The ruptured arteries in cases 2 and 3 shared many histological features with the Dieulafoy lesion in case 1. The lesions in cases 1 and 2 were associated with recent oral non-steroidal anti-inflammatory therapy, suggesting coincidental mucosal ulceration as a contributory factor.

Acute diverticulitis of the right colon

BACKGROUND

Acute diverticulitis of the right colon is a rare condition with a higher incidence in Oriental populations than in Occidental populations.

PATIENTS AND METHODS

A retrospective review was conducted between 1982 and 1993 on 22 surgically treated Chinese patients (14 men, 8 women; mean age 47 years) with documented right colon diverticulitis.

RESULTS

Most patients presented with right lower quadrant pain and local peritoneal signs. Acute appendicitis was the preoperative diagnosis in 82% (18/22) of the patients. Only one diagnosis subsequently proved correct. The pathology was easily recognized in 4 patients during surgery, while examination of the resected specimen confirmed the intraoperative suspicion in 13 patients. The right colon was resected and an ileocolonic anastomosis performed in 21 patients; the remaining patient underwent diverticulectomy and drainage of a pericolic abscess. There was no postoperative mortality, and 4 patients developed wound infection.

CONCLUSIONS

Our results showed that acute diverticulitis of the right colon was encountered once in 180 cases of acute appendicitis. Local resection or colectomy with primary anastomosis without bowel preparation is the procedure of choice.

CT of inflammatory disease of the colon

CT plays an important role in the evaluation of patients with suspected colonic inflammation. High-resolution, thin-section imaging of the gastrointestinal tract allows assessment of both the intraluminal and extraluminal components of colonic disease, thereby enabling radiologists to detect and stage colonic pathology accurately. In addition, CT can be used to guide percutaneous drainage of abscess collections, often obviating the need for surgical intervention. This article describes CT techniques for diagnosing inflammatory diseases of the colon as well as the typical CT appearances.

Surgery for complicated diverticulitis

The surgical treatment of acute, complicated diverticulitis remains controversial. No randomized studies have been performed to clarify which operative procedure best fits each situation. As a result, the surgeon must use accumulated knowledge and judgment to make the correct decisions for an individual patient. The morbidity and mortality of patients with complicated diverticular disease in 1993 depend, not so much on the operative procedure, but on the severity of the disease and the associated comorbid conditions, namely the presence of fecal or purulent peritonitis, past medical problems, immune status, and nutritional status. However, adherence to the several principles detailed in this report will minimize morbidity and mortality. The surgeon should always attempt to convert the patient from an emergency to an urgent or elective operative status. In the absence of free perforation, this goal usually can be achieved. Rushing into surgery in patients with a normal immune system is generally ill advised. It is far preferable to stabilize the patient, percutaneously drain abscesses if possible, prepare the bowel before exploration, and thus keep the option of primary anastomosis open. A primary anastomosis done first thing in the morning is far preferable to an end-stoma created in the middle of the night in an emergency situation. The algorithm displayed in Figure 1 provides a useful guideline for treating patients with complicated diverticulitis.

Sonography in acute colonic diverticulitis. A prospective study

The clinical value of high-resolution real-time sonography for the diagnosis of acute and complicated colonic diverticulitis was prospectively studied in 130 consecutive patients with abdominal complaints, because of which the disease entered into differential consideration. The results of ultrasound investigation were compared with those of clinical examination on admission. Regarding history and initial clinical evaluation, diverticulitis was graded as "highly suspected" in 19 (36.5 percent) out of a total of 52 patients with later proven colonic diverticulitis (prevalence 40 percent), as "possible but equivocal" in 24 (46.2 percent), and as "very unlikely" in the remaining nine (17.3 percent) patients. Ultrasonography enabled the diagnosis of diverticulitis with an overall accuracy of 97.7 percent, a sensitivity of 98.1 percent, and a specificity of 97.5 percent. The predictive values of positive and negative ultrasound examinations were 96.2 percent and 98.5 percent, respectively. The echomorphologic features of acute diverticulitis include visualization of a colon segment presenting with local tenderness on gradual compression, which showed hypoechogenic thickening of the wall and a targetlike appearance in transverse view due to inflammatory changes and muscular thickening. Sonographic signs of peridiverticulitis (hyperechoic halo) were found in 96 percent of patients, echogenic diverticula in 86 percent. Twelve (92 percent) of 13 abdominal abscesses were detected on initial ultrasound examination and could be treated by percutaneous drainage in seven cases, while six required surgical intervention. These results indicate that high-resolution sonography with graded compression is highly sensitive and specific for the imaging diagnoses of acute colonic diverticulitis and complicating abscess.

