Clinically distinguishing between appendicitis and right-sided colonic diverticulitis at initial presentation

Right-sided acute diverticulitis in a North African country: Presentation and management in one surgical center

PURPOSE

Right-sided diverticulitis is a rare entity in North Africa. Therefore, it is usually misdiagnosed, and the management of cecal diverticulitis is aggressive in most cases, whereas nowadays, most studies recommend a conservative approach with promising results. This study aims to describe the presentation, management, and outcomes of right-sided diverticulitis (RSD) and to present the experience of one surgical center in Tunisia.

METHODS

This is a retrospective study including all patients presented with RSD, in the Department of Surgery "A" of the Charles Nicolle Hospital between 2007 and 2021.

RESULTS

Forty patients were included in our study. The mean age was 42 years with a standard deviation of 14. The sex ratio was 1.1. Only 2 patients had chronic constipation. All patients presented right-sided abdominal pain, and only 3 patients had diarrhea. Twenty one patients were diagnosed during surgery. Fourteen patients were treated successfully by conservative management. An operative procedure was performed in 26 cases: 21 had a diverticulectomy (80%), two had an ileal resection (8%), and three had a right colectomy (11.5%). No postoperative events occurred with a short hospital stay (5 ± 3 days). Follow-up showed no recurrences.

CONCLUSION

Right-sided diverticulitis has a lower incidence and complication rate compared to left-sided diverticulitis. Conservative treatment has demonstrated favorable outcomes in managing RSD, although the available evidence remains limited.

Right-sided acute diverticulitis in the West: experience at a university hospital in Argentina

PURPOSE

In the West, diverticular disease is located mainly in the left colon. However, it can also present in the right colon, with an incidence of 1% to 2% in Caucasians. The purpose of this study was to describe our experience in right-sided acute diverticulitis (RD).

METHODS

In this retrospective study, 410 patients with acute diverticulitis treated from 2013 to 2020 were included in a university hospital in Córdoba, Argentina. Colonic diverticulitis was stratified into 2 groups; RD and left-sided acute diverticulitis. Demographic and clinical variables, laboratory and imaging findings, type of treatment, follow-up, and recurrence were analyzed.

RESULTS

Sixteen patients (3.9%) with RD were identified; 62.5% were male and the mean age was 40.7±11.7 years. A total of 81.3% were Caucasian and 18.7% Native American. Significant differences were found between both groups of diverticulitis; patients with RD were younger (P=0.001), with lower BMI (P=0.01), comorbidity rate (P=0.01), Charlson comorbidity index (P=0.02), hospital stay (P=0.01), severity according to the Hinchey classification (P=0.001) and had a lower recurrence rate (P=0.001). There were no significant differences in sex (P=0.95), duration of pain until admission (P=0.05), laboratory findings (P=0.23) and treatment (P=0.34).

CONCLUSION

Conservative treatment predominated in RD, with a lower rate of complications and recurrences, providing data that support conservative therapy as initial treatment in RD in our environment.

Laparoscopic diverticulectomy of perforated right‐sided colonic diverticulitis

The perforation of the right‐sided colonic diverticulitis (RSCD) is a rare surgical emergency with highly variable clinical presentations. The preoperative distinction between acute appendicitis and perforated diverticulitis represent a dilemma for surgeon. The laparoscopic repair is a feasible method instead of ileocecectomy in selected cases.

Management and long-term outcomes of acute right colonic diverticulitis and risk factors of recurrence

Background

Acute right-sided colonic diverticulitis (RCD) is a common disease in Asian populations for which the optimal treatment remains controversial. The aim of this study was to investigate management and evaluate long-term outcomes of treatment in patients with acute RCD.

Methods

We retrospectively collected and analyzed clinical data for patients with acute RCD admitted to the Tongren Hospital, Shanghai Jiao Tong University School of Medicine from December 2015 to December 2020. The patients were divided into two groups, according to primary treatment strategy, which was either conservative treatment or surgical treatment.

