Right-sided colonic diverticulitis: management of an unusual entity

In Western countries, acute colonic diverticulitis occurs mainly in the sigmoid colon. Right-sided diverticula account for only 5% of diverticulosis cases and 1.5% of diverticulitis in Western countries. In contrast, in Asian countries up to 20% of diverticulosis and 75% of diverticulitis occur in the right colon (RCD). Although colonic diverticulosis is most often asymptomatic, it can be clinically significant because of the serious complications it can present, such as abscess, perforation or bleeding. Unlike diverticula of the left colon, diverticula of the right colon are usually unique and, in these cases, are 'true' congenital diverticula with protrusion of the entire colon wall. Colon.¹ Patients with RCD tend to be younger than those with the same entity on the left side. In addition, RCD is associated with a lower risk of recurrence. Early diagnosis of RCD is often difficult due to its clinical presentation and resemblance to acute appendicitis.² Treatment varies from conservative with antibiotics to urgent surgery, depending on severity.³ The aim of our study was to evaluate a cohort of patients with RCD attending our ED, to analyse patterns of presentation, recurrences and treatment performed.

We reviewed the electronic records of all patients admitted to the hospital for RCD between 2016 and 2019 and recorded all follow-up events.

A total of 24 patients were analysed, 56% male, with a mean age of 53 years. None of the patients presented with fever on arrival at the emergency department. Laboratory findings showed that 70.8% of patients had leukocytosis at presentation and 75% had an elevated CRP (>50 mg/dL). Twenty-two (91.7%) presented with their first episode and only 2 were recurrences. All patients were diagnosed by computed axial tomography. Hinchey classification on admission was: Ia: 22 (91.7%), Ib: 2 (8.3%). Only one patient required surgical intervention (right hemicolectomy) due to poor clinical and analytical evolution despite antibiotic treatment. The other 23 cases (95.9%) were treated with antibiotics, with a different variety of regimens. Patients with uncomplicated diverticulitis were treated with amoxicillin-clavulanic acid or the combination of ceftriaxone and metronidazole. However, those with complicated diverticulitis received antibiotic treatment with piperacillin-tazobactam. Diverticulitis occurred in 29.2% of the patients in the cecum (Fig. 1) and 70% of the patients in the ascending colon (Fig. 2). The average length of stay was 6.04 days (range 3–12). During follow-up, 3 patients required readmission, one of them for RCD and the other 2 for left-sided colonic diverticulitis.

Fig. 1.

Diverticulitis of the cecum.

Fig. 2.

Diverticulitis in right and transverse colon, with mural thickening.

RCD is a rare entity that can usually be treated with antibiotics and appears to be less recurrent than left diverticulitis.⁴ Although right-sided colonic diverticulosis is most often asymptomatic, it can be clinically significant because of serious complications such as abscess, perforation or bleeding, and may require surgical intervention in some cases.⁵ Although the published literature indicates that race is a risk factor (more common in Asians), it can also occur in Western populations (all our patients were European Caucasians). Its presentation may mimic other common conditions such as acute appendicitis with right lower quadrant abdominal pain in young people, so imaging techniques are usually mandatory for diagnosis. This cohort study highlights the importance of an uncommon condition that should be considered in the differential diagnosis of patients with right-sided abdominal pain⁶ and should be known to all surgeons working in the emergency department.⁷

Funding

This study received no funding.