Discussion
Diverticulosis is extremly common in the United States and Europe. It is estimated that half of the population older than age 50 years has colonic diverticula. The true prevalence
of colonic diverticulosis is difficult to ascertain, however it appears that about 8.5% of people in western countries are afflicted [
1]. The sigmoid colon is the most common site of diverticulosis. Right-sided diverticula occur more often in younger patients than do left-sided diverticula, and are more common in people of Asian descent than in the other populations. The majority of colonic diverticula are false diverticula in which the mucosa and muscularis mucosa have herniated through the colonic wall [
2]. Solitary diverticulum of the cecum is thought to be a congenital lesion arising as a sacular projection during the sixth week of embryonic development [
2,
3].
Most patients with right side diverticula are asymtomatic. However, diverticulitis does occur occasionally. Because patients are young and present with right lower quadrant pain, they are often thought to suffer from acute appendicitis, and the diagnosis of right-sided diverticulitis is subsequently made in the operating room. It is difficult to differentiate cecal diverticulitis from acute appendicitis. More than 70% of patients with cecal diverticulitis were operated on with a preoperative diagnosis of acute appendicitis [
3]. The correct preoperative diagnosis was made in only 5.3% of 318 patients, according to the report of Wagner and Zollinger [
4]. A number of reviews report that the incidence of a correct intraoperative diagnosis oscillates between 65 and 85% [
4]. In all of our cases except one, the preoperative diagnosis was acute appendicitis.
Ultrasound and computer tomography (CT) have both been evaluated in the diagnosis of right-sided diverticulitis. Chou et al [
5] reviewed 934 patients with clinically indeterminate right-sided abdominal pain who went on to have an abdominal ultrasound. They reported that ultrasound has demonstrated a sensitivity of 91.3%, a specificity of 99.8% and overall accuracy of 99.5% in the diagnosis of cecal diverticulitis [
5]. CT scans have a sensitivity and specificity of 98% in the diagnosis of acute appendicitis, and are highly cost-effective; hence, some authors suggest its routine use for abdominal pain in the right lower quadrant, which would probably reduce surgeries and hospital stays [
5,
6]. Recognition of specific imaging findings enables the radiologist to make the correct diagnosis and helps in establishing the appropriate surgical or medical therapy, thus avoiding unnecessary exploration or surgery for some of these nonsurgical conditions mimicking acute appendicitis. If preoperative examination suggests cecum diverticulitis, the most important diagnostic tool is the CT. The CT findings were similar to those of left side diverticulitis, including focal pericolonic inflammation, diverticula, colonic wall thickening, thickening of the adjacent fascia, and extraluminal mass effect.
In patients with preoperative diagnosis of cecal diverticulitis without signs of peritonitis, medical treatment with antibiotics may be sufficient [
6,
7]. In our cases, almost all of our patients had no history of appendectomy, so appendicitis was the main clinical suspicion in these cases, which led to the operative exploration of the abdomen. An intraoperative diagnosis is difficult upon initial exploration. In addition, when the diagnosis is made intraoperatively, the surgical management of the disease is controversial. Conservative management with antibiotics has been suggested for cecal diverticulitis diagnosed intraoperatively, but most surgeons recommend resection [
8,
9]. In the presence of an inflammatory mass, diverticulectomy is usually impossible, and colectomy is required. A literature review of 279 cases of surgically treated cecal diverticulitis found no mortality after ileocecal resection, but a mortality rate of 1.8% after right hemicolectomy [
10,
11]. Fang et al. recommend wide resection, since 29% of patients undergoing only appendectomy in their study had recurrent episodes of right diverticulitis, with 12.5% of them requiring a later right hemicolectomy [
11]. In all of our patients, a diverticulectomy and incidental appendectomy were performed and postoperative periods were uneventful.
In conclusion, Preoperative diagnosis of cecal diverticulitis is important in order to decide how to manage to this condition. During the surgical procedure, if the diagnosis of acute appendicitis is in doubt, further exploration should be performed. We recommend diverticulectomy as a safe and adequate treatment for cecal diverticulitis. However, if the histopathological examination of the specimen reveals the presence of colonic cancer, a right hemicolectomy can always be performed.