Presentation of solitary caecal diverticulitum imitating acute appendicitis

Description

Caecal diverticula are rare phenomena in the Western world especially among the Caucasian cohort.¹ The incidence in Europe is 1–2% compared with 43–50% within Eastern Asia.¹ In most situations, the presentation is similar to appendicitis offering an interesting diagnostic dilemma.

A 50-year-old athletic woman with no medical or surgical history presented with a 1-day history of constant abdominal pain. She initially developed central abdominal pain which migrated to the right iliac fossa. She felt nauseous but had no vomiting or urinary symptoms.

On examination, she had no fever, her pulse was 46 bpm and blood pressure 96/52 (observations consistent with her hobby of fell running). There was no respiratory compromise. Abdominal examination revealed localised tenderness and guarding in the right iliac fossa. Her preoperative bloods were normal, and a presumptive clinical diagnosis of acute appendicitis was made. She had no preoperative radiological investigations performed as the suspicion of acute appendicitis was high.

On exploration a normal appendix was found with a solitary caecal inflamed diverticulum. She underwent a caecal diverticulectomy and appendicectomy, and was discharged with oral analgesia 3 days later. A specimen histology revealed inflammation of a caecal diverticulum and normal appendix (figure 1).

Figure 1.

Inflamed caecal diverticula presenting as acute appendicitis (appendix not visible).

Caecal diverticula are thought to be congenital in origin. Other contributory factors include decreased fibre intake and lack of exercise—factors absent in this lady.²

Conservative management is only applicable if a strong diagnosis of right-sided diverticulitis is made through radiological investigations. Otherwise surgical management should be undertaken ranging from diverticulectomy, ileocaecal resection or right hemicolectomy.³

Learning points.

• Consider caecal diverticulitis in patients presenting with right iliac fossa pain.

• Radiological investigations such as ultrasound, CT and MRI can be useful in determining caecal diverticulitis.

• The surgical management should be tailored to the individual patient depending on their clinical picture, discovery on radiological investigations and during exploration in the operating theatre—sometimes a simple excision compared with radical hemicolectomy is enough. Furthermore, this lady could have had a laparoscopic procedure. This has the advantage of improved diagnostic capability, reduced pain as a result of smaller incisions, shorter recovery time and shorter hospital stay.