Right-sided Diverticulitis Research Articles

Stenosis of the colorectal anastomosis after surgery for diverticulitis: A national retrospective cohort study.

The aim of this work was to investigate the association between early postoperative anastomotic leakage or pelvic abscess (AL/PA) and symptomatic anastomotic stenosis (SAS) in patients after surgery for left colonic diverticulitis. This is a retrospective study based on a national cohort of diverticulitis surgery patients carried out by the Association Française de Chirurgie. The assessment was performed using path analyses. The database included 7053 patients operated on for colonic diverticulitis, with surgery performed electively or in an emergency, by open access or laparoscopically. Patients were excluded from the study analysis where there was (i) right-sided diverticulitis (the initial database included all consecutive patients operated on for colonic diverticulitis), (ii) no anastomosis was performed during the first procedure or (iii) missing information about stenosis, postoperative abscess or anastomotic leakage. Of the 4441 patients who were included in the final analysis, AL/PA occurred in 327 (4.6%) and SAS occurred in 82 (1.8%). AL/PA was a significant independent factor associated with a risk for occurrence of SAS (OR = 3.41, 95% CI = 1.75-6.66), as was the case for diverting stoma for ≥100 days (OR = 2.77, 95% CI = 1.32-5.82), while central vessel ligation proximal to the inferior mesenteric artery was associated with a reduced risk (OR = 0.41; 95% CI = 0.19-0.88). Diverting stoma created for <100 days or ≥100 days was also a factor associated with a risk for AL/PA (OR = 3.08, 95% CI = 2-4.75 and OR = 12.95, 95% CI = 9.11-18.50). Interestingly, no significant association between radiological drainage or surgical management of AL/PA and SAS could be highlighted. AL/PA was an independent factor associated with the risk for SAS. The treatment of AL/PA was not associated with the occurrence of anastomotic stenosis. Diverting stoma was associated with an increased risk of both AL/PA and SAS, especially if it was left for ≥100 days. Physicians must be aware of this information in order to decide on the best course of action when creating a stoma during elective or emergency surgery.

Right-sided acute diverticulitis in a North African country: Presentation and management in one surgical center.

Right-sided diverticulitis is a rare entity in North Africa. Therefore, it is usually misdiagnosed, and the management of cecal diverticulitis is aggressive in most cases, whereas nowadays, most studies recommend a conservative approach with promising results. This study aims to describe the presentation, management, and outcomes of right-sided diverticulitis (RSD) and to present the experience of one surgical center in Tunisia. This is a retrospective study including all patients presented with RSD, in the Department of Surgery "A" of the Charles Nicolle Hospital between 2007 and 2021. Forty patients were included in our study. The mean age was 42years with a standard deviation of 14. The sex ratio was 1.1. Only 2 patients had chronic constipation. All patients presented right-sided abdominal pain, and only 3 patients had diarrhea. Twenty one patients were diagnosed during surgery. Fourteen patients were treated successfully by conservative management. An operative procedure was performed in 26 cases: 21 had a diverticulectomy (80%), two had an ileal resection (8%), and three had a right colectomy (11.5%). No postoperative events occurred with a short hospital stay (5±3days). Follow-up showed no recurrences. Right-sided diverticulitis has a lower incidence and complication rate compared to left-sided diverticulitis. Conservative treatment has demonstrated favorable outcomes in managing RSD, although the available evidence remains limited.

Perforated mucinous diverticulitis of the appendix: a case report

Acute right lower quadrant (RLQ) abdominal pain typically raises the suspicion of appendicitis and must be ruled out, as the treatment is primarily surgical. Other differentials, many of which are medically treated, ought to also be considered. Right sided diverticulitis, although uncommon, often mimics appendicitis due to its inflammatory nature and its location of pain. A 37-year-old woman with a history of recurrent right-sided diverticulitis presented with rapidly escalating RLQ pain. While appendicitis was a prime suspect, additional imaging was refused due to radiation concerns, hence clinical judgement had to be aptly applied. Facing diagnostic ambiguity, Hickam's dictum (seeking the most probable cause) pointed towards appendicitis, while Ockham's razor (favouring the simplest explanation) supported recurrent right sided diverticulitis. This uncertainty necessitated a definitive approach, weighing up the risks and benefits of medical vs surgical treatment for an unconfirmed pathology. To resolve the uncertainty, a diagnostic laparoscopy was performed. Contrary to expectations, it revealed a perforated diverticulum of the appendix with a mucinous tip and free-floating mucin, making both leading differentials, that is, right sided diverticulitis and appendicitis, correct. We explore the diagnostic reasoning used in the case, including the anticipated management strategies and outcomes, if other differentials were encountered. This case aims to support clinicians in pursuing further investigations, or need be, a diagnostic laparoscopy, in order to prioritise patient safety, if clinical concern is present.

