American Journal of Emergency Medicine 33 (2015) 475.e7–475.e9
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Perforated posterior cecal diverticulum: challenges in establishing an accurate preoperative diagnosis of a rare emergency☆,☆☆ Abstract Solitary cecal diverticulitis is a rare cause of abdominal pain in Western countries. The preoperative diagnosis is very difficult to establish and most patients are operated on with a presumptive diagnosis of acute appendicitis based on clinical grounds. We describe a very rare case of perforated posterior cecal diverticulum and discuss the challenges in establishing a correct preoperative diagnosis. We conclude that although very rare, the possibility of perforated posterior cecal diverticulum should always be considered in the differential diagnosis of patients presenting with atypical clinical manifestations of acute appendicitis. A perforation of a posterior cecal diverticulum may be associated with a mild clinical course without signs of peritonitis. A thorough preoperative evaluation including a computed tomography scan is essential in order to establish a correct preoperative diagnosis which is of utmost importance for treatment planning in the emergency setting. Simple diverticulectomy is an effective surgical treatment in the absence of extensive inflammatory changes and when a colonic tumor can be ruled out. Right- sided diverticular disease is uncommon in Western countries, that is, found in only 1% to 2% of surgical specimens [1]. Conversely, in Oriental countries the disease is more common with an incidence that can be up to 43% to 50% of specimens [1]. Most patients are asymptomatic but some may develop complications such as diverticulitis, bleeding, perforation and fistula formation [1]. Acute solitary cecal diverticulitis (SCD) is a rare clinical entity that is encountered in 1 in 300 cases operated with a diagnosis of acute appendicitis [2], comprising 2.5% of the patients with acute right lower abdominal pain [3]. Preoperative diagnosis of cecal diverticulitis is very difficult and more than 70% of the patients are operated on with a presumptive diagnosis of acute appendicitis [2,4–6]. A correct preoperative diagnosis, which is essential for treatment planning, has been reported in only 7% to 9% of the cases and mostly in patients with a history of previous appendectomy [2,6,7]. In a review including 30 patients with acute diverticulitis of the right colon, all were diagnosed preoperatively as having appendicitis [8]. Even at the time of surgery a correct diagnosis has been reported in 58% to 65% of the cases [6,7]. We describe a case of a cecal diverticulitis with gangrene and perforation. A correct preoperative diagnosis was made based on patient’s clinical manifestations and computed tomography findings. We discuss the challenges in establishing an accurate preoperative diagnosis of this rare emergency. A 27-year-old white man was admitted with a 24 hour history of right lower abdominal pain. The pain had started and remained ☆ Sources of support: None. ☆☆ Conflicts of interest: None. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
localized in the right iliac fossa. He denied anorexia nausea and vomiting. His past medical history was unremarkable. Upon admission, he had temperature of 37 °C, blood pressure of 120/70 mmHg, and pulse rate of 70 beats per minute. Abdominal examination revealed mild tenderness on deep palpation of the right lower abdominal quadrant over McBurney's point. There was no rebound tenderness, or abdominal wall rigidity. A hemogramm revealed a white cell count of 13200 × 103/mL, with 84% neutrophils and a haemoglobin level of 13.7 g/dL. Biochemical investigations revealed elevated levels of C-reactive protein: 10 mg/L (range b5 mg/L). Urinalysis was normal. A computed tomography (CT) scan of the abdomen was obtained which revealed thickness of the cecum and the presence of an inflamed diverticulum with surrounding peridiverticular inflammation recognized by enhancement of the diverticular wall (Fig. 1). In addition, small fluid collections were noted in the right paracolic gutter and pelvis. At laparotomy, performed through a low right paramedian incision, the cecum and the appendix appeared macroscopically normal. However, on palpation an indurated and thickened area of the posterior wall of the cecum was found. The cecum was then mobilized by dividing Toldt's line and a 4-cm gangrenous perforated solitary diverticulum was found on its posterior wall. Since there was no evidence of extensive inflammatory changes a simple diverticulectomy and appendectomy were performed (Figs. 2 and 3). Histopathology of the resected diverticulum showed features of acute inflammation and gangrene with perforation, but no evidence of malignancy. The diverticulum composed of all layers of the colonic wall indicating that it was a “true” type. Histopathological examination of the appendix revealed no remarkable findings. The patient had an uncomplicated postoperative course and was discharged home 4 days later. He is well and asymptomatic 3 months after surgery. Solitary cecal diverticulosis was first described by Potier in 1912 [9]. It represents a true diverticula consisting of all layers of colonic wall including the muscularis layer and is believed to be of congenital origin [10,11]. It is a rare clinical entity that is encountered in only 10 of 5000 radiologic examinations and mostly affects young individuals of Asian descent [7]. In a retrospective review of 881 patients with diverticulum of the cecum and ascending colon, Sardi et al [6] reported that the average age of the patients was 43.6 years with a male to female ratio of 3:2. The clinical presentation of SCD is almost indistinguishable from acute appendicitis including right abdominal pain, low grade fever, nausea, vomiting, abdominal tenderness, and leukocytosis [8,12–14]. It has been suggested that a less toxic presentation of a patient despite a longer duration of abdominal pain and absence of nausea and vomiting may be distinctive clinical features indicating cecal diverticulitis rather than acute appendicitis [1,2,11]. Acute abdomen is a very rare presentation [1]. CT imaging characteristics of SCD include thickening of the intestinal wall, pericolic fat infiltration, pericolic abscess or extraluminal air [2].
