# Current Recommendations on Diagnosis and Management of Right-Sided Diverticulitis

Authors: Dana A. Telem; Kerri E. Buch; Scott Q. Nguyen; Edward H. Chin; Kaare J. Weber; Celia M. Divino
Journal: Gastroenterology Research and Practice
 (2009)

---

## Abstract

We present the case of a 52-year-old female with recurrent symptomatic ascending colon diverticulitis who ultimately underwent elective laparoscopic right hemicolectomy. The following is a case report and literature review pertaining to right colonic diverticular disease.


---

## Body

## 1. Case Report

A 52-year-old female presented to the emergency department
complaining of several years of right-sided abdominal pain which had recently
become more acute and frequent. On presentation, she described right upper
quadrant pain radiating to the right middle and lower quadrants. The pain was
associated with nausea and decreased appetite, but she did not identify any
exasperating events. She denied fevers,
chills, chest pain, shortness of breath, or change in bowel function. In the
preceding year, she had experienced multiple self-limited attacks of right
upper quadrant abdominal pain. These
symptoms prompted a workup which demonstrated cholelithiasis, and she underwent
laparoscopic cholecystectomy. Initially her pain remitted, but returned several
months later. Her past history was significant for gastroesophageal reflux
disease, appendectomy ten years prior, cesarean section, abdominoplasty and
right oophorectomy secondary to ovarian torsion.On exam, the patient was afebrile and hemodynamically stable.
Her abdominal exam was remarkable for moderate right upper, middle, and lower
quadrant tenderness to palpation without guarding or rebound tenderness. Her
bowel sounds were normoactive, and no hernias were appreciated. The remainder of
her physical exam was unremarkable. Her leukocyte count was normal at9.7×103/mm3,
as were the remainder of her laboratory values.A computed tomography (CT) scan was performed and
demonstrated multiple ascending colon diverticula with pericolonic stranding
and colonic wall thickening (Figures1 and 2), consistent with right colonic
diverticulitis. The patient was admitted to the hospital, placed on bowel rest,
and started on intravenous antibiotic therapy. During the course of her
hospitalization, her symptoms gradually resolved and she was discharged home on
hospital day three. The patient was followed as an outpatient, at which time
she elected for resection of the affected colon.Figure 1
Transverse
CT  image demonstrating right-sided colonic diverticulitis.Figure 2
Coronal
CT  image demonstrating right-sided colonic diverticulitis.Six-weeks following her hospitalization, an uncomplicated
laparoscopic right hemicolectomy with ileotransverse anastomosis was performed.
Her postoperative course was unremarkable, and she was discharged on
postoperative day four tolerating a regular diet. Specimen pathology revealed
multiple ascending colonic diverticula. Currently, she remains asymptomatic
with no recurrence of right-sided abdominal pain.


