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Print version ISSN 2237-9363
J. Coloproctol. (Rio J.) vol.32 no.2 Rio de Janeiro Apr./June 2012
Ricardo PastoreI; Roberto da Mata LenzaII; Flávio Batista RodriguesIII; Lucas Vieira TostesIII; Natalia Cavasini GuerraIII; Eduardo CremaIV
IProfessor, Discipline of General Surgery and Surgical Technique at the Universidade Federal do Triângulo Mineiro (UFTM) - Uberaba (MG), Brazil
IIDigestive Tract Surgeon and Physician at the Emergency Service at the UFTM - Uberaba (MG), Brazil
IIIAcademicians of Medicine at the UFTM - Uberaba (MG), Brazil
IVFull Professor, Discipline of Digestive Tract Surgery at the UFTM - Uberaba (MG), Brazil
The objective of this article was to report a case of cecal diverticulitis and point out the differential diagnosis of acute appendicitis. The clinical manifestations of these pathological conditions are similar, and the accurate diagnosis of cecal diverticulitis before the surgery is difficult. Therefore, most diagnoses are made during the surgery. Moreover, cecal diverticulum is uncommon in western countries, but it is prevalent in Asian people and their descendants. We report a case of a 55-year-old female patient, whose imaging exams (ultrasonography and computed tomography) and blood tests were not enough to diagnose the affection, requiring laparotomy and pathological exams for the final diagnosis. Some studies suggesting the best practice in case of diverticulum of the cecum were revised, as the diagnosis usually occurs during the surgery.
Keywords: appendicitis; diverticulitis; cecum; diverticulum.
O objetivo deste trabalho foi relatar um caso de diverticulite no ceco e chamar a atenção para o diagnóstico diferencial com apendicite aguda. As manifestações clínicas das duas afecções são semelhantes, dificultando o diagnóstico exato de diverticulite cecal, além de ser incomum, em nosso meio, o aparecimento de divertículo em cólon direito, sendo essa entidade mais comum em asiáticos e em seus descendentes. Relata-se atendimento a uma paciente de 55 anos, cujos exames de imagem (ultrassonografia e tomografia computadorizada) e de sangue não foram suficientes para o diagnóstico. Houve necessidade de realizar-se laparotomia exploradora e exames anatomopatológicos para a confirmação. Também foram revisados alguns trabalhos que sugerem qual a melhor conduta a ser tomada quando se encontra divertículo cecal no perioperatório, já que, na maioria das vezes, o diagnóstico é feito neste momento.
Palavras-chave: apendicite; diverticulite; ceco; divertículo.
Cecal diverticulitis is a rare condition1,2,3, with prevalence of 0.004 to 2.1%4, affecting more often the Asian people3,5,6 and their descendants1,7,8. The first description was reported in 18633. The preoperative diagnosis is difficult, as its signs and symptoms can be confused with the signs and symptoms of acute appendicitis1,5,7,9-12. Consequently, the diagnosis is most of the times during the surgery2,9,11-13 and confirmed only with an anatomopathological exam1.
M.A.C., female, 55 years old, came to the emergency service at the Hospital das Clínicas da Universidade Federal do Triângulo Mineiro complaining of pain in the right iliac fossa and gradual worsening for a week. She said she had no nauseas, vomiting or alteration to bowel habits. She presented anorexia and no fever since the beginning of this condition. The physical examination showed peritoneal reaction in the right iliac fossa (positive Blumberg sign).
Pelvic ultrasonography (US) showed fecalith in the right iliac fossa, with peritoneal reaction around it (Figure 1) and no collections. The report suggested appendicitis as the most probable diagnosis or focal diverticulitis near the cecum. Abdominal computed tomography (CT) showed a tubular shape posterolaterally to the cecum. The lesion area was highlighted after the intravenous infusion of contrast medium and calcified focus in its proximal segment, as well as densification of surrounding mesenteric fat. No colonic diverticular formations with evidence of acute inflammatory were observed. Then, based on CT, the patient's condition was compatible with acute appendicitis. Two complete blood tests were performed, which did not present alterations.