Acute Cecal Perforated Diverticulitis Synchronous with Acute Appendicitis. Clinical Case

Introduction: Diverticular disease of the colon is an increasingly common condition in developed countries. Diverticula can develop in any segment of the colon, but are more common on the left side. The prevalence of cecal diverticula in Western countries is 1-2%, while in the East it represents 43-50% of colonic diverticula. Furthermore, in the West, the majority are solitary. When they are solitary, they are generally congenital and true, and if they are multiple, they are typically false (pseudodiverticula) and acquired. Clinical case: 50-year-old female, administrative employee, with a history of systemic arterial hypertension and mixed dyslipidemia; that she presented to the emergency medical service reporting anorexia, generalized abdominal pain, fever of 38.2 °C on one occasion and in the absence of alterations in fecal evacuations. On physical examination, the abdomen was presented with decreased peristalsis, slightly tympanic on percussion, painful on palpation in the left iliac fossa with involuntary muscular resistance. An abdominal mass was also palpated in the left iliac fossa. Additionally, he reported mild pain on palpation in the iliac fossa. right, doubtful Mc Burney sign, negative rebound. During his hospitalization, laboratory studies were performed, which reported leukocytosis, neutrophilia and thrombocytopenia, in addition to a simple and contrasted abdominopelvic tomography which reported multiple diverticular formations in the descending and sigmoid colon, which were accompanied by striation of the pericolic fat, with fluid. free in the left slide, pelvic and perihepatic cavity, with gas particles in the slide, thickening and increased enhancement of the walls of the descending colon and sigmoid. Discussion. Right-sided diverticulitis is a rare disease in the West, accounting for 1 to 3.6% of total cases of diverticular disease. Approximately 80% of right-sided diverticula are located on the anterior surface of the cecum, close to the ileocecal valve, and are usually asymptomatic.

Comparison between single and serial computed tomography images in classification of acute appendicitis, acute right-sided diverticulitis, and normal appendix using EfficientNet.

This study aimed to develop a convolutional neural network (CNN) using the EfficientNet algorithm for the automated classification of acute appendicitis, acute diverticulitis, and normal appendix and to evaluate its diagnostic performance. We retrospectively enrolled 715 patients who underwent contrast-enhanced abdominopelvic computed tomography (CT). Of these, 246 patients had acute appendicitis, 254 had acute diverticulitis, and 215 had normal appendix. Training, validation, and test data were obtained from 4,078 CT images (1,959 acute appendicitis, 823 acute diverticulitis, and 1,296 normal appendix cases) using both single and serial (RGB [red, green, blue]) image methods. We augmented the training dataset to avoid training disturbances caused by unbalanced CT datasets. For classification of the normal appendix, the RGB serial image method showed a slightly higher sensitivity (89.66 vs. 87.89%; p = 0.244), accuracy (93.62% vs. 92.35%), and specificity (95.47% vs. 94.43%) than did the single image method. For the classification of acute diverticulitis, the RGB serial image method also yielded a slightly higher sensitivity (83.35 vs. 80.44%; p = 0.019), accuracy (93.48% vs. 92.15%), and specificity (96.04% vs. 95.12%) than the single image method. Moreover, the mean areas under the receiver operating characteristic curve (AUCs) were significantly higher for acute appendicitis (0.951 vs. 0.937; p < 0.0001), acute diverticulitis (0.972 vs. 0.963; p = 0.0025), and normal appendix (0.979 vs. 0.972; p = 0.0101) with the RGB serial image method than those obtained by the single method for each condition. Thus, acute appendicitis, acute diverticulitis, and normal appendix could be accurately distinguished on CT images by our model, particularly when using the RGB serial image method.

Right-sided diverticulitis in a Western population.

