Right Colon, Sigmoid Colon, and Transverse Colon Diverticulitis in the Same Patient: Report of a Case

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1 Right Colon, Sigmoid Colon, and Transverse Colon Diverticulitis in the Same Patient: Report of a Case Marc Greenwald, M.D., Tzvi Nussbaum, M.D. Department of Surgery, Division of Colon and Rectal Surgery, North Shore University Hospital, Great Neck, New York Although sigmoid colon diverticulitis is frequently seen, right colon and transverse colon diverticulitis remain rare forms of the disease. This case report examined the disease course of a 46-year-old female who first presented to our institution in 1990 with perforated right-sided diverticulitis. During the next 11 years, she developed sigmoid colon diverticulitis and then transverse colon diverticulitis. The right and sigmoid colon diverticulitis were treated with surgery and the transverse colon diverticulitis was managed conservatively. This is the first reported case of a single patient who had separate episodes of diverticulitis in the right, transverse, and sigmoid colon. The evaluation and management of this patient has mirrored a trend in the literature and clinical practice. [Key words: Diverticulitis; Sigmoid colon; Transverse colon; Right colon] A lthough sigmoid colon diverticulitis is a common occurrence, right colon diverticulitis remains an infrequent phenomenon, and transverse colon diverticulitis is even more rare. After an extensive search of the literature, we were unable to find a documented case of a single patient succumbing to diverticulitis in these three separate locations. REPORT OF A CASE A 46-year-old female presented to our institution in February 1990 with four days of progressive, right, Reprints are not available Correspondence to: Marc Greenwald, M.D., Suite 203, 310 East Shore Road, Great Neck, New York 11023, ymg@ mindspring.com Dis Colon Rectum 2005; 48: DOI: /s y The American Society of Colon and Rectal Surgeons Published online: 7 December 2004 lower-quadrant abdominal pain and nausea. On physical examination she had a temperature of 37.8 C, tenderness in the right lower quadrant, and localized peritoneal findings. Her peripheral blood leukocyte count on admission was 10,400/mm 3 and six hours later it was 20,400/mm 3. She was taken to the operating room with a preoperative diagnosis of perforated appendicitis. A CT scan was not performed. Intraoperatively, a 10-cm 5-cm inflammatory mass in the proximal ascending colon associated with multiple right colonic diverticula was noted and a partial right colectomy with a primary anastomosis was performed. The postoperative course was unremarkable and the patient was discharged home six days after surgery. The pathology revealed perforated diverticulitis associated with a 9-cm 4.5-cm inflammatory mass located 6 cm from the ileocecal valve (Figs. 1 and 2). In 1995, the patient had a routine colonoscopy, which demonstrated sigmoid colon diverticulosis. In July 1996, she returned to the hospital emergency room with the acute onset of left lower quadrant pain and tenderness, a temperature of 38 C and a peripheral blood leukocyte count of 16,300/mm 3. She was diagnosed with acute sigmoid colon diverticulitis, which was confirmed on CT scan (Fig. 3). In August 1999, the patient had another clinical episode of sigmoid colon diverticulitis confirmed by CT scan. Six weeks later, a colonoscopy demonstrated sigmoid colon diverticulosis with thickened folds. Diverticulosis also was noted in the descending colon and the remaining right colon adjacent to the previous anasto- 162

2 Vol. 48, No. 1 RIGHT, SIGMOID, & TRANSVERSE COLON DIVERTICULITIS 163 Figure 3. CT examination demonstrating segmental thickening of the sigmoid colon and pericolic inflammation consistent with acute diverticulitis. Figure 1. Low-power view of diverticulitis (hematoxylin and eosin; 125). Figure 2. Higher-power view of diverticulitis demonstrating inflammatory exudate (hematoxylin and eosin; 250). mosis. The report stated that the transverse colon was free of diverticula. After these two significant episodes of sigmoid colon diverticulitis, the patient had an elective sigmoid resection in October Her postoperative course was once again unremarkable. In February 2001, at age 57 years, she