Current recommendations on diagnosis and management of right-sided diverticulitis

Beyond the Norm: Acute Multifocal Diverticulitis

Colonic diverticulitis is inflammation of diverticula, which are sac-like protrusions in the colonic wall. It is thought that increased intraluminal pressure and trapped food leads to inflammation. Newer theories suggest that alterations in the gut microbiome and chronic inflammation play a role as well. Diverticulitis commonly affects discrete sections of colon. Acute multifocal diverticulitis is defined as diverticulitis in at least 2 different sites of the colon separated by at least 10 cm, which is very rare. Ideal management is unclear; however, our patient improved with supportive measures and antibiotics without complications of abscess, perforation, or need for surgery.

Case Series of Right Colon Diverticulitis in the West: A Neglected Disease?

Introduction Right colon diverticulitis (RCD) is an uncommon condition in Western populations, but its incidence has increased over the last decades. Due to its rarity, many surgeons are unfamiliar with this disease, which is often mistakenly diagnosed as acute appendicitis. The lack of data about the diagnosis and management of RCD in Western populations makes it difficult to establish the optimal therapeutic strategy.

Objective To evaluate the outcomes of patients treated for acute RCD and to propose a therapeutic algorithm for the diagnosis and treatment.

Methods A retrospective analysis of the medical records of patients treated for acute RCD between 2008 and 2020 by a single experienced colorectal surgeon was performed.

Results In total, 12 patients were identified, 8 male and 4 female subjects, with a mean age of 49.6 years; 9 of these patients were of Western origin. The median follow-up time was of 49 months (range: 12 to 144 months). The most frequent symptoms were abdominal pain (100%) and fever (66%). Diagnostic errors in imaging exams occurred in four patients. A total of 6 patients were managed clinically, and the other 6 underwent surgical treatment with right colectomy (n = 5) and total colectomy (n = 1), 2 via laparoscopy and 4 through a laparotomy. The anatomopathological examination confirmed RCD in all operated patients. There was no incidental finding of neoplasia and there were no deaths during the study period.

Conclusion Uncomplicated RCD can be treated conservatively with a high success rate. Recurrent cases that impact quality of life or complicated forms of RCD should undergo surgical treatment, preferably through a right laparoscopic colectomy. The authors present a diagnostic and therapeutic algorithm to facilitate the diagnosis and to guide the management of this uncommon disease.

Clinical Impacts of Juxtapapillary Duodenal Diverticulum Detected on Computed Tomography

BACKGROUND

Diverticula are commonly observed in the duodenum. Duodenal diverticulum (DD) usually does not give symptoms throughout life and is diagnosed by coincidence. However, it may present with different symptoms in patients.

OBJECTIVE

This study aims to evaluate the prevalence of DD and juxtapapillary duodenal diverticulum (JDD) and its association with other possible pathologies and to determine its clinical impact by using Computed Tomography (CT).

METHODS

This retrospective observational study, which was taken consecutively between the years of 2013-2020, was evaluated in the Radiology Department. The total number of cases was 4850 (male-2440; female-2410). CT images were evaluated by two experienced radiologists at the workstation. DD and JDD prevalence and clinical findings in the hospital registry system were examined.

RESULTS

The age of the patients included in the study ranged from 17 to 92 years (mean age 46.94±16.42). In patients with DD (female-130; male-101), mean age was 62.24 ± 12.69 (21-92). The prevalence of DD was 4.76% (n=231). The prevalence of JDD was 4.02% (n=195) and increased with age (p<0.01). The average diameter of the JDD was measured as 23.29±8.22(9.5-55.3) mm. A significant positive correlation was found between age and DD diameter (p=0.039). DDs were found most commonly 84.42% (n=195) in the second segment of the duodenum as JDD. In patients with JDD, the mean diameter of choledochus and wirsung canal were 6.7 ± 2.4 (3-15.3) mm and 0.31 ± 0.1 (0.1-6.5) mm respectively. The choledochal diameter was correlated with the JDD size (p = 0.004). Cholelithiasis (n=56), choledocholithiasis (n=20), cholecystitis (n=52), diverticulitis (n=15), duodenitis (n=37), pancreatitis (n=5) and hiatal hernia (n=60) with JDD were observed. Periampullary carcinoma was detected in one patient.

CONCLUSION

Our study shows that cholelithiasis, choledocholithiasis, cholecystitis, diverticulitis, duodenitis, pancreatitis may be associated with JDD. Therefore, in contrast-enhanced abdominal CT scans taken for various reasons, investigation of the presence and characteristics of JDD and detection of pathologies that may be associated with JDD are important for patients to benefit from early diagnosis and treatment opportunities and to take precautions against possible complications.

