Diverticula Disease of the Colon in Japan
A Review of 61,5 Cases
KENICItI SIrGItfARA, M.D., TESTUICHIRO MUTO, M.D., YASUItIKO MORIOKA. M.D.,
AKIRA ASANO, M.D., TAKASHI YAMAMOTO. M.D.
Sugihara K, Muto T, Morioka Y, Asano A, YamamotoT. Diverticular
disease of the colon in Japan: a review of 615 cases. Dis Colon Rectum
1984;27:531-537.
Of 615 patients with diverticular disease of the colon, 429 had divertic-
ula in the cecum and ascending colon, 98 in the sigmoid and descend-
ing colon and 88 in both the right- and left-side colon. T h e right-sided
type was more common in younger people and more predominant in
men, whereas the left-sided type was more common in the elderly and
showed no difference in numbers between men and women. More than
50 per cent of patients were asymptomatic and 25 per cent complained
of disturbed bowel function. T h e frequency of diverticulitis was not
related to location, but to the number of diverticula. Seventy-seven were
complicated by acute inflammation (rlght-sided diverticulitis, 61, and
left-sided diverticulitis, 16). Many patients with right-sided diverticuli-
tis improved with medical treatment and the operative procedure of
choice was drainage of the inflamed area with supplemental appendec-
tomy. [Key words: Diverticular diseases; Diverticula; Diverticulum;
Diverticula of the right-side colon; Cecal diverticulum; Diverticulitis]
IN THE FIRST QUARTER of this century, diverticular
disease of the colon was recognized as a medical problem
of increasing magnitude in western countries and, in the
1960s, the clinical, surgical, pathologic, and physiologic
aspects were studied. However, almost all diverticulax
disease in western countries is left sided, whereas in Japan
right-sided diverticular disease is more common. As Jap-
anese lifestyle has been westernized recently, it is expected
that left-sided diverticular disease will increase in the near
future.
This paper presents the clinical features of 615 Japa-
nese patients with diverticular disease and the outcome of
management of 85 patients with complications of divertic-
ulitis and hemorrhage, with special reference to the com-
parison between right-sided and left-sided diverticular
disease and to the management of right-sided diverticulitis.
M a t e r i a l s a n d Methods
A total of 1839 consecutive double-contrast barium-
enema examinations performed between 1975 and 1982 in
the outpatient clinic of the T o k y o Kohseinenkin Hospi-
tal were reviewed, and the frequency of diverticular dis-
Received for publication December20, 1983.
Address reprint requests to Dr. Sugihara, Department of Surgery,
University of Tokyo, 7-3-1 Hongo Bunkyo-ku Tokyo Japan 113.
From the Department of Surgery,
University o] Tokyo, and the Department of Surgery,
Tokyo Kohseinenkin ttospital, Tokyo, Japan
ease of the colon for each year and every decade was
analyzed.
Records of 625 patients with diverticular disease pre-
senting to the Departments of Surgery of T o k y o Univer-
sity Hospital and T o k y o Kohseinenkin Hospital between
1971 and 1982 were reviewed. Diagnosis of diverticular
disease of the colon was made by double-contrast barium-
enema examinations in most patients and by plain film
of the abdomen after upper gastrointestinal barium-meal
examinations in a few.
Diverticular disease was divided into four types accord-
ing to distribution of diverticula as follows: right-sided
type, with diverticula present in the cecum and ascending
and proximal transverse colon; transverse colon type,
with diverticula only in the transverse colon; left-sided
type, with diverticula in the sigmoid and descending
colon; bilateral type, with diverticula, in both the cecum
a n d / o r ascending colon and in the sigmoid a n d / o r de-
scending colon, including involvement of the entire
colon. Ten of the transverse colon type were excluded
from this study in order to clarify the difference between
right-sided and left-sided types.
According to the number of diverticula, diverticular
disease was also divided into three types: solitary; scat-
tered, which had two to 14 diverticula; and ,grouped,
which had more than 15 diverticula in one segment of the
colon.
On the basis of clinical manifestations, 615 patients
with diverticular disease were classified into four ,groups:
,group 1 consisted of asymptomatic patients with inciden-
tal demonstration on barium-enema examination for
other reasons; group 2 consisted of patients who com-
plained of abnormal bowel habit, abdominal discomfort,
and pain, or symptoms similar to irritable bowel syn-
drome; ,group 3 consisted of patients with inflammation,
that is, diverticulitis, diffuse peritonitis, and fistula; and
g r o u p 4 consisted of patients with hemorrhage. Diagno-
sis of diverticulitis was based on one or more of the
 532 SUG,IHARA, ET AI..
following: clinical findings with elevation of leukocyte
count, radiologic evidence of diverticula with typical
deformity of the diseased segment (Fig. 1), and confirma-
tion of local i n f l a m m a t i o n of the diseased segment at
operation.
Results
C l i n i c a l Features
Frequency: Of 1839 b a r i u m - e n e m a examinations per-
formed, 244 (13.3 per cent) revealed diverticular disease of
the colon. T h e frequency in patients with the right-sided
type was 9.7 per cent, w h i c h was five times gqeater than
that of patients with the left-sided type; however, the
frequency of both types increased with advancing years
FIG. 1. Double-contrast barium enema reveals muhiple diverticula
o[ the cecum and ascending colon and the app(!ndix filled witlt barium.
The colonic wall shows the discrete defect with limited distensibility at
the midpordon of the ascending colon.
August 198,t
(Fig. 2). T h e left-sided type increased in fiequency with
increasing age u p to the eighth decade, whereas the right-
sided type had a higher frequency in y o u n g e r patients,
with a peak in the seventh decade (Fig. 3). T h e c h a n g i n g
frequency of the bilateral tytye, both with year and with
age, was similar to that of the left-sided type.
Distribution of Diverticula: Of 615 patients with diver-
ticular disease, 429 had the right-sided type, 98 had the
left-sided type, and 88 had the bilateral type.
Age at Diagnosis: A c o m p a r i s o n of age distribution of
the three types is s h o w n in T a b l e 1. T h e age distribution
in patients with the right-sided type was definitely differ-
ent from that of the left-sided and bilateral t,ytYes. Patients
in the fifth decade had the greatest n u m b e r of right-sided
type,, as c o m p a r e d with patients in the seventh decade for
the left-sided and bilateral types. T h e average age of
patients with the right-sided type was 51.0 years, which
was 13.9 years y o u n g e r than that of patients with the
left-sided type. Of 122 patients under 40 years of age, 97.5
per cent had the right-sided type, whereas 64.9 per cent of
patients over 70 years of age had the left-sided or bilateral
type, the rate of the left-sided and bilateral type increasing
with a d v a n c i n g age. T h e youngest patient with the right-
sided type complicated by diverticulitis of the ascending
colon was a 16-year-old girl and the youngest patient with
the left-sided type was a 36-year-old m a n without com-
plaints.
Sex Ratio: There were 403 men and 212 women. Sex
ratio varied with the differing distribution and n u m b e r of
diverticula. T h e right-sided and bilateral types were more
prevalent in men and male-to-female ratio increased in
p r o p o r t i o n to the n u m b e r of diverticula (Table 2).
Number of Diverticula: T h e nmnbers of diverticula
were different in the right-sided and left-sided types, one-
%
2O 9 a right-sided
... . . . -. left-sided
:~----~: bilateral
ii1
C
(J 10
k.
~ ' . ~ ,~ ~ ~ ~r~.,~. ~ ~-../~
'75 "76 '77 '78 "79 '80 '81 '82
Year
FIG. '2. The fi'e(luencyof diverticulal disease of the ('olon has beer
gradually increasing with advancing ",ears not only in the left-sided
but also the right-sided tYI,~'.
 Volume 27
Number 8 COLONIC DIVERTICULAR DISEASE 53~