Results

A total of 162 consecutive patients with acute RCD were enrolled in the study. There was no significant difference in age, sex, history of abdominal surgery, medical co-morbidities, fever, previous history of RCD, treatment success rate and incidence of complications between the conservative and surgery groups. However, the recurrence rate in conservative groups was significantly higher than in surgery groups (16.53% vs 2.44%, P = 0.020). And more frequent bowel movements and previous history of RCD increased the risk of recurrence of acute RCD. Moreover, there was no significant difference in either treatment success rate or the overall recurrence rate between the patients with uncomplicated diverticulitis and patients with complicated diverticulitis.

Conclusions

Surgical treatment is also safe and effective for acute RCD. Surgical treatment should mainly be considered for patients with acute RCD with recurrence risk factors (more frequent bowel movements and previous history of RCD) or with complicated acute RCD.

Acute appendicitis–advances and controversies

Being one of the most common causes of the acute abdomen, acute appendicitis (AA) forms the bread and butter of any general surgeon’s practice. With the recent advancements in AA’s management, much controversy in diagnostic algorithms, possible differential diagnoses, and weighing the management options has been generated, with no absolute consensus in the literature. Since Alvarado described his eponymous clinical scoring system in 1986 to stratify AA risk, there has been a burgeoning of additional scores for guiding downstream management and mortality assessment. Furthermore, advancing literature on the role of antibiotics, variations in appendicectomy, and its adjuncts have expanded the surgeon’s repertoire of management options. Owing to the varied presentation, diagnostic tools, and management of AA have also been proposed in special groups such as pregnant patients, the elderly, and the immunocompromised. This article seeks to raise the critical debates about what is currently known about the above aspects of AA and explore the latest controversies in the field. Considering the ever-evolving coronavirus disease 2019 situation worldwide, we also discuss the pandemic’s repercussions on patients and how surgeons’ practices have evolved in the context of AA.

Clinical Difference between Acute Appendicitis and Acute Right-Sided Colonic Diverticulitis

Background

Clinical presentations of acute appendicitis (AA) and acute right-sided colonic diverticulitis (ARCD) are similar. However, the usual treatment for each disease differs between surgical and conservative management. The aim of this study was to identify clinical differences between AA and ARCD.

Method

We performed a single-center retrospective study on adult patients, with uncomplicated AA and ARCD confirmed by computed tomography, who visited an emergency department between March 2018 and August 2019. Clinical variables including past medical history, presented symptoms and signs, and laboratory findings were compared between the two groups. A logistic regression analysis was subsequently performed to differentiate ARCD from AA based on results of univariate analyses.

Results

A total of 212 (79.1%) and 56 (20.9%) patients were enrolled in AA and ARSD groups, respectively. Logistic regression analysis revealed that a past history of diverticulitis [OR: 102.679 (95% CI: 9.964–1058.055), p < 0.001] was associated with ARCD, while ketonuria [OR: 2.907 (95% CI: 1.091–7.745), p=0.033], anorexia [OR: 21.544 (95% CI: 3.905–118.868), p < 0.001], and neutrophilia [OR: 3.406 (95% CI: 1.243–9.336), p=0.017] were associated with AA.

Conclusion

Anorexia, neutrophilia, and ketonuria were predictors of AA while a history of diverticulitis was a predictor of ARCD.

Management of cecal diverticulitis diagnosed by computed tomography scan

PURPOSE

Cecal diverticulitis is a rare entity causing right iliac fossa pain. Its symptoms may mimic acute appendicitis. Therefore, the majority of these patients undergo unnecessary surgery for suspected diagnosis of appendicitis.

METHODS

We report a case series of solitary cecal diverticulitis, right-sided colonic diverticulitis, and perforated cecal diverticulitis diagnosed by computed tomography scan.

RESULTS

The first two cases were successfully managed conservatively with intravenous antibiotics, rehydration, and temporary bowel rest. The third case developed a retroperitoneal abscess, which was initially drained under computed tomography guidance. However, due to development of septicemia, the patient underwent urgent right hemicolectomy. All patients recovered and were discharged during the further course.