Special Situations in the Management of Diverticular Disease

Diverticular disease affects a large percentage of the US population, affecting over 30% among those older than 45 years old. It is responsible for ∼300,000 hospitalizations per year in the United States and can lead to serious complications such as hemorrhage, obstruction, abscess, fistulae, or bowel perforation. 2 It is an extremely common reason for emergency room and outpatient visits and evaluations by general and colorectal surgeons. In the US, patients usually present with sigmoid diverticulitis in the setting of a normal immune system so surgeons will follow well-established practice guidelines for treatment. However, there may be special circumstances in which the management of diverticulitis is not as straightforward. In this article, we will address patients who present with multifocal disease, giant colonic diverticulum, right-sided diverticulitis, and diverticulitis in the setting of immunosuppression and hopefully provide guidance for treatment in these special circumstances.

Assessment of Duodenal Diverticula: Computed Tomography Findings

AIMS

To demonstrate the prevalence, accompanying pathologies, imaging and follow up findings of Duodenal Diverticula (DD) with Multidetector Computed Tomography (MDCT).

MATERIALS AND METHODS

Consecutive 2910 abdominal MDCTs were retrospectively reviewed on axial, coronal and sagittal planes. DD were evaluated for prevalence, location, number, size, contents, diverticular neck, accompanying pancreaticobiliary pathologies, jejunal and colonic diverticula, respectively.

RESULTS

DD were diagnosed in 157 cases (5.4%) and found mostly in the second part of the duodenum. Juxta-ampullary DD was the most common type (78.3%) and mostly located ventral (n:86, 69.9%) to the ampulla of Vater. DD was solitary in 123 patients (78.3%) and more than one in 34 patients (21.7%). The median diameter of DD was 2.5 cm (range 1.5-3.6 cm) in the long-axis. The lumen of DD contains air and contrast agent (n:96, 61.1%); air, contrast agent and debris (n:42, 26.7%) in most cases. Colonic diverticula (n:36, 22.9%), cholelithiasis (n:32, 20.4%), choledocholithiasis (n:7, 4.4%), and biliary dilatation (n:8, 5.1%) were the most common additional findings. Median follow-up time was 23 months (range 11 to 41 months). In three cases, new findings (cholelithiasis, n:3, choledocholithiasis, n:1) were detected.

CONCLUSION

Accompanying pathologies with DD diagnosis are valuable for physicians in order to manage the patients. Following clinical and radiological features of well-diagnosed DD might reduce the possible complications.

Perforated cecal diverticulitis with CT diagnosis and medical management

Acute diverticulitis is a painful condition of the gastrointestinal tract that results from sudden inflammation of one or more diverticula in the bowel wall. Right-sided acute diverticulitis, such as cecal diverticulitis, is uncommon diagnosis that can be easily misdiagnosed as acute appendicitis as it shares similar clinical presentation. An unusual complication of right-sided acute diverticulitis such as perforated cecal diverticulitis has different management from acute appendicitis. Thus, definitive diagnosis of this clinical condition with imaging is crucial to optimal management. We report a case of 43-year-old man who presented to the Emergency Department with acute onset severe right lower quadrant abdominal pain associated with anorexia, fever, and nausea. Computed tomography scans obtained showed findings consistent with perforated diverticulitis limited to the cecum, and normal caliber appendix. Conservative medical treatment was decided based on localized imaging findings with excellent outcome.

Right-sided acute diverticulitis: A single Western center experience

INTRODUCTION

Right sided diverticular disease is a rare condition in Western countries whereas is common amongst Asian population. The aim of this study is to evaluate options and outcomes for the treatment of right colonic diverticulitis.

METHOD

We included only patients undergoing surgery with right colon diverticulitis (RCD) proven at histological specimen examination from September 2011 to December 2016.

RESULTS

We performed 18 operations for RCD. Age was lower compared to left sided disease (49 ± 16 vs 67 ± 14; P < 0.001). Three patients were Asian (16.7%). RCD was diagnosed preoperatively in 8 cases (44.4%), whereas appendicitis was suspected in 9 cases (50%) and neoplasm in one (5.6%). We performed resection with anastomosis in 13 patients (72.2%) and in 5 cases we performed a diverticulectomy. Laparoscopy was performed in 14 cases (77.8%). Postoperative morbidity occurred in 3 patients (16.7%; grade 2 or 3a according to Clavien-Dindo) with no mortality. No postoperative events occured after diverticulectomy with shorter hospital stay (4 ± 1.5 vs 11 ± 13; P = 0.022), as no recurrence or need for elective surgery after a mean follow-up of 20 months.

CONCLUSION

RCD is a rare but not irrelevant condition. Minimally invasive surgery is often feasible and complication rate is low. In selected patients, diverticulectomy can be a valid alternative to treat this condition providing improved postoperative results.

Diagnosis and management of right colonic diverticular disease: A review

The aim of this narrative review is to define the clinical-pathological characteristics and to clarify the management of right colonic diverticular disease. It is rare in Europe, USA and Australia and more common in Asia. In the recent years its incidence has increased in the West, with various distributions among populations. Many studies have reported that it is difficult to differentiate the presenting symptoms of this disease from those of appendicitis before surgery, because the signs and symptoms are similar, so misdiagnosis is not infrequent. With accurate imaging studies it is possible to reach a precise preoperative diagnosis, in order to assess an accurate treatment strategy. Currently the management of this disease is not well defined, no clear guidelines have been proposed and it is not known whether the guidelines for left colonic diverticular disease can also be applied for it. Several authors have stated that conservative management is the best approach, even in case of recurrence, and surgery should be indicated in selected cases.