TABLE1. Age Distribution of Three Types of Diverticular TABLE2. Sex Ratio Variation with the Differing Distribution and the
Disease of the Colon Number of Diverticula
Patient Age Right-sided Left-sided Bilateral Total Distribution Right-sided Left-sided Bilateral Total
(Years) (Per Cent) (Per Cent) (Per Cent) (Per Cent)
Solitary 1.5 0.9 -- 1.4
--<19 3 (0.7) -- -- 3 (0.5) Scattered 2.2 0.9 1.7 1.8
20-29 33 (7.7) -- 1 (1.1) 34 (5.5) Grouped 27.0 2.4 4.4 4.9
30-39 83 (19.3) 1 (1.0) 1 (1.1) 85 (13.8) TOTAL 2.1 1.2 2-l 1.9
40-49 108(25.2) 3(3.1) 8(9.1) 119(19.3)
50-59 87 (20.3) 20 (20.0) 16 (18.2) 123 (20.2)
60-69 83 (19.3) 44 (44.9) 33 (37.5) 160 (26.0) o n l y diverticula of the c o l o n w i t h o u t any lesions o n
70-79 30 (7.0) 25 (25.5) 28 (31.8) 83 (13.5) b a r i u m - m e a l e x a m i n a t i o n and gastroduodenoscopy.
80> 2 (0.5) 5 (5.1) 1 (1.1) 8 (1.3)
TOTAL 429 (100) 98 (100) 88 (100) 615 (100) Emergency a n g i o g r a p h y was performed in two patients
w i t h o u t positive findings.

third of the right-sided type being solitary (Table 3). O u t c o m e of T r e a t m e n t of Diverticulitis

