Management of solitary cecum diverticulitis
– Single-Center Experience
Leczenie zapalenia samotnego uchyłka jelita ślepego
– doświadczenie z jednego ośrodka
Emre Gonullu
1, Merve Yigit
1, Baris Mantoglu
1, Recayi Capoglu
1, Tarik Harmantepe
1, Yasemin Gunduz
2, Fatih Altintoprak
3,
Zulfu Bayhan
3, Unal Erkorkmaz
41General Surgery Department, Sakarya University Training and Research Hospital, Sakarya, Turkey
2Radiology Department, Sakarya University Faculty of Medicine, Sakarya, Turkey
3General Surgery Department, Sakarya University Faculty of Medicine, Sakarya, Turkey
4Department of Biostatistics, Sakarya University Faculty of Medicine, Sakarya, Turkey
Article history: Received: 26.01.2021 Accepted: 15.03.2021 Published: 16.03.2021
ABSTRACT: Introduction: Cecal diverticulitis may be encountered as a real etiological factor in 1/300 appendectomies. Differential diagnosis of acute appendicitis and cecal diverticulitis is crucial because of the different treatment methods.
Aim: Our aim is to reveal the importance of distinguishing acute appendicitis from cecal diverticulitis.
Methods: The data of patients who were admitted to hospital between 2015 and 2019 with a complaint of abdominal pain and then finally diagnosed with colon diverticular disease, colon diverticulitis, or acute appendicitis, analyzed retrospectively.
Results: A total of 19 cecum diverticulitis patients were detected during surgery for acute appendicitis or during clinical and radiological evaluation. As many as 1247 appendectomies were evaluated; the final diagnosis was cecal diverticulitis in 5 patients (0.4%). One hundred and nineteen patients diagnosed with colonic diverticulitis at admission were evaluated, while 105 (88.2%) of them had left-sided diverticulitis, and 14 (11.7%) had solitary cecal diverticulitis. All of the solitary cecal diverticulitis patients were treated conservatively, except one patient, with Hinchey 3 diverticulitis.
Conclusion: Differential diagnosis of cecum diverticulitis with acute appendicitis is important because cecum diverticulitis can be managed conservatively in most cases. In order to prevent unnecessary surgical interventions, this importance has been on the increase, especially during the COVID-19 pandemic period.
KEYWORDS: acute appendicitis, appendectomy, cecum diverticulitis, cecum diverticulum, diverticulitis
STRESZCZENIE: Wstęp: Zapalenie uchyłka jelita ślepego może być faktycznym czynnikiem etiologicznym odpowiedzialnym za ok. 1/300 zabiegów appendektomii. Diagnostyka różnicowa ostrego zapalenia wyrostka robaczkowego i zapalenia uchyłka jelita ślepego ma kluczowe znaczenie z uwagi na różnice w leczeniu obu tych schorzeń.
Cel: Celem niniejszej pracy jest ujawnienie znaczenia rozróżnienia między ostrym zapaleniem wyrostka robaczkowego a zapaleniem uchyłka jelita ślepego.
Materiał i metody: Wykonano retrospektywną analizę danych pochodzących od pacjentów poddawanych w latach 2015–2019 hospitalizacji w związku z następczym ostatecznym rozpoznaniem choroby uchyłkowej jelita grubego, zapalenia uchyłków jelita grubego lub ostrego zapalenia wyrostka robaczkowego.
Wyniki: W trakcie zabiegu chirurgicznego wykonywanego w związku z ostrym zapaleniem wyrostka robaczkowego lub też w trakcie oceny klinicznej i radiologicznej wykryto łącznie 19 przypadków zapalenia uchyłka jelita ślepego. Dokonano oceny 1247 zabiegów appendektomii. W tej liczbie ostateczne rozpoznanie zapalenia uchyłka jelita ślepego postawiono u 5 pacjentów (0,4%). Ocenie poddano również 119 osób z rozpoznaniem zapalenia uchyłków jelita grubego w momencie rozpoznania; 105 pacjentów (88,2%) w tej grupie cierpiało na lewostronne zapalenie uchyłków, zaś 14 (11,7) na zapalenie samotnego uchyłka jelita ślepego. Wszystkich chorych z zapaleniem samotnego uchyłka jelita ślepego poddano leczeniu zachowawczemu, z wyjątkiem jednego, u którego stwierdzono zapalenie uchyłka stopnia 3 w skali Hincheya.
Wniosek: Różnicowe rozpoznawanie zapalenia uchyłka jelita ślepego i ostrego zapalenia wyrostka robaczkowego ma znaczenie, ponieważ pierwsze z wymienionych schorzeń można w większości przypadków leczyć zachowawczo. Znaczenie tego rozpoznania dla zapobieżenia zbędnym interwencjom chirurgicznym rośnie szczególnie w okresie pandemii COVID-19.
