Solitary Cecal Diverticula*
C. L.
DIVERTICULAR DISEASE o f t h e c o l o n is a c o m m o n condition that always affects the sigmoid and freq u e n t l y i n v o l v e s t h e m o r e p r o x i m a l c o l o n as well. T h e s o l i t a r y c e c a l d i v e r t i c u l u m is a w e l l - r e c o g n i z e d e n t i t y , a b o u t 2 0 0 cases h a v i n g b e e n d e s c r i b e d in B r i t i s h a n d American medical literature. Three recent cases of a c u t e i n f l a m m a t i o n in s o l i t a r y c e c a l d i v e r t i c u l a a r e described. Report of Three Cases (Fig. 1) Patient 1: A 64-year-old man was admitted to the hospital with a 48-hour history of increasing abdominal pain, which had started in the epigastrium and had seemed to radiate to the right iliac fossa. He complained of anorexia and nausea but had not vomited. He also complained of severe headaches, which had started a few hours prior to admission. The patient was obese. Temperature was 99 F. There was vague abdominal tenderness, mainly in the right iliac fossa, especially on deep palpation. Routine examination of the eyes revealed nothing abnormal. A diagnosis of acute appendicitis was made. At operation there was a slight amount of clear fluid in the peritoneum. The appendix looked normal, but there was a hard mass, close to the ileocecal junction, wrapped in edematous omentum. The surrounding cecal wall was also edematous, with enlarged lymph nodes in the mesentery. By invaginating the cecal wall a definite ostium, blocked by a hard fecalith, could be felt at the base of the mass, which was then diagnosed as an inflamed solitary diverticulum. The appendix was removed and a drain inserted down to the inflammatory mass. Closure was effected in layers (as for the usual appendiceal incision). Ampicillin (500 mg, six-hourly) was prescribed postoperatively. The day after operation the headaches continued and acute glaucoma was diagnosed, necessitating treatment by an ophthalmologist. There was no abdominal complications, the pain and fever abating within three days. The drain was removed on the second postoperative day and stitches after seven days. The patient has remained well, with no recurrence of abdominal symptoms. Patient 2: A 59-year-old man was admitted to the hospital with a two-day history of central abdominal pain radiating to the right iliac fossa. He had not vomited, but complained of nausea. On examination, temperature was 99.5 F, and the tongue was furred. There was tenderness in the right iliac fossa, where there was a suggestion of a mass. A diagnosis of acute appendicitis was made. At operation there was a hard mass, enveloped in edematous omentum, on the anterior surface of the cecum close to the ileocecal valve. The appendix looked normal. There were enlarged lymph nodes in the mesentery. Through a small cecostomy the atrium of the sofitary diverticulum couldbe identified and was seen to be blocked by a large fecafith. The appendix was removed, a * Received for publication June 5, 1978. Address reprint requests to Dr. Cutajar at his present address: King Faisal Military Hospital, P.O. Box 101, Khamis Mushayt, Saudi Arabia.
CUTAJAR, M . D . ,
F.R.C.S.
(ENG.), F . R . C . S . (EDIN.)
Department of Surge,y, St. Luke's Hospital, Malta drain was inserted down to the inflammatory mass, and the patient was treated conservatively with Ampicillin postoperatively. He made an uneventful recovery. Patient 3: A 52-year-old housewife was admitted to the hospital with an 18-hour history of abdominal pain, mainly in the right iliac fossa, and pyrexia. She had vomited once. On admission, temperature was 100.2 F and there was a tender mass in the right iliac fossa. At operation, findings were similar to those in the previous two cases: the appendix was congested but not acutely inflamed, and a hard, edematous mass was present in the anterior wall of the cecum close to the ileocecal junction. T h r o u g h a cecotomy, the ostium of the diverticulum was visualized. The appendix was removed. After insertion of a drain the wound was closed, and the patient was treated postoperatively with antibiotics. The immediate postoperative course was uneventful, and the patient was discharged from the hospital after eight days. However, a few months later, she again sought medical treatment, for an incisional hernia. This was repaired using general anesthesia. At operation the opportunity was taken to inspect the cecum: it looked remarkably healthy, with complete disappearance of the diverticulum. Postoperative barium studies showed a completely normal large bowel.
