Cecal diverticula, although rare, may result in acute or chronic diverticulitis. Rarely does acute hemorrhage arise from cecal diverticula. The diagnosis of acute diverticulitis usually is evident at operation and an appropriate resection is usually feasible, although the local status and general condition of the patient modifies treatment in some instances. Chronic cecal diverticulitis is usually difficult to distinguish from carcinoma and a resection is justified

Block, M. A.

Brush, B. E.

Grodsinsky, C.

Soares, J.

English

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Henry Ford Hospital Medical Journal Volume 20 Number 1 Article 6 3-1972 The Role of Surgery in Cecal Diverticulitis C. Grodsinsky J. Soares M. A. Block B. E. Brush Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Grodsinsky, C.; Soares, J.; Block, M. A.; and Brush, B. E. (1972) "The Role of Surgery in Cecal Diverticulitis," Henry Ford Hospital Medical Journal : Vol. 20 : No. 1 , 33-40. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol20/iss1/6 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal V ol. 20, No. 1, 1972 The Role of Surgery in Cecal Diverticulitis C. Grodsinsky, M.D.; J. Soares, M.D.; M. A. Block, M.D., and B. E. Brush, M.D.* Cecal diverticula, although rare, may result in acule or chronic diverticulitis. Rarely does acule hemorrhage arise from cecal diverticula. The diagnosis of acute divcriiculitis usually is evident al operation and an appropriate reseclion is usually feasible, although the local status and general condition of the patient modifies treatment in .some instances. Chronic cecal diverticulitis is usually dilli-cult lo distinguish from carcinoma and a reseclion is justified. Symptomatic cecal diverticula mimic other more common pathological le-sions such as appendicitis and carci-noma. Since the presence of the disease often is recognized first in the operating room, surgeons must then decide the nature and extent of the surgical pro-cedure that must be done. Our experi-ence with ten cases of cecal diverticu-litis indicates that individualized management is based on extent of peritonitis and condition of the patient. From a clinical and surgical stand-point, disease arising from cecal diver-ticula may be grouped into three main categories: I- .Acute cecal diverticulitis as in "acute abdomen", indistinguish-able from other inflammatory conditions in the right abdomen. Chronic cecal diverticulitis sim-uiating malignancy. •'department of Surgery 11. I I I . Acute gastrointestinal bleeding or chronic blood loss from ce-cal diverticula. I. Acute Cecal Diverticulitis: Our experience with eight patients with acute cecal diverticulitis is pre-sented in the following case abstracts. Case No. I : A 21-year-old white man. with a two-day history of right lower ab-dominal pain, was admitted through the Emergency Rt)om on November 21, 1965. Positive physical findings included a lem-perature of 99.4°F, tenderness and rebound in the right lower quadrant, and rectal tenderness on the right. The white blood cell count was lO.OOO/cu mm and urinalysis was within normal limits. The patient underwent operation following diagnosis of .ICIIIL- appendicitis. Although Ihc appendix appeared normal, an inflammatory mass involving the cecum was found 1.5 cms from the ileocecal valve. Appendectomy and wedge resection of the cecal mass was done. The pathological report confirmed diagnosis at operation of acute cecal diverticiililis. His postoperative course was uneventful. 33 Grodsinsky, Soares, Block and Brush Case No. 2: A 40-year-old white man was admitted on September 15. 1965, with a two-day history of epigastric and subcostal pain, diarrhea, and vomiting. His temperature on admission was 99.2°F. Positive physical findings consisted of right upper quadrant guarding and tenderness. The white blood cell count was 6.800/cu mm; serum amylase was 96 units, and urinalysis was within normal limits. The patient was admitted with a diagnosis of acute cholecystitis. Under observation for one day. the patient reported pain localized to the right lower quadrant with rebound tenderness at •McBurney s point. Rectal examination in-dicated tenderness on the right. The white blood cell count increased to 10.800/cu mm. Wilh a diagnosis of acute appendicitis, the patient underwent surgical operation using