Surgical Approach to Cecal Diverticulitis
John S Lane, MD, Rajabrata Sarkar, MD, PhD, Paul J Schmit, MD, FACS, Charles F Chandler, MD, FACS,
Jesse E Thompson Jr, MD, FACS
Background: Cecal diverticulitis is a rare condition in
the Western world, with a higher incidence in people of
Asian descent. The treatment for cecal diverticulitis has
ranged from expectant medical management, which is
similar to uncomplicated left-sided diverticulitis, to
right hemicolectomy.
Study Design: A retrospective chart review was con-
ducted of the 49 patients treated for cecal diverticulitis
at Olive View-UCLA Medical Center from 1976 to
1998. This was the largest-ever single-institution review
of cecal diverticulitis reported in the mainland US.
Results: The clinical presentation was similar to that of
acute appendicitis, with abdominal pain, low-grade fe-
ver, nausea/vomiting, abdominal tenderness, and leuko-
cytosis. Operations performed included right hemico-
lectomy in 39 patients (80%), diverticulectomy in 7
patients (14%), and appendectomy with drainage of in-
traabdominal abscess in 3 patients (6%). Of the 7 pa-
tients who had diverticulectomy, 1 required right hemi-
colectomy at 6 months followup for continued
symptoms. Of the three patients who underwent appen-
dectomy with drainage, all required subsequent hemico-
lectomy for continued inflammation. Of the 39 patients
who received immediate hemicolectomies, there were
complications in 7 (18%), with no mortality.
Conclusions: We endorse an aggressive operative ap-
proach to the management of cecal diverticulitis, with
the resection of all clinically apparent disease at the time
of the initial operation. In cases of a solitary diverticu-
lum, we recommend the use of diverticulectomy when it
is technically feasible. When confronted with multiple
diverticuli and cecal phlegmon, or when neoplastic dis-
ease cannot be excluded, we advocate immediate right
hemicolectomy. This procedure can be safely performed
No competing interests declared.
Presented at the American College of Surgeons 84th Annual Clinical
Congress, Orlando, FL, October 1998.
Received October 26, 1998; Revised February 23, 1999; Accepted February 26,
1999.
From the Department of Surgery, UCLA School of Medicine, Olive View-
UCLA Medical Center, Sylmar, CA 91342.
Correspondence address: Jesse E Thompson Jr, MD, Department of Surgery,
Olive View-UCLA Medical Center, 14445 Olive View, Sylmar, CA 91342.
© 1999 by the American College of Surgeons
Published by Elsevier Science Inc.
in the unprepared colon with few complications. Exci-
sional treatment for cecal diverticulitis prevents the re-
currence of symptoms, which may be more common in
the Western population. (J Am Coll Surg 1999;188:
629–634. © 1999 by the American College of Surgeons)
Cecal diverticulitis is a rare condition that presents
the surgeon with a diagnostic dilemma. Its presenta-
tion can mimic acute appendicitis with fever, leuko-
cytosis, and right lower quadrant abdominal pain.1
For this reason, the correct preoperative diagnosis of
cecal diverticulitis is rarely made, and the surgeon is
often confronted with this condition at the time of
laparotomy. But with the increased use of radiologic
studies in the evaluation of right lower quadrant ab-
dominal pain,2 a correct preoperative diagnosis can
be made. The surgeon must be prepared to treat this
rare condition both before and during the operative
procedure.
The incidence of cecal diverticulitis is low in
the Western population, with a higher occurrence
among people of Asian descent. This difference in
incidence may be explained by distinct pathophysio-
logic mechanisms that are responsible for the disease.