Discussion Incidence: P o t i e r s was t h e first to d e s c r i b e a c u t e inflammation of a solitary diverticulum of the cecum. S i n c e t h e n , a b o u t 2 0 0 c a s e s h a v e b e e n r e c o r d e d in t h e English language medical literature. T h e f i n d i n g o f t h r e e cases, d e s c r i b e d i n t h e p r e s e n t series, o c c u r r i n g w i t h i n a f e w w e e k s o f e a c h o t h e r m u s t b e c o i n c i d e n t a l . I n fact, t h e c o n d i t i o n is u n c o m m o n . W i l l i a m s , 11 in a r e v i e w o f a l a r g e s e r i e s o f barium-enemas examinations, found an incidence of o n l y 0.1 p e r c e n t o f s o l i t a r y c e c a l d i v e r t i c u l a , a l t h o u g h 5 p e r c e n t o f cases s h o w e d i n v o l v e m e n t o f t h e c e c u m with generalized diverticulosis. Podesta and Pace/in a s u r v e y o f t h e i n c i d e n c e o f d i v e r t i c u l a r d i s e a s e in Malta, based on radiologic and necropsy studies of more than 5,000 patients, found only eight cases of d i v e r t i c u l a l i m i t e d to t h e r i g h t c o l o n . O f t h e s e , o n l y t h r e e w e r e s o l i t a r y c e c a l d i v e r t i c u l a , a n d o n l y o n e was associated with clinical symptoms (melena); the others were mainly incidental findings at postmortem examination. A review of the reported cases reveals no significant difference in sex incidences. Average ages of the pat i e n t s h a v e r a n g e d f r o m 39 to 47 y e a r s ? 'I~ T h e p a -
0012-3706/78/1100/0627/$00.65 9 American Society of Colon and Rectal Surgeons
627
628
c.L.
CUTAJAR
Dis. CoL & Rect. Nov.-Dec. 1978
FIG. 1. Sites of solitary cecal diverticula. tients in the p r e s e n t series were older (average age 58 years). Etiology: T h e solitary cecal diverticulum a p p e a r s to be a d i f f e r e n t entity f r o m the c o m m o n diverticular disease o f the sigmoid colon. T h e r e is usually no muscle thickening. Most authorities r e g a r d it as congenital in origin, a l t h o u g h this is by no means c e r t a i n ) '6 Williams u suggests that some o f these diverticula m a y be acquired but o c c u r at a spot w h e r e there is a congenital weakness in the wall o f the cecum. Complications: Diverticulitis is the most c o m m o n c o m p l i c a t i o n . P e r f o r a t i o n o f the d i v e r t i c u l a acc o u n t e d for 20 p e r cent o f the cases r e p o r t e d by Williams, at H e m o r r h a g e is rare. r Diagnosis: In the vast majority o f these cases, the patients have b e e n o p e r a t e d on for acute a p p e n dicitis, u O n l y occasionally has the condition b e e n suspected when the a p p e n d i x has b e e n r e m o v e d . L a i m o n a n d C o h n a state that " . . . the s y m p t o m s and clinical findings were so similar to acute a p p e n dicitis that even in r e t r o s p e c t it was impossible t o . . . exclude the diagnosis o f appendicitis." H o w e v e r , o u r three cases did have some peculiar features that m i g h t suggest the correct diagnosis. I n particular: 1) relatively long histories of increasing
a b d o m i n a l pain, r a n g i n g f r o m t h r e e days to 24 h o u r s b e f o r e admission; 2) Relative lack o f toxicity despite the d u r a t i o n o f s y m p t o m s ; 3) v o m i t i n g is not common; 4) Local t e n d e r n e s s is usually not m a r k e d a n d is elicited mainly on d e e p palpation. Similar findings have b e e n r e p o r t e d by others.-" O p e r a t i v e F i n d i n g s : T h e findings at o p e r a t i o n were r e m a r k a b l y similar in the three cases in this series, a n d correlate closely with those r e p o r t e d p r e viously: 1) In all cases the a p p e n d i x looked n o r m a l . 2) T h e c e c u m was e d e m a t o u s a n d i n f l a m e d a n d contained a h a r d fixed mass, a b o u t the size o f an o r a n g e , close to the ileocecal j u n c t i o n . T h e mass was enveloped in e d e m a t o u s o m e n t u m . 