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Acute heal diverticulitis
Vol. 93, No. 3, 1998 ISSN O@l2-9270/98/$19.00 PIJ s0002-9270(97)00121-4
THE AMERICAN JOURNAL OF GASTRO~ROLOGY Copyright 8 1998 by Am. Cdl. of Gastroenterology Published by Elsevier Science Inc.
Acute Heal Diverticulitis Chandra Prakash, M.D., and Ray E. Clouse, M.D. Division
of Gastroenterology,
Washington
University
Acute diverticulitis of the distal ileum is a rare condition with a clinical presentation usually misinterpreted as acute appendicitis. Most reported cases were diagnosed correctly only after the patient had reached surgery or autopsy (l-3). Primarily because of diagnostic uncertainties, an urgent or semiurgent surgical approach has been considered the treatment of choice with resection of the affected ileal segment. The degree of inflammation accompanying the acute episodes complicates the procedure and often results in additional resection. We report the presentation and good outcome of four patients with ileal diverticulitis who were initially managed conservatively, and suggest that contemporary diagnostic strategies can lead to elective intervention for this uncommon condition.
Missouri
Case 3 A 49-yr-old man presented with intermittent right lower quadrant pain and fevers that had occurred over a 5-wk period. He had been hospitalized for similar complaints on two prior instances, 6 months and 18 months earlier, at which times appendicitis and Crohn’s disease had been suspected (Fig. 2). Prior CT scans h,ad shown inflammatory changes in the region of the terminal ileum, but colonoscopy and terminal ileal biopsy were negative for Crohn’s disease. Physical examination revealed a febrile patient with localized tenderness over a palpable mass in the right lower quadrant. His white blood cell count was 16,400 cells/mm3 with 73% neutrophils, but the rest cmfhis laboratory studies were witbin normal limits. A CT scan of the abdomen showed inflammatory thickening of the base of the cecum and terminal ileum. The appendix was well seen and appeared normal. Treatment with broad-spectrum intravenous antibiotics and bowel rest led to marked improvement over the next several days. A small-bowel barium study showed
CASE REPORTS Case I A 77-yr-old woman presented with constant, nonradiating periumbilical abdominal pain of 4 days’ duration. She had no nausea, vomiting, change in bowel habits, or fever. Physical examination was significant for diffuse abdominal tenderness that was most marked in the right lower quadrant. Admission laboratory studies revealed a white blood cell count of 6600 cells/mm3 (75% neutrophils); chemistry studies including liver enzyme levels were within normal limits. A CT scan of the abdomen showed a 5- X -5-cm density in the right lower abdomen suggestive of a mass lesion in the ascending colon (Fig. 1). However, a complete Nov.
St. Louis,
Case 2 A 58-yr-old man presented with 1 day of epigastric discomfort that migrated to the right lower quadrant. He had mild anorexia but no fever, nausea, vomiting, or change in bowel habits. Physical examination revealed mild right lower quadrant tenderness withou: guarding or rebound tenderness. The white blood cell count was 17,200 cells/ mm3 (78.3% neutrophils). A CT scan of the abdomen showed inflammatory changes centered around the terminal ileum, and the patient was placed on intravenous antibiotics. Small-bowel barium radiographs obtained the following day showed ileal diverticulitis with localized perforation. The patient improved with continued antibiotics and was discharged on the tenth hospital day. Colonoscopy performed a month later showed only scattered colonic diverticuli.
INTRODUCTION
June 16, 1997; accepted
of Medicine,
colonoscopy to the terminal ileum on the following day failed to reveal abnormalities other than scattered colonic diverticuli. An inflammatory process was suspected because of the acute presentation, and antibiotics were initiated. The patient had dramatic improvement in symptoms and complete resolution of abdominal pain and tenderness within 24 h. Small-bowel barium radiographs 2 wk after discharge showed multiple diverticuli in the terminal ileal region. The patient has done well without recurrence of symptoms over 4 months of observation.