a Rocky-Davis incision. The cecum appeared to be acutely inflamed, while the appendix was normal. No excisions were done on either the appendix or cecum. The patient then was treated conservatively postopera-tively and discharged on the fifth postopera-tive day. Followup for two years was un-eventful. Case No. 3: A 62-year-old white woman, with a cecal diverticulum evidenced two years previously (Figure 1). was admitted K Figure I—Case No. Three on April 27, 1964, because of two days oi pain in the right lower quadrant. On admission, the patient was afebr le. had marked tenderness and rebound at McBurneys point, but showed a norma! white blood cell count. The admitting diag-nosis was acute appendicitis or acute di'. er-ticulilis. Exploratory surgery through an infra-um-bilical transverse incision indicated an aciiteh inflamed cecal diverticulum with marked induration of the lateral cecal wall. Tht appendix was normal. Resection of the cecum and terminal ileum was performed with end-to-end anas-tomosis of the ascending colon and terminal ileum. The specimen revealed that the ostium of the cecal diverticulum was occluded bi faecalith. Study of microscopic sections con-firmed the diagnosis of acute cecal divcriicu-litis. The postoperative course was iim- eni ful. Case No. 4: A 70-year-old while w nar who had sustained cerebral thrombosis in th« past, reported a two-day history of epn i^ Ui. pain which was localizing to the righl lower quadrant. She was afebrile, had tenderness and re-bound at McBurney's point, a white blood cell count of 6.750 cu mm with a norma! difl'erential. and a negative urinalysis. Tht admitting diagnosis was acute appenili.-iii' Exploratory operation through a righ: paramedian incision indicated a normal ap-pearing appendix and a severeh intbme>: cecal wall. The appendix and cecum «e'; left undisturbed. The patient had an unevent-ful postoperative recovery. A followup bar-ium enema ten da\s later demonstrated tlw presence of cecal diverticula (Figure 2). Case No. 5: This 43-year-old white mar was admitted to the hospital with a histop of peri-umbilical pain which gradually local ized to the right lower quadrant during thf previous three days. At the time of admission, he had ^  temperature of 100.4°F and severe tender ness and rebound tenderness in the righ! lower quadrant of the abdomen. The wni'' blood cell count was 20,250/cu mm a shift to the left by differential count. Ln' alysis was within normal limits. The clinic* diagnosis was acute appendicitis. An exploratory operation through a n?*^  transverse abdominal incision indicated normal appearing appendix. However, thfl* was a retrocecal abscess with a cc^.il J'^ -ticulum at the base. An appendectomy performed and the abscess drained. postoperative course was uneventful. 34 The Role of Surgery in Cecal Diverticulitis Figure 2—Case No. Four Case No. 6: A 78-year-old white man |-*me to the Emergency Room with right o*er quadrant discomfort and evidence of ['kl' 'ower quadrant tenderness with ^oound tenderness. He had a history of f^ Piic ulcer disease, confirmed by an x-ray ^ w' '^'^ upper gastrointestinal tract, ''h a diagnosis of acute appendicitis. an exploratory operation was performed. The appendix appeared normal but there was a gangrenous diverticulum in the cecum (Figure 3). Since there was considerable induration, it was difficult to eliminate the possibility of a perforated malignancy. Therefore, a right colectomy was performed. The pathologists reported the presence of 35 Grodsinsky, Soares, Block and Brush Figure 3—Case No. Six necrotizing cecitis. His postoperative course was uneventful and he experienced no further problems. Case No. 7: A 34-year-old white man complained of right abdominal pain for approximately 28 hours before coming to the hospital. He experienced no nausea or vomiting, but had noted anorexia. The white blood cell count was elevated: he was febrile, and abdominal tenderness was present superiorly and laterally to McBur-ney's point. Retrocecal appendicitis was sus-pected and an operation was performed. The .ippendix was found to be normal, but a si-.ilcd-olT perforation of a cecal diverticulum u.is pn-scnl A nuHlilicd lichl colcclomv w.is done Postoperalivelv. the patient developed a wound infection but recovered satisfac-torily othcrv^ise. ( .i-c No ^ \ 4S-\c.ir-i>ld