3) E n l a r g e d , firm, m e s e n t e r i c l y m p h nodes w e r e p r e s e n t in all cases. In two cases cecostomy r e v e a l e d the i n d u r a t e d ostium o f the d i v e r t i c u l u m at the center o f the mass. At least one diverticulum c o n t a i n e d a palpable fecalith. T h e closeness o f the mass to the ileocecal j u n c t i o n has b e e n described by several investigators (Table 1). L a u r i d s e n a n d Ross 4 c o m m e n t e d that 80 p e r cent o f i n f l a m e d solitary diverticula o f the c e c u m o c c u r r e d within 2.5 cm o f the ileocecal valve. This f e a t u r e has b e e n t h o u g h t by s o m e aa possibly to p o i n t to the pathogenesis o f solitary cecal d i v e r t i c u l a - - f o o d p r o -
TABLE 1. Clinical Data
Temperature (F) Vomiting Central Pain Tenderness, right iliac fossa Mass, right iliac fossa Preoperative diagnosis Operative diagnosis Postoperative complication
Patient 1 M, 64 Years Old
Patient 2 M, 59 Years Old
Patient 3 F, 52 Years Old
99 +
99.5 +
100.2 1 +
+ Acute appendicitis Solitary cecal diverticulum
+ + Acute appendicitis Solitary cecal diverticulum
+ + Acute appendicitis Solitary cecal diverticulum
Acute glaucoma
Nil
Nil
Volume 2 i Number 8
T.*BLr 2.
Reference Anderson t (1947) Waite 1~ (1954) Parker and Serjeant ~ (1957) Williams 11 (1960) Anscombe et al."- (1967) Present series (I978)
629
SOLITARY CECAL DIVERTICULA
Treatment of Solitary Cecal Diverticula*
Number of Patients
Cecotomy or Right Hemicolectomy
Appendectomy + Drainage + Antibiotics
Simple Diverticulectomy
96 58 3 10 10 3
32 25 1 5 7 0
11 8 2 5 3 3
53 28 -----
* Treatment was mentioned in 180 of approximately 200 cases reported. These are the cases summarized here.
jecting through the ileocecal valve hits a possibly congenital weak spot close to the valve, thus causing a diverticulum to form. Surgical Treatment: A review of the literature has revealed surprising inconsistencies in the treatment of this condition (Table 2). There appear to have been two major problems. The first is the diagnosis of the lesion. Even at operation, misdiagnosis of the lesion has been surprisingly common in all reported series. A third of Anderson's 1 96 patients collected f r o m the l i t e r a t u r e had hemicolectomy for carcinoma. Even when the correct diagnosis has been made, treatment has been far from uniform. Some still preferred to do a major amputation (cecectomy or right hemicolectomy). Others excised the diverticulum. Simple drainage of the inflamed area (usually comb i n e d with a p p e n d e c t o m y ) , with p o s t o p e r a t i v e broad-administration of spectrum antibiotics, has been employed in a smaller proportion of cases, including the three reported here. In the series reported by Lauridsen and Ross, 4 the mortality rate following diverticulectomy was 1.6 per cent, and that following hemicotectomy, 11.4 per cent. In other series mortality rates following simple drainage and antibiotics have ranged from 0 to 0.9 per cent. Although in recent series postoperative mortality following hemicolectomy has been reduced, undoubtedly due to better use of antibiotics postoperatively and improved postoperative care of the patient, it is felt that simple drainage, with postoperative administration of antibiotics, is a simple, safe procedure, which should be the preferred treatment. Our patients had remarkably smooth postoperative courses as regards abdominal pathology. The first patient had an unexpected complication in the form of an attack of acute glaucoma (possibly triggered by preoperative administration of atropine to a susceptible patient), but it was not related to the abdominal condition. Moreover, the stay in hospital following this simple procedure is a third that associated with hemicolectomy.