returned to the emergency room with a three-day history of epigastric pain and reported low-grade fevers at home. At the time of admission, she was afebrile and had a peripheral blood leukocyte count of 13,500/mm 3.A CT of the abdomen and pelvis revealed diverticulosis of the transverse colon and associated inflammatory changes consistent with diverticulitis (Fig. 4). She was admitted and treated conservatively with bowel rest and intravenous antibiotics. Her symptoms resolved and her diet was advanced. After five days in the hospital, she was discharged home to complete a Figure 4. CT examination demonstrating an inflamed transverse colon diverticulum and pericolic inflammation consistent with acute diverticulitis. course of oral antibiotics. A follow-up colonoscopy confirmed the presence of multiple transverse colon diverticula. The patient s transverse colon diverticulitis has not returned after two years of follow-up. DISCUSSION Although the cause of diverticulosis of the sigmoid colon may be attributed to sudden contractions in a high-pressure zone, 1 the cause of diverticulosis in the right and transverse colon remains poorly understood. Some authors have argued that transverse colon diverticulosis may possibly be a variant of right colon diverticulosis and congenital in origin, 2,3 and others have commented that right colon diverticula are acquired in a mechanism similar to those of the left colon. 4 When Beranbaum et al. 1 published their article, Diverticular Disease of the Right Colon, in June 1972, they implied that a solitary diverticulum of

3 164 GREENWALD AND NUSSBAUM Dis Colon Rectum, January 2005 the right colon was most probably congenital in origin, whereas multiple diverticula were a result of proximal progression of left-sided diverticulosis. In Wagner and Zollinger s review of the early literature on diverticular disease, they noted that 80 percent of patients with diverticulosis had diverticula in the descending and sigmoid colon, 10 percent had it in the transverse colon, 4 percent had it in the ascending colon, and 2 percent had it in the cecum. 5 The drop in incidence in diverticulosis from the sigmoid colon to the cecum suggests a distal-to-proximal progression of the disease. However, there is a striking increase in the incidence of diverticulitis of the right colon compared with the transverse colon. 6 As suggested by Beranbaum et al., 1 it is the large diameter of the cecum that produces eccentric or asymmetric narrowing and deformity, which ultimately results in diverticulosis and subsequent diverticulitis. 1 Therefore, although diverticulosis of the transverse colon may be more common than diverticulosis of the right colon, diverticulitis may be more common in the right colon. Before the availability of the CT scan to assist in the diagnosis of a patient with abdominal pain, the preoperative diagnosis of right colon diverticulitis was very difficult. Patients with right, lower-quadrant peritonitis were explored and the diagnosis often was made at surgery. During the past decades, a variety of procedures have been recommended for patients with acute right colon diverticulitis discovered at surgery; however, Lo and Chu s 7 review of the literature in 1996 clearly recommends colon resection as the procedure of choice. In 1961, Wagner and Zollinger 5 reported that a correct preoperative diagnosis was made in only 5.3 percent of the 318 cases of right colon diverticulitis that they reviewed. The preoperative diagnosis was appendicitis in 79.6 percent of the cases and cancer was the diagnosis in 4.1 percent of the cases. The first major report in the radiology literature on the CT appearance of right colon diverticulitis was not published until The CT findings of focal pericolonic inflammation, diverticula, and colonic wall thickening were similar to those of leftsided diverticulitis. If a normal appendix could be identified, or if the inflammatory process was cephalad to the ileocecal valve, appendicitis was very unlikely. In and then again in 2002, 9 published case reports of right colon diverticulitis started to include patients who had CT scans as part of their initial evaluation. These case reports and others 4 demonstrated that early CT scans in patients with right, lower-quadrant abdominal pain can help make