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Special Feature
March 01, 2008

Image of the Month—Diagnosis

Arch Surg. 2008;143(3):310. doi:10.1001/archsurg.143.3.310
Answer: Cecal Diverticulitis

On examination of the cecum and appendix, it became apparent that the firm, whitish structure protruding from the anterior aspect of the cecum was a diverticulum. It measured 2.0 × 2.0 × 1.8 cm and appeared grossly necrotic with considerable inflammation in the surrounding area. Although the appendix seemed superficially inflamed, this was secondary to the inflamed diverticulum. Other than the findings noted earlier and a second, noninflamed diverticulum near the ileocecal junction, the cecum and the remainder of the colon appeared normal and free of diverticuli. The patient underwent an uncomplicated laparoscopic-assisted limited ileocecectomy with ileocolostomy and was without symptoms 1 year after discharge. Histopathological analysis of the specimen revealed mucosal inflammation and necrosis of a true diverticulum of the cecum without extension into the muscularis. The rest of the cecum, the appendix, and the remainder of the specimen had no evidence of any other abnormalities.

Diverticulum of the cecum is a rare condition that was first described in 1912 by Potier.1When it manifests in the presence of diffuse diverticulosis of the colon, it is likely to be a false diverticulum, consisting of an outpouching of mucosa through a weakened area in the muscularis. However, an isolated cecal diverticulum in the absence of generalized colonic involvement is more likely to be a true diverticulum. In this case, we had a true diverticulum of the cecum as confirmed by histopathological analysis. It has been argued that right-sided diverticulitis has a benign natural history, and the same may hold true for isolated cecal diverticulitis.2,3However, in a large series of 112 cases, aggressive management with segmental resection and anastomosis was advocated because of a high recurrence rate (25%) with conservative management.4Diverticulectomy is an option if it can be accomplished without encroaching on the ileocecal valve or endangering the blood supply of the cecum.5In the case at hand, extensive gangrene of the diverticulum with phlegmon formation involving a large part of the cecum as well as the presence of a second diverticulum at the ileocecal junction precluded a diverticulectomy. Cecal diverticulitis is more often than not discovered during surgery for presumed appendicitis, and awareness of this diagnostic pitfall can better prepare the surgeon and the patient regarding therapeutic options.

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Submissions

Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgeryhas temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid-2008. Thank you.

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Article Information

Correspondence:C. Joe Northup, MD, Department of Surgery, University of Virginia Health System, PO Box 800709, Charlottesville, VA 22908-0709 (cjn5t@virginia.edu).

Accepted for Publication:November 28, 2006.

Author Contributions:Study concept and design: Schirmer and Northup. Acquisition of data: Gupta. Analysis and interpretation of data: Schirmer. Drafting of the manuscript: Gupta. Critical revision of the manuscript for important intellectual content: Schirmer and Northup. Statistical analysis: Gupta. Administrative, technical, and material support: Gupta. Study supervision: Schirmer and Northup.

Financial Disclosure:None reported.

References
1.
Potier  F Diverticulite et appendicite. Bull Mem Soc Anat Paris 1912;13729- 31
2.
Oudenhoven  LFKoumans  RKPuylaert  JB Right colonic diverticulitis: US and CT findings: new insights about frequency and natural history. Radiology 1998;208 (3) 611- 618
PubMedArticle
3.
Harada  RNWhelan  TJ  Jr Surgical management of cecal diverticulitis. Am J Surg 1993;166 (6) 666- 671
PubMedArticle
4.
Fang  JFChen  RJLin  BCHsu  YBKao  JLChen  MF Aggressive resection is indicated for cecal diverticulitis. Am J Surg 2003;185 (2) 135- 140
PubMedArticle
5.
Ngoi  SSChia  JGoh  MYSim  ERauff  A Surgical management of right colon diverticulitis. Dis Colon Rectum 1992;35 (8) 799- 802
PubMedArticle
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