While left-sided colonic diverticular disease is common in Western Caucasian populations, right-sided colonic disease (RCD) is rare. The present study aimed to determine the rate of RCD and to identify the symptoms, clinical features, treatment, and outcomes in a single medical center in Israel. Data for this descriptive retrospective analysis were collected from the electronic medical records of all patients diagnosed with colonic diverticulitis from January 2014 to June 2019. During the study period, 1000 patients with diverticulitis were admitted to our institution, of which 99 had RCD (10%). Mean age was 50.2years. The main presenting symptom was acute onset of right-sided abdominal pain. The diagnosis was made almost exclusively by computed tomography scan and the cecum was the most frequent site. The clinical course was benign, without major complications for most patients (90.1%). Nine patients presented with abscess (n = 1), covered perforation (n = 7), or partial obstruction (n = 1). All patients were treated with intravenous antibiotics with a median length of hospital stay of 3days and a median 9days of antibiotic treatment. Only 1 patient underwent diagnostic laparoscopy due to suspected intestinal perforation. Three patients experienced disease recurrence after a median follow-up of 48months. Upon recovery, half of the patients underwent colonoscopy; no further pathology was found in any. Unlike sigmoid colon diverticulitis, the incidence of RCD in Western populations is low. The clinical course is benign, with conservative treatment without the need for surgery. The complication and recurrence rates are low.

Management and long-term outcomes of acute right colonic diverticulitis and risk factors of recurrence

BackgroundAcute right-sided colonic diverticulitis (RCD) is a common disease in Asian populations for which the optimal treatment remains controversial. The aim of this study was to investigate management and evaluate long-term outcomes of treatment in patients with acute RCD.MethodsWe retrospectively collected and analyzed clinical data for patients with acute RCD admitted to the Tongren Hospital, Shanghai Jiao Tong University School of Medicine from December 2015 to December 2020. The patients were divided into two groups, according to primary treatment strategy, which was either conservative treatment or surgical treatment.ResultsA total of 162 consecutive patients with acute RCD were enrolled in the study. There was no significant difference in age, sex, history of abdominal surgery, medical co-morbidities, fever, previous history of RCD, treatment success rate and incidence of complications between the conservative and surgery groups. However, the recurrence rate in conservative groups was significantly higher than in surgery groups (16.53% vs 2.44%, P = 0.020). And more frequent bowel movements and previous history of RCD increased the risk of recurrence of acute RCD. Moreover, there was no significant difference in either treatment success rate or the overall recurrence rate between the patients with uncomplicated diverticulitis and patients with complicated diverticulitis.ConclusionsSurgical treatment is also safe and effective for acute RCD. Surgical treatment should mainly be considered for patients with acute RCD with recurrence risk factors (more frequent bowel movements and previous history of RCD) or with complicated acute RCD.

Right sided diverticulitis in western countries: A review.

BACKGROUNDAlthough the treatment guidelines for left sided diverticulitis are clear, the management of right colonic diverticulitis is not well established. This disease can no longer be ignored due to significant spread throughout Asia.AIMTo analyse epidemiology, diagnosis and treatment of right-sided diverticulitis in western countries.METHODSMEDLINE and PubMed searches were performed using the key words “right-sided diverticulitis’’, ‘‘right colon diverticulitis’’, ‘‘caecal diverticulitis’’, ‘‘ascending colon diverticulitis’’ and ‘‘caecum diverticula’’ in order to find relevant articles published until 2021.RESULTSA total of 18 studies with 422 patients were found. Correct diagnosis was made only in 32.2%, mostly intraoperatively or via CT scan. The main reason for misdiagnosis was a suspected acute appendicitis (56.8%). The treatment was a non-operative management (NOM) in 184 patients (43.6%) and surgical in 238 patients (56.4%), seven of which after NOM failure. Recurrence rate was low (5.45%), similar to eastern studies and inferior to left -sided diverticulitis. Recurrent patients were successfully conservatively retreated in most cases.CONCLUSIONThe management of right- sided diverticulitis is not well clarified in the western world and no selective guidelines have been considered even if principles are similar to those with left- sided diverticulitis. Wrong diagnosis is one of the most important problems and CT scan seems to be the best imaging modality. NOM offers a safe and effective treatment; surgery should be considered only in cases of complicated diverticulitis or if malignancy cannot be excluded. Further studies are needed to clarify the correct treatment.