There is also evidence that acute inflammation of a diverticulum can resolve spontaneously, and may even produce its obliteration? In most reported series, patients treated with antibiotics and drainage have survived without recurrence of symptoms, and subsequent barium-enema studies have failed to demonstrate the cecal diverticulum in many of them. Our three patients have remained very well postoperatively. In the case of Patient 3, there was visual and x-ray evidence of disappearance of the diverticulum. This is thought to be the first published case where complete disappearance of a solitary cecal divert i c u l u m has been c o n f i r m e d at s u b s e q u e n t laparotomy.
Conclusion Three cases of inflammation of a solitary cecal diverticulum are described. T h e preoperative and peroperative difficulties in diagnosis are emphasized. It is suggested that the safest course of treatment is drainage of the inflamed area, with postoperative administration of antibiotics.
References 1. Anderson L: Acute diverticulitis of the cecum: Study of ninety-nine surgical cases. Surgery 22: 479, 1947 2. Anscombe AR, Keddie NC, Schofield PF: Solitary ulcers and diverticulitis of the caecum. Br J Surg 5.4: 553, 1967 3. Laimon H, Cohn P: Diverticulitis of the cecum: A report of eight cases. A m J Surg 103: 146, 1962 4. Lauridsen J, Ross FP: Acute diverticulitis of the cecum: A report o f four cases and review o f one hundred fifty-three surgical cases. Arch Surg 64: 320, 1952 5. Parker RA, Serjeant JC: Acute solitary ulcer and diverticulitis o f the caecum. B r J Surg 45: 19, 1957 6. Perry PM, Morson BC: Right-sided diverticulosis of the colon. B r J Surg 58: 902, 1971 7. Podesta MT, Pace JL: Diverticular disease in Malta. St Luke's Hosp Gaz Malta 8: 126, 1973 8. Potier F: Diverticulit8 et appendicitc Bull Mere Soc Anat Paris 137: 29, 1912 9. Reid DR: Acute diverticulitis of the caecum and ascending colon. Br J Surg 39: 76, 1951 10. Waite VC: Diverticulitis of the cecum. Am J Surg 88:718, 1954 11. Williams KL: Acute solitary ulcers and acute diverticulitis o f the caecum and ascending colon. Br J Surg 47: 35t, 1960
C. L.
DIVERTICULAR DISEASE o f t h e c o l o n is a c o m m o n condition that always affects the sigmoid and freq u e n t l y i n v o l v e s t h e m o r e p r o x i m a l c o l o n as well. T h e s o l i t a r y c e c a l d i v e r t i c u l u m is a w e l l - r e c o g n i z e d e n t i t y , a b o u t 2 0 0 cases h a v i n g b e e n d e s c r i b e d in B r i t i s h a n d American medical literature. Three recent cases of a c u t e i n f l a m m a t i o n in s o l i t a r y c e c a l d i v e r t i c u l a a r e described. Report of Three Cases (Fig. 1) Patient 1: A 64-year-old man was admitted to the hospital with a 48-hour history of increasing abdominal pain, which had started in the epigastrium and had seemed to radiate to the right iliac fossa. He complained of anorexia and nausea but had not vomited. He also complained of severe headaches, which had started a few hours prior to admission. The patient was obese. Temperature was 99 F. There was vague abdominal tenderness, mainly in the right iliac fossa, especially on deep palpation. Routine examination of the eyes revealed nothing abnormal. A diagnosis of acute appendicitis was made. At operation there was a slight amount of clear fluid in the peritoneum. The appendix looked normal, but there was a hard mass, close to the ileocecal junction, wrapped in edematous omentum. The surrounding cecal wall was also edematous, with enlarged lymph nodes in the mesentery. By invaginating the cecal wall a definite ostium, blocked by a hard fecalith, could be felt at the base of the mass, which was then diagnosed as an inflamed solitary diverticulum. The appendix was removed and a drain inserted down to the inflammatory mass. Closure was effected in layers (as for the usual appendiceal incision). Ampicillin (500 mg, six-hourly) was prescribed postoperatively. The day after operation the headaches continued and acute glaucoma was diagnosed, necessitating treatment by an ophthalmologist. There was no abdominal complications, the pain and fever abating