*Specialist Registrar, Dept of Surgery
Dudley Group of Hospitals, Dudley
United Kingdom
kushyash@gmail.com
**Specialist Registrar, Dept of Surgery
Royal Shrewsbury Hospital, Shrewsbury
United Kingdom
dalmiasanjay@hotmail.com
***Consultant Surgeon, Dept of Surgery
Dudley Group of Hospitals, Dudley
United Kingdom
raj.patel@dudley.nhs.uk


Address for Correspondence:

Mr. Sanjay Dalmia
2 Outwoods Close
Burton on Trent
Staffordshire
DE13 0QY
United Kingdom
e-mail: dalmiasanjay@hotmail.com
Tel: 01283 511511 Ex-2362
Mobile: 07931247483


Abstract:
Diverticulitis of a true caecal diverticulum is not an uncommon condition. It is usually diagnosed at surgery for suspected appendicitis. Its appropriate management has been a matter of debate with some studies suggesting right hemicolectomy or ileo-caecal resection in all cases. Despite being a congenital condition its incidence in children is low. We report a case of caecal diverticulitis in a 12 year old boy who presented just like appendicitis and was treated with diverticulectomy and primary closure with good effect.We advocate a conservative approach is safe for this condition and only a limited procedure in form of diverticulectomy rather than resection, particularly in children.


Background
Diverticulitis of a true caecal diverticulum is not an uncommon condition. It is however usually diagnosed at surgery for suspected appendicitis. Most surgeons have come across this problem in a patient during appendicectomy. As most of appendicectomies are performed by Trainee Surgeons a clear management policy is essential in these patients. Its appropriate management has been a matter of debate with some studies suggesting right hemicolectomy or ileo-caecal resection in all cases. Moreover despite being a congenital condition its incidence in children is low.

Case Presentation
A 12yr old boy presented as an emergency admission with a one day history of right iliac fossa pain, associated with nausea, vomiting and loss of appetite. Pain had always been in the right iliac fossa and there was no classical shift that one would associate with an attack of appendicitis. Clinically he appeared to be unwell with mild pyrexia at 37.3 0C. His pulse was 105/min and BP was 123/71 mmHg. There was guarding and localised tenderness in the right iliac fossa with rebound tenderness. Rovsing's sign was positive. A clinical diagnosis of acute appendicitis was made and the patient was taken to theatre for an appendicectomy. The appendix was approached through a Lanz incision. An appendix like structure in relation to the caecum was mobilised and brought out into the surgical wound. During manipulation with a Babcock's forceps the structure split open and a faecolith was noted in the lumen. The strange appearance of the lesion prompted further mobilisation of the caecum which revealed the structure to be a split, true, anterior caecal wall diverticulum adjacent to the ileocaecal junction. There was a normal looking appendix at the base of the caecum. The diverticulum was dissected off the caecal wall leaving a residual hole which was closed using interrupted 2-0 Vicryl sutures. Routine appendicectomy was carried out and the stump was inverted. Post operative period was uneventful with good recovery. Histopathology noted severe acute diverticulitis with focal peritonitis. No evidence of acute appendicitis was noted.

 

1. Forceps are applied to the mucosa; a separate muscle layer clearly lay between this and the serosa.

 