EP.FRI.12Meta-analysis of demographic and prognostic significance of right-sided versus left-sided acute diverticulitis

Abstract Aims To compare the demographic and prognostic outcomes of right-sided versus left-sided acute colonic diverticulitis Methods We performed a systematic review in accordance with the PRISMA statement standards to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis. We used the ROBINS-I tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data. Results Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients (MD:-14.16,P&amp;lt;0.00001) and more male patients (OR:1.33,P=0.02) compared with left-sided diverticulitis. Smoking (OR:2.23,P&amp;lt;0.0001), alcohol consumption (OR:1.85,P=0.002) and co-morbidity (OR:0.21,P&amp;lt;0.00001) were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group (OR:0.21,P=0.001). More patients in the right-sided diverticulitis group had modified Hinchey stage I disease (OR:10.21,P&amp;lt;0.0001) while more patients in the left-sided group had stage II (OR:0.19,P&amp;lt;0.00001), stage III (OR:0.08,P=0.009) or stage IV disease (OR:0.02,P&amp;lt;0.00001). Right-sided diverticulitis was associated with a lower risk of recurrence (OR:0.49,P=0.04), failure of conservative management (OR:0.14,P=0.0006), the need for emergency surgery (OR:0.13,&amp;lt;0.00001) and shorter length of hospital stay (MD:-1.70,P=0.02). Conclusions Right-sided acute colonic diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence, and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.

Congenital cecal diverticulitis in a pediatric patient.

Diverticulitis in the pediatric population is a very rare cause of abdominal pain. When present in the cecum or ascending colon, it is often incorrectly diagnosed preoperatively as acute appendicitis. This is especially true in Western countries where right-sided diverticulitis is less common. Here we detail a case of a pediatric patient with complicated congenital cecal diverticulitis and review the literature on pertinent management. An extensive work up with imaging and endoscopy was completed and definitive surgical treatment with diverticulectomy an appendectomy was performed. As the incidence of diverticular disease in younger individuals increases, right sided diverticulitis is worthy of consideration on the differential diagnosis.

Seeking outpatient management of right-sided diverticulitis

Seeking outpatient management of right-sided diverticulitis

Conservative treatment of uncomplicated right-sided diverticulitis: a systematic review and meta-analysis.

Right-sided diverticulitis has different epidemiologic features compared to left-sided diverticulitis. However, data on the appropriate treatment of right-sided diverticulitis are lacking. This systematic review aimed to examine the outcomes of conservative treatment for uncomplicated right-sided diverticulitis. MEDLINE, Embase, and the Cochrane Library were searched for articles published from January 1, 1990, to May 31, 2020. A total of 21 studies were included in the systematic review. We calculated proportions and 95% confidence intervals (CIs) to assess the outcomes of individual studies and pooled the results using a random effects model. A total of 2811 patients (59.1% men; mean and median age, 37-54 years) with right-sided diverticulitis were included. The pooled rate of treatment failure was 2.5% (95% CI 1.2-4.3%; p <0.01; I2 = 64.0%). The recurrence rate ranged from 0 to 26.9%, and the pooled recurrence rate was 10.9% (95% CI 8.1-14.1%; p <0.01; I2 = 78.2%). The pooled rate of complicated diverticulitis at recurrence was 4.4% (95% CI 1.4-9.0%; p = 0.84; I2 = 0%). The pooled rate of emergency surgery at recurrence was 9.0% (95% CI 4.6-14.7%; p = 0.12; I2 = 30.3%). Conservative treatment of uncomplicated right-sided diverticulitis results in a low rate of recurrence and complicated diverticulitis at recurrence. Based on these results, unnecessary surgery may be avoided and a new treatment paradigm for uncomplicated right-sided diverticulitis may be introduced.

Special Situations in the Management of Diverticular Disease.

Diverticular disease affects a large percentage of the US population, affecting over 30% among those older than 45 years old. It is responsible for ∼300,000 hospitalizations per year in the United States and can lead to serious complications such as hemorrhage, obstruction, abscess, fistulae, or bowel perforation. 2 It is an extremely common reason for emergency room and outpatient visits and evaluations by general and colorectal surgeons. In the US, patients usually present with sigmoid diverticulitis in the setting of a normal immune system so surgeons will follow well-established practice guidelines for treatment. However, there may be special circumstances in which the management of diverticulitis is not as straightforward. In this article, we will address patients who present with multifocal disease, giant colonic diverticulum, right-sided diverticulitis, and diverticulitis in the setting of immunosuppression and hopefully provide guidance for treatment in these special circumstances.

Meta-analysis of the demographic and prognostic significance of right-sided versus left-sided acute diverticulitis.

