Manejo de la Diverticulitis Apendicular: una patología poco común

La diverticulitis apendicular es una enfermedad poco frecuente, con una incidencia aproximada de 1%. Se define por la presencia de divertículos verdaderos o falsos en la pared del apéndice cecal. Durante la fase aguda posee una clínica indistinguible a la apendicitis, sin embargo en ocasiones presenta características clínicas particulares que la distinguen de la apendicitis aguda, tales como la presencia de dolor abdominal insidioso o intermitente y/o ausencia de sintomatología gastrointestinal (náuseas, vómitos o anorexia). En la diverticulitis apendicular las técnicas imagenológicas son de utilidad limitada al otorgar información inespecífica, por lo que el diagnóstico tiende a realizarse mediante el estudio anatomopatológico del apéndice posterior a una intervención quirúrgica en paciente con cuadro clínico compatible con apendicitis aguda. El tratamiento de elección corresponde a la apendicectomía, lo que permite evitar complicaciones futuras como por ejemplo perforación apendicular, neoplasias, entre otros. Se obtuvieron los datos de fuentes como Pubmed y Scielo. Específicamente la búsqueda de artículos originales y de revisiones sistemáticas, preferentemente menores a 15 años de publicación en revistas científicas de alto índice de impacto, con las palabras "diverticulitis apendicular", "diverticulosis" y "complicaciones diverticulares".

Appendiceal diverticulitis is a rare disease with an incidence of approximately 1%. It is defined by the presence of true or false diverticula in the wall of the cecal appendix. During the acute phase, it has symptoms that are indistinguishable from appendicitis, however, it sometimes presents particular clinical characteristics that distinguish it from acute appendicitis, such as the presence of insidious or intermittent abdominal pain and/or the absence of gastrointestinal symptoms (nausea, vomiting, or anorexia). In appendiceal diverticulitis, imaging techniques are of limited utility as they provide non-specific information, so the diagnosis tends to be made through the pathology study of the treatment after surgery in a patient with a clinical picture compatible with acute appendicitis. The treatment of choice corresponds to appendectomy, which allows avoiding future complications such as appendiceal perforation, neoplasms, among others. Data were obtained from sources such as Pubmed and Scielo, specifically searching for original articles and systematic reviews with the words "apendicular diverticulitis", "diverticulosis" and "diverticular complications". The criteria used were articles mainly under 5 years of publication in high-impact scientific journals.

Diverticulitis apendicular, reporte de un caso

Objetivo: Presentar un caso de diverticulitis apendicular y compararlo con la literatura actual. Material y M étodo: Registro clínico de un paciente que ingresa a urgencias del Hospital Padre Hurtado, incluyendo cuadro clínico, imagenología, manejo quirúrgico y anatomía patológica. Resultados: Paciente se presenta con cuadro de dolor abdominal atípico, con imagen sugerente de apendicitis diverticular. En pabellón se logra completar apendicectomía laparoscópica con buena evolución posterior. Al estudio patológico se confirman características histológicas de diverticulitis perforada apendicular. Discusión: Se presenta un cuadro clínico que se condice con lo descrito en la literatura actual, aportando imágenes características, tanto de radiología como histopatología. Conclusión: Debido a su mayor riesgo de perforación y mortalidad, la diverticulitis apendicular es una patología que debe considerarse en los diagnósticos diferenciales de dolores abdominales atípicos, en hombres mayores de 30 años, especialmente con los hallazgos imagenológicos característicos.

Objective: To present a clinical case of appendiceal diverticulitis and compare it to contemporary literature. Material and Method: Clinical record of a patient who attends the emergency service of Hospital Padre Hurtado, including clinical presentation, image studies, surgical management and histopathology studies. Results: A patient presents with atypical abdominal pain, image studies suggest appendiceal diverticulitis. Laparoscopic appendectomy was performed with optimal postoperative results. Pathological biopsy studies confirm histological characteristics of a perforated appendiceal diverticulitis. Discussion: A clinical case is presented, which correlates well with contemporary literature of the subject. We provide characteristic image and histopathological studies. Conclusion: Due to its higher perforation rate and mortality, appendiceal diverticulitis is a pathology which must be considered in the differential diagnosis of atypical abdominal pain, in males over 30 years old, especially with characteristic image studies.

Diverticulitis apendicular, como diagnóstico diferencial / Appendiceal diverticulitis as differential diagnosis

RESUMEN La diverticulitis apendicular (DA) es una patología poco frecuente, considerada clínicamente indistinguible de la apendicitis aguda, aunque podría presentar una sintomatología más leve. Este es el caso de un paciente masculino de 59 años, que concurre al Servicio de Urgencias presentando signos y síntomas sugestivos de una apendicitis aguda; una ecografía informa un asa tubular parcialmente compresible de 7,8 mm de diámetro y una fina banda de líquido laminar, compatible con proceso apendicular agudo. La apendicectomía se realizó de manera convencional evidenciándose un apéndice inflamado principalmente en su región distal. La histología reveló diverticulitis apendicular complicada con rotura. El paciente evolucionó favorablemente y se externó a las 24 horas. Existe una asociación de DA y neoplasia apendicular, por lo que se recomienda una colonoscopia y el seguimiento de este tipo de pacientes.