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N.S. Salemis et al. / American Journal of Emergency Medicine 33 (2015) 475.e7–475.e9
Fig. 3. Postoperative photo showing the perforated (arrow) resected diverticulum.
Fig. 1. CT scan of the abdomen shows an inflamed cecal diverticulum with enhancement of the diverticular wall (arrow).
Jang et al [14] reported that inflamed diverticula and a preserved enhancement pattern of the thickened wall were the two most statistically significant CT findings in differentiating cecal diverticulitis from colonic cancer. In 10% of the cases however, SCD is indistinguishable from colonic carcinoma on CT [11]. Ultrasonography has been reported to be accurate in differentiating SCD from acute appendicitis. In a retrospective study of 934 patients with right lower abdominal pain, Chou et al [3] reported that ultrasonography had a sensitivity of 91.3%, a specificity of 99.8% and an overall accuracy of 99.5% in the diagnosis of cecal diverticulitis. Most typical sonographic findings of SCD include a rounded or oval shaped hypoechoic structure protruding from a thickened colonic wall [3]. Experience is however essential since ultrasound is considered to be an operator-dependent examination [2,11]. The optimal treatment of SCD is controversial ranging from conservative management to aggressive surgical resections [4]. Due to the rarity of the disease there are no randomized trials comparing
Fig. 2. Intraoperative photo showing the cecal diverticulum with gangrene and perforation.
conservative management with surgical treatment [12]. For uncomplicated patients diagnosed preoperatively a conservative treatment with antibiotics is effective [1,11,15]. If SCD is encountered during surgery for presumed appendicitis a conservative approach including prophylactic appendectomy and postoperative antibiotics is recommended [5,8]. More aggressive surgical resections such as cecectomy or formal right hemicolectomy should be considered in complicated cases such as those with multiple diverticula, presence of extensive inflammatory changes or when an underlying tumor cannot be excluded [1,4,13]. Emergent right hemicolectomy has been reported to be safe with low complication rates even in the unprepared bowel [10,13]. Where there are no extensive inflammatory changes and a colonic tumor can be ruled out a simple diverticulectomy, as performed in our case, is a safe and adequate treatment [4,10,12]. Some authors however suggest that an aggressive surgery should be performed at the time of initial operation [5,13]. In a retrospective review of 49 patients, Lane et al [13], reported that 40% of the patients treated with diverticulectomy or antibiotics alone required subsequent right hemicolectomy. In addition, Fang et al [5] reported that less than 40% of the patients who were treated conservatively remained recurrencefree during the follow-up. In 80% of the cases cecal diverticulum is found 1 to 2 cm from the ileocecal valve and in 60% of the cases is located on the anterior cecal wall [2,7]. Anterior diverticula are prone to perforation thus leading to subsequent peritonitis, but the posteriorly situated lesions may produce a mass mimicking a tumor without signs of peritonitis [7]. In our case the diverticula was found 10 cm from the ileocecal valve in the posterior wall of the distal cecum. Macroscopically the cecum appeared normal, but a posteriorly located indurated mass was found on palpation. The lesion was found after the cecum was mobilized by incising the peritoneal attachment along the line of Toldt. This type of lesion could easily have been missed if a laparoscopy had been initially performed. We decided not to proceed with laparoscopy since the diagnosis of a posterior cecal diverticulum had been correctly preoperatively established based on CT findings. Due to the retrocecal location of the lesion, the anterior abdominal findings were less striking. In conclusion, although very rare in Western countries, the possibility of perforated cecal diverticulum should always be considered in the differential diagnosis of patients presenting with an atypical clinical course of acute appendicitis. A covered perforation of a posterior cecal diverticulum may run a mild clinical course without signs of peritonitis. A thorough preoperative evaluation
N.S. Salemis et al. / American Journal of Emergency Medicine 33 (2015) 475.e7–475.e9
including a CT scan is essential in order to establish a correct preoperative diagnosis which is of utmost importance for treatment planning in the emergency setting.