SŁOWA KLUCZOWE: appendektomia, ostre zapalenie wyrostka robaczkowego, uchyłek jelita ślepego, zapalenie uchyłka jelita ślepego, zapalenie uchyłków
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The patients who had non-operative treatment with a pre-diag- nosis of solitary cecal diverticulitis by radiological examinations were evaluated within the scope of the study.
Patients with diverticulitis, other than solitary cecal diverticu- litis, or who were misdiagnosed as acute appendicitis, and were later diagnosed with cecum diverticulitis as a result of surgery, or patients whose records were irregular or who cannot be reached even by phone were excluded from the study.
Records of the patients within the scope of the study were evalu- ated retrospectively for demographic data, clinical findings at the time of admission, laboratory results, radiological findings, and early treatment results. Charlson Comorbidity Index (CCI) was calculated due to diversities between the demographic variables of the patients. Modified Hinchey Classification (MHC), defined by Wasvary et al., was used to evaluate and classify radiological findings [9] (Tab. I.).
RESULTS
In the above mentioned period, the data of 119 patients diagnosed with colon diverticulitis were evaluated, and 14 of them (6.4%) were recorded as cecum diverticulitis. As many as 1247 appen- dectomies were assessed, with the final diagnosis cecal diverticu- litis established during surgery in 5 patients (0.4%). Right hemi- colectomy was performed in 2 cases (40%); appendectomy and drainage procedures were performed in 3 cases (60%), although the appendix was normal. Preoperative diagnosis of these patients was acute appendicitis according to both clinical and ultrasonog- raphy (USG) findings.
A total of 13 patients diagnosed as solitary cecal diverticulitis treat- ed non-operatively were identified. One patient, with Hinchey 3 diverticulitis at admission, underwent right hemicolectomy after 72 hours due to the fact that the clinical findings did not regress despite the medical therapy. Nine (64.2%) of these patients were male, five (35.8%) were female, and the mean age was 46 (26–88) years. At admission, all patients had abdominal right lower quad- rant pain and tenderness (100%). Apart from abdominal pain, there was nausea in 6 patients (42.8%), fever in 2 patients (14.2%), and vomiting in 1 patient (7.1%). The average duration between the onset of complaints and admission to hospital was 2.6 (1–5) days.
In laboratory examinations, all patients had leukocytosis (mean 10.8 K/µL and elevated C-reactive protein level (mean 58.3 mg/L).
The Charlson Comorbidity Index ranged from 0 to 9 (median: 2).
At admission, eight of the solitary cecal diverticulitis (SCD) patients (57.1%) underwent abdominal USG examination and pericecal in- flammatory changes (Fig. 1.) were common in all patients (100%).
The preliminary diagnosis was reported to be acute appendicitis based on USG in 4 patients (50%); the appendix was interpreted as non-visualized in 4 patients (50%). All 14 patients (100%) under- went abdominal computed tomography (CT) examination, and all CTs were interpreted by the same radiologist (Y.G.), with experi- ence in abdominal emergency pathologies. Local or pericecal in- flammatory changes on the cecal wall were common CT findings (100%). Appendices were visualized in all patients, and the mean diameter was 0.56 mm (0.42–0.76 mm), and it was determined
ABBREVIATIONS
ASCRS – American Society of Colon and Rectal Surgeons CCI – Charlson Comorbidity Index
CT – computed tomography
MHC – Modified Hinchey Classification NPO – nil per os
SCD – solitary cecal diverticulitis USG – ultrasonography
WSES – World Society for Emergency Surgery
INTRODUCTION
Colon diverticulitis continues to be an outstanding health prob- lem worldwide. The incidence of colonic diverticulosis is below 20 percent at the age of 40, and around 60 percent at the age of 60 [1]. Five to 45 percent of the western population has colonic di- verticulosis, usually diverticulosis in the left colon [2, 3]. On the other hand, diverticulosis in the Asian population shows the prev- alence rates of 13 to 25 percent, with most of the cases in the right colon [4]. The diverticulum usually originates from the anterior aspect of the cecum. In the event of inflammation, it can be per- forated and cause peritonitis. On the other hand, if it originates from the posterior aspect of the cecum, in the case of inflamma- tion or perforation, it does not cause peritonitis and may probably engender a mass [5].
Potier made the first description of solitary cecal diverticulum in 1912 [6]. A solitary cecal diverticulum is less common than the right colon diverticulosis. Diverticulum, located in the cecum, of- ten remains uneventful. The most common complication is diver- ticulitis, and it occurs in very few cases [7]. Diverticulitis of the cecum may be confused with acute appendicitis due to similarities in the clinical, laboratory, and radiological findings [5]. It is quite challenging to make a differential diagnosis between appendicitis and cecal diverticulitis preoperatively by using clinical evaluation alone. It requires tight surgeon-radiologist cooperation as well as clinical experience [8]. Although the rate of detection of solitary cecal diverticulitis is not high among the patients operated on with the diagnosis of acute appendicitis (1/300) [5], it is crucial to dis- tinguish these preoperatively, since both present with right lower quadrant pain and may cause acute abdomen syndrome but the treatment methods are different.
