Teaching Case

A 42-year-old man was admitted to the Emergency Department of our hospital with pain located in the right iliac fossa radiating to the back, which started 12 hours prior to admission. He presented no other symptoms.
A laboratory test showed leukocytosis with blood white cell of 16, 6 /mmc.

Physical examination revealed pain in the right iliac fossa with local rebound tenderness.

An abdominal computed tomography (CT) was performed after injection of a iodine contrast medium.
CT demonstrated a solitary diverticulum in the caecum with thickening of the caecal wall, enhancing diverticular wall, stranding of the surrounding fat, a small amount of free fluid located in the right iliac fossa and some bubbles of air adjacent to the diverticulum in relation with micro-perforation.
No signs of inflammation were present in the appendix.
In this case we had a patient with caecal diverticulitis complicated by micro-perforation with Hinchey II stage.
The patient was treated conservatively with antibiotic therapy: ciprofloxacin and metronidazole were administered intravenously for seven days. The patient recovered well with resolution of the symptoms and normal laboratory tests previously to discharge.
Surgeons decided on conservative management since there was no evidence of diffuse peritonitis or failure of conservative treatment.

Caecal diverticulitis is rare in Western countries [1]. Solitary diverticula of the caecum are rare and were first described by Potier in 1912 [2].
Solitary diverticulum of the caecum is believed to be congenital in origin and appears in the 6th week of pregnancy.
Clinically, patients with caecal diverticulitis present with findings similar to caecal appendicitis.
Multi-detector row CT findings consist of asymmetric or circumferential thickening of the caecal wall, focal pericolic inflammation, and demonstration of diverticula. CT can detect complications such as perforation or abscess formation [3-5].
The differential diagnosis of diverticulitis of the right colon is wide and includes acute appendicitis, urinary tract infection, ureteric calculi, pelvic inflammatory disease, caecum malignancy, ileocaecal tuberculosis, and Crohn´s disease [6].
Caecal diverticulitis can mimic acute appendicitis, in these cases the demonstration of a normal appendix and the presence of diverticula in the caecum with inflammatory changes allow for a correct diagnosis [7].
Acute diverticulitis is divided into complicated diverticulitis and uncomplicated diverticulitis.
Complicated diverticulitis is defined as acute inflamed diverticula causing abscess formation, perforation or fistula, and distal septic complications [8].
The severity of acute complicated diverticulitis is classified according to the Hinchey classification.
All guidelines recommend conservative management of small mesocolic abscesses with antibiotics and recommend percutaneous drainage for larger abscesses (size >5 cm) [8]. Surgical treatment is required for patients with diffuse peritonitis for those where nonoperative management of acute diverticulitis failed [9].
The use of CT in the evaluation of right abdominal pain is very helpful for a careful preoperative assessment to exclude malignancy and to diminish the possibility of surgical intervention and patient hospitalization.