within three days. The drain was removed on the second postoperative day and stitches after seven days. The patient has remained well, with no recurrence of abdominal symptoms. Patient 2: A 59-year-old man was admitted to the hospital with a two-day history of central abdominal pain radiating to the right iliac fossa. He had not vomited, but complained of nausea. On examination, temperature was 99.5 F, and the tongue was furred. There was tenderness in the right iliac fossa, where there was a suggestion of a mass. A diagnosis of acute appendicitis was made. At operation there was a hard mass, enveloped in edematous omentum, on the anterior surface of the cecum close to the ileocecal valve. The appendix looked normal. There were enlarged lymph nodes in the mesentery. Through a small cecostomy the atrium of the sofitary diverticulum couldbe identified and was seen to be blocked by a large fecafith. The appendix was removed, a * Received for publication June 5, 1978. Address reprint requests to Dr. Cutajar at his present address: King Faisal Military Hospital, P.O. Box 101, Khamis Mushayt, Saudi Arabia.
CUTAJAR, M . D . ,
F.R.C.S.
(ENG.), F . R . C . S . (EDIN.)
Department of Surge,y, St. Luke's Hospital, Malta drain was inserted down to the inflammatory mass, and the patient was treated conservatively with Ampicillin postoperatively. He made an uneventful recovery. Patient 3: A 52-year-old housewife was admitted to the hospital with an 18-hour history of abdominal pain, mainly in the right iliac fossa, and pyrexia. She had vomited once. On admission, temperature was 100.2 F and there was a tender mass in the right iliac fossa. At operation, findings were similar to those in the previous two cases: the appendix was congested but not acutely inflamed, and a hard, edematous mass was present in the anterior wall of the cecum close to the ileocecal junction. T h r o u g h a cecotomy, the ostium of the diverticulum was visualized. The appendix was removed. After insertion of a drain the wound was closed, and the patient was treated postoperatively with antibiotics. The immediate postoperative course was uneventful, and the patient was discharged from the hospital after eight days. However, a few months later, she again sought medical treatment, for an incisional hernia. This was repaired using general anesthesia. At operation the opportunity was taken to inspect the cecum: it looked remarkably healthy, with complete disappearance of the diverticulum. Postoperative barium studies showed a completely normal large bowel.
Discussion Incidence: P o t i e r s was t h e first to d e s c r i b e a c u t e inflammation of a solitary diverticulum of the cecum. S i n c e t h e n , a b o u t 2 0 0 c a s e s h a v e b e e n r e c o r d e d in t h e English language medical literature. T h e f i n d i n g o f t h r e e cases, d e s c r i b e d i n t h e p r e s e n t series, o c c u r r i n g w i t h i n a f e w w e e k s o f e a c h o t h e r m u s t b e c o i n c i d e n t a l . I n fact, t h e c o n d i t i o n is u n c o m m o n . W i l l i a m s , 11 in a r e v i e w o f a l a r g e s e r i e s o f barium-enemas examinations, found an incidence of o n l y 0.1 p e r c e n t o f s o l i t a r y c e c a l d i v e r t i c u l a , a l t h o u g h 5 p e r c e n t o f cases s h o w e d i n v o l v e m e n t o f t h e c e c u m with generalized diverticulosis. Podesta and Pace/in a s u r v e y o f t h e i n c i d e n c e o f d i v e r t i c u l a r d i s e a s e in Malta, based on radiologic and necropsy studies of more than 5,000 patients, found only eight cases of d i v e r t i c u l a l i m i t e d to t h e r i g h t c o l o n . O f t h e s e , o n l y t h r e e w e r e s o l i t a r y c e c a l d i v e r t i c u l a , a n d o n l y o n e was associated with clinical symptoms (melena); the others were mainly incidental findings at postmortem examination. A review of the reported cases reveals no significant difference in sex incidences. Average ages of the pat i e n t s h a v e r a n g e d f r o m 39 to 47 y e a r s ? 'I~ T h e p a -
0012-3706/78/1100/0627/$00.65 9 American Society of Colon and Rectal Surgeons
627
628
c.L.