The aim of this work was to compare demographic factors, outcomes and prognosis for right-sided versus left-sided acute colonic diverticulitis. We searched MEDLINE, CINAHL, EMBASE, CENTRAL, Scopus and unpublished literature to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis (PROSPERO registration number CRD42020180075). We used the QUIPS tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data. Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients [mean difference (MD) -14.16 (-17.19, -11.14), P<0.00001] and more male patients [odds ratio (OR) 1.33 (1.04, 1.71), P=0.02] compared with left-sided diverticulitis. Smoking [OR 2.23 (1.50, 3.32), P<0.0001], alcohol consumption [OR 1.85 (1.26, 2.71), P=0.002] and comorbidity [OR 0.21 (0.15, 0.30), P<0.00001] were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group [OR 0.21 (0.08, 0.55), P=0.001]. More patients in the right-sided diverticulitis group had modified Hinchey Stage I disease [OR 10.21 (3.34, 31.22), P<0.0001] while more patients in the left-sided group had Stage II [OR 0.19 (0.10, 0.38), P<0.00001], Stage III [OR 0.08 (0.01, 0.54), P=0.009] or Stage IV disease [OR 0.02 (0.00, 0.08), P<0.00001]. Right-sided diverticulitis was associated with a lower risk of recurrence [OR 0.49 (0.25, 0.98), P=0.04], failure of conservative management [OR 0.14 (0.04, 0.43), P=0.0006], the need for emergency surgery [OR 0.13 (0.05, 0.36), P<0.00001] and a shorter length of hospital stay [MD -1.70 (-3.08, -0.33), P=0.02]. Right-sided acute diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.

Recurrence of Acute Right Colon Diverticulitis Following Nonoperative Management: A Systematic Review and Meta-analysis.

There are currently no guidelines on the management of right colon diverticulitis. Treatment options have been extrapolated from the management of left-sided diverticulitis. Gaining knowledge of the risk and morbidity of diverticulitis recurrence is integral to weighing the benefit of elective surgery for right-sided diverticulitis. The purpose of this study was to summarize the recurrence rate and the morbidity of recurrence of Hinchey classification I/II, right-sided diverticulitis following nonoperative management. PubMed, EMBASE, and Cochrane Database of Collected Reviews were searched up to June 2019. Observational cohort studies evaluating outcomes following nonoperative management were reviewed. No randomized controlled trials were available. Intravenous antibiotics with or without percutaneous drainage of associated abscess were administered. The primary outcomes measured were the recurrence rate and morbidity associated with recurrence. Two independent investigators extracted data. The rates of recurrence were pooled by using a random-effects model. There were 1584 adult participants from a total of 11 studies (9 retrospective cohort and 2 prospective cohort studies) included in the analysis. Over a median follow-up period of 34.2 months, the pooled recurrence rate was 12% (95% CI, 10%-15%). Twenty of 202 patients (9.9%) required urgent surgery at the time of first recurrence. There was no mortality. Subset analysis excluding 3 studies that included percutaneous drainage as a nonoperative treatment option did not change the recurrence rate (12% (95% CI, 9%-15%)) or heterogeneity. Funnel plot assessment revealed no publication bias. There were no randomized controlled trials available. The statistical heterogeneity was moderate (I = 46%). Nonoperative management of Hinchey I/II right-sided diverticulitis is safe and feasible. The recurrence rate is relatively low, and complications that require urgent operation are uncommon. CRD42019131673.

Clinical Difference between Acute Appendicitis and Acute Right-Sided Colonic Diverticulitis.

Background Clinical presentations of acute appendicitis (AA) and acute right-sided colonic diverticulitis (ARCD) are similar. However, the usual treatment for each disease differs between surgical and conservative management. The aim of this study was to identify clinical differences between AA and ARCD. Method We performed a single-center retrospective study on adult patients, with uncomplicated AA and ARCD confirmed by computed tomography, who visited an emergency department between March 2018 and August 2019. Clinical variables including past medical history, presented symptoms and signs, and laboratory findings were compared between the two groups. A logistic regression analysis was subsequently performed to differentiate ARCD from AA based on results of univariate analyses. Results A total of 212 (79.1%) and 56 (20.9%) patients were enrolled in AA and ARSD groups, respectively. Logistic regression analysis revealed that a past history of diverticulitis [OR: 102.679 (95% CI: 9.964–1058.055), p < 0.001] was associated with ARCD, while ketonuria [OR: 2.907 (95% CI: 1.091–7.745), p=0.033], anorexia [OR: 21.544 (95% CI: 3.905–118.868), p < 0.001], and neutrophilia [OR: 3.406 (95% CI: 1.243–9.336), p=0.017] were associated with AA. Conclusion Anorexia, neutrophilia, and ketonuria were predictors of AA while a history of diverticulitis was a predictor of ARCD.

