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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 169-171

Rare case of acute abdomen: Right colon perforation due to the colon diverticulitis


1 Department of General Surgery, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey
2 Department of Emergency Medicine, Faculty of Medicine, Bozok University, Yozgat, Turkey
3 Department of Emergency Medicine, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey

Date of Web Publication10-Sep-2018

Correspondence Address:
Faruk Pehlivanli
Department of General Surgery, Faculty of Medicine, Kirikkale University, 71850 Kirikkale
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_38_18

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  Abstract 


Colonic diverticula and related complications are common pathologies in elderly patients. In older patients, colonic diverticulum perforation is more common in the sigmoid colon, whereas right colon diverticulum perforation is rather rare. In younger patients, especially in patients under 30 years of age, right colon diverticula are more common than left colonic diverticula. Therefore, right colon diverticulum perforation should be considered in patients with acute abdomen in this age group. In this case, right column diverticulum perforation is presented in a patient with acute abdomen findings.

Keywords: Acute abdomen, diverticulitis, perforation, right colon


How to cite this article:
Pehlivanli F, Karaca G, Aydin O, Vural S, Coskun F. Rare case of acute abdomen: Right colon perforation due to the colon diverticulitis. Apollo Med 2018;15:169-71

How to cite this URL:
Pehlivanli F, Karaca G, Aydin O, Vural S, Coskun F. Rare case of acute abdomen: Right colon perforation due to the colon diverticulitis. Apollo Med [serial online] 2018 [cited 2019 Oct 22];15:169-71. Available from: http://www.apollomedicine.org/text.asp?2018/15/3/169/240940




  Introduction Top


Right colon diverticulum is a rare pathology that is less common than sigmoid colon diverticulum. Cecum and right colon diverticula are more common in young population.[1],[2] These diverticula are more prevalent in Asian populations.[3] Cecum and right colon diverticula can cause acute abdomen and can often be difficult to diagnose because it can be confused with the most common complicated acute appendicitis in this age group. Right colon diverticula can also be misinterpreted as colon tumors in this region.[4],[5] In this case, the right colon diverticulum perforation is discussed in a 47-year-old male patient who was admitted to emergency service due to acute abdomen and underwent right hemicolectomy.


  Case Report Top


A 47-year-old male patient was admitted to the emergency room with complaints of abdominal pain, distention, nausea, and vomiting that started 2 days ago. The patient had a history of smoking and alcohol consumption and there was no history of drug use. The patient's blood pressure was measured as 130/60 mmHg and fever as 37.5°C. On physical examination, there were tenderness, muscular defense, and rebound in all quadrants with distension. Routine laboratory tests revealed leukocytes: 20,600/mm3, Hb: 13.3 g/dL, Hct: 40, blood glucose: 173 mg/dL, blood urea nitrogen: 59 mg/dL, creatinine: 0.45 mg/dL, Na+: 136 mEq/L, K+: 3.9 mmol/L, Ca + 2: 7.9 mg/L. Liver function tests were normal. Intravenous 0.9% NaCl was initiated and direct abdominal X-ray showed dense gas in the colon and small intestine. Abdominal computed tomography with intravenous contrast showed increased wall thickness in the proximal section of the ascending colon, as well as increased density and minimal fluid consistent with diffuse contamination of the mesenteric fat tissue [Figure 1]. The patient was diagnosed with acute abdomen and was operated. There was blurred fluid in the abdomen. It was seen that the 7-cm long piece of the proximal part of the right colon was severely inflamed [Figure 2] and [Figure 3]. Right hemicolectomy was performed. Pathologic examination was reported as perforated diverticulitis. The patient was discharged without any problems on the 5th postoperative day.
Figure 1: Abdominal computed tomography concentric thickening in the right colon, stenosis in the passage and contamination of the mesentery

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Figure 2: Perforated diverticulum

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Figure 3: Diverticulitis internal lumen and inflammatory mass

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  Discussion Top


Colonic diverticular diseases are a common clinical condition, especially in western societies, and are frequently seen in the left colon (50%–90%). Right colonic diverticula are less common in general population in western countries (0.9%–5%).[6] Right colonic diverticula are more common in Asian populations.[7] In diverticular disease of the right colon, the patient usually presents with right lower quadrant pain. Clinical findings may be mistaken for other acute abdominal diseases and patients are usually diagnosed with acute appendicitis preoperatively.[8] Right colonic diverticular diseases may also be associated with infectious diseases as well as malignant colonic diseases, inflammatory bowel diseases, foreign body perforations, and Yersinia enteritis. Patients with right-sided diverticulosis usually present with right lower quadrant pain and local peritoneal findings, but in this case, there was widespread tenderness and rebound in the abdomen in addition to abdominal pain in the right lower quadrant. For this reason, other pathologic conditions were considered in differential diagnosis rather than appendicitis.