In the present study, the results of patients undergoing medical treatment with the diagnosis of solitary cecal diverticulitis are evaluated, and the current literature is reviewed.
MATERIALS AND METHODS
The Ethics Committee of the Sakarya University, Faculty of Medicine approved the study and data collection (71522473/050.01.04/236).
The data of patients who were admitted to hospital with the com- plaint of abdominal pain and who were finally diagnosed with co- lon diverticular disease, colon diverticulitis, or acute appendicitis at the Department of General Surgery, Sakarya University Medi- cal Faculty Hospital between January 2015 and January 2019, were analyzed retrospectively.
that the appendix was not responsible for the clinical condition.
Classification of solitary cecal diverticulitis detected by CT was as follows: Hinchey 1a was found in 3 patients (21.4%), Hinchey 1b in 3 patients (21.4%), Hinchey 2 in 6 patients (42.8%), and Hinchey 3 in 2 patients (14.3%) (Tab. II., Fig. 2.–4.).
Oral food intake was restricted (nil per os) for all patients for 24–48 hours according to the severity of the physical examination find- ings. Intravenous antibiotherapy (Ampicillin + Sulbactam) and anti-inflammatory (Dexketoprofen) treatment were started and continued throughout the hospitalization. When the physical ex- amination and laboratory parameters improved after 48 hours of hospitalization, the oral food restriction was suspended.
Even with exclusion of the patient hospitalized for 15 days due to comorbid diseases, the mean length of hospital stay was determined
to be 4.3 (3–6) days. On discharge, oral forms of antibiotics and anti- inflammatory drugs were prescribed to all patients for one week.
There was no evidence of edema or inflammation in the colon mucosa on colonoscopic examinations of all patients, performed under elective conditions at least six weeks after discharge. There was no recurrence of the complaints of patients who were followed for at least 6 (6–18) months.
DISCUSSION
The rate of right colon diverticulitis among all diverticulosis cases, which is 5% in western societies, may increase up to 75% in eastern societies [2, 10]. As many as 4–15% of people with diverticulosis may develop diverticulitis throughout their lives [11]. In our pa- tient group, most of the diverticulitis cases were in the left colon, as in western societies. We think that the reason for this situation is high consumption of fiber in the Turkish society and the adop- tion of a western- lifestyle along with urbanization.
Diverticulitis management differs depending on whether divertic- ulum is complicated or not. Uncomplicated diverticulitis can be treated nonoperatively in 70 to 100 percent of patients [12]. There is no doubt about the necessity of medication for pain and fluid de- ficiency, but the need for antibiotics is controversial. A clear-liquid diet, or even complete bowel rest with nil per os (NPO), would be necessary. Two trials, i.e. Sweden 2012 and Diablo (DIverticuli- tis: AntiBiotics Or cLose Observation?) 2018, including 623 and 528 patients respectively, do not recommend the use of antibiot- ics in uncomplicated diverticulitis, in line with World Society for Emergency Surgery (WSES) guidelines for the management of acute left-sided colonic diverticulitis [13–15]. American Society of Colon and Rectal Surgeons (ASCRS) recommends routine use of antibiotics in diverticulitis in 2014 guidelines [16]. We limited oral intake in our hospitalized diverticulitis patients and adminis- tered antibiotics for 3–5 days because 12 of 14 patients had com- plicated diverticulitis (Hinchey 1b and above), and all of them had high CRP and WBC values at admission to hospital.
Sonographic features for right-sided acute colonic diverticulitis are diverticular wall thickening, surrounding echogenic fat and intradiverticular echogenic material, adjacent lymph node en- largement, fluid accumulation, and increased color flow signal [17]. Experienced radiologists may distinguish diverticulitis from acute appendicitis with USG. Some authors declared sensitivity and specificity of USG in cecal diverticulitis as high as 89–91 per- cent [18]. What is more, Y. H. Chou et al., in their studies evaluat- ing the right lower quadrant with USG in 934 patients, reported a sensitivity of 91.3%, a specificity of 99.8%, and an overall accuracy rate of 99.5% for acute right-side diverticulitis [19]. Acute appendi- citis was considered as a preliminary diagnosis in half of our SCD patients undergoing USG. Due to the fact that SCD is observed less frequently in our society compared to eastern communities, we cannot obtain an accurate diagnosis with USG.
