Caecal diverticulitis can be misdiagnosed as acute appendicitis: a systematic review of the literature

Abstract

Aim Caecal diverticulitis (CD) is an uncommon condition which can be misdiagnosed as acute appendicitis due to similar clinical presentations. Further, its management varies among medical centres. The aim of this study was to review cases of patients with CD, to identify the factors differentiating CD from acute appendicitis and to provide a summary of existing diagnostic methods and therapeutic alternatives regarding its management. Methods This systematic review was conducted in accordance with the PRISMA guidelines and the AMSTAR2 checklist. We searched MEDLINE and Embase from inception until 1 October 2018 for original publications reporting cases of CD. Results Out of the 560 identified studies, 146 publications (988 patients) were included in the qualitative synthesis. Most frequent symptoms of CD were right iliac fossa pain (93.2%), nausea and/or vomiting (35.4%) and fever (26.9%). A total of 443 patients (44.8%) underwent radiological imaging, which reported CD in 225 patients (22.8%). For the other patients, the diagnosis was obtained by surgical exploration (73.9%). Among patients diagnosed with CD by imaging, 67 (29.8%) underwent surgery and 158 (70.2%) were treated conservatively. Among patients who underwent surgical exploration, treatment consisted most frequently of right hemi‐colectomy (33%), appendectomy (18.8%) and diverticulectomy with appendectomy (16.3%). Conclusion CD can be misdiagnosed as acute appendicitis, therefore resulting in unnecessary surgical exploration. The review of the literature starting from 1930 highlights the critical role of medical imaging in supporting the clinician to diagnose this condition and administer adequate treatment.

Diverticulitis cecal. A propósito de un caso

“…El diagnóstico preoperatorio del divertículo cecal es raro y han sido descritos en el 1% de los casos. En el estudio realizado por Uhe y colaboradores (3) el 93,2% de los pacientes presentaron dolor abdominal en fosa ilíaca derecha y el 70% de los pacientes fueron llevados a cirugía exploradora con el diagnóstico preoperatorio de apendicitis aguda, como el caso descrito en esta presentación.…”

“…El dcs se encuentra con mayor frecuencia entre la población asiática, en quienes la enfermedad diverticular es predominantemente derecha (70%) y puede ser solitaria en el 80% de los casos. (3) Los divertículos cecales se pueden clasificar en congénitos y adquiridos; los congénitos se desarrollan a partir de la sexta semana de gestación de una bolsa exterior del ciego que involucra las tres capas de la pared del colon, denominados divertículos verdaderos. Los divertículos falsos o adquiridos se desarrollan a partir de una protrusión de la mucosa y submucosa a través de una debilidad de la capa muscular, similar a los divertículos sigmoideos.…”

“…El diagnóstico clínico preoperatorio es bastante difícil, esta entidad se detecta en aproximadamente 1/300 casos operados con diagnóstico preoperatorio de apendicitis aguda. (3) Se presenta el caso de un paciente con diagnóstico preoperatorio de apendicitis aguda que posterior a la laparoscopia exploradora se demuestra proceso inflamatorio pericecal sugestivo de diverticulitis cecal solitaria.…”

Stercoral perforation of a cecal diverticulum: A rare presentation

“…While left-sided colonic diverticular disease is common in Western countries and is largely thought to be related to diet, right-sided disease is considered rare [1][2][3]. They represent approximately 3.6% of all colonic diverticula and are more common in Asian populations [8,9]. The majority of cecal diverticula tend to arise from the anterior aspect of the caecum, and right-sided diverticulitis typically affects a younger population with the average age being 43.6 years and a male to female ratio of 3:2most commonly being mistaken for acute appendicitis on presentation [9].…”

“…In cases of severe cecal diverticulitis or perforation of a cecal diverticulum from causes such as stercoral colitis, surgical treatment methods like the ileocecal resection or right hemicolectomy may be required [2,6,9]. Where the underlying pathology is unclear, including when malignancy cannot be excluded, or when there is extensive inflammation, a right hemicolectomy is the suggested approach [8,9]. Peritoneal fluid culture in stercoral perforation is typically positive for gramnegative and anaerobic organisms, so patients should be treated with antibiotics effective against these organisms, in addition to the definitive surgical intervention [10].…”