white woni.in was admitted to the hospital after two days of pain in the right lower quadrant of the abdomen. The pain was constant, aching. did not radiate, and was aggravated i) motion. She noticed nausea but no vomitint Examination of the abdomen sho»« tenderness in the right lower quadrant »itt minimal rebound tenderness. Operation «^ performed following diagnosis of acuif appendicitis. A 4 x 4 cm area of induration was found in the lateral wall of the . directly opposite the ileo-cecal valve. The area appeared inflamed but since its natu'; could not be determined a modified righ^ colectomy was performed. The pathologist-reported acute diverticulitis of the ceding The patient experienced an uneventful po^^ •iperative course. The infrequent occurrence of ced diverticulitis and the resemblance c its manifestations to the more cominc^  lesion of acute appendicitis makes ti"-latter the usual primarv' preoperati^ ' 36 The Role of Surgery in Cecal Diverticulitis di, :nosis for these patients (Cases 1-8). Of the 318 cases of cecal diverticulitis re\iewed by Wagner and Zollinger in 19(1.' only 5.3''c were correctly diag-nosed preoperatively. A correct pre-operative diagnosis of acute cecal diverticulitis is most likely in the patient who has had an appendectomy or whose cecal diverticula had been revealed in the past by barium enema. (Case No. 3). This limited group of patients may be treated conservatively since only 5"'o are reported to develop generalized peritonitis secondary to perforation of the inflamed cecal diverticulum.-At laparotomy, cecal diverticulitis, like acute appendicitis, presents varying degrees of inflammation. Most often :he diagnosis is obvious and a segmen-tal excision should suflicc. However, when the degree of induration is .•\ere. the possibility exists of a car-cinoma. Greaney and Snyder' estimated that one-third of the cases are of the "hidden type". They advise a right colectomy. Cecotomy and examination f*! the mucosa is a useful procedure, u^t its advantages have to be weighed against the risk of possible fecal coo-jniinatiim. dissemination of malignant ^lls, and unnecessary delay of the ''peration. Since acute appendicitis was the preoperative diagnosis, eight of our '^ 1 cases of cecal diverticulitis were emergency operations. .Although the '^ fgical procedure varied greatly, in "•<^ t instances the local situation and Inpatient's condition permitted some >Peof resection. In one case, treatment •-"listed of simple diverticulectomy *i'h Wedge resection of the base of the -fcal diverticulum. In two cases, the degree of inflammation was moderate and the treatment consisted of excision of the cecum and the terminal ileum with end-to-end anasiiMiiosis. Two cases were treated by right colectomy. One case of a perforated cecal diverti-culum with a localized abscess was treated by adequate drainage. In two cases, we elected to close the abdomen, leaving the cecal diverticula and appen-dix intact. No patients experienced any major postoperative complications. II. Chronic Cecal Diverticulitis: I he two patients manifesting chronic cecal diverticulitis presented the follow-ing features: Case No. 9: A 58-year-old white man with vague upper abdominal pain, had a persistent round tilling defect in the cecum, lewaled by barium enema study during gastrointestinal investigation. The clinical inipicssion \sas either mucocele of the appendix or lipoma. An exploratory operation through a ri.ehl transverse incision uncovered a soft tumor mass involving the appendix and cecum. It was resected. Pathology reports indicated a chronic inflammation of Ihc wall of the cecum with an incidental finding of diverti-cula of Ihc appendix (Figure 4). Case No. 10: While in the hospital for treatmeni of right shoulder pain due to a peritendonitis. a 59-year-old white man was found to have mild diabetes. polycythcMii:i. and a mass in the right lower quadrant. X-ray studies indicated the mass was in the area of the cecum. With a diagnosis of possible malignant lesion, an oper;ition was performed. Exploration of Ihe abdomen revealed a hard, apparently inflammatory mass in the cecum, involving the terminal ileum. This had adhered to the iliac bone creating chronic osteomyelitis, l ollowing an extensive right colectomy, the pathological report showed diverticulitis of the cecum with