Four cases of acute ileal diverticulitis are presented wherein early diagnosis helped avoid emergent surgery. All patients did well initially with conservative medical management. Acute ileal diverticulitis, although uncommon, should be suspected when the clinical presentation indicates an intlammatory condition of the lower right abdomen. Surgery, when required for recurrent disease, can be reserved for the interval between acute episodes. (Am J Gastroenterol 1998;93:452-454. 0 1998 by Am. Coll. of Gastroenterology)
Received
School
IO, 1997. 452
ACUTE
AJG - March 1998
ILEAL
DIVERTKULITIS
453
FIG. 1. CT scan of the abdomenfrom the first case. An inflammatory mass (white arrowheads) is present in the right lower abdomen in the region of the terminal ileum and indenting the cecum (c). The appendix (black arrowheads) appeared normal on the images.
Case
Cl Acute episode
1w
i
x
Diagnosis
0
Surgery
FIG. 3. One film from a barium small-bowel sturdy in the fourth case. A series of small diverticuli (white arrowhe&) was present in the terminal ileum just proximal to the ileocecal valve. c = cecum.
4I
I
0
I
I
I
I
I
I
I
4 8 12 16 Time after first episode (mo)
I
I1
20
FIG. 2. The time course of presentation and diagnosis of acute ileal diverticulitis in the four subjects. Diagnosis was made during the first episode in three cases. Both patients with recurrent episodes have undergone surgical resection, whereas the other two patients remain under medical observation (arrows).
several diverticuli projecting from the terminal ileum, with extrinsic indentation of the medial aspect of the ascending colon near the ileocecal valve. The diagnosisof acute ileal diverticulitis was made, and the patient was discharged on the sixth hospital day with plans for elective resection. A limited resection of the terminal ileum and cecum with primary ileo-ascendinganastomosiswas uneventful; pathological examination of the resection specimenconfirmed the diagnosisof ileal diverticulitis. Case 4 A 67-yr-old woman presentedwith aching epigastric pain of 2 days’ duration, which rapidly migrated to the right lower quadrant. She reported several loose bowel move-
mentson the day of presentationbut no fever, chills, nausea, or vomiting. Physical examination revealed focal tenderness in the right lower quadrant over a mass that was also palpated on rectal exam. Her white blood cell count was 16,300cells/mm3with 85% neutrophils, whereasthe rest of her laboratory studies were unremarkable. A CT scan showed wispy inflammation of mesentec.cfat in the region of the distal ileum and ileocecal valve without abscess formation. Colonoscopy was normal, including mucosalbiopsies of the terminal ileum. She improved rapidly with broad-spectrum antibiotics and bowel rest. Small-bowel barium radiographs showed distal ileal diverticuli (Fig. 3), and the patient was dischargedhome on the seventhhospital day to complete a course of oral antibiotics. She was readmitted 2 monthslater with an identical presentationand later in the hospital course underwent terminal ileal and cecal resection with primary ileocolic anastomosis.Pathological examination of the resected segmentidentified a perforated ileal diverticulum with localized hemorrhageand fat necrosis. DISCUSSION The first report of an acquired diverticulum of the terminal ileum appearedin 1854 by Bristowe 111).Ileal diverticulosis has since become a recognized disorder with a prev-
454
PRAKASH
AND CLOUSE
alence varying from 0.3-1.4% in autopsy studies (4). It was not until 1941 that ileal diverticulitis was first described by Koeletsky (5). In that report, a 55-yr-old man was explored for presumed appendiceal perforation and abscess. The patient subsequently died and a necrotic ileal diverticulum was discovered at autopsy. Small intestinal diverticuli are usually multiple and are most commonly found in the proximal small bowel. The ratio of jejunal to ileal diverticuli has been reported as 5: 1 (6). Possibly related to increased intraluminal pressure in the region, ileal diverticuli are commonly clustered near the ileocecal valve. The divert&Ii are usually acquired and “false,” consisting of a thin-walled sac rimmed by mucosa, submucosa, and serosa, but without a muscularis layer. The abnormalities are located on the mesenteric border at the sites of