## 2. Literature Review

Diverticula are mucosal
herniations that protrude through openings created by the vasa recta in the
colon wall. In western countries, right-sided
diverticulosis affects approximately 5% of the population and accounts for 1.5%
of patients presenting with diverticulitis. Disease prevalence is significantly
higher in Asian countries where right-sided diverticulosis accounts for 20% of
patients with diverticular disease and 75% of cases of diverticulitis [1]. This
discrepancy is assumed secondary to dietary and genetic factors. In comparison
with patients of left-sided diverticular disease, patients with right colonic diverticular
disease are younger at presentation, mean of 35 to 45 years of age, with equal
gender distribution [2].Right-sided
diverticula may be solitary or numerous and can be found in the appendix, cecum,
or throughout the ascending colon. When
right-sided diverticula are solitary, they are usually congenital and true diverticula;
when multiple, they are typically acquired and false diverticula. For acquired
diverticula, increased intraluminal pressure and abnormal ascending colon motility
play an important role in disease pathogenesis [3]. Patient presentation ranges
from asymptomatic disease incidentally found on imaging study to
gastrointestinal bleed or inflammatory process. Approximately 3% to 15% of
patients with colonic diverticulosis will present with a gastrointestinal
bleed. Bleeding frequently occurs at the neck of the diverticulum from the vasa
recti. Though the majority of diverticular GI bleeds stop spontaneously, studies
have demonstrated a significant recurrence rate quoted at 10% by 1 year and 50%
by 10 years. Right-sided diverticula are responsible for greater than 50% of diverticular
GI bleeds [4, 5].When an inflammatory
process occurs, right-sided diverticulitis often mimics appendicitis. Significant clinical findings suggestive of
right-sided diverticulitis versus appendicitis include a low incidence of nausea,
emesis, and anorexia accompanying the abdominal pain as well as variable point
of maximum tenderness to palpation on abdominal exam [6]. Other etiologies which
right-sided diverticulitis may mimic include cholecystitis, gastritis, and
peptic ulcer disease [7]. Prior to routine use of radiographic imaging, the majority
of patients were diagnosed at time of laparotomy. Several published series demonstrate that
correct preoperative clinical diagnosis occurs in 4% to16% of cases. The
reported incidence of finding diverticulitis during presumed appendectomy is quoted
at 1 in 300 cases [6–8].Diagnostic
accuracy is essential, as the mainstay of therapy for right-colonic
diverticulitis is medical rather than operative management. Historically,
contrast enema was the procedure of choice for diagnosing right colonic
diverticula. Though accurate, this technique is limited to asymptomatic
patients secondary to risk of perforation during an acute disease flare. Currently, CT scan, ultrasound (US), and magnetic resonance (MR) imaging have all been described as effective modalities
to preoperatively differentiate right-sided diverticulitis from other intra-abdominal
pathology.CT scan in many
institutions has become the diagnostic modality of choice to delineate the
etiology of right-sided abdominal pain. Findings on CT scan consistent with a
diagnosis of right colon diverticulitis are similar to those appreciated with
left-sided disease. Findings include colonic wall thickening, presence of extraluminal
mass, haziness and stranding of adjacent pericolic fat, and thickening of nearby
fascial planes [9–12]. Though CT
scan has a documented diagnostic accuracy rate of 90% to 95%, right-sided
diverticulitis may still be radiographically mistaken for appendicitis with
abscess, Crohn's disease, omental infarction, or colon cancer [9–11].Another
widely used modality for assessing right-sided abdominal pain is US. US confers many advantages over CT scan as it
does not use ionizing radiation, is readily available in almost every hospital,
and is cost effective. The use of US in diagnosing right-sided diverticulitis
has been heavily investigated. On US,
the presence of rounded hypo- or anechoic structures that protrude from
thickened bowel wall, with or without strong echoes representing gas, feces or
stone, is consistent with a diagnosis of right-colonic diverticulitis [13]. US
for right-sided diverticulitis, when performed by an experienced operator, has quoted 91.3% sensitivity and 99.8% specificity for correct diagnosis
[9, 12–14].Though
CT and US both have a high sensitivity and specificity for diagnosing right
colon diverticulitis, they have limitations. US is variable and operator
dependent; several reports describe cases of right colonic diverticulitis being
misdiagnosed as appendicitis with fecalith resulting in unnecessary operative
intervention [15]. CT scans utilize ionizing radiation which is a relative
contraindication in pregnancy and for young patients. For these reasons, MR has
also been explored as a diagnostic option. A recent study from the Netherlands
demonstrated