Infraumbilical median exploratory laparotomy was the selected method and a tumor mass was found in the cecum. Then, segmental colectomy was performed, with removal of the cecum and the mass involving it, as well as the appendix, which presented unaltered aspect. In addition, termino-terminal ileocolic anastomosis was performed. The anatomopathological exam showed ulcerated and abscessed diverticulum in the wall of the large bowel and contained by the peri-intestinal adipose tissue (Figure 2).
The (false) left colon diverticulosis occurs predominantly in the sigmoid and affects the western population more often9,14,15, while the (true) right colon diverticulosis occurs predominantly in the cecum and affects the young population and descendants of Asians more often1,9. Cecal diverticulitis is rare in western population, but it is prevalent in Asian countries.6,7,14. The preoperative diagnosis is difficult9 and infrequent, despite de use of radiological imaging. The diagnostic certainty is obtained only with the anatomopathological exam16. The differential diagnoses are: Crohn's disease, actinomycosis, perforation by a strange body, amebiasis, carcinoid tumor, tuberculosis, gastroenteritis, ureteral colic, ectopic pregnancy, ovarian cyst rupture, pelvic inflammatory disease and, especially, acute appendicitis2,17. The clinical presentation of cecal diverticulitis with fever and abdominal pain in the right lower quadrant is practically indistinguishable from acute appendicitis1, but there are some differences: the pain in diverticulitis starts directly in the right iliac fossa, instead of starting vaguely in the periumbilical region, as it occurs in appendicitis. Diverticulitis is more insidious and extended, and its systemic toxic signs are mild, with rare nauseas and vomiting7. A case has been reported of cecal diverticulitis initially causing pain in the periumbilical region, and the patient presented recurrent abdominal pain for six months, without alteration to bowel habits or systemic toxic signs3, compatible with the clinical condition suggested for cecal diverticulitis. The blood test may show elevated white blood cell count1,9. However, in our case, no alteration was observed in the absolute number of leucocytes.
US and CT are very helpful, enabling the correct diagnosis and preventing unexpected findings during the surgery2. A study that analyzed 934 patients18 with pain of undetermined nature in the right iliac fosse showed that US presented 100% accuracy when distinguishing diverticulitis from appendicitis. However, this is a limited exam, as it depends on the examiner's experience, a fact that becomes a problem, particularly in western countries, where the experience with cecal diverticulitis is low2. CT offers good cost-benefit ratio at the differential diagnosis of abdominal pain conditions involving suspicion of acute appendicitis19. Helical CT may suggest or define the diagnosis of cecal diverticulitis18.
In this report, only ultrasonography suggested that it was cecal diverticulitis. When the diagnosis of cecal diverticulitis is secured, antibioticotherapy can be applied in patients without signs of peritonitis1,9,20,21. As the right colonic diverticulitis is benign, the conservative treatment with minimal surgical intervention should be the best therapeutic option10. Exploratory laparotomy is suggested in cases without diagnostic certainty1. However, the greatest dilemma is what to do when cecal diverticulitis is incidentally found during appendicectomy3. There is no standard procedure for the treatment of solitary cecal diverticulitis3. The surgical resection of diverticulum is recommended9 plus colectomy, if the histopathological exam shows the presence of neoplasm9. When the diagnosis is secured, the procedure of diverticulectomy combined with appendicectomy is suggested3. Otherwise, colectomy is suggested3. In this case, the second approach was selected, with segmental colectomy.
A successful clinical treatment was reported in a case whose diagnosis was made without laparotomy, but the patient had history of appendicectomy for 15 years and no pain at rapid decompression1. In addition, emergency colectomy is well accepted in the treatment of complicated diverticulitis10. Two cases have been reported in which right hemicolectomy was performed, without complications in both cases2,3. Laparoscopy could be applied for diagnostic purposes, but it involves the risk of not detecting diverticula in the posterior wall of the cecum22.
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Dr. Eduardo Crema
Disciplina de Cirurgia Geral, Universidade Federal do Triângulo Mineiro (UFTM)
Avenida Frei Paulino, 30 - Abadia
CEP: 38025-180 - Uberaba (MG), Brazil
Submitted on: 10/14/2010
Approved on: 11/18/2010
Financing source: none.
Conflict of interest: nothing to declare.
Study carried out at the Discipline of General Surgery, Universidade Federal do Triângulo Mineiro (UFTM) - Uberaba (MG), Brazil.