G r o u p e d type was less in the right-sided type than in the
other types. T h e r e was n o relationship between average
age a n d n u m b e r of diverticula in each type (Table 4).
Clinical Manifestations: Patients with diverticular dis-
ease were classified into four g r o u p s on the basis of clini-
cal manifestations. T h e p r o p o r t i o n of the four groups
was similar in each type, with more than 50 per cent of
patients being a s y m p t o m a t i c and 25 per cent complain-
ing of a b n o r m a l bowel function (Table 5). Seventy-seven
patients (12.5 per cent) had inflammation; 61 had right-
sided diverticulitis, and 16 had left-sided diverticulitis.
With the increasing n u m b e r of diverticula, the diseased
segments tended to be associated with diverticulitis more
frequently (Table 6). Diverticulitis was more predomi-
n a n t in men; there were 50 m e n and 11 w o m e n with
right-sided diverticulitis and 15 m e n a n d one w o m a n
with left-sided diverticulitis. T h e average age of patients
with right-sided diverticulitis was 40.1 years, the youngest
being a 16-year-old girl and the oldest a 72-year-old man,
whereas the average age for those with left-sided divertic-
ulitis was 58.7 years, the y o u n g e s t being a 44-year-old
m a n a n d the oldest an 83-year-old w o m a n with diffuse
peritonitis. Patients under 40 years of age with diverticula
of the r i g h t colon suffered from diverticulitis more fre-
q u e n t l y (Table 7). T h e average interval f r o m . o n s e t of
s y m p t o m s of right-sided diverticulitis to hospital admis-
sion was five days (two to 14 days).
H e m o r r h a g e f r o m diverticula occurred in only eight
patients. Bleeding from diverticula was diagnosed w h e n
b a r i u m - e n e m a e x a m i n a t i o n a n d c o l o n o s c o p y revealed
and H e m o r r h a g e
R i g h t - s i d e d Diverticulitis: Figure 4 shows results of
treatment in 61 patients with right-sided diverticulitis. Of
36 patients treated medically, 35 were i m p r o v e d a n d 26
required no further treatment. Eight h a d resection of the
diseased segment because of repeated inflammation; three
h a d recurrent attacks w i t h i n a year a n d the others had
several repeated attacks in three years. Gastrectomy and
right h e m i c o l e c t o m y were performed in one patient with
c a r c i n o m a of the stomach after i n f l a m m a t i o n had sub-
sided. O n e patient, w h o did not i m p r o v e with medical
treatment, required ileocecal resection. O n l y ten of 36
patients were diagnosed correctly as h a v i n g diverticulitis
on the first visit to the hospital, b u t only w h e n acute
appendicitis was ruled out because the site of tenderness
was lateral or cranial to McBurney's spot or the patient
h a d a previous history of appendectomy. N o n e of the
patients w h o h a d emergency operations was diagnosed
preoperatively as h a v i n g diverticulitis. T h e c o m m o n
preoperative diagnosis was acute appendicitis in 18
patients and intra-abdominal abscess in five. L a p a r o t o m y
disclosed i n f l a m m a t o r y involvement of the cecum or
ascending colon with the n o r m a l appendix. Appendec-
t o m y a n d drainage were performed o n 22 patients a n d
resection of the diseased segment with anastomosis o n
three. E m e r g e n c y resection of the bowel was d o n e in the
early period of this study because the i n f l a m m a t o r y mass
could not be differentiated from carcinoma. Coiocutane-
ous fistula developed in one patient after drainage. T h e
operation rate was 57 per cent o n the whole, with n o

TABLE3. Number of Diverticula oJ Three Types of Diverticular TABLE4. Average Age of Patients with Three Types of
Disease oJ the Colon Diverticular Disease of the Colon

Right-sided Left-sided Bilateral Total Patient Age (Years)

Type of Disease (Per Cent) (Per Cent) (Per Cent) (Per Cent) Right-sided Left-sided Bilateral Total
Solitary 133 (31.0) 13 (13.3) -- 146'(23.7) Solitary 47.9 62.4 -- 49.2
Scattered 268 (62.5) 58 (59.2) 61 (69.3) 387 (62.9) Scattered 53.0 65.7 62.2 56.3
Grouped 28 (6.5) 27 (17.6) 27 (30.7) 82 (13.3) Grouped 47.1 64.6 62.6 58.0
TOTAL 429 ((100) 98 (100) 88 (100), 615 (100) TOTAL 51.0 64.9 62.3 54.8
 534 SUGIHARA, ET AL. Augus 1984