In the Western population, most cecal diverticuli are
solitary; 81% of the cases in a study by Graham and
Ballantyne1 were solitary. Solitary diverticuli are be-
lieved to be congenital, arising as an outpouching of
the cecum at 6 weeks’ gestation.3 These are consid-
ered true diverticuli and are comprised of all layers of
the colon wall, including the muscular layer. Patho-
logic studies are often unable to identify the muscular
layer in specimens of solitary diverticuli because of
concomitant inflammatory changes. Multiple diver-
ticuli are seen more commonly in the Asian popula-
tion and are thought to be pathophysiologically re-
lated to the false diverticuli of the left colon.4 In the
largest-ever review of an Asian population for cecal
diverticulitis, Sugihara and associates4 found that, of
614 patients with diverticulosis, 80% had right-sided
disease. They also found higher intraluminal pres-
sures in the right colon in those patients with diver-
ISSN 1072-7515/99/$19.00
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 630 Lane et al Cecal Diverticulitis
Table 1. Clinical Characteristics of Patients with Cecal
Diverticulitis
Characteristic
Median age (y) 32 (range 12 to 72)
Sex distribution (M:F) 30:19
Asian: non-Asian distribution 11:38
Abdominal pain duration* (days) 3.660.4 days
Nausea/vomiting duration* (days) 2.160.3 days
Temperature* 37.660.1°C
Hematocrit* (%) 41.760.5
WBC* 13,400 6500
RLQ tenderness (%) 92
RLQ mass (%) 8 operation and included right hemicolectomy, divert-
*Measurements expressed as mean 6 SE.
RLQ, right lower quadrant.
ticulosis than in control subjects. These findings in-
dicate that the disease may have two etiologies with
distinct natural histories in different groups of
patients.
The treatment for cecal diverticulitis has ranged
from expectant management to aggressive surgical
resection. Most surgeons agree that if the diagnosis is
made preoperatively, a trial of conservative manage-
ment with intravenous antibiotics is warranted.4-8
But there is considerable controversy surrounding
the surgical treatment of cecal diverticulitis found at
the time of laparotomy. Reports from Hawaii9 and
Singapore,10 where the majority of patients are of
Asian descent have favored a conservative surgical
approach. This involves a prophylactic appendec-
tomy and leaving nonperforated diverticular disease
in situ. Those studies found a low complication and
recurrence rate with subsequent medical therapy.
Other reports11-14 from the mainland US have
recommended resection of all gross disease and had
favorable results. The purpose of this study is to
review our experience with surgical management of
cecal diverticulitis in a predominately non-Asian
population.
METHODS
From 1976 to 1998, 49 patients were treated for
cecal diverticulitis at Olive View-UCLA Medical
Center, a university affiliated county hospital that
serves the greater Los Angeles area. This was the
largest-ever single-institution review of cecal diver-
ticulitis reported in the mainland US. All charts with
a pathologic diagnosis of cecal or right colonic diver-
ticulitis were reviewed. Specific data extracted in-
cluded presenting complaints and physical signs,
preoperative diagnosis, laboratory and radiographic
findings, length of symptoms before treatment, indi-
J Am Coll Surg
cations for operative intervention, operation(s) per-
formed, and morbidity and mortality.
No recognized cases were managed nonopera-
tively. All patients received broad-spectrum antibiot-
ics before operation and continued on them for 3 to
7 days postoperatively. Surgical exploration was car-
ried out through either a right lower quadrant appen-
dectomy incision or a midline approach; this was left
to the discretion of the operating surgeon. The extent
of surgical resection was determined at the time of
iculectomy, or appendectomy with drainage alone.
Intestinal anastomoses were performed using a stan-
dard, hand-sewn, double-layer technique in most
cases (93%), or by the use of surgical stapling devices.
Nasogastric and urinary catheters were used when it
was deemed clinically necessary. Patients were dis-
charged when they were afebrile, tolerated oral feed-
ing, and when all complications had been addressed.
They were seen in a followup clinic 2 weeks after
discharge, with additional visits when appropriate.
Data were compiled on an IBM personal computer,
using a standard Excel 5.0 spreadsheet. Statistical
analyses were performed using IBM software (Mi-
crosoft, Seattle, WA).
RESULTS
Demographics
Forty-nine patients were identified as having cecal
diverticulitis between 1976 and 1998. During this
same period, approximately 7,300 patients were
treated for acute appendicitis; the ratio of appendici-
tis to cecal diverticulitis was 150:1. There were 30
males (61%) and 19 females (39%) with a median
age of 32 (range 12 to 72 years). Eleven patients were
of Asian decent (22%) and 38 were non-Asian
(78%).
The clinical presentation of cecal diverticulitis
was similar to that of acute appendicitis (Table 1).
Acute abdominal pain was present in all patients,
with an average duration of 3.6 days (range 1 to 21
days). Nausea or vomiting occurred in only 5 (11%)
patients for an average of 2.1 days (range 1 to 5 days).