CUTAJAR
Dis. CoL & Rect. Nov.-Dec. 1978
FIG. 1. Sites of solitary cecal diverticula. tients in the p r e s e n t series were older (average age 58 years). Etiology: T h e solitary cecal diverticulum a p p e a r s to be a d i f f e r e n t entity f r o m the c o m m o n diverticular disease o f the sigmoid colon. T h e r e is usually no muscle thickening. Most authorities r e g a r d it as congenital in origin, a l t h o u g h this is by no means c e r t a i n ) '6 Williams u suggests that some o f these diverticula m a y be acquired but o c c u r at a spot w h e r e there is a congenital weakness in the wall o f the cecum. Complications: Diverticulitis is the most c o m m o n c o m p l i c a t i o n . P e r f o r a t i o n o f the d i v e r t i c u l a acc o u n t e d for 20 p e r cent o f the cases r e p o r t e d by Williams, at H e m o r r h a g e is rare. r Diagnosis: In the vast majority o f these cases, the patients have b e e n o p e r a t e d on for acute a p p e n dicitis, u O n l y occasionally has the condition b e e n suspected when the a p p e n d i x has b e e n r e m o v e d . L a i m o n a n d C o h n a state that " . . . the s y m p t o m s and clinical findings were so similar to acute a p p e n dicitis that even in r e t r o s p e c t it was impossible t o . . . exclude the diagnosis o f appendicitis." H o w e v e r , o u r three cases did have some peculiar features that m i g h t suggest the correct diagnosis. I n particular: 1) relatively long histories of increasing
a b d o m i n a l pain, r a n g i n g f r o m t h r e e days to 24 h o u r s b e f o r e admission; 2) Relative lack o f toxicity despite the d u r a t i o n o f s y m p t o m s ; 3) v o m i t i n g is not common; 4) Local t e n d e r n e s s is usually not m a r k e d a n d is elicited mainly on d e e p palpation. Similar findings have b e e n r e p o r t e d by others.-" O p e r a t i v e F i n d i n g s : T h e findings at o p e r a t i o n were r e m a r k a b l y similar in the three cases in this series, a n d correlate closely with those r e p o r t e d p r e viously: 1) In all cases the a p p e n d i x looked n o r m a l . 2) T h e c e c u m was e d e m a t o u s a n d i n f l a m e d a n d contained a h a r d fixed mass, a b o u t the size o f an o r a n g e , close to the ileocecal j u n c t i o n . T h e mass was enveloped in e d e m a t o u s o m e n t u m . 3) E n l a r g e d , firm, m e s e n t e r i c l y m p h nodes w e r e p r e s e n t in all cases. In two cases cecostomy r e v e a l e d the i n d u r a t e d ostium o f the d i v e r t i c u l u m at the center o f the mass. At least one diverticulum c o n t a i n e d a palpable fecalith. T h e closeness o f the mass to the ileocecal j u n c t i o n has b e e n described by several investigators (Table 1). L a u r i d s e n a n d Ross 4 c o m m e n t e d that 80 p e r cent o f i n f l a m e d solitary diverticula o f the c e c u m o c c u r r e d within 2.5 cm o f the ileocecal valve. This f e a t u r e has b e e n t h o u g h t by s o m e aa possibly to p o i n t to the pathogenesis o f solitary cecal d i v e r t i c u l a - - f o o d p r o -
TABLE 1. Clinical Data
Temperature (F) Vomiting Central Pain Tenderness, right iliac fossa Mass, right iliac fossa Preoperative diagnosis Operative diagnosis Postoperative complication
Patient 1 M, 64 Years Old
Patient 2 M, 59 Years Old
Patient 3 F, 52 Years Old
99 +
99.5 +
100.2 1 +
+ Acute appendicitis Solitary cecal diverticulum
+ + Acute appendicitis Solitary cecal diverticulum
+ + Acute appendicitis Solitary cecal diverticulum
Acute glaucoma
Nil
Nil
Volume 2 i Number 8
T.*BLr 2.