CONCLUSIONS

Computed tomography is of great value for the diagnosis of cecal diverticulitis and its differentiation from acute appendicitis. Conservative treatment is sufficient in uncomplicated cases, while surgery is reserved for those with associated large abscess or free perforation.

Clinical differentiation of acute appendicitis and right colonic diverticulitis: A case-control study

BACKGROUND

Acute right colonic diverticulitis (ARCD) is an important differential diagnosis of acute appendicitis (AA) in Asian countries because of the unusually high prevalence of right colonic diverticula. Due to qualitative improvement and the high penetration rate of computed tomography (CT) scanning in Japan, differentiation of ARCD and AA mainly depends on this modality. But cost, limited availability, and concern for radiation exposure make CT scanning problematic. Differential findings of ARCD from AA are based on several small studies that used univariate comparisons from Korea and Taiwan. Previous studies on clinical and laboratory differences between AA and ARCD are limited.

AIM

To determine clinical differences between AA and ARCD for differentiation of these two diagnoses by creating a logistic regression model.

METHODS

We performed an exploratory single-center retrospective case-control study evaluating 369 Japanese patients (age ≥ 16 years), 236 (64.0%) with AA and 133 (36.0%) with ARCD, who were hospitalized between 2012 and 2016. Diagnoses were confirmed by CT images. We compared age, sex, onset-to-visit interval, epigastric/periumbilical pain, right lower quadrant (RLQ) pain, nausea/vomiting, diarrhea, anorexia, medical history, body temperature, blood pressure, heart rate, RLQ tenderness, peritoneal signs, leukocyte count, and levels of serum creatinine, serum C-reactive protein (CRP), and serum alanine aminotrans-ferase. We subsequently performed logistic regression analysis for differentiating AA from ARCD based on the results of the univariate analyses.

RESULTS

In the AA and ARCD groups, median ages were 35.5 and 41.0 years, respectively (p=0.011); median onset-to-visit intervals were 1 [interquartile range (IQR): 0-1] and 2 (IQR: 1-3) days, respectively (P < 0.001); median leukocyte counts were 12600 and 11500/mm³, respectively (P = 0.002); and median CRP levels were 1.1 (IQR: 0.2-4.1) and 4.9 (IQR: 2.9-8.5) mg/dL, respectively (P < 0.001). In the logistic regression model, odds ratios (ORs) were significantly high in nausea/vomiting (OR: 3.89, 95%CI: 2.04-7.42) and anorexia (OR: 2.13, 95%CI: 1.06-4.28). ORs were significantly lower with a longer onset-to-visit interval (OR: 0.84, 95%CI: 0.72-0.97), RLQ pain (OR: 0.28, 95%CI: 0.11-0.71), history of diverticulitis (OR: 0.034, 95%CI: 0.005-0.20), and CRP level > 3.0 mg/dL (OR: 0.25, 95%CI: 0.14-0.43). The regression model showed good calibration, discrimination, and optimism.

CONCLUSION

Clinical findings can differentiate AA and ARCD before imaging studies; nausea/vomiting and anorexia suggest AA, and longer onset-to-visit interval, RLQ pain, previous diverticulitis, and CRP level > 3.0 mg/dL suggest ARCD.

Solitary cecal diverticulitis, a rare cause of right lower quadrant pain: Four cases

Solitary cecal diverticulitis is a rare clinical condition. Like diverticulitis in other segments of the colon, it requires immediate surgical intervention if it is causing complications. Solitary cecal diverticulitis may be misdiagnosed as acute appendicitis, since it causes right lower quadrant pain, or as a cecal tumor or inflammatory bowel disease, due to an intraoperative appearance resembling an inflammatory mass. Four patients with solitary cecum diverticulitis presenting with acute right lower quadrant pain are discussed in this report. Three patients underwent surgery with a preliminary diagnosis of acute appendicitis or cecal tumor, and 1 patient was diagnosed with cecal diverticulitis and treated medically. The treatment approach may change depending on a preoperative or intraoperative diagnosis of cecal diverticulitis. Therefore, in areas where this disease is uncommon, cecum diverticulitis should not be forgotten in the differential diagnosis of acute right lower quadrant pain or inflammatory bowel mass.

Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review of literature

Background:

The importance of cecal pathologies lie in the fact that being the first part of the large intestine, any disease involving the cecum affects the overall functioning of the large bowel. Primary cecal pathologies presenting as acute abdomen have not been described in any previous study in terms of presentation, management, and outcome.

Objectives:

The objective of this study was to identify the reported causes of primary cecal pathologies presenting as acute abdomen and the various causes presenting in our setting, the to discuss morbidity and mortality associated with cecal pathologies, and to critically analyze the various management modalities employed in an emergency setting.

Materials and Methods:

This is a retrospective analysis of a prospectively collected data of all adult patients admitted to our unit in the last 10 years for acute abdomen, in whom cecal pathology was identified as the primary offending agent.

Results:

Our analysis of 43 patients revealed cecal perforation secondary to amebic colitis along with the simultaneous presence of liver abscess to be the most common primary cecal entity met in practice as acute abdomen. Other pathologies that were encountered included volvulus, diverticulitis, and idiopathic typhlitis. Primary acute cecal pathologies are associated with high mortality rates (≈42%). Delay in diagnosis seems to be the most important factor contributing to high mortality as these conditions are commonly misdiagnosed as appendicular pathology. Most of our patients were managed by conservative colonic resection with proximal diversion. This seems to be a more plausible option in current practice in an emergency setting (mortality rate ≈ 36%) as hemicolectomy is associated with proportionately higher mortality rates (67%).

Conclusion:

A high index of suspicion, timely and adequate pre-operative workup, optimal resuscitation, and surgical conservatism with proximal diversion might help in early accurate identification of these conditions and possibly improved outcome.

Perforated diverticulitis: is the right and left difference present here too?

BACKGROUND

It is unclear if location of disease matters in perforated diverticulitis. Management guidelines for perforated diverticulitis currently do not make a distinction between right perforated diverticulitis (RPD) and left perforated diverticulitis (LPD). We aim to compare disease presentation and management outcomes between RPD and LPD.

METHODS

This was a 10-year retrospective comparative cohort study of 99 patients with acute perforated diverticulitis between 2004 and 2013 in a single institution. Patients were divided into RPD and LPD groups based on location of disease and compared. Disease presentation was compared using modified Hinchey classification. Management outcomes assessed were failure of therapy, length of stay, mortality, surgical complications, and disease recurrence. Univariate analysis was performed using Student's t test and χ² test where appropriate.

RESULTS

RPD patients were younger (45.7 ± 16.1 versus 58.3 ± 14.7 years) and presented with lower modified Hinchey stage and no Hinchey IV diverticulitis when compared to LPD (14.3% Hinchey III versus 44.0% Hinchey III or IV). Conservative management of Hinchey I and II RPD and LPD was similarly successful (96.1 versus 96.5%), although RPD patients had shorter inpatient stay (4.6 ± 2.2 versus 6.3 ± 3.8 days) and less disease recurrence (3.1 versus 17.9%). Ten (20.4%) Hinchey I and II RPD patients were initially misdiagnosed with appendicitis and underwent surgery.

CONCLUSION

LPD is a more aggressive disease presenting with greater clinical severity in older patients and is associated with frequent disease recurrence when treated conservatively. Misdiagnosis of RPD as appendicitis is common and may lead to unnecessary surgery.

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.

Risk factors for recurrence of right colonic uncomplicated diverticulitis after first attack

PURPOSE

Most patients with acute right colonic uncomplicated diverticulitis can be managed conservatively. The aim of this study was to assess the clinical and radiologic risk factors for recurrence in patients with right colonic uncomplicated diverticulitis.