the diagnosis of right colon diverticulitis and exclude the diagnosis of appendicitis. Furthermore, several recent studies examining the use of early CT scans in patients with suspected appendicitis have demonstrated its efficacy in reducing the negative appendectomy rate In a prospective, randomized study, Walker et al. 10 reported a negative appendectomy rate of 19 percent in patients who did not have CT scans, whereas 5 percent of patients who had CT scans had negative explorations. Thus, the use of the CT scan has improved the accuracy of the preoperative diagnosis of appendicitis, increased the chance of making the diagnosis of right colon diverticulitis, and allowed the initiation of nonoperative management of right colon diverticulitis under the appropriate clinical circumstances. Laparoscopy also has been advocated in two, recent, randomized trials as a means of decreasing the negative appendectomy rate. 13,14 Unfortunately, both of these studies contained foregone conclusions based on flawed study designs. Each of these studies called for the removal of every appendix in the patients randomized to open surgery, and the selective removal in the patients randomized to laparoscopy. None of the patients had preoperative CT scans. In another recent study, Decadt et al. 15 randomized 120 patients with acute, nonspecific, abdominal pain to urgent laparoscopy and observation. Twenty-three of 59 laparoscopy patients had appendicitis and only 8 of 61 observation patients were ultimately diagnosed with appendicitis. Conversely, 11 laparoscopy patients and 39 observed patients were diagnosed with nonspecific abdominal pain. The authors concluded that laparoscopy was associated with a higher diagnostic accuracy than observation and that less appendicitis was diagnosed in the observed patient group because early appendicitis may have resolved with empirical antibiotic therapy. Although only two of the observed patients and none of the laparoscopy patients had CT scans, three of the laparoscopy patients and none of the observation patients were diagnosed with cecal diverticulitis. Based on the previous cited literature, it is likely that the diagnostic accuracy of the observation group would have significantly increased if more CT scans were performed. Both early appendicitis and right colon diverticulitis may have been diagnosed rather than successfully treated with empirical antibiotics and labeled as nonspecific abdominal pain. The evolution of the literature examining transverse colon diverticulitis is similar to that of right colon di-

4 Vol. 48, No. 1 RIGHT, SIGMOID, & TRANSVERSE COLON DIVERTICULITIS 165 verticulitis. Since Thompson and Fox first published their case report of a perforated solitary diverticulum of the transverse colon in 1944, 16 the literature has been limited until recently to case reports in which a great majority of patients had resections because of the failure to make the diagnosis preoperatively. 2,3,17 22 It wasn t until 1999, when Jasper et al. 22 published their article on the nonoperative management of transverse colon diverticulitis in a series of four patients that conservative management was considered. In all four patients, the diagnosis of transverse colon diverticulitis was made with a CT scan. In their series, two of four patients who were treated nonoperatively were found to have pancolonic diverticulosis: one had diverticulosis of the transverse and sigmoid colon, and the last had diverticula limited to the transverse colon. One patient of the group developed sigmoid colon diverticulitis. However, none of the patients developed diverticulitis in all three segments of the colon. The clinical course of diverticulitis in three separate locations in the patient in this report mirrors the trend in clinical practice and in the literature toward the more liberal use of the CT scan in the assessment of a patient with abdominal pain. Our patient was first seen in 1990 with right colon diverticulitis. The patient did not have a CT scan, and a laparotomy and right colectomy were performed partially because of an incorrect preoperative diagnosis of perforated appendicitis and because the correct diagnosis of acute right colon diverticulitis was not made until the right lower quadrant was explored at surgery. It is