Cecal diverticulitis: The challenge goes on

Diverticula are more common in the left colon and isolated right-sided diverticulum of the colon with perforation is a rare entity. Right sided diverticulitis of the colon is diagnosed in patients approximately a decade younger than the average of those presenting with left sided diverticulitis. Right-sided disease is more frequent in Asian countries like Thailand and Japan. The clinical picture closely mimics appendicitis, but in right-sided diverticulitis pain begins and remains in the right lower abdomen, has a longer symptomatic period and, not infrequently, is intermittent and chronic. In patients exhibiting symptoms lasting 72 h or more, with the absence of nausea, vomiting, and no abdominal mass, diverticulitis of the right colon should be suspected. Both the intra- and extraluminal manifestations of diverticulitis may be demonstrated by a CT scan of the abdomen. Ultrasonography and plain abdominal films are of no diagnostic value. Lately, the use of video laparoscopy has facilitated the differentiation of this entity with appendicitis. Operation should be carried out only if the patient does not improve after initial supportive management. The uncomplicated diverticulum may be managed by simple excision and primary closure. Resection and exteriorization is reserved for those cases where cancer is suspected, or for free perforation or peritonitis. However, right hemicolectomy might be the appropriate procedure for the unexpected cecal mass. Guidelines for the correct approach of the patient complaining of right lower quadrant abdominal pain are provided in a complete flow-chart. Despite great advance in imaging techniques, the disease remains a diagnostic challenge.