METHODS

The present survey included 469 patients who were successfully managed conservatively for the first episode of right colonic uncomplicated diverticulitis between 2002 and 2012 in a referral center, and records were reviewed from collected data. Patients were divided into two groups: a nonrecurrent and a recurrent group. The clinical and radiologic features of all patients were analyzed to identify possible risk factors for recurrence. The Kaplan-Meier method and Cox regression were used.

RESULTS

Seventy-four (15.8 %) patients had recurrence, and 15 (3.2 %) received surgery at recurrence within a median follow-up of 59 months. The mean recurrence interval after the first attack was 29 months. In univariate and multivariate analyses, risk factors for recurrence were confirmed multiple diverticula (relative risk [RR], 2.62; 95 % confidence interval [CI], 1.56-4.40) and intraperitoneally located diverticulitis (RR, 3.73; 95 % CI, 2.13-6.52). Of 66 patients with two risk factors, 36 (54.5 %) had recurrence and 10 (15.2 %) received surgery at recurrence.

CONCLUSIONS

In patients with right colonic uncomplicated diverticulitis who have multiple diverticula and intraperitoneally located diverticulitis, the possibility of recurrence and surgical rate are high. Poor outcome may be cautioned in these patients.

Outpatient antibiotic use and the incidence of acute appendicitis in Finland: a nationwide study from 1990-2008

BACKGROUND

The incidence of acute appendicitis (AA) has decreased in Finland. We hypothesized that changing trends in outpatient antibiotic use might explain at least part of this declining incidence of AA.

METHODS

The number of all patients with AA in Finland was extracted from the national data base from 1990 to 2008. For comparison, the incidence of acute diverticulitis of the colon (AD) was also recorded. All outpatient prescriptions of antibiotics belonging to the major groups of these drugs were also recorded. We used unit root and co-integration analyses for statistical analysis of the data in the study.

RESULTS

The incidence of AA in Finland declined from 14.5 to 9.8 per 10,000 inhabitants (32%) and the incidence of AD increased by 47% between 1993 and 2007. The total outpatient use of antibiotics did not increase during this same period, but the use of antibiotics effective widely against colonic pathogens (macrolides, fluoroquinolones, and cephalosporins) increased significantly. No correlation was found between the incidence of AA, that of AD, and the use of different groups of antibiotics.

CONCLUSIONS

Our nationwide registry study indicated that changes in outpatient antibiotic use do not explain the decreasing trend in AA in Finland. Other factors, such as improved diagnosis of AA, may have some role in the decreasing incidence of AA.

Right-sided diverticulitis mimics appendicitis

BACKGROUND

Right-sided diverticulitis is a rare source of right lower quadrant pain in Western society; however, it is quite common in Asian societies. Right-sided diverticulitis presents very similarly to appendicitis, with right lower quadrant pain, fever, nausea, and laboratory abnormalities, and is often seen in young patients.

OBJECTIVES

In this report, we present a case of right-sided diverticulitis. We review right-sided diverticulitis' diagnosis and management. It is important to diagnose right-sided diverticulitis because it is a good mimic of appendicitis and ideally should be diagnosed before a patient has unnecessary surgery.

CASE REPORT

A 26-year-old Asian woman presented for evaluation of right lower quadrant pain and fever. She was initially thought to have appendicitis clinically, but had right-sided diverticulitis diagnosed by computed tomography (CT) scan. She was admitted and received intravenous antibiotics and bowel rest. Her right-sided diverticulitis resolved in 3 days.

CONCLUSIONS

Severe right lower quadrant pain in young patients of Asian descent can be right-sided diverticulitis. Right-sided diverticulitis is a benign condition managed medically that mimics appendicitis. CT imaging seems to be the best way to avoid unnecessary surgery.

Imaging findings in right-sided diverticulitis in a child

We report the imaging findings in a case of acute right-sided diverticulitis in a 13-year-old boy. Based on this diagnosis the patient was successfully treated conservatively with intravenous antibiotics. This entity should be considered in patients with right lower quadrant pain and a sonographically normal appendix, particularly in those of Asian or Pacific descent.