Right lower quadrant tenderness was the most com-
mon physical sign, found in 45 (92%) patients,
and this was accompanied by a palpable mass in
only 4 (8%) patients. A low-grade fever (mean 6
SE) of 37.8 6 0.1°C was often present, along with
mild leukocytosis (13,400 6 500 WBC).
 Vol. 188, No. 6, June 1999
Preoperative studies
Radiologic studies were performed in 59% of pa-
tients: abdominal plain x-rays in 18 (36%), contrast
enema in 6 (12%), CT scan in 7 (14%), and abdom-
inal ultrasound in 10 (20%). A correct radiologic
diagnosis was possible in only three patients; one was
made using barium enema and two confirmed on
CT scan. Despite these correct radiologic diagnoses,
no patients were managed nonoperatively. The most
common preoperative diagnosis was acute appendi-
citis in 82% of patients. In all patients, the indication
for surgery was intraabdominal sepsis from a correct-
able surgical etiology.
Operations performed
At the time of laparotomy, a correct intraoperative
diagnosis of cecal diverticulitis was possible in 41
patients (84%). In the other eight patients, an in-
flammatory mass was found in the right colon and a
perforated carcinoma could not be excluded. Initial
operations performed included right hemicolectomy
in 39 patients (80%), diverticulectomy in 7 (14%),
and appendectomy with drainage of intraabdominal
abscess in 3 (6%). This was performed with a right
lower quadrant incision in 34 patients (69%), while a
midline laparotomy was used in 15 (31%). Subse-
quent operations included four additional right
hemicolectomies, which were performed as reopera-
tive procedures in patients with continued inflam-
matory symptoms. In 1 patient who underwent ini-
tial diverticulectomy, residual diverticular disease
was left in place, necessitating elective right hemico-
lectomy at 6 months. The three patients who under-
went appendectomy and drainage procedure re-
quired reoperation and right hemicolectomy despite
postoperative antibiotic treatment. One patient re-
quired emergent reexploration for intraabdominal
sepsis at 4 days postoperatively, and the remaining
two underwent elective hemicolectomy after 3 to 6
weeks for continued inflammation. Overall, 43 pa-
tients received right hemicolectomy as the definitive
treatment for cecal diverticulitis.
Outcomes
No deaths occurred in any patients treated for cecal
diverticulitis in this period. Seven of 39 patients
(18%) who underwent immediate right hemicolec-
tomy experienced complications. These included 2
superficial wound infections, 1 intraabdominal ab-
scess that required percutaneous drainage, 1 flank
abscess, and 1 wound dehiscence that required oper-
ative closure on postoperative day 10. There were 2
Lane et al Cecal Diverticulitis 631
cases of anastomotic leaks, 1 of which required emer-
gent ileal diversion for peritonitis; intestinal continu-
ity was re-established in this patient in 3 months. The
second leak presented as a fistula 21 months postop-
eratively and resolved without surgical intervention.
Of the 7 patients who underwent diverticulectomy,
there was only 1 complication (14%). This was the
result of an inadequate surgical resection of a pre-
sumed solitary diverticulum that required interval
hemicolectomy. All three patients who underwent
appendectomy with drainage required reoperation
and hemicolectomy for continued inflammation.
Pathologic examination revealed 37 patients
with solitary diverticuli (76%) and 12 with multiple
diverticuli (24%). Because of the severity of the in-
flammatory response, the delineation between true
and false diverticuli was not possible in a significant
number of patients (Fig. 1).
The length of stay in patients who underwent
emergent right hemicolectomy was 10.561.3 days.
In those who underwent diverticulectomy alone,
hospital stay was 4.960.5 days. For the three pa-
tients who had appendectomy with drainage, hospi-
tal stay was prolonged because they required reopera-
tion; the average stay in this group was 25.3613.5
days, with individual stays of 52, 15, and 9 days.