MR to accurately diagnose patients with right colonic diverticulitis [16].
Though availability and use of MR is limited in some hospitals, it may be a
valuable alternative in select patients with contraindications to CT scan in
whom US is nondiagnostic.The
treatment of right-sided diverticula depends on severity of presentation and
modality of diagnosis. Asymptomatic diverticula incidentally found on imaging
do not require intervention. Diverticula presenting as a GI bleed are initially
managed conservatively with hemodynamic support as 75% of episodes are
self-limited. If bleeding persists, endoscopic intervention should be
attempted. In cases where endoscopic management fails, right hemicolectomy may
be necessary [4, 5]. For
patients with recurrent GI bleed from right colon diverticula requiring
multiple transfusions or hospitalizations, the authors recommend consideration
of elective right hemicolectomy.With
the exception of isolated cecal diverticulitis, no consensus currently exists
on optimal treatment of patients with right-sided colonic diverticulitis found incidentally
at time of operation. While some surgeons advocate no intervention, others recommend
at minimum appendectomy or diverticulectomy if inflammation is minimal. Right
hemicolectomy is reserved for extensive inflammation, perforation, or mass
suspicious for carcinoma [17]. In cases of isolated cecal diverticulitis, resection
is strongly recommended [18].If a preoperative diagnosis of uncomplicated
diverticulitis is made, patient management should consist of bowel rest and intravenous
antibiotics. Right-sided diverticulitis differs from left-colon diverticulitis
as it has a more indolent course. Several published series demonstrate long-term remission and control of disease solely with medical therapy. Komuta et al. published a study demonstrating
99% of patients preoperatively diagnosed with uncomplicated right colon
diverticulitis were successfully treated with bowel rest and antibiotics. Over
an average of 3 years, 20% experienced a recurrent attack of uncomplicated
diverticulitis all of whom resolved with medical therapy. Of the 20% who
recurred, 15% experienced a third attack. Again, all patients who recurred a third time had
uncomplicated presentations and were successfully treated without operative
intervention [19]. Another recently published study examined the management and
outcome of 113 patients with right colon diverticulitis over 10 years. This
paper again demonstrated an uncomplicated recurrence rate of 20% [20]. In
contrast to recommendations for left-colon disease, age and frequency of
attacks should not prompt elective colon resection as recurrence requiring
emergent intervention is rare [21]. Elective resection, however, should be
considered in cases of frequent recurrence that interfere with activities of
daily living as was the case in our patient.An exception to continued
medical therapy is isolated cecal diverticulitis. Cecal diverticulitis is an
uncommon occurrence which is rarely preoperatively diagnosed. Surgical therapy
ranges from diverticulectomy with or without cecectomy to right hemicolectomy depending on the extent of
inflammation. Most surgeons advocate aggressive resection, as cecal
diverticulitis infrequently resolves with medical therapy and has a high rate
of complicated recurrence [22, 23].For patients presenting with
complicated right colon diverticulitis, initial therapy is similar to patients
with left colon diverticulitis. Patients who present with abscess, but are
otherwise hemodynamically stable, should be treated with percutaneous abscess
drainage, bowel rest, and intravenous antibiotics. Though uncommon, patients
with overt perforation or who are clinically unstable should be taken for immediate
operative intervention.


## 3. Conclusion

Right colon diverticulitis is a
rare entity in the West which is frequently mistaken for other diseases
processes, most commonly appendicitis. Radiographic imaging, with either CT
scan or US, is essential for proper diagnosis as the mainstay of therapy is
medical rather than operative management. Though imaging has greatly decreased
unnecessary operative intervention; right colonic diverticulitis is still incidentally
encountered at time of operation and treatment should be tailored to the extent of
disease process. In cases of incidental operative discovery where a normal
appendix is found and colonic inflammation minimal, our recommendation is that
no intervention be undertaken. For cases of uncomplicated diverticulitis
accurately diagnosed prior to operative intervention, initial therapy should
consist of bowel rest with intravenous antibiotics, even in cases of
recurrence. Elective resection should be considered based on patient preference
or in cases where malignancy is suspected. Complicated diverticulitis
presenting as abscess should be treated either by percutaneous abscess drainage
or by operative intervention in cases of patient instability. Patients who present
with hemodynamic instability or perforation should undergo emergent operative
intervention.



---

*Source: 359485-2009-03-24.xml*