2. Forceps projecting into the hole in the caecum.

Discussion:
Despite being a congenital condition, the average age of presentation is 40yrs and it is unusual for caecal diverticulitis to occur in a child. Caecal diverticulitis was first described in 1912 by Portier (1). Greaney reported the incidence at 1:1000 emergency laparotomies(2). It is a condition that is more common in males (3) and in the Asian population (4). Caecal diverticulae are classified as true or false. True caecal diverticulae are usually solitary, contain all the layers of the bowel wall and are thought to be congenital. False caecal diverticulae are often in continuity with the acquired pulsion diverticular disease of the left side and do not contain muscle in their wall. The symptoms are very similar to acute appendicitis and various studies have shown that 70-100% of patients with caecal diverticulitis have had emergency surgery for presumed acute appendicitis (2). The ability to diagnose the condition pre-operatively is dependent upon the practice of the use of CT scan to isolate a cause for right lower abdominal pain. The statement by Silen that ''the differential diagnosis of right lower abdominal pain is an encyclopaedic compendium of every abdominal disease that causes pain'' (5) captures the essence of the problem. In cases of suspected acute appendicitis open surgery, without preoperative imaging, remains the usual approach. The roles of CT scan for pre-operative diagnosis of right sided abdominal pain and of laparoscopic surgery for suspected appendicitis have yet to be established. Rao et al reported that appendiceal CT was 98% accurate in the diagnosis of acute appendicitis and concluded that CT scan improved care in management of patients suspected to have appendicitis (6). Based on a review of literature it would appear that many surgeons would manage uncomplicated caecal diverticulitis conservatively if a pre-operative diagnosis was made.(11,12) Shetgiri et al (7) in their case report managed to avoid resection in a case of caecal diverticulitis by use of laparoscopy where the diagnosis was not clear on CT scan. Oudenhoven et al (13) in their review found that 41 of the 44 patients in their study with right colonic diverticulitis settled with conservative management. Only two patients in their series underwent elective surgery. They concluded that the natural history of right colonic diverticulitis is benign and surgical intervention can be avoided in the vast majority of the patients. Caecal diverticulitis has been managed according to the clinical findings at the time of surgery or the information obtained from pre-operative investigation. It varies from right hemicolectomy if there is clinical suspicion about cancer, to antibiotics alone. Intermediate forms of management include ileo-caecal resection, diverticulectomy & appendicectomy, appendicectomy and post-operative antibiotics, and CT or U/S guided drainage. All of these procedures can be effective in appropriate clinical circumstances[3, 4, 8, 9, 10 ]

Conclusion
Our experience alongwith literature review suggests that if a preoperative diagnosis can be made with reasonable confidence, a conservative approach with antibiotics is effective in both the short and medium term. Usually however the diagnosis is made at surgery: we advocate diverticulectomy, particularly in younger patients.

Competing Interest: None declared

Acknowledgements:
We acknowledge Jo Webb for her secretarial support.

References:
1. Potier F. Diverticulite et appendicite. Mem Soc Anat Paris 1912; 137: 29-31.
2. Greany EM, Snyder WH. Acute Diverticulitis of the caecum encountered at emergency surgery. Am J Surg 1957; 94:270-281.
3. Schmit PJ, Bennion RS, Thompson JE Jr. Caecal diverticulitis: a continuing diagnostic dilemma. World J Surg 1991; 15:367-371.
4. Harada RN, Whelan TJ Jr. Surgical management of cecal diverticulitis. 1993; 166:666-669.
5. Silen W. (1998) Appendicitis. In Harrison's Principles of Internal Medicine (eds. Braunwald E, Isselbacher KJ, Petersdorf RG, Wilson JD,Martin JB and Fauci AS) pp. 1304-6. McGraw-Hill Book Company, New York.
6. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338:141-6
7. Shetgiri P, Angel L, Lebenthal A, Divino CM. Cecal Diverticulitis: A Case Report and Review of the Current Literature. Int Surg 2001;86:191-194
8. Lane JS, Sarkar R, Schmit PJ, Chandler CF et al. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999; 188:629-634.
9. Wyble EJ, Lee WC Cecal diverticulitis: Changing trends in management. South Med J 1988; 81:313-316.
10. Poon RT, Chu KW, Inflammatory cecal mass in patients presenting appendicitis. World J Surg 1999; 23:713-716.
11. Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996; 171:244-6.
12. Graham SM, Ballantyne GH. Cecal Diverticulitis. A review of the American experience. Dis Colon Rectum 1987; 30:821-7.
13. Oudenhoven LFIJ, Koumans RKJ, Puylaert JBCM. Right colonic diverticulitis: US and CT findings. New insights about frequency and natural history. Radiology 1998; 206:611-18.