Short- and Long-Term Outcomes of Right-Sided Diverticulitis: Over 15 Years of North American Experience.

Right-sided colonic diverticulitis represents less than 5% of diverticulitis cases in North America. The purpose of this study was to describe the management and outcomes for patients with a first episode of right-sided diverticulitis in a North American center. This was a retrospective cohort study, including all patients managed for right-sided diverticulitis at a single tertiary-care institution from 2000 to 2017. Patient demographics, disease characteristics, and treatment strategies were described. Short- (emergency surgery, operative morbidity, treatment failure) and long-term (recurrence, elective operation) outcomes were reported. Patients with right-sided diverticulitis were then compared to a cohort of patients with left-sided diverticulitis. Sixty-seven patients were managed for a first episode of right-sided diverticulitis, three (4.5%) of which were subsequently diagnosed with right-sided colon cancer; 64 patients therefore formed the population. Mean age was 51.2 ± 17.7years. Eight patients (12.5%) self-identified as being Asian. The majority of patients had uncomplicated disease (90.6%); six (9.4%) presented with complicated diverticulitis. Most cases were diagnosed by computed tomography (78.1%), while 17.2% were diagnosed intra-operatively and 4.7% by pathology. Almost all patients diagnosed by computed tomography were managed nonoperatively. Fifteen patients (23.4%) were managed surgically: ten for suspected appendicitis, three for suspected colon mass, and two for diffuse peritonitis. After a median follow-up of 74.8months (IQR 30.2-130.5), only two patients (3.1%) developed recurrent right-sided diverticulitis. Among patients managed nonoperatively, recurrence was significantly lower in patients with right-sided diverticulitis relative to left-sided diverticulitis (4.1% vs. 32.8%, p < 0.001). Right-sided diverticulitis can be successfully managed nonoperatively with low rates of recurrence. In populations in which this condition is more seldom observed, underlying colon cancers should be considered.

Special Considerations of Diverticulitis and Diverticular Bleeding

Diverticulitis in certain subpopulations of patients may require different treatments, especially in the elective setting. Diverticular bleeding, another complication of diverticulosis, is another source of burden on United States healthcare from diverticular disease. This chapter discusses the special circumstances of right-sided diverticulitis, diverticulitis in young patients or immunocompromised patients, recurrent diverticulitis after resection, giant colonic diverticulum, and rare presentations of diverticulitis. Atypical types of diverticulitis such as segmental colitis associated with diverticulosis (SCAD), symptomatic uncomplicated diverticular disease (SUDD), and smoldering diverticulitis are also reviewed, and indications for surgical intervention are summarized. Current controversies are reviewed, including the decision to operate in young or immunocompromised patients; management of SCAD, SUDD, or smoldering diverticulitis; and best localization method to diagnose diverticular bleeding. This review contains 6 figures, 2 tables, and 55 references. Key Words: atypical diverticulitis, diverticular bleeding, diverticular disease, diverticulosis, gastrointestinal bleeding, right-sided diverticulitis, segmental colitis associated with diverticulosis, smoldering diverticulitis, symptomatic uncomplicated diverticular disease, total abdominal colectomy