Nikolaos S. Salemis, MD, PhD⁎ Konstantinos Grapatsas, MD Ioannis Matzoukas, MD Emmanuel Lagoudianakis, MD, PhD Second Department of Surgery 401 Army General Hospital, Athens, Greece ⁎Corresponding author. Consultant Surgical Oncologist Head of 2nd Department of Surgery Army General Hospital Athens, Greece, 19 Taxiarhon Street 19014 Kapandriti, Athens, Greece E-mail address: [email protected] (N.S. Salemis)
http://dx.doi.org/10.1016/j.ajem.2014.08.059 References [1] Radhi JM, Ramsay JA, Boutross-Tadross O. Diverticular disease of the right colon. BMC Res Notes 2011;4:383.
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[2] Yildar M, Ozkan OF, Caglayan K, Ozkul F, Cavdar F, Saygın I. An unusual cause of right lower quadrant pain: the caecum diverticulitis. Case Rep Surg 2012; 2012:789397. [3] Chou YH, Chiou HJ, Tiu CM, Chen JD, Hsu CC, Lee CH, et al. Sonography of acute right side colonic diverticulitis. Am J Surg 2001;181:122–7. [4] Karatepe O, Gulcicek OB, Adas G, Battal M, Ozdenkaya Y, Kurtulus I, et al. Cecal diverticulitis mimicking acute appendicitis: a report of 4 cases. World J Emerg Surg 2008;3:16. [5] Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Aggressive resection is indicated for cecal diverticulitis. Am J Surg 2003;185:135–40. [6] Sardi A, Gokli A, Singer JA. Diverticular disease of the cecum and ascending colon. A review of 881 cases. Am Surg 1987;53:41–5. [7] Kurer MA. Solitary caecal diverticulitis as an unusual cause of a right iliac fossa mass: a case report. J Med Case Rep 2007;1:132. [8] Chiu PW, Lam CY, Chow TL, Kwok SP. Conservative approach is feasible in the management of acute diverticulitis of the right colon. ANZ J Surg 2001;71:634–6. [9] Potier F. Diverticulite et appendicite. Bull Mem Soc Anat Paris 1912;137:29–31. [10] Papapolychroniadis C, Kaimakis D, Fotiadis P, Karamanlis E, Stefopoulou M, Kouskouras K, et al. Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the literature. Tech Coloproctol 2004; 8(Suppl 1):s116–8. [11] Griffiths EA, Date RS. Acute presentation of a solitary caecal diverticulum: a case report. J Med Case Rep 2007;1:129. [12] Connolly D, McGookin RR, Gidwani A, Brown MG. Inflamed solitary caecal diverticulum—it is not appendicitis, what should I do? Ann R Coll Surg Engl 2006;88:672–4. [13] Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson Jr JE. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999;188:629–34. [14] Jang HJ, Lim HK, Lee SJ, Lee WJ, Kim EY, Kim SH. Acute diverticulitis of the cecum and ascending colon: the value of thin-section helical CT findings in excluding colonic carcinoma. AJR Am J Roentgenol 2000;174:1397–402. [15] Yang HR, Huang HH, Wang YC, Hsieh CH, Chung PK, Jeng LB, et al. Management of right colon diverticulitis: a 10-year experience. World J Surg 2006;30:1929–34.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Perforated posterior cecal diverticulum: challenges in establishing an accurate preoperative diagnosis of a rare emergency☆,☆☆ Abstract Solitary cecal diverticulitis is a rare cause of abdominal pain in Western countries. The preoperative diagnosis is very difficult to establish and most patients are operated on with a presumptive diagnosis of acute appendicitis based on clinical grounds. We describe a very rare case of perforated posterior cecal diverticulum and discuss the challenges in establishing a correct preoperative diagnosis. We conclude that although very rare, the possibility of perforated posterior cecal diverticulum should always be considered in the differential diagnosis of patients presenting with atypical clinical manifestations of acute appendicitis. A perforation of a posterior cecal diverticulum may be associated with a mild clinical course without signs of peritonitis. A thorough preoperative evaluation including a computed tomography scan is essential in order to establish a correct preoperative diagnosis which is of utmost importance for treatment planning in the emergency setting. Simple diverticulectomy is an effective surgical treatment in the absence of extensive inflammatory changes and when a colonic tumor can be ruled out. Right- sided diverticular disease is uncommon in Western countries, that is, found in only 1% to 2% of surgical specimens [1]. Conversely, in Oriental countries the disease is more common with an incidence that can be up to 43% to 50% of specimens [1]. Most patients are asymptomatic but some may develop complications such as diverticulitis, bleeding, perforation and fistula formation [1]. Acute solitary cecal diverticulitis (SCD) is a rare clinical entity that is encountered in 1 in 300 cases operated with a diagnosis of acute appendicitis [2], comprising 2.5% of the patients with acute right lower abdominal pain [3]. Preoperative diagnosis of cecal diverticulitis is very difficult and more than 70% of the patients are operated on with a presumptive diagnosis of acute appendicitis [2,4–6]. A correct preoperative diagnosis, which is essential for treatment planning, has been reported in only 7% to 9% of the cases and mostly in patients with a history of previous appendectomy [2,6,7]. In a review including 30 patients with acute diverticulitis of the right colon, all were diagnosed preoperatively as having appendicitis [8]. Even at the time of surgery a correct diagnosis has been reported in 58% to 65% of the cases [6,7]. We describe a case of a cecal diverticulitis with gangrene and perforation. A correct preoperative diagnosis was made based on patient’s clinical manifestations and computed tomography findings. We discuss the challenges in establishing an accurate preoperative diagnosis of this rare emergency. A 27-year-old white man was admitted with a 24 hour history of right lower abdominal pain. The pain had started and remained ☆ Sources of support: None. ☆☆ Conflicts of interest: None. 0735-6757/© 2014 Elsevier Inc. All rights reserved.
localized in the right iliac fossa. He denied anorexia nausea and vomiting. His past medical history was unremarkable. Upon admission, he had temperature of 37 °C, blood pressure of 120/70 mmHg, and pulse rate of 70 beats per minute. Abdominal examination revealed mild tenderness on deep palpation of the right lower abdominal quadrant over McBurney's point. There was no rebound tenderness, or abdominal wall rigidity. A hemogramm revealed a white cell count of 13200 × 103/mL, with 84% neutrophils and a haemoglobin level of 13.7 g/dL. Biochemical investigations revealed elevated levels of C-reactive protein: 10 mg/L (range b5 mg/L). Urinalysis was normal. A computed tomography (CT) scan of the abdomen was obtained which revealed thickness of the cecum and the presence of an inflamed diverticulum with surrounding peridiverticular inflammation recognized by enhancement of the diverticular wall (Fig. 1). In addition, small fluid collections were noted in the right paracolic gutter and pelvis. At laparotomy, performed through a low right paramedian incision, the cecum and the appendix appeared macroscopically normal. However, on palpation an indurated and thickened area of the posterior wall of the cecum was found. The cecum was then mobilized by dividing Toldt's line and a 4-cm gangrenous perforated solitary diverticulum was found on its posterior wall. Since there was no evidence of extensive inflammatory changes a simple diverticulectomy and appendectomy were performed (Figs. 2 and 3). Histopathology of the resected diverticulum showed features of acute inflammation and gangrene with perforation, but no evidence of malignancy. The diverticulum composed of all layers of the colonic wall indicating that it was a “true” type. Histopathological examination of the appendix revealed no remarkable findings. The patient had an uncomplicated postoperative course and was discharged home 4 days later. He is well and asymptomatic 3 months after surgery. Solitary cecal diverticulosis was first described by Potier in 1912 [9]. It represents a true diverticula consisting of all layers of colonic wall including the muscularis layer and is believed to be of congenital origin [10,11]. It is a rare clinical entity that is encountered in only 10 of 5000 radiologic examinations and mostly affects young individuals of Asian descent [7]. In a retrospective review of 881 patients with diverticulum of the cecum and ascending colon, Sardi et al [6] reported that the average age of the patients was 43.6 years with a male to female ratio of 3:2. The clinical presentation of SCD is almost indistinguishable from acute appendicitis including right abdominal pain, low grade fever, nausea, vomiting, abdominal tenderness, and leukocytosis [8,12–14]. It has been suggested that a less toxic presentation of a patient despite a longer duration of abdominal pain and absence of nausea and vomiting may be distinctive clinical features indicating cecal diverticulitis rather than acute appendicitis [1,2,11]. Acute abdomen is a very rare presentation [1]. CT imaging characteristics of SCD include thickening of the intestinal wall, pericolic fat infiltration, pericolic abscess or extraluminal air [2].