Reference Anderson t (1947) Waite 1~ (1954) Parker and Serjeant ~ (1957) Williams 11 (1960) Anscombe et al."- (1967) Present series (I978)
629
SOLITARY CECAL DIVERTICULA
Treatment of Solitary Cecal Diverticula*
Number of Patients
Cecotomy or Right Hemicolectomy
Appendectomy + Drainage + Antibiotics
Simple Diverticulectomy
96 58 3 10 10 3
32 25 1 5 7 0
11 8 2 5 3 3
53 28 -----
* Treatment was mentioned in 180 of approximately 200 cases reported. These are the cases summarized here.
jecting through the ileocecal valve hits a possibly congenital weak spot close to the valve, thus causing a diverticulum to form. Surgical Treatment: A review of the literature has revealed surprising inconsistencies in the treatment of this condition (Table 2). There appear to have been two major problems. The first is the diagnosis of the lesion. Even at operation, misdiagnosis of the lesion has been surprisingly common in all reported series. A third of Anderson's 1 96 patients collected f r o m the l i t e r a t u r e had hemicolectomy for carcinoma. Even when the correct diagnosis has been made, treatment has been far from uniform. Some still preferred to do a major amputation (cecectomy or right hemicolectomy). Others excised the diverticulum. Simple drainage of the inflamed area (usually comb i n e d with a p p e n d e c t o m y ) , with p o s t o p e r a t i v e broad-administration of spectrum antibiotics, has been employed in a smaller proportion of cases, including the three reported here. In the series reported by Lauridsen and Ross, 4 the mortality rate following diverticulectomy was 1.6 per cent, and that following hemicotectomy, 11.4 per cent. In other series mortality rates following simple drainage and antibiotics have ranged from 0 to 0.9 per cent. Although in recent series postoperative mortality following hemicolectomy has been reduced, undoubtedly due to better use of antibiotics postoperatively and improved postoperative care of the patient, it is felt that simple drainage, with postoperative administration of antibiotics, is a simple, safe procedure, which should be the preferred treatment. Our patients had remarkably smooth postoperative courses as regards abdominal pathology. The first patient had an unexpected complication in the form of an attack of acute glaucoma (possibly triggered by preoperative administration of atropine to a susceptible patient), but it was not related to the abdominal condition. Moreover, the stay in hospital following this simple procedure is a third that associated with hemicolectomy.
There is also evidence that acute inflammation of a diverticulum can resolve spontaneously, and may even produce its obliteration? In most reported series, patients treated with antibiotics and drainage have survived without recurrence of symptoms, and subsequent barium-enema studies have failed to demonstrate the cecal diverticulum in many of them. Our three patients have remained very well postoperatively. In the case of Patient 3, there was visual and x-ray evidence of disappearance of the diverticulum. This is thought to be the first published case where complete disappearance of a solitary cecal divert i c u l u m has been c o n f i r m e d at s u b s e q u e n t laparotomy.
Conclusion Three cases of inflammation of a solitary cecal diverticulum are described. T h e preoperative and peroperative difficulties in diagnosis are emphasized. It is suggested that the safest course of treatment is drainage of the inflamed area, with postoperative administration of antibiotics.
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