Intraoperative diagnosis of solitary cecal diverticulum not requiring surgery: is appendectomy indicated?

Aim

To compare experience with solitary cecal diverticulum (SCD) with literature on the indication for appendectomy in cases of solitary cecal diverticulitis.

Methods

We retrospectively reviewed all cases of SCD in our institution from September 2011 to March 2013. Data on sex, age, ethnic origin, presence of pain in the right iliac fossa, duration of symptoms, diagnosis, management, intraoperative findings, histologic examination, hospital stay, complications, and follow-up were reviewed and analyzed. We compared this to related literature reported between 2000 and 2015.

Results

In the study period, 10 patients presented with an SCD. Male sex and Asian origin were predominant. All patients had pain in the right iliac fossa, with a duration of 2–5 days. In nine cases the diagnosis was made by clinical examination and laboratory testing. One patient who had undergone a previous appendectomy was diagnosed with SCD by computed tomography. This last patient was treated conservatively, four patients were treated with resection of the cecum “en bloc” with the last jejunal loop and appendix, and the other five patients were treated with appendectomies. Two patients had minor complications. All patients were followed up for a minimum of 12 to a maximum of 24 months. No recurrence was recorded in either the case treated conservatively or the cases treated by appendectomies.

Conclusions

In cases of operative but conservative treatment for SCD, appendectomy could be justified to avoid misdiagnosis in case of future episodes of solitary cecal diverticulitis.

Evaluating the Patient with Right Lower Quadrant Pain

Right lower quadrant pain is one of the most common indications for imaging evaluation of the abdomen in the emergency department setting. This article reviews important imaging findings associated with acute appendicitis as well as major differential considerations including: mesenteric adenitis, Meckel diverticulum, neutropenic colitis, right-sided diverticulitis, epiploic appendagitis, omental infarction, and inflammatory bowel diseaseRight lower quadrant pain is one of the most common indications for imaging evaluation of the abdomen in the emergency department setting. This article reviews important imaging findings associated with acute appendicitis as well as major differential considerations including: mesenteric adenitis, Meckel diverticulum, neutropenic colitis, right-sided diverticulitis, epiploic appendagitis, omental infarction, and inflammatory bowel disease.

Hospital volume and other risk factors for in-hospital mortality among diverticulitis patients: A nationwide analysis

BACKGROUND

Previous studies have found that a higher volume of colorectal surgery was associated with lower mortality rates. While diverticulitis is an increasingly common condition, the effect of hospital volume on outcomes among diverticulitis patients is unknown.

OBJECTIVE

To evaluate the relationship between hospital volume and other factors on in-hospital mortality among patients admitted for diverticulitis.

METHODS

Data from the Nationwide Inpatient Sample (years 1993 to 2008) were analyzed to identify 822,865 patients representing 4,108,726 admissions for diverticulitis. Hospitals were divided into quartiles based on the volume of diverticulitis cases admitted over the study period, adjusted for years contributed to the dataset. Mortality according to hospital volume was modelled using logistic regression adjusting for age, sex, race, comorbidities, health care insurance, admission type, calendar year, colectomy, disease severity and clustering. Risk estimates were expressed as adjusted ORs with 95% CIs.

RESULTS

Patients at high-volume hospitals were more likely to be admitted emergently, undergo surgical treatment and have more severe disease. In-hospital mortality was higher among the lowest quartile of hospital volume compared with the highest volume (OR 1.13 [95% CI 1.05 to 1.21]). In-hospital mortality was increased among patients admitted emergently (OR 2.58 [95% CI 2.40 to 2.78]) as well as those receiving surgical treatment (OR 3.60 [95% CI 3.42 to 3.78]).

CONCLUSIONS

Diverticulitis patients admitted to hospitals with a low volume of diverticulitis cases had an increased risk for death compared with those admitted to high-volume centres.

Imaging of acute right lower quadrant abdominal pain: differential diagnoses beyond appendicitis

Evaluation of acute right lower quadrant pain remains a common and challenging clinical scenario for emergency medicine physicians due to frequent nonspecific signs, symptoms, and physical examination findings. Therefore, imaging has evolved to play a pivotal role in the emergency setting. While appendicitis is a common cause for acute pain, there are numerous other important differential considerations with which the radiologist must be aware. The purpose of this review is to list an anatomy-based, encompassing differential diagnosis in addition to acute appendicitis for right lower quadrant pain; demonstrate the key imaging findings of numerous differential considerations; and describe helpful imaging and clinical features useful in narrowing the differential diagnosis.

Current management of diverticular disease of the colon

The medical treatment plays the first role in the vast majority of cases. Severe acute diverticulitis requires hospitalization and supporting care with intravenous fluids and antibiotics such as ciprofloxacin and metronidazole. Emergency operative intervention is necessary if complication occurs. Laparoscopic surgery has a well-defined place and such colectomy has been gaining, nowadays, more popularity.