unclear from the record whether our patient could have avoided a right colectomy if an early CT scan was performed. The patient had progressive right lower quadrant peritoneal findings and a rising peripheral blood leukocyte count while being observed. Furthermore, the preoperative diagnosis was perforated appendicitis, which is an indication of the severity of the clinical presentation. The pathologic evaluation of the right colon of our patient revealed multiple diverticula, which is consistent with an acquired origin. Unfortunately, the inflammation was so severe that the histology could not confirm this presumption. CONCLUSIONS Several articles since 1990 support the use of an early CT scan in patients with right-sided abdominal pain in an effort to reduce the negative appendectomy rate by more accurately diagnosing intraabdominal pathology. This has increased the opportunity for nonoperative management of patients with acute right colon diverticulitis in appropriate cases, similar to the use of nonoperative management of patients with acute sigmoid colon diverticulitis. In 1996 and 1999, the early CT scan was used in our patient to assist in the diagnosis and initial conservative management of sigmoid colon diverticulitis. These CT documented episodes of sigmoid colon diverticulitis ultimately led to an elective sigmoid resection in the end of In 2001, the use of the CT scan helped to avoid a laparotomy and to preserve our patient s remaining transverse colon. This case report and literature review clearly support the growing trend of the broader use of the early CT scan as an adjunct to the evaluation of the patient with acute abdominal pain. REFERENCES 1. Beranbaum SL, Zausner J, Land B. Diverticular disease of the right colon. Radiology 1972;115: Chughtai SQ, Ackerman NB. Perforated diverticulum of the transverse colon. Am J Surg 1974;127: McClure ET, Welch JP. Acute diverticulitis of the transverse colon with perforation. Arch Surg 1979;114: Katz DS, Lane MJ, Ross BA, Gold BM, Jeffrey RB, Mindelzun RE. Diverticulitis of the right colon revisited. Am J Rad 1998;171: Wagner DE, Zollinger RW. Diverticulitis of the cecum and ascending colon. Arch Surg 1961;83: Wood CD. Acute perforations of the colon. Dis Colon Rectum 1977;20: Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996;171: Nirula R, Greaney G. Right-sided diverticulitis: a difficult diagnosis. Am Surg 1997;63: Funicello A, Fares L, Oza K, Valaulikar G, Ernits M. Right-sided diverticulitis surgical and nonsurgical treatment: two case reports and review of the literature. Am Surg 2002;68: Walker S, Haun W, Clark J, McMillin K, Zeren F, Gilliland T. The value of limited computed tomography with rectal contrast in the diagnosis of acute appendicitis. Am J Surg 2000;180: Rao P, Rhea J, Novelline R, Mostafavi A, McCabe C. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998;338: Horton M, Counter S, Florence M, Hart M. A prospective

5 166 GREENWALD AND NUSSBAUM Dis Colon Rectum, January 2005 trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient. Am J Surg 2000;179: Larsson P-G, Henriksson G, Olsson M, et al. Laparoscopy reduces unnecessary appendectomies and improves diagnosis in fertile women. Surg Endosc 2001; 15: Laine S, Rantala A, Gullichsen R, Ovaska J. Laparoscopic appendectomy is it worthwhile? Surg Endosc 1997; 11: Decadt B, Sussman L, Lewis MP, et al. Randomized clinical trial of early laparoscopy in the management of acute non-specific abdominal pain. Br J Surg 1999;86: Thompson GF, Fox PF. Perforated solitary diverticulum of the transverse colon. Am J Surg 1944;66: Kent SJ. Diverticulitis of the transverse colon. BMJ 1973; 2: Lockhart-Mummery HE. Localized diverticulitis in the transverse colon. Br J Surg 1949;36: Shperber Y, Halevy A, Oland J, Orda R. Perforated diverticulitis of the transverse colon. Dis Colon Rectum 1986;29: Law WL, Liu CL, Chan WF, Ho JW, Chu KW. Perforated diverticulitis of the transverse colon. Eur J Surg 2000; 166: Yamamoto M, Okamura T, Tomikawa M, et al. Perforated diverticulum of the transverse colon. Am J Gastroenterol 1997;92: Jasper DR, Weinstock LB, Balfe DM, Heiken J, Lyss CA, Silvermintz SD. Transverse colon diverticulitis: successful nonoperative management in four patients. Report of four cases. Dis Colon Rectum 1999;42:955 8.