There are various factors in the etiology of diverticular diseases. These include nutrition with low fiber diet, smoking and alcohol use, use of corticosteroids, increased acetylcholine activity in the sigmoid colon, and aging.[9],[10],[11] In our case, there were no additional factors other than smoking and alcohol intake in the patient.

Methods used radiologically in the diagnosis of diverticular disease are also important. In recent studies, it has been reported that right colon diverticulitis is better diagnosed by computerized tomography and the treatment option is determined according to the imaging results.[4],[12],[13] Computerized tomography is useful in differential diagnosis of especially other conditions such as inflammatory bowel disease, tuberculosis, and amebiasis, which give colonic mass images. The radiological appearance of our case has been difficult to diagnose as diverticulum perforation is similar to right colon tumor. Although tomographic examination shows diverticula, the fact that the lesion cannot be distinguished from the colon tumor in the case of diverticulitis affects the intraoperative decision mechanisms as in this case.

The choice of treatment for colonic diverticulitis varies according to the location of the lesion and its complications. A conservative approach is recommended in cases with no complications. Surgery is necessary, however, in cases of complications arising despite conservative treatment.[14] Bleeding, perforation, fistula, and peritonitis should be taken into account when choosing treatment. Surgical options in right colon diverticular diseases range from diverticulectomy to right hemicolectomy. In this case, right hemicolectomy was performed because of the lack of diagnostic accuracy of the imaging technique and presence of perforation.


  Conclusion Top


Although right colon diverticula are rare, they should be kept in mind in the differential diagnosis of acute abdomen, especially in young patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chan CC, Lo KK, Chung EC, Lo SS, Hon TY. Colonic diverticulosis in hong kong: Distribution pattern and clinical significance. Clin Radiol 1998;53:842-4.  Back to cited text no. 1
    
2.
Katz DS, Lane MJ, Ross BA, Gold BM, Jeffrey RB Jr., Mindelzun RE, et al. Diverticulitis of the right colon revisited. AJR Am J Roentgenol 1998;171:151-6.  Back to cited text no. 2
    
3.
Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med 1998;338:1521-6.  Back to cited text no. 3
    
4.
Salzman H, Lillie D. Diverticular disease: Diagnosis and treatment. Am Fam Physician 2005;72:1229-34.  Back to cited text no. 4
    
5.
Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996;171:244-6.  Back to cited text no. 5
    
6.
Nirula R, Greaney G. Right-sided diverticulitis: A difficult diagnosis. Am Surg 1997;63:871-3.  Back to cited text no. 6
    
7.
Jung JY, Park YS, Baek DH, Choi JH, Jo YJ, Kim SH, et al. The prevalence of yersinia infection in adult patients with acute right lower quadrant pain. Korean J Gastroenterol 2011;57:14-8.  Back to cited text no. 7
    
8.
Komuta K, Yamanaka S, Okada K, Kamohara Y, Ueda T, Makimoto N, et al. Toward therapeutic guidelines for patients with acute right colonic diverticulitis. Am J Surg 2004;187:233-7.  Back to cited text no. 8
    
9.
Ornstein MH, Littlewood ER, Baird IM, Fowler J, North WR, Cox AG, et al. Are fibre supplements really necessary in diverticular disease of the colon? A controlled clinical trial. Br Med J (Clin Res Ed) 1981;282:1353-6.  Back to cited text no. 9
    
10.
Papagrigoriadis S, Macey L, Bourantas N, Rennie JA. Smoking may be associated with complications in diverticular disease. Br J Surg 1999;86:923-6.  Back to cited text no. 10
    
11.
Golder M, Burleigh DE, Belai A, Ghali L, Ashby D, Lunniss PJ, et al. Smooth muscle cholinergic denervation hypersensitivity in diverticular disease. Lancet 2003;361:1945-51.  Back to cited text no. 11
    
12.
Oudenhoven LF, Koumans RK, Puylaert JB. Right colonic diverticulitis: US and CT findings – New insights about frequency and natural history. Radiology 1998;208:611-8.  Back to cited text no. 12
    
13.
Jang HJ, Lim HK, Lee SJ, Lee WJ, Kim EY, Kim SH, et al. Acute diverticulitis of the cecum and ascending colon: The value of thin-section helical CT findings in excluding colonic carcinoma. AJR Am J Roentgenol 2000;174:1397-402.  Back to cited text no. 13
    
14.
Wada M, Kikuchi Y, Doy M. Uncomplicated acute diverticulitis of the cecum and ascending colon: Sonographic findings in 18 patients. AJR Am J Roentgenol 1990;155:283-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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