Quiz - Antwort

Answer: Cecal Diverticulitis
On examination of the cecum and appendix, it became apparent that the firm, whitish structure protruding from the anterior aspect of the cecum was a diverticulum. It measured 2.0 × 2.0 × 1.8 cm and appeared grossly necrotic with considerable inflammation in the surrounding area. Although the appendix seemed superficially inflamed, this was secondary to the inflamed diverticulum. Other than the findings noted earlier and a second, noninflamed diverticulum near the ileocecal junction, the cecum and the remainder of the colon appeared normal and free of diverticuli. The patient underwent an uncomplicated laparoscopic-assisted limited ileocecectomy with ileocolostomy and was without symptoms 1 year after discharge. Histopathological analysis of the specimen revealed mucosal inflammation and necrosis of a true diverticulum of the cecum without extension into the muscularis. The rest of the cecum, the appendix, and the remainder of the specimen had no evidence of any other abnormalities.
Diverticulum of the cecum is a rare condition that was first described in 1912 by Potier.1 When it manifests in the presence of diffuse diverticulosis of the colon, it is likely to be a false diverticulum, consisting of an outpouching of mucosa through a weakened area in the muscularis. However, an isolated cecal diverticulum in the absence of generalized colonic involvement is more likely to be a true diverticulum. In this case, we had a true diverticulum of the cecum as confirmed by histopathological analysis. It has been argued that right-sided diverticulitis has a benign natural history, and the same may hold true for isolated cecal diverticulitis.2,3 However, in a large series of 112 cases, aggressive management with segmental resection and anastomosis was advocated because of a high recurrence rate (25%) with conservative management.4 Diverticulectomy is an option if it can be accomplished without encroaching on the ileocecal valve or endangering the blood supply of the cecum.5 In the case at hand, extensive gangrene of the diverticulum with phlegmon formation involving a large part of the cecum as well as the presence of a second diverticulum at the ileocecal junction precluded a diverticulectomy. Cecal diverticulitis is more often than not discovered during surgery for presumed appendicitis, and awareness of this diagnostic pitfall can better prepare the surgeon and the patient regarding therapeutic options.

REFERENCES
1. Potier F. Diverticulite et appendicite. Bull Mem Soc Anat Paris 1912, 137:29–31
2. Oudenhoven LF, Koumans RK, Puylaert JB. Right colonic diverticulitis: US and CT findings: new insights about frequency and natural history. Radiology 1998, 208(3):611–618
3. Harada RN, Whelan TJ, Jr. Surgical management of cecal diverticulitis. Am J Surg 1993, 166(6):666–671
4. Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Aggressive resection is indicated for cecal diverticulitis. Am J Surg 2003, 185(2):135–140


Gupta, Naren MD, PhD; Schirmer, Bruce D. MD; Northup, C. Joe MD
Archives of Surgery Volume 143(3), March 2008, p 309