penetrating vessels from the mesenteric circulation. This is in contrast to Meckel’s diverticulum, which occurs at an antimesenteric site (6, 7). Acute diverticulitis is one of the more common complications of ileal diverticulosis, but free perforation, intestinal obstruction, and hemorrhage also have been reported (1,4, 8). The presentation commonly mimics acute appendicitis, a perforated cancer, or Crohn’s disease of the ileocecal region. Although making the correct diagnosis has allowed successful medical management (9), surgery in the acute setting with or without a period of preoperative antibiotic therapy has been the usual treatment approach (1, 3, 4, 8). Most reports have predated the common use of CT scans and colonoscopy to help clarify the cause of this clinical presentation. We describe four patients aged 49-77 yr with ileal diverticulitis who responded well to conservative management during the acute episodes. In our small series, all patients were of an age group in which appendicitis is less common, and other diagnoses, e.g., inflammatory bowel disease and neoplasia, must be considered first in the differential diagnosis of an acute lower right abdominal process. Colonoscopy and CT scanning helped steer attention away from the appendix and colon, toward the terminal ileum, and barium radiographs subsequently confirmed the diagnosis. This type of contemporary investigative approach avoided early exploration, as had been commonly reported in the past for patients with this diagnosis. Our observations suggest that the acute presentation can be treated similarly to colonic diverticulitis, with bowel rest and antibiotics, provided the correct diagnosis is suspected
AJG .- Vol. 93, No. 3, 1998
or established. Two of the four patients had recurrent symptoms after intervals ranging from 2 months to a year, indicating that recurrences are sufficient1.y common to consider surgical resection an important component of overall management. However, this option could be reserved for those with complicated acute presentations or who have had at least two episodes. Resection in the elective setting or after a period of antibiotic therapy to allow resolution of the inflammatory mass is likely to simplify the procedure and potentially limit the extent of resection. However, it remains unproved whether deferred operative intervention is truly superior to emergent surgery when considering the various outcome measures, and surgery should not be delayed if appendicitis remains suspected. In summary, acute ileal diverticulitis, although uncommon, should be included in the differential diagnosis when physical findings and imaging studies suggest an inflarmnatory process in the right lower abdomen. Suspicion should be heightened if the CT scan and colonoscopy speak against appendicitis, inflammatory bowel disease, or other colonic disorders. Acute ileal diverticulitis responds rapidly to bowel rest and antibiotic treatment. Surgical intervention is not mandated by the diagnosis, can be reserved for patients with recurring episodes, and can be delayed safely until resolution of the acute process in uncomplicated cases. Reprint requests and correspondence: Ray E. Clouse, M.D., Digestive Disease Clinical Center, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110.
REFERENCE!< 1. Cocks JR, Zino FJ. Acute diverticulitis of I he terminal ileum. Br J Surg 1968;55:45-9. 2. Ikenaga T, Takeuchi Y. Acute diverticulitis of the terminal ileum. Am J Gastroenterol 1972;57:68-73. 3. Clements JL. Berman M. Acute diverticulitis of the terminal ileum. Am J Gastroenterol 1970;53: 169-72. 4. Nazir M, Saebo A. Small bowel diverticulosis complicated by diverticulitis and paralytic ileus. Report of a case. Acta Chir Belg 1991;91: 227-8. 5. Koeletsky S. Ruptured diverticulum of ileum; case report presenting clinical features. Ohio State Med J 1941;?z7:1078. 6. Lee RE, Finby N. Jejunal and ileal diverticulosis. Arch Int Med 1958; 102:97-102. 7. Wigh R, Swenson PC. Roentgenologic aspects of diverticulitis and its complications. Am J Surg 1951;82:587-96. 8. Fisher JK, Fortin D. Partial small bowel obstruction secondary to ileal diverticulitis. Radiology 1977;122:321-2. 9. Miller WB, Felson B. Diverticulitis of the terminal ileum. Am J Roentgenol Rad Ther Nucl Med 1966;96:361-5.