DISCUSSION
The diagnosis and treatment of patients with right
lower quadrant pain and cecal diverticulitis has been
the subject of considerable controversy. Because this
entity mimics acute appendicitis, a correct preopera-
tive diagnosis is often not possible. The surgeon may
first be confronted with the disease at the time of
operation, and the disease may exist in two distinct
pathophysiologic entities. Solitary diverticuli are
more commonly found in the US and are thought to
be congenital in origin.1 Multiple diverticuli are
more frequently seen in the Asian population, and
may be more closely related to the false diverticuli
found in the left colon.4
Previously, it has been thought that routine ra-
diologic examination of patients with right lower
quadrant pain was neither feasible nor cost-
effective.11 With the publication of the landmark ar-
ticle by Rao and coworkers,2 the use of appendiceal
CT in the evaluation of right lower quadrant pain has
become more commonplace. These authors found
appendiceal CT scans to be 98% sensitive and 98%
specific in the diagnosis of acute appendicitis. This
would make routine CT scanning a cost-effective
tool in the diagnosis of acute appendicitis by reduc-
 632 Lane et al Cecal Diverticulitis
Figure 1. Low-power photomicrograph of a solitary cecal diverticulum. Note the surrounding inflammatory response
with nonvisualization of the muscular layer.
ing unnecessary hospitalization and negative explo-
rations for appendicitis. Interestingly, in the course of
their study, the authors were able to correctly diag-
nose two patients with right lower quadrant pain
with cecal diverticulitis; no followup data were pro-
vided. In another study,8 six of seven patients diag-
nosed radiologically with cecal diverticulitis on heli-
cal CT scan were successfully treated without surgical
intervention. In a study from the Netherlands,15 37
of 44 cases of cecal diverticulitis diagnosed by CT or
ultrasound were successfully treated nonoperatively.
Despite differences in philosophy regarding routine
CT scanning, the surgeon may now be faced with an
increasing number of patients with a preoperative
diagnosis of cecal diverticulitis (Fig. 2).
When confronted with the diagnosis of cecal di-
verticulitis in the operating room, the surgeon
should elect to perform a complete resection of all
visible disease. This policy is supported by a number
of observations. First, a review of the American liter-
ature found that a correct intraoperative diagnosis
was possible in only 65% of patients who underwent
emergent right hemicolectomy,1 similar to the 84%
in our review. In this situation, a diagnosis of carci-
noma cannot be excluded and an appropriate cancer
operation should be performed. Second, if divertic-
ular disease is left in place, the recurrence risk of
J Am Coll Surg
right-sided diverticulitis may range from 15%9 to
71%.15 Third, patients with residual diverticular dis-
ease after the initial operation require prolonged hos-
pital stays for antibiotic treatment; this yields a min-
imal reduction in the length of stay.9 Finally,
retrospective reviews have shown that emergent right
hemicolectomies can be performed safely for cecal
diverticulitis with a low mortality rate (1.4%).1
The operative treatment of cecal diverticulitis has
varied in Asia and in the West. Most studies for the
mainland US advocate the use of surgical resection
when addressing cecal diverticulitis.11-14 Some re-
ports from centers that treat predominately Asian
populations have shown the benefit of taking a con-
servative surgical approach.9,10 Ngoi and co-
authors,10 in a study from Singapore, treated 68 pa-
tients with appendectomy and drainage alone for
cecal diverticulitis, and with diverticulectomy in the
case of a perforated diverticulum. Hemicolectomy
was reserved for cases in which carcinoma could not
be excluded. The only significant complications in
this study occurred in patients treated with appen-
dectomy only (cecal fistula and liver abscess) and
followup showed one patient with recurrent symp-
toms that required hemicolectomy. Harada and asso-
ciates,9 in a study from Hawaii, reviewed 90 cases of
cecal diverticulitis, 78% of which were Asian descen-
 Vol. 188, No. 6, June 1999 Lane et al Cecal Diverticulitis 633

Figure 2. Contrast CT scans obtained in a patient with cecal diverticulitis. (A) The cecal wall is thickened with
visualization of multiple diverticuli (large arrow), pericecal inflammation, and fat stranding (small arrows). (B) A normal
appendix (large arrow).

dants. They found only 1 patient of 29 treated with
appendectomy alone developed a complication. The
complication, however, was progressive peritonitis
with azotemia and septicemia, and the complication
rate in that study does not agree with our experience
with appendectomy alone. In a 10-year followup,
Harada and associates found that only 4 of 27 pa-
tients (15%) who had appendectomy developed re-
current symptoms.
While these studies have been used to support a
 634 Lane et al Cecal Diverticulitis
conservative surgical approach to cecal diverticulitis
in a predominately Asian population, we believe that
they underscore the need for a complete surgical re-
section to reduce the risk posed by leaving disease in
situ. Because the pathophysiology of cecal diverticuli
may be different in a predominately Asian popula-
tion, these studies may not be applicable to the main-
land US.