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N.S. Salemis et al. / American Journal of Emergency Medicine 33 (2015) 475.e7–475.e9
Fig. 3. Postoperative photo showing the perforated (arrow) resected diverticulum.
Fig. 1. CT scan of the abdomen shows an inflamed cecal diverticulum with enhancement of the diverticular wall (arrow).
Jang et al [14] reported that inflamed diverticula and a preserved enhancement pattern of the thickened wall were the two most statistically significant CT findings in differentiating cecal diverticulitis from colonic cancer. In 10% of the cases however, SCD is indistinguishable from colonic carcinoma on CT [11]. Ultrasonography has been reported to be accurate in differentiating SCD from acute appendicitis. In a retrospective study of 934 patients with right lower abdominal pain, Chou et al [3] reported that ultrasonography had a sensitivity of 91.3%, a specificity of 99.8% and an overall accuracy of 99.5% in the diagnosis of cecal diverticulitis. Most typical sonographic findings of SCD include a rounded or oval shaped hypoechoic structure protruding from a thickened colonic wall [3]. Experience is however essential since ultrasound is considered to be an operator-dependent examination [2,11]. The optimal treatment of SCD is controversial ranging from conservative management to aggressive surgical resections [4]. Due to the rarity of the disease there are no randomized trials comparing
Fig. 2. Intraoperative photo showing the cecal diverticulum with gangrene and perforation.
conservative management with surgical treatment [12]. For uncomplicated patients diagnosed preoperatively a conservative treatment with antibiotics is effective [1,11,15]. If SCD is encountered during surgery for presumed appendicitis a conservative approach including prophylactic appendectomy and postoperative antibiotics is recommended [5,8]. More aggressive surgical resections such as cecectomy or formal right hemicolectomy should be considered in complicated cases such as those with multiple diverticula, presence of extensive inflammatory changes or when an underlying tumor cannot be excluded [1,4,13]. Emergent right hemicolectomy has been reported to be safe with low complication rates even in the unprepared bowel [10,13]. Where there are no extensive inflammatory changes and a colonic tumor can be ruled out a simple diverticulectomy, as performed in our case, is a safe and adequate treatment [4,10,12]. Some authors however suggest that an aggressive surgery should be performed at the time of initial operation [5,13]. In a retrospective review of 49 patients, Lane et al [13], reported that 40% of the patients treated with diverticulectomy or antibiotics alone required subsequent right hemicolectomy. In addition, Fang et al [5] reported that less than 40% of the patients who were treated conservatively remained recurrencefree during the follow-up. In 80% of the cases cecal diverticulum is found 1 to 2 cm from the ileocecal valve and in 60% of the cases is located on the anterior cecal wall [2,7]. Anterior diverticula are prone to perforation thus leading to subsequent peritonitis, but the posteriorly situated lesions may produce a mass mimicking a tumor without signs of peritonitis [7]. In our case the diverticula was found 10 cm from the ileocecal valve in the posterior wall of the distal cecum. Macroscopically the cecum appeared normal, but a posteriorly located indurated mass was found on palpation. The lesion was found after the cecum was mobilized by incising the peritoneal attachment along the line of Toldt. This type of lesion could easily have been missed if a laparoscopy had been initially performed. We decided not to proceed with laparoscopy since the diagnosis of a posterior cecal diverticulum had been correctly preoperatively established based on CT findings. Due to the retrocecal location of the lesion, the anterior abdominal findings were less striking. In conclusion, although very rare in Western countries, the possibility of perforated cecal diverticulum should always be considered in the differential diagnosis of patients presenting with an atypical clinical course of acute appendicitis. A covered perforation of a posterior cecal diverticulum may run a mild clinical course without signs of peritonitis. A thorough preoperative evaluation
N.S. Salemis et al. / American Journal of Emergency Medicine 33 (2015) 475.e7–475.e9
including a CT scan is essential in order to establish a correct preoperative diagnosis which is of utmost importance for treatment planning in the emergency setting.