abscess formation and a diverticulum in the appendix. Postoperatively, the patient ilevelopeil a wound infection which eventually cleared. Chronic cecal diverticulitis presents a less urgent problem than the acute 37 Grodsinsky, Soares, Block and Brush Figure 4—Case No. Nine variety. Physical exainination of the chronic patient may reveal abdominal pain and/or a mass. Barium enema studies or colonoscopy may show alter-ations that are indistinguishable from malignancy of the cecum. It is also diflicult to distinguish a chronic granu-lomatous inflammation arising in the appendix' from chronic cecal diverticu-litis. Because of the inability to exclude a malignancy even at operation, a right colectomy is performed frequently when chronic cecal diverticulitis is present. III. Gaslroiniestiiuil Hemorrhage As-sociated with Cecal Diverticulae: Ulceration in cecal diverticulae has been shown to be the cause of massive GI bleeding. •• Although we have treated patients with bleeding asso-ciated with extensive diverticulosis of the colon, including the cecum, none of the cases in this report require; operation for massive hemorrhage from isolated cecal diverticulae. Discussion The first reported case of diverticula of the cecum evidently appeared i" the 1863 catalogue of the pathologic^ ' specimens of the Hunterian collectioc of the Royal College of Surgeon>_ Oschner and Bargen" estimated tha! the frequency of cecal diverticula i" the general population is 1.7%. Leich' 38 The Role of Surgery in Cecal Diverticulitis Table I INCIDENCE OF CECAL DIVERTICULAE Anderson (Mayo Clinic 1947) Greaney and Snyder (1957) Rodkey and Hermann (1961) 9 among 700 cases of surgically treated diverticulitis 14 in a review of 6,781 emergency laparotomies 269 left colon diverticulae and 14 right colon diverticulae in a 20-year review of diverticular disease ling' considered that inflammation of cecal diverticula occurs in 0.1% of all cases of diverticulosis of the colon. \\ith what frequency cecal diverticula become symptomatic is not known, but it is a rather uncommon entity (Figure Kurosu" reported diverticulitis to be more common in the right than the left colon in Japan. It is likely that cecal diverticula are J^sually congenital in origin. Some authors'"' " claim that this formation of the lesion may be predisposed by 3 simple ulcer of the cecum. Among other lesions primarily affecting the cecum, necrotizing cecitis may play a role in the development of solitar>^ diverticulum of the cecum (Figure 3). In our series of patients both sexes were equally affected. Our experience indicates that cecal diverticulitis presents difliculty in diag-nosis and management both preopera-tively and at operation. Surgical judge-ment is necessary to individualize therapy. Decision should rest primarily on whether an appropriate resection is indicated and safe for the patient. REFERENCES ' Wagner. D. E. and Zollinger, R. W.: Diverticulitis of the cecum and ascending colon. Arch Surg. 83:4.'<6-43, Sept 1961. Anderson, L.: Acute diverticulitis of the cecum. Surgery. 22:479-88. Sept l'>47. -^ Greaney. E. M. and Snyder. W. H.: Acute diverticulitis of the cecum encountered at emergency surgery. Am J Surg 94:270-81, Aug 1957. 39 Grodsinsky, Soares, Block and Brush 4. Wilson. J. W. et al.: Granulomas of the ileocecal region secondary to appendiciti!| (ligneous cecitis) which simulate neoplasma. Arch Surg 59:933-56, Oct 1949. 5. Taylor, R. S.: Massive haemorrhage complicating solitary caecal diverticulitis. Br J Sur; 53:947-8, Nov 1966. 6. Solitary diverticulum of the caecum. Br Med J 4:659-60. 14 Dec 1968. 7. Ochsner, H. C. and Bargen, J. A.: Diverticulosis of the large intestine. Ann Intern Mcc\ 9:282-96, Sept 1935. 8. Leichtling. J. J.: Acute cecal diverticulitis. Gastroenterology 29:453-60. Sept 1955. 9. Kurosu, Y., Suzuki, T. and Koga, T.: Cecal diverticulitis in the Japanese. Henry FOK\ Hosp Med J 19:251-6, Winter 1971. 10. Fairbank, T. J. and Rob, C. G.: Solitary diverticulitis of the caecum and ascending colot Br J Surg, 35:105-7, July 1947. 11. Dorling. G. C.: Solitary diverticulum of the caecum. Br Med J. 1:513-4. 14 Apr 1945. 40 

The Role of Surgery in Cecal Diverticulitis

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The Role of Surgery in Cecal Diverticulitis

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