CT features of acute colonic diverticulitis are thickening of the cecal wall, focal pericecal inflammation extending to the adjacent fascia, abscess, extraluminal air, and mass. Hinchey classification is used for staging diverticulitis. The sensitivity and specificity of CT have been reported to be 98% in literature [20]. In a study by
STAGE EXPLANATION
0 Mild clinical diverticulitis
1a Confined pericolic inflammation or phlegmon 1b Pericolic or mesocolic abscess
2 Pelvic, distant intraabdominal, or retroperitoneal abscess 3 Generalized purulent peritonitis
4 Generalized fecal peritonitis
Tab. I. Modified Hinchey classification by Wasvary et al. (1999).
Fig. 1. Pericecal inflammatory changes on abdominal USG examination.
Fig. 2. Hinchey 1 diverticulitis on CT examination.
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Joshua Tseng et al., 11841 appendectomies were analyzed using the 2016 ACS-NSQIP database. It was observed that the negative appendectomy rates, which were 9.1% only when USG was used, decreased to 2.5% when only CT was used [21]. Therefore, CT comes to the fore in differential diagnosis of acute appendicitis, which is most confused with SCD. All of fourteen patients were evaluated with CT, and all of them were diagnosed with cecal diver- ticulitis. Thus, thirteen of them could be managed conservatively.
Many studies revealed that in some disorders, in which an acute surgical approach had been applied in the past, a conservative ap- proach is sometimes an alternative today. Acute appendicitis and acute diverticular disease are the most notable examples of this issue [14, 22–23]. We also prefer conservative treatment of some, appropriate cases of SCD, particularly with the guidance of CT. This
allows for the patient to avoid unnecessary surgical interventions and risks; moreover, a cost-effective approach should be adopted.
In studies conducted on patients infected with SARS-CoV-2, it was observed that mortality and morbidity increased due to surgery [24, 25]. For this reason, the differential diagnosis of cecal diver- ticulitis and acute appendicitis has gained on importance, espe- cially during the COVID-19 pandemic period.
In addition to being a retrospective study, the limitations of our study are the low number of cases and a single-center experience.
In conclusion, the first step of the conservative approach in SCD treat- ment is to be able to make an accurate diagnosis. We think that with a correct diagnosis, conservative treatment may be the first choice.
YEAR AGE SEX ABDOMINAL PAIN AND
TENDERNESS VOMITING NAUSEA FEVER
DURATION OF SYMPTOMS (DAY)
CCI* WBC CRP HYNCHEY TREATMENT HOSPITALIZATION (DAY)
2015 34 M Yes No No No 2 0 9.7 42.5 1a Medical 3
2015 44 F Yes No No No 3 3 7.2 154 2 Medical 4
2015 79 F Yes No No No 3 7 10.5 20 1a Medical 6
2016 31 M Yes No No No 4 0 8.2 30 2 Medical 3
2016 33 F Yes No Yes No 2 0 11.2 83.5 1b Medical 3
2016 90 F Yes Yes Yes Yes 2 9 12.2 11 3 Surgery 15
2017 27 M Yes No No No 1 0 6 6.7 1a Medical 5
2017 64 M Yes No Yes No 2 3 12.5 102 1b Medical 6
2017 82 M Yes No No No 5 5 12.4 190 2 Medical 7
2018 49 M Yes No No No 2 2 12 88 2 Medical 3
2018 45 M Yes No Yes No 3 0 13 20.6 2 Medical 3
2018 52 M Yes No Yes No 1 1 14.7 26.7 1b Medical 2
2018 65 F Yes No No Yes 2 2 9 13.6 3 Medical 4
2918 73 M Yes No Yes No 3 4 13 28.7 2 Medical 5
* Charlson Comorbidity Index
Tab. II. Demographic information and complaints of the patients on admission.
Fig. 3. Hinchey 2 diverticulitis on CT examination. Fig. 4. Hinchey 3 diverticulitis on CT examination.
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10.5604/01.3001.0014.8057 Table of content: https://ppch.pl/resources/html/articlesList?issueId=0 Some right reserved: Fundacja Polski Przegląd Chirurgiczny. Published by Index Copernicus Sp. z o. o.
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The full terms of this license are available on: https://creativecommons.org/licenses/by-nc/4.0/legalcodeode Dr. Zulfu Bayhan (ORCID: 0000-0002-7587-7267); General Surgery Department, Sakarya University Faculty of Medicine, Sakarya, Turkey; Phone: + 90 530 928 5873; E-mail: zulfubayhan@gmail.com
Gonullu E., Yigit M., Mantoglu B., Capoglu R., Harmantepe T., Gunduz Y., Altintoprak F., Bayhan Z., Erkorkmaz U.: Management of solitary cecum diverticulitis – Single-Center Experience; Pol Przegl Chir 2021; 93 (1-6); DOI: 10.5604/01.3001.0014.8057 (Advanced online publication)
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