Nikolaos S. Salemis, MD, PhD⁎ Konstantinos Grapatsas, MD Ioannis Matzoukas, MD Emmanuel Lagoudianakis, MD, PhD Second Department of Surgery 401 Army General Hospital, Athens, Greece ⁎Corresponding author. Consultant Surgical Oncologist Head of 2nd Department of Surgery Army General Hospital Athens, Greece, 19 Taxiarhon Street 19014 Kapandriti, Athens, Greece E-mail address: [email protected] (N.S. Salemis)
http://dx.doi.org/10.1016/j.ajem.2014.08.059 References [1] Radhi JM, Ramsay JA, Boutross-Tadross O. Diverticular disease of the right colon. BMC Res Notes 2011;4:383.
475.e9
[2] Yildar M, Ozkan OF, Caglayan K, Ozkul F, Cavdar F, Saygın I. An unusual cause of right lower quadrant pain: the caecum diverticulitis. Case Rep Surg 2012; 2012:789397. [3] Chou YH, Chiou HJ, Tiu CM, Chen JD, Hsu CC, Lee CH, et al. Sonography of acute right side colonic diverticulitis. Am J Surg 2001;181:122–7. [4] Karatepe O, Gulcicek OB, Adas G, Battal M, Ozdenkaya Y, Kurtulus I, et al. Cecal diverticulitis mimicking acute appendicitis: a report of 4 cases. World J Emerg Surg 2008;3:16. [5] Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Chen MF. Aggressive resection is indicated for cecal diverticulitis. Am J Surg 2003;185:135–40. [6] Sardi A, Gokli A, Singer JA. Diverticular disease of the cecum and ascending colon. A review of 881 cases. Am Surg 1987;53:41–5. [7] Kurer MA. Solitary caecal diverticulitis as an unusual cause of a right iliac fossa mass: a case report. J Med Case Rep 2007;1:132. [8] Chiu PW, Lam CY, Chow TL, Kwok SP. Conservative approach is feasible in the management of acute diverticulitis of the right colon. ANZ J Surg 2001;71:634–6. [9] Potier F. Diverticulite et appendicite. Bull Mem Soc Anat Paris 1912;137:29–31. [10] Papapolychroniadis C, Kaimakis D, Fotiadis P, Karamanlis E, Stefopoulou M, Kouskouras K, et al. Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the literature. Tech Coloproctol 2004; 8(Suppl 1):s116–8. [11] Griffiths EA, Date RS. Acute presentation of a solitary caecal diverticulum: a case report. J Med Case Rep 2007;1:129. [12] Connolly D, McGookin RR, Gidwani A, Brown MG. Inflamed solitary caecal diverticulum—it is not appendicitis, what should I do? Ann R Coll Surg Engl 2006;88:672–4. [13] Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson Jr JE. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999;188:629–34. [14] Jang HJ, Lim HK, Lee SJ, Lee WJ, Kim EY, Kim SH. Acute diverticulitis of the cecum and ascending colon: the value of thin-section helical CT findings in excluding colonic carcinoma. AJR Am J Roentgenol 2000;174:1397–402. [15] Yang HR, Huang HH, Wang YC, Hsieh CH, Chung PK, Jeng LB, et al. Management of right colon diverticulitis: a 10-year experience. World J Surg 2006;30:1929–34.