As a result of our experience, we advocate an
aggressive operative approach to the management of
cecal diverticulitis. In our initial experience, three
cases of perforated cecal diverticulitis were treated
with appendectomy alone; all required subsequent
right hemicolectomy. More recently, when con-
fronted with this diagnosis at the time of operation,
we resected all clinically apparent disease with better
outcomes. We advocate diverticulectomy in cases of a
solitary diverticulum, and immediate right hemico-
lectomy in the case of cecal phlegmon or multiple
diverticuli. This procedure can be safely performed
in the unprepared colon, with few complications.
Excisional treatment for cecal diverticulitis prevents
the recurrence of symptoms, which may be more
common in the Western population. Future studies
will be necessary to verify the use of nonoperative
treatment when a preoperative radiologic diagnosis
of cecal diverticulitis is made.
References
1. Graham SM, Ballantyne GH. Cecal diverticulitis. A review of the
American experience. Dis Colon Rectum 1987;30:821–826.
2. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed
tomography of the appendix on treatment of patients and use
of hospital resources [see comments]. N Engl J Med
1998;338:141–146.
3. Waugh TR. Appendix vermiformis duplex. Arch Surg 1941;42:
311–320.
4. Sugihara K, Muto T, Morioka Y, et al. Diverticular disease of the
colon in Japan. A review of 615 cases. Dis Colon Rectum
1984;27:531–537.
5. Asch MJ, Markowitz AM. Cecal diverticulitis: report of 16 cases
and a review of the literature. Surgery 1969;65:906–910.
6. Fischer MG, Farkas AM. Diverticulitis of the cecum and ascend-
ing colon. Dis Colon Rectum 1984;27:454–458.
7. Crist DW, Fishman EK, Scatarige JC, Cameron JL. Acute diver-
ticulitis of the cecum and ascending colon diagnosed by computed
tomography. Surg Gynecol Obstet 1988;166:99–102.
8. Lane MJ, Katz DS, Ross BA, et al. Unenhanced helical CT for
suspected acute appendicitis. AJR 1997;168:405–409.
9. Harada RN, Whelan TJ Jr. Surgical management of cecal diver-
ticulitis. Am J Surg 1993;166:666–669.
10. Ngoi SS, Chia J, Goh MY, et al. Surgical management of right
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11. Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg
1996;171:244–246.
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1981;142:56–59.
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14. Schmit PJ, Bennion RS, Thompson JE Jr. Cecal diverticulitis: a
continuing diagnostic dilemma [see comments]. World J Surg
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Invited Commentary
Jack Pickleman, MD, FACS
Maywood, IL
This is one of the largest institutional experiences
with cecal diverticulitis, and so the authors’ conclu-
sions should be carefully weighed. Much has been
made in the past of the differences between “true”
right-sided and solitary diverticula versus “false” di-
verticula that occur as part of a more diffuse colonic
process. In reality, these two entities may be impos-
sible to differentiate once inflammation occurs, and
so much rumination is not fruitful.
In no published series has the preoperative diag-
nosis of cecal diverticulitis been made with any fre-
quency, so virtually all decisions will be made in the
operating room, usually during a laparotomy per-
formed for suspected appendicitis through a small
right lower quadrant incision. The authors’ ratio of
appendicitis to cecal diverticulitis of 150:1 bears this
out. Occasionally, however, there will be a suspicion
preoperatively that acute appendicitis is not the cul-
prit; most obvious, of course, would be the patient
with a prior appendectomy. Elderly patients or those
with repeated bouts of right lower quadrant pain are
more likely to harbor cecal diverticulitis or, of course,
a perforated cecal carcinoma. In such patients, an
abdominal CT scan should be performed, as an ab-
scess may be present because of any condition that
causes a perforated cecum, and this should be percu-
taneously drained. If only a cecal phlegmon is noted,
the diagnosis is still unclear, and although these pa-
tients may be safely treated with antibiotics only,
colonoscopy to rule out a cecal neoplasm is manda-
tory once signs of acute inflammation have subsided.
Although it is true that some patients with cecal di-
verticulitis may be definitively treated with antibiot-
ics only, recurrence of the process is common and I
agree with the authors that all such patients should
undergo an elective resection.
As emphasized by the authors, most decisions
will be made in the operating room, usually during