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Clinical Case

RIGHT-SIDED DIVERTICULITIS


D Mutter, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


This case report describes the recurrence of an infectious complication of a diverticulum in the right colon, three years after a resection for the first occurrence of diverticulitis.

2. Keywords


Right colon, abscess, diverticulum

3. Patient


Male, 67-year-old

4. Past medical history


Medical:
Small cell bronchial adenocarcinoma diagnosed in 1994. Patient is currently NED.
Paraneoplastic sensory-motor neuropathy

Surgical:
Ileocecectomy with primary anastomosis via midline laparotomy for perforated cecal diverticulitis 3 years ago

5. History of present illness


1 month history of right lower quadrant mass, evolving into a septic picture.

6. Laboratory values


- WBC 12,100 /mm3;
- Hgb 10,5 g/dL;
- CRP 97,4 mg/L.

7. Gastrograffin enema


Significant 5 cm long stenosis in the right colon. It appears to be due to inflammation or extrinsic compression.

8. CT scan 1


Phlegmon around the bowel in the right iliac fossa.

9. CT scan 2


Inflammatory aspect of the colon at the site of the ileocolic anastomosis.

10. Clinical progress


The patient is explored via a midline laparotomy. A large indurated mass is found involving the right colon and terminal ileum.
A right colectomy is performed with primary anastomosis.

11. Pathologic findings


Phlegmonous acute diverticulitis with abscess formation.

12. Discussion


Acute diverticulitis may occur as a result of congenital or acquired diverticula. The acquired form of the disease is predominantly left sided and is prevalent in western countries while the congenital form of diverticular disease is predominantly right-sided and more prevalent in the far East. Right-sided diverticular inflammation occurs in less than 5% of patients with diverticulitis. Right-sided diverticula can be grouped into 2 types: Acquired (or false diverticula) and congenital (true diverticula). Congenital diverticula are usually solitary, with 88% located in the cecum.
Right-sided diverticulitis frequently presents at a younger age than its left-sided counterpart and is often misdiagnosed as appendicitis. More recently, CT-scanning may have increased the preoperative diagnostic accuracy. It has also been found to be helpful in differentiating acute phlegmonous diverticulitis from perforated colon cancer. CT findings of an inflamed diverticula and a preserved enhancement pattern of the thickened colonic wall were the two most statistically significant findings of acute diverticulitis involving the cecum and ascending colon that distinguished diverticulitis from colonic carcinoma.

13. References


  1. Graham SM, Ballantyne GH. Cecal diverticulitis. A review of the American experience. Dis Colon Rectum 1987;30:821-6.
  2. Jang HJ, Lim HK, Lee SJ et al. Acute diverticulitis of the cecum and ascending colon: the value of thin-section helical CT findings in excluding colonic carcinoma. AJR Am J Roentgenol 2000;174:1397-402.
  3. Nirula R, Greaney G. Right-sided diverticulitis: a difficult diagnosis. Am Surg 1997;63:871-3.
  4. Violi V, Roncoroni L, Boselli AS et al. Diverticulitis of the caecum and ascending colon: an unavoidable diagnostic pitfall? Int Surg 2000;85:39-47.
  5. Wong SK, Ho YH, Leong AP et al. Clinical behavior of complicated right-sided and left-sided diverticulosis. Dis Colon Rectum 1997;40:344-8.