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RIGHT SIDED DIVERTICULAR DISEASE
Simran Singh*, K Shakthi Kumar*, Roshan Dath**,M Paul Korath***, K Jagadeesan****
*DNB Resident, Radiodiagnosis; **Resident in Surgery; ***Chief Physician; ****Director, KJ Hospital Research and Post Graduate Centre, Chennai - 600 084.
INTRODUCTIONDiverticular disease of colon is often localised to one part of colon usually the sigmoid. It is commoner in the West but rare in Africans and Asians who eat a diet rich in natural fibre. On the other hand right sided colonic diverticuli is a distinct disease entity more common in the East. Its incidence in China and Hongkong is more than that reported in India. We present here a case of right sided diverticular disease (RSDD) of the colon.
CASE REPORT
A 40 year old man was admitted to our hospital with complaints of diffuse pain over right lumbar and iliac fossa of three months duration which had increased in intensity since the past 10 days. There was no associated vomiting but the pain worsened in the night and on taking alcohol.
There was no significant contributory past, personal or family history. Clinically his general physical examination was normal. He was mildly febrile with normal vital signs. Principle systems were normal except per abdominally there was tenderness with guarding in the right lumbar and iliac fossa and mild distension of the abdomen. Provisionally three possible diagnosis were thought of 1) High lying appendicitis, 2) Diverticulitis and 3) Right sided renal calculus.
Haematological investigations revealed mild leucocytosis but biochemical tests, urine and stool routine were normal. Plain chest skiagram and KUB skiagram were normal. Excretory urogram was also reported normal except for slight spasm of the calyces, bilaterally. Sonogram of the abdomen and pelvis did not pick up any pathology which could be responsible for the patient's symptoms.
A gastrograffin enema was done and it revealed multiple diverticula more numerous in the right colon. A contrast filled appendix was also seen.
DISCUSSION
Diverticula of the colon are acquired herniations of mucosa protruding through the circular muscle at the points where blood vessels penetrate the colonic wall. These occur in rows and are most commonly seen in the sigmoid colon, right sided colon being rarely involved.[1] Prevalence of colonic diverticulosis has a wide geographic and ethnic variation and has been considered to be quite low in India. Most patients are city dwellers, vegetarians and belong to upper socio economic status.[2]
Incidence of right sided diverticular disease increases in middle aged subjects.[3] High intraluminal pressure and abnormal motility in the ascending colon plays an important role in pathogenesis of RSDD.[4] Two types of diverticula have been described in right colon on the basis of aetiology and pathological features-multiple diverticula and solitary caecal diverticula. The most common clinical presentation of right sided colonic diverticula is an acute inflammatory complication which is difficult to distinguish from other causes of right iliac fossa pain.[5] Pre operative diagnosis of appendicitis is almost always made in these patients.[6]
Diagnosis of diverticular disease is made usually on Barium or gastrograffin enema. In patients who undergo surgery for appendicitis right sided diverticular disease should be sought if a normal appendix is discovered. Barium enema must be done only when any acute inflammation has subsided. Computed tomography has been helpful for early diagnosis. On CT regional thickening of colonic wall, an extraluminal mass involving the caecum and or ascending colon, haziness and strands in adjacent pericolic fat and thickening of nearby fascial planes. Besides these features extraluminal air and contrast filled structures can be seen thus making CT a useful tool for evaluation of right sided diverticular disease.[7]
Management is conservative in acute phase. About ten per cent of these patients require surgery usually resections of the involved segment followed by end to end anastomosis either for recurrent attacks which affect quality of life or for complications.
Our patient responded to conservative management with rest, antibiotics, and was advised right hemicolectomy.
CONCLUSION
Our patient did not undergo a CT scan as the diagnosis was confirmed on the gastrograffin enema. He was managed conservatively although he was advised right hemicolectomy, he wished to defer the same. He has been reviewed twice following discharge and is reported to be doing fine.
REFERENCES1.Carus T, Rohn D. Diagnosis and surgical therapy of right colonic diverticulitis. Langenbecks Arch Chir 1995; 380 (5) : 288-91.
2.Goenka MK, Nagi B, Kochhar R, et al. Colonic diverticulosis in India; the changing scene. Indian J of Gastroenterol July, 1994; 13 (3) : 86-8.
3.Miura S, Kodaira S, Aoki H, et al. Bilateral type diverticular disease of colon. Int J Colorectal Dis 1996; 11 (2) : 71-5.
4.Sugihara K, Muto T, Morioka Y. Motility study in right sided diverticular disease of the colon. Gut Dec., 1983; 24 (12) : 1130-4.
5.Giuffrida MC, Gelarda E, Mezzatesta P, et al. Diverticula of right colon. The diagnosis and treatment of complications. Minerva Chir Dec., 1997; 52 (12) : 1503-12.
6.Nirula R, Greaney G. Right sided diverticulitis; a difficult diagnosis. An Surg Oct., 1997; 63 (10) : 871-3.
7.Scatarige JC, Fishman EK, Crist DW, et al. Diverticulitis of the right colon. Am J Roentgenol Apr., 1987; 148 (4) : 737-9.
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