Diverticulitis: An atypical presentation

Introduction Diverticulitis is a well described inflammatory condition of the wall of the gastrointestinal tract with an overall prevalence of 2-10% in developing countries. Typically, the descending and sigmoid colon are affected more commonly than the ascending colon and small bowel in the Western population. Diverticula of the distal ileum are particularly uncommon, with a reported rate of 0.06-1.3% (Jeong et al. 2014). Due to difficulty in pre-operative diagnosis, there is no consensus on therapeutic strategy for right-sided diverticulitis (Lee et al. 2010). Here, the authors present a case of non-Meckel’s diverticulitis of the distal ileum in a Caucasian U.K. patient. Case description A 63 year old man presented to the Emergency Department with a one day history of abdominal distension, periumbilical pain radiating to the right iliac fossa, nausea and sweats. He had not defecated for 2 days but reported passing flatus. Past medical history included gout, rheumatoid arthritis and Ulcerative Colitis, managed with Sulfasalazine. He was not a smoker. On examination, abdomen was visibly distended. There was maximal tenderness in the lower central abdomen and guarding to palpation. Digital rectal examination was normal. Chest radiograph was unremarkable. Plain abdominal film showed faecal loading of the colon, but no obstructive features. C-Reactive Protein (CRP), amylase and white cell count on admission were normal. On repeat testing, CRP was 208mg/L, white cell count 10x10 9 /L, venous lactate 2.3mmol/L and haemoglobin 13.1g/L. Intravenous fluids and broad spectrum antibiotics were commenced. CT imaging was arranged in view of the severity of symptoms, biochemical findings, patient’s age, medication and history of colitis. CT abdomen pelvis with oral contrast showed a severely inflamed ileal diverticulum. There was no suggestion of a diverticulum on previous radiological or endoscopic investigations. The patient proceeded to surgery for open resection of perforated diverticulum (39cm of ileum) and small bowel anastomosis. Results and Conclusions After 24 hour High Dependency observation, the patient made an uneventful recovery. Histological analysis confirmed a thin-walled, diffusely ulcerated, perforated ileal diverticulum resulting from obstructing food. Anatomically, diverticula are characterised by herniation of mucosa and submucosa through the muscular bowel wall and a true diverticulum should involve all layers. Diverticula of the small bowel are more commonly proximal (75% jejunal, versus 5% ileal). The position, conversely to a Meckel’s diverticulum, is usually on the mesenteric side of the bowel. The aetiology of jejuneo-ileal diverticula is not fully understood however focal muscular weakness, motility dysfunction, high segmental intraluminal pressure and biogenetic factors are believed to contribute (Nakatani et al. 2016). There is close clinical and biochemical overlap between a presentation of appendicitis and right sided diverticulitis. However, previous studies have suggested subtle clinical variations to aid their distinction, such as duration of onset, location or migration of pain and severity of systemic response (Lee et al. 2010). The use of ultrasonography and CT to aid diagnosis has been advocated, which may show bowel wall thickening, peri-colonic fat infiltration, extra-luminal air or abscess. Compared to duodenal, small bowel diverticula are almost 4 times more likely to perforate (Nakatani et al. 2016). Take home message Although less common than appendicitis, diverticulitis of the ascending colon or terminal ileum should be considered in patients presenting with right iliac fossa pain. Limited small bowel resection and anastomosis or diverticulectomy is a safe surgical method to use in some cases of ileal diverticulitis. Many cases of uncomplicated small bowel diverticulitis may be treated conservatively without requiring operative intervention. Thus accurate and early diagnosis, aided by radiological imaging can ensure appropriate clinical management and avoid unnecessary surgery and its associated risks for patients presenting with acute, uncomplicated small bowel diverticulitis.

Asian patients with Hinchey Ia acute diverticulitis: a condition for the ambulatory setting?

Diverticulitis in Asians is a different disease entity from Western counterparts. Few Asian studies have evaluated the management of acute Hinchey Ia diverticulitis with consideration for outpatient management. The purpose of this study was to evaluate the outcomes of Asian patients with Hinchey Ia acute diverticulitis. A retrospective review of all patients who were treated for Hinchey Ia acute colonic diverticulitis between 2012 and 2014 was performed. All patients were diagnosed on computed tomography (CT). There were 129 patients with Hinchey Ia acute diverticulitis. Fifty-five (42.6%) patients were male, and the median age was 54years (range, 30-86). Eighty-seven (67.4%) patients had right-sided diverticulitis. Most patients were treated empirically with intravenous ceftriaxone and metronidazole (89.1%). They were then discharged with oral antibiotics. Only 6.1% of patients had a positive blood culture. The median length of stay in the hospital was 4 (range, 3-4) days. Only three (2.3%) patients were readmitted for acute diverticulitis within 30days. They were managed with antibiotics and discharged well. The repeated CT scans reconfirmed Hinchey Ia diverticulitis. No patients required emergency surgery, and there were no 30-day mortalities. Asian patients with Hinchey Ia diverticulitis recovered well with conservative management and could be amenable to outpatient therapy. Future prospective studies should be performed amongst Asians to evaluate managing this condition in an ambulatory setting.