Diverticulitis of the right colon--experience from Hong Kong

Diverticulitis affects the right side of the colon more commonly than the left side in the Far East. A consecutive series of 35 patients (mean age 44 years) with right sided diverticulitis seen at this hospital is presented. All had localised pain in the right iliac fossa but systemic upset was uncommon. All but one were thought to have acute appendicitis. Thirty one were explored through a right iliac fossa incision but in more than half this had to be closed and a full laparotomy performed. A correct diagnosis was then made at the time of surgery in 28 (80%). Five patients underwent simple diverticulectomy, the remainder having a right hemicolectomy. On histological analysis most (26) had a single false diverticulum. All patients made a satisfactory recovery from surgery.

Cecal diverticulitis: a continuing diagnostic dilemma

Cecal diverticulitis is a rare entity and remains a difficult diagnostic problem. A retrospective review was undertaken of 16 patients (11 men, 5 women; average age, 33.2 years) with a pathologic diagnosis of cecal or right colon diverticulosis who received treatment from 1979 to the present. Preoperative symptoms were difficult to distinguish from appendicitis. The majority complained of right lower quadrant pain and tenderness. Diagnostic studies were not helpful. Preoperative diagnosis was appendicitis in 88% (14 of 16) and correct in 1 patient (6%). At exploratory celiotomy, the surgeon was able to make the diagnosis of cecal diverticulitis in 9 (60%) of the 15 patients in whom the correct diagnosis had not been made preoperatively. Neoplasm was suspected in 5 patients, and an appendiceal abscess was suspected in 1. Treatment was colectomy in 9 and local excision in 4 patients. In 3 patients, the inflamed diverticulum was left in situ at initial exploration; all underwent later excision, one of these urgently for sepsis. No patient died; however, one anastomotic leak requiring reoperation occurred. On the basis of this experience, we recommend excisional therapy in all cases in which the intraoperative diagnosis is certain. Suspicion of a neoplastic process continues to prompt colectomy in an emergency setting.

Solitary diverticulum of the cecum and right colon. Report of six cases

Diverticulum of the cecum is a rare, benign, generally asymptomatic lesion that manifests itself only following inflammatory or hemorrhagic complications. A personal series of six cases discusses the difficulty of differential diagnosis at both the preoperative and intraoperative levels. The preferable treatment is simple resection.

Changing patterns in the surgical treatment of diverticular disease

This paper includes a brief historic summary of the surgical aspects of diverticular disease and of corresponding developments in the Massachusetts General Hospital from 1911 to the present. The 350 cases observed in 1974-1983 are compared with 338 seen in the previous decade. Major trends include a decrease in hospital admissions for diverticular disease but a sustained number of operations; increased severity of the disease in hospitalized patients manifested by an increased percentage of patients with immunosuppression or serious other diseases (p less than 0.001), an increased number with sepsis and general peritonitis (p less than 0.001); an increased percentage of cases with one-stage resection and anastomosis (p less than 0.02); in patients with general peritonitis, resection of the perforated segment at the time of the original operation was accompanied by the lowest mortality (p less than 0.02); incidental splenectomy appears to be dangerous, with three deaths in eight cases; and overall mortality in the last decade is 6.4%; for emergency cases 10.2%, for urgent 9.7%, and for elective cases 2.4%.

Diverticulitis of the cecum and ascending colon

Twelve cases of acute solitary diverticulitis of the cecum or ascending colon are reviewed. This is frequently indistinguishable from acute appendicitis preoperatively and is often mistaken for carcinoma at laparotomy. There are subtle clinical features that may help to suggest the diagnosis both before and during surgery. If diagnosed preoperatively, it can be treated effectively with broad spectrum antibiotics without surgical intervention. When diagnosed intraoperatively, hemicolectomy can often be avoided. Appendectomy should be done if resection is not performed.