ABSTRACT Appendiceal diverticulitis (AD) is a rare condition considered clinically identical to acute appendicitis although it may present milder symptoms. We report the case of a 59-year-old male patient who visited the emergency department due to signs and symptoms suggestive of acute appendicitis. An abdominal ultrasound showed partially compressible tubular loop with a diameter of 7.8 mm and a thin band of laminar fluid, consistent with acute appendiceal process. During conventional appendectomy the appendix had signs of inflammation, mainly in the distal region. The histology revealed appendiceal diverticulitis complicated with rupture. The patient had favorable outcome and was discharged 24 hours later. As, there is a clear association between AD and appendiceal neoplasms, colonoscopy and patient monitoring is recommended.

Clinical characteristics of acute appendiceal diverticulitis / 대한외과학회지

PURPOSE: Diverticulitis of vermiform appendix is known as a rare cause of acute appendicitis, most of which are diagnosed after surgery. We compared appendiceal diverticulitis with acute appendicitis to study the clinical characteristics of appendiceal diverticulitis. METHODS: Among 1,029 patients who received appendectomy from January 2009 to May 2011, 38 patients with appendiceal diverticulitis (diverticulitis group) were compared with 98 randomly collected patients with acute appendicitis (appendicitis group) during the same period. Patients' characteristics, clinical features, laboratory findings, operative findings, and postoperative course were compared between the two groups. RESULTS: Thirty-eight patients (3.7%) were pathologically diagnosed with acute appendiceal diverticulitis among 1,029 cases of appendectomy. The mean age of patients in the diverticulitis group was significantly older than that of the appendicitis group (49.0 +/- 15.2 years vs. 25.4 +/- 14.2 years, P < 0.05). Mean duration of preoperative symptoms was longer in the diverticulitis group (3.6 +/- 3.8 days vs. 1.8 +/- 3.2 days, P < 0.05). The site of abdominal pain, fever, signs of localized peritonitis, accompanying gastrointestinal symptoms, and white blood cell count showed no differences between the two groups. Twenty-five patients (65.8%) of the diverticulitis group and 10 patients (10.2%) of the appendicitis group showed perforation of appendix (P < 0.05). Mean operating time and postoperative hospital stay were longer in the diverticulitis group (55.3 +/- 28.8 minutes vs. 41.4 +/- 17.8 minutes, 6.8 +/- 3.4 days vs. 4.9 +/- 1.5 days, P < 0.05). CONCLUSION: Acute diverticulitis of the appendix can be classified into quite different disease entities compared with acute appendicitis. Regarding high rates of perforation, immediate surgical treatment is needed for patients with a high index of suspicion of acute diverticulitis of the appendix.

Appendiceal Diverticulitis

Appendiceal diverticula are uncommon lesions. A retrospective study of appendiceal diverticula was done for 1379 appendectomies is performed from June 1991 to May 1996. Thirty-six cases (2.6%) of appendiceal diverticula were found. Only one case was detected operatively; the rest of them were diagnosed pathologically. These thirty-six cases have been classified into three groups: 23 cases of primary appendiceal diverticulitis, 8 of secondary appendiceal diverticulitis, and 5 of simple diverticulosis. The clinical manifestations of primary appendiceal diverticulitis were different from those of typical acute appendicitis. Primary appendiceal diverticulitis was seen mainly after the fourth decade of life. The pain came on rather insidiously and seemed to extend over a longer period. A history of previous attack was frequent. The rate of perforation in primary appendiceal diverticulitis was 78.2%.The false form of appendiceal diverticula was more common in most series. Also, no case was detected in appendectomies performed on many patients under 10 years of age with a diagnosis of appendicitis. They seemed to develop after birth and were seen frequently along the mesenteric border. The rate of mucosal hyperplasia in appendiceal diverticula was 61.1%, higher than that for appendicitis. Vascular hiatus between muscular bundles along the mesenteric side, and the mesenteric covering over the diverticula, as well as the inability of false diverticula to endure high intraluminal pressures, seem to be pathophysiologically associated with the cause and the high perforation rate in appendiceal diverticula. The clinical picture and the pathologic findings of primary appendiceal diverticulitis are definitely different from those of acute appendicitis. We suggest primary appendiceal diverticulitis be regarded as a clinical entity, not a variant of acute appendicitis. The patient with atypical right lower quadrant pain should be examined with this diagnosis in mind.