THE AMERICAN JOURNAL OF GASTRO~ROLOGY Copyright 8 1998 by Am. Cdl. of Gastroenterology Published by Elsevier Science Inc.
Acute Heal Diverticulitis Chandra Prakash, M.D., and Ray E. Clouse, M.D. Division
of Gastroenterology,
Washington
University
Acute diverticulitis of the distal ileum is a rare condition with a clinical presentation usually misinterpreted as acute appendicitis. Most reported cases were diagnosed correctly only after the patient had reached surgery or autopsy (l-3). Primarily because of diagnostic uncertainties, an urgent or semiurgent surgical approach has been considered the treatment of choice with resection of the affected ileal segment. The degree of inflammation accompanying the acute episodes complicates the procedure and often results in additional resection. We report the presentation and good outcome of four patients with ileal diverticulitis who were initially managed conservatively, and suggest that contemporary diagnostic strategies can lead to elective intervention for this uncommon condition.
Missouri
Case 3 A 49-yr-old man presented with intermittent right lower quadrant pain and fevers that had occurred over a 5-wk period. He had been hospitalized for similar complaints on two prior instances, 6 months and 18 months earlier, at which times appendicitis and Crohn’s disease had been suspected (Fig. 2). Prior CT scans h,ad shown inflammatory changes in the region of the terminal ileum, but colonoscopy and terminal ileal biopsy were negative for Crohn’s disease. Physical examination revealed a febrile patient with localized tenderness over a palpable mass in the right lower quadrant. His white blood cell count was 16,400 cells/mm3 with 73% neutrophils, but the rest cmfhis laboratory studies were witbin normal limits. A CT scan of the abdomen showed inflammatory thickening of the base of the cecum and terminal ileum. The appendix was well seen and appeared normal. Treatment with broad-spectrum intravenous antibiotics and bowel rest led to marked improvement over the next several days. A small-bowel barium study showed
CASE REPORTS Case I A 77-yr-old woman presented with constant, nonradiating periumbilical abdominal pain of 4 days’ duration. She had no nausea, vomiting, change in bowel habits, or fever. Physical examination was significant for diffuse abdominal tenderness that was most marked in the right lower quadrant. Admission laboratory studies revealed a white blood cell count of 6600 cells/mm3 (75% neutrophils); chemistry studies including liver enzyme levels were within normal limits. A CT scan of the abdomen showed a 5- X -5-cm density in the right lower abdomen suggestive of a mass lesion in the ascending colon (Fig. 1). However, a complete Nov.
St. Louis,
Case 2 A 58-yr-old man presented with 1 day of epigastric discomfort that migrated to the right lower quadrant. He had mild anorexia but no fever, nausea, vomiting, or change in bowel habits. Physical examination revealed mild right lower quadrant tenderness withou: guarding or rebound tenderness. The white blood cell count was 17,200 cells/ mm3 (78.3% neutrophils). A CT scan of the abdomen showed inflammatory changes centered around the terminal ileum, and the patient was placed on intravenous antibiotics. Small-bowel barium radiographs obtained the following day showed ileal diverticulitis with localized perforation. The patient improved with continued antibiotics and was discharged on the tenth hospital day. Colonoscopy performed a month later showed only scattered colonic diverticuli.
INTRODUCTION
June 16, 1997; accepted
of Medicine,
colonoscopy to the terminal ileum on the following day failed to reveal abnormalities other than scattered colonic diverticuli. An inflammatory process was suspected because of the acute presentation, and antibiotics were initiated. The patient had dramatic improvement in symptoms and complete resolution of abdominal pain and tenderness within 24 h. Small-bowel barium radiographs 2 wk after discharge showed multiple diverticuli in the terminal ileal region. The patient has done well without recurrence of symptoms over 4 months of observation.
