The etiology of the colonic diverticulum is currently unknown and generally has no clinical symptoms. In the United States, 4% of patients have clinical symptoms, and 15% of them have complicated disease . In European and American countries, the incidence of acute left-sided colonic diverticulitis (ALCD) is higher, the right-sided colonic diverticulitis (ARCD) is relatively rare, and the ALCD is more common in the elderly . Through a retrospective analysis of colonic diverticulitis in our hospital, ARCD is more common, and ALCD is rare. the proportion of males is higher. The onset age of ARCD is relatively young. This is consistent with some reports in China [3, 4].
Because the location of colonic diverticulitis varies greatly in different regions, there are also great differences in clinical manifestations and treatment plans. Caecal and ascending colonic diverticulitis are the most common in China, especially near ileocecum, which is similar to the clinical symptoms of acute appendicitis, including metastatic right lower abdominal pain, right lower abdominal fixed tenderness, and disease progression, etc . Our hospital prefers non-surgical treatment for acute colonic diverticulitis, and the conservative effect is also commendable. There were no cases of surgical treatment due to conservative inefficacy. However, 24.3% of the cases underwent surgery, mainly because they could not be distinguished from acute appendicitis. All patients underwent a CT examination of the abdomen before surgery, and even experienced doctors may have misdiagnosis. When we carefully analyzed the abdominal CT before an operation, we found that it could be distinguished if we read carefully. However, Acute colonic diverticulitis is usually characterized by acute abdominal pain, so it is difficult to make a rapid diagnosis before an operation. Ultrasonography is recommended for ARCD according to 2020 WESE guidelines because these patients are young and CT poses radiation . Combined with the characteristics of clinical cases in our hospital, the author thinks that CT has more advantages than ultrasound. The most common disease of acute abdominal pain is acute appendicitis in China. Once ultrasound is misdiagnosed as acute appendicitis, we may have an emergency operation. We know that most of them do not require surgical treatment, and abdominal CT can also exclude other diagnoses. However, we know that most diverticulitis does not require surgery. In addition, abdominal CT can also distinguish other diagnoses.
Compared with acute appendicitis, we have found that the clinical symptoms of ARCD were milder, and the symptoms can be relieved in a short time after treatment. Timely and effective treatment rarely leads to diffuse peritonitis or intestinal leakage, which inevitably makes surgeons mistakenly think that diverticulitis is mild. However, in a number of surgical exploration cases, we found that the diverticulum has suppurated and perforated. It has been partially wrapped by the greater omentum, so the clinical symptoms are mild. As mentioned earlier, the patient underwent emergency surgery because we were misdiagnosed as acute appendicitis without severe clinical symptoms. Therefore, we suspect that more patients with suppuration and perforation are in the conservative group. In this article, we found that preoperative CT is difficult to accurately assess whether the ARCD is perforated. There is a higher proportion of grade II in the operation group, but preoperative CT assessment is grade I. CT imaging evaluation is insufficient for Hinchey's classification of ARCD. After consulting the domestic literature in China, the author found that there were many cases of colonic diverticulum perforation, among which sigmoid colon was the most common [5, 6]. The reason may be related to the protection of the greater omentum. ARCD has been wrapped by the greater omentum before suppuration and perforation. The sigmoid colon is not easily wrapped by the omentum, and the patients with sigmoid diverticulitis are generally older.
Colonic diverticulitis is often accompanied by increased inflammation indicators. Some patients with mild symptoms may have normal inflammation indexes. The sensitivity of CRP is relatively high, and the sensitivity of WBC is relatively low. If the inflammation index is not high, the patient can recover quickly without special treatment. MÄKELÄ et al. published a study that showed that CRP > 150 mg/L is an independent risk factor for colonic diverticulitis . In our study, the proportion of patients with CRP > 150 mg/L was relatively less. Simultaneously, there was no significant increase in CRP in the early stage, which did not play an important reference role in treatment. However, CRP has important reference value for the treatment effect. CT imaging can effectively and quickly evaluate the severity of diverticulitis, and patients with limited inflammation usually recover better.
By comparing the operation group with the non-operation group, we found that there was no significant difference in the recurrence rate. But the length of stay in the non-operation group was significantly less than that in the operation group, and the cost of conservative treatment was also lower than that in the operation group. Therefore, we prefer conservative treatment, which is consistent with the results of foreign studies . At present, the main surgical method is colectomy, but surgical trauma is relatively large [8, 9, 10]. There are no detailed guidelines for the treatment of ARCD. In China, colonic diverticulitis often occurs in the cecum and ascending colon. Right hemicolectomy may be required [11, 12]. Most of the cases in our hospital underwent resection and repair of the colonic diverticulum or abdominal drainage. There was no intestinal leakage after operations, and the postoperative recurrence rate was low. Colectomy is not recommended for uncomplicated diverticulitis. It is a question whether it is feasible to repair for acute complicated diverticulitis. We lack a large number of sample studies on the feasibility of diverticulectomy and repair of sigmoid diverticulitis. Only one case of uncomplicated sigmoid diverticulitis in our hospital underwent diverticulum resection, and there was no intestinal leakage after operations.
In this research, we found that colonic diverticulitis usually relapsed within 1 year, and the recurrence rate is low. Colonoscopy is not recommended during hospitalization, which may aggravate the condition. Colonoscopy is routinely recommended for 2–3 months after discharge, but some patients do not undergo colonoscopy. There is a high proportion of young people with diverticulitis in China, who often refuse colonoscopy.