Four cases of acute ileal diverticulitis are presented wherein early diagnosis helped avoid emergent surgery. All patients did well initially with conservative medical management. Acute ileal diverticulitis, although uncommon, should be suspected when the clinical presentation indicates an intlammatory condition of the lower right abdomen. Surgery, when required for recurrent disease, can be reserved for the interval between acute episodes. (Am J Gastroenterol 1998;93:452-454. 0 1998 by Am. Coll. of Gastroenterology)
Received
School
IO, 1997. 452
ACUTE
AJG - March 1998
ILEAL
DIVERTKULITIS
453
FIG. 1. CT scan of the abdomenfrom the first case. An inflammatory mass (white arrowheads) is present in the right lower abdomen in the region of the terminal ileum and indenting the cecum (c). The appendix (black arrowheads) appeared normal on the images.
Case
Cl Acute episode
1w
i
x
Diagnosis
0
Surgery
FIG. 3. One film from a barium small-bowel sturdy in the fourth case. A series of small diverticuli (white arrowhe&) was present in the terminal ileum just proximal to the ileocecal valve. c = cecum.
4I
I
0
I
I
I
I
I
I
I
4 8 12 16 Time after first episode (mo)
I
I1
20
FIG. 2. The time course of presentation and diagnosis of acute ileal diverticulitis in the four subjects. Diagnosis was made during the first episode in three cases. Both patients with recurrent episodes have undergone surgical resection, whereas the other two patients remain under medical observation (arrows).
several diverticuli projecting from the terminal ileum, with extrinsic indentation of the medial aspect of the ascending colon near the ileocecal valve. The diagnosisof acute ileal diverticulitis was made, and the patient was discharged on the sixth hospital day with plans for elective resection. A limited resection of the terminal ileum and cecum with primary ileo-ascendinganastomosiswas uneventful; pathological examination of the resection specimenconfirmed the diagnosisof ileal diverticulitis. Case 4 A 67-yr-old woman presentedwith aching epigastric pain of 2 days’ duration, which rapidly migrated to the right lower quadrant. She reported several loose bowel move-
mentson the day of presentationbut no fever, chills, nausea, or vomiting. Physical examination revealed focal tenderness in the right lower quadrant over a mass that was also palpated on rectal exam. Her white blood cell count was 16,300cells/mm3with 85% neutrophils, whereasthe rest of her laboratory studies were unremarkable. A CT scan showed wispy inflammation of mesentec.cfat in the region of the distal ileum and ileocecal valve without abscess formation. Colonoscopy was normal, including mucosalbiopsies of the terminal ileum. She improved rapidly with broad-spectrum antibiotics and bowel rest. Small-bowel barium radiographs showed distal ileal diverticuli (Fig. 3), and the patient was dischargedhome on the seventhhospital day to complete a course of oral antibiotics. She was readmitted 2 monthslater with an identical presentationand later in the hospital course underwent terminal ileal and cecal resection with primary ileocolic anastomosis.Pathological examination of the resected segmentidentified a perforated ileal diverticulum with localized hemorrhageand fat necrosis. DISCUSSION The first report of an acquired diverticulum of the terminal ileum appearedin 1854 by Bristowe 111).Ileal diverticulosis has since become a recognized disorder with a prev-
454
PRAKASH
AND CLOUSE
alence varying from 0.3-1.4% in autopsy studies (4). It was not until 1941 that ileal diverticulitis was first described by Koeletsky (5). In that report, a 55-yr-old man was explored for presumed appendiceal perforation and abscess. The patient subsequently died and a necrotic ileal diverticulum was discovered at autopsy. Small intestinal diverticuli are usually multiple and are most commonly found in the proximal small bowel. The ratio of jejunal to ileal diverticuli has been reported as 5: 1 (6). Possibly related to increased intraluminal pressure in the region, ileal diverticuli are commonly clustered near the ileocecal valve. The divert&Ii are usually acquired and “false,” consisting of a thin-walled sac rimmed by mucosa, submucosa, and serosa, but without a muscularis layer. The abnormalities are located on the mesenteric border at the sites of penetrating vessels from the mesenteric circulation. This is in contrast to Meckel’s diverticulum, which occurs at an antimesenteric site (6, 7). Acute diverticulitis is one of the more common complications of ileal diverticulosis, but free perforation, intestinal obstruction, and hemorrhage also have been reported (1,4, 8). The presentation commonly mimics acute appendicitis, a perforated cancer, or Crohn’s disease of the ileocecal region. Although making the correct diagnosis has allowed successful medical management (9), surgery in the acute setting with or without a period of preoperative antibiotic therapy has been the usual treatment approach (1, 3, 4, 8). Most reports have predated the common use of CT scans and colonoscopy to help clarify the cause of this clinical presentation. We describe four patients aged 49-77 yr with ileal diverticulitis who responded well to conservative management during the acute episodes. In our small series, all patients were of an age group in which appendicitis is less common, and other diagnoses, e.g., inflammatory bowel disease and neoplasia, must be considered first in the differential diagnosis of an acute lower right abdominal process. Colonoscopy and CT scanning helped steer attention away from the appendix and colon, toward the terminal ileum, and barium radiographs subsequently confirmed the diagnosis. This type of contemporary investigative approach avoided early exploration, as had been commonly reported in the past for patients with this diagnosis. Our observations suggest that the acute presentation can be treated similarly to colonic diverticulitis, with bowel rest and antibiotics, provided the correct diagnosis is suspected
AJG .- Vol. 93, No. 3, 1998
or established. Two of the four patients had recurrent symptoms after intervals ranging from 2 months to a year, indicating that recurrences are sufficient1.y common to consider surgical resection an important component of overall management. However, this option could be reserved for those with complicated acute presentations or who have had at least two episodes. Resection in the elective setting or after a period of antibiotic therapy to allow resolution of the inflammatory mass is likely to simplify the procedure and potentially limit the extent of resection. However, it remains unproved whether deferred operative intervention is truly superior to emergent surgery when considering the various outcome measures, and surgery should not be delayed if appendicitis remains suspected. In summary, acute ileal diverticulitis, although uncommon, should be included in the differential diagnosis when physical findings and imaging studies suggest an inflarmnatory process in the right lower abdomen. Suspicion should be heightened if the CT scan and colonoscopy speak against appendicitis, inflammatory bowel disease, or other colonic disorders. Acute ileal diverticulitis responds rapidly to bowel rest and antibiotic treatment. Surgical intervention is not mandated by the diagnosis, can be reserved for patients with recurring episodes, and can be delayed safely until resolution of the acute process in uncomplicated cases. Reprint requests and correspondence: Ray E. Clouse, M.D., Digestive Disease Clinical Center, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110.
REFERENCE!< 1. Cocks JR, Zino FJ. Acute diverticulitis of I he terminal ileum. Br J Surg 1968;55:45-9. 2. Ikenaga T, Takeuchi Y. Acute diverticulitis of the terminal ileum. Am J Gastroenterol 1972;57:68-73. 3. Clements JL. Berman M. Acute diverticulitis of the terminal ileum. Am J Gastroenterol 1970;53: 169-72. 4. Nazir M, Saebo A. Small bowel diverticulosis complicated by diverticulitis and paralytic ileus. Report of a case. Acta Chir Belg 1991;91: 227-8. 5. Koeletsky S. Ruptured diverticulum of ileum; case report presenting clinical features. Ohio State Med J 1941;?z7:1078. 6. Lee RE, Finby N. Jejunal and ileal diverticulosis. Arch Int Med 1958; 102:97-102. 7. Wigh R, Swenson PC. Roentgenologic aspects of diverticulitis and its complications. Am J Surg 1951;82:587-96. 8. Fisher JK, Fortin D. Partial small bowel obstruction secondary to ileal diverticulitis. Radiology 1977;122:321-2. 9. Miller WB, Felson B. Diverticulitis of the terminal ileum. Am J Roentgenol Rad Ther Nucl Med 1966;96:361-5.