% TABLE5. Clinical Manifestations of Three Types of Diverticular

Disease of the Colon
15
Right-sided Left-sided Bilateral Total
: _- r i g h t - s i d e d
(Per Cent) (Per Cent) (Per Cent) (Per Cent)
~-. - . - ~ left-sided
Group 1 240 (55.9) 58 (59.1) 52 (59.1) 350 (56.9)
Group 2 131 (30.5) 27 (26.7) 22 (25.0) 180 (29.2)
Group 3 54 (12.5) 12 (12.1) 11 (12.5) 77 (12.5)
10 Group 4 4 (0.9) 1 (1.0) 3 (3.4) 8 (1.3)
t~ Group 1 = asymptomatic; Group 2 = disturbed bowel function;
Group 3 = diverticulitis; Group 4 = hemorrhage.
ID
O
t- gency o p e r a t i o n g r o u p was as h i g h as 40 per cent.
O
o. Hemorrhage: A l l e i g h t p a t i e n t s w i t h massive b l e e d i n g
5
were treated m e d i c a l l y a n d n o f u r t h e r t r e a t m e n t was
performed.

Discussion
D i v e r t i c u l a r disease was n o t widely recognized in
10~ 20-- 30~ 40~ 50~ 60~ 70~ 80-- J a p a n ~u n t i l a b o u t 1970 because, first, lefi-sided diverticu-
Age l a disease was infrequent; second, double-contrast b a r i u m -
e n e m a e x a m i n a t i o n was n o t w i d e l y p e r f o r m e d and, third,
FIG.3. Changing frequency with age. The right-sided type is more
common in the younger age group. The left-sided type is increasing r i g h t - s i d e d d i v e r t i c u l a r disease h a d n o serious clinical
with age. p r o b l e m s . H o w e v e r , over the last ten years, various dis-
orders of the l a r g e b o w e l have b e e n i n c r e a s i n g in n u m b e r
o p e r a t i v e deaths. O p e r a t i v e f i n d i n g s were p e r i d i v e r t i c u l i - a n d o n e of t h e m (diverticular disease) has d r a w n the
tis o r p e r i c o l i c abscess in all patients, a n d there was n o a t t e n t i o n of m a n y gastroenterologists. Because J a p a n e s e
diffuse p e r i t o n i t i s . P a t h o l o g i c e x a m i n a t i o n of 11 resected lifestyle has b e e n westernized recently, it is n o t u n r e a -
s p e c i m e n s revealed that all of 53 diverticula of the c e c u m s o n a b l e to e x p e c t to see m o r e left-sided diverticular dis-
a n d a s c e n d i n g c o l o n were false d i v e r t i c u l a a n d consisted ease. T h e s t u d y ~ of 12,505 b a r i u m - e n e m a e x a n a i n a t i o n s
of o n l y m u c o s a a n d s u r r o u n d i n g m u s c u l a r i s m u c o s a d u r i n g 14 years s h o w e d that d i v e r t i c u l a r disease has
w i t h o u t m u s c l e coat. increased year b y year, the f r e q u e n c y i n the last three years
Left-sided Diverticulitis: Sixteen patients m a n i f e s t e d b e i n g 12.4 p e r cent. F u r t h e r m o r e , n o t o n l y left-sided b u t
left-sided diverticulitis (Fig. 5). Of ten p a t i e n t s w h o h a d also r i g h t - s i d e d diverticular disease has increased, as
successful m e d i c a l treatment, six h a d n o f u r t h e r treat- s h o w n in this study.
m e n t a n d four u n d e r w e n t elective resection of the diseased It has been g e n e r a l l y accepted that i n western c o u n t r i e s
s e g m e n t w i t h p r i m a r y a n a s t o m o s i s after i n f l a m m a t i o n d i v e r t i c u l a r disease is a c o m m o n c o n d i t i o n , affecting
h a d subsided. O n e p a t i e n t w i t h a colovesical f i s t u l a h a d a m o s t l y the s i g m o i d a n d d e s c e n d i n g colon; however,
one-stage o p e r a t i o n . T h e r e were n o p o s t o p e r a t i v e c o m - d i v e r t i c u l a of the c e c u m a n d a s c e n d i n g colon are rare. I n
p l i c a t i o n s in the g r o u p w h o h a d elective o p e r a t i o n s . p o s t m o r t e m surveys, SlacM c o u l d n o t find r i g h t - s i d e d
E m e r g e n c y o p e r a t i o n was p e r f o r m e d o n five p a t i e n t s d i v e r t i c u l a r disease, Parks 4 f o u n d it o n l y in 2.7 p e r cent,
w i t h free p e r f o r a t i o n a n d diffuse peritonitis, three of t h e m a n d H u g h e s 5 in 5 p e r cent. R o e n t g e n o l o g i c e x a m i n a -
b e i n g in septic shock. S u t u r e o f the p e r f o r a t e d site, d r a i n - t i o n s 6-s also disclosed the very l o w frequency of the c o n d i -
age, a n d d i v e r t i n g c o l o s t o m y were d o n e in four; two tion. O n the o t h e r h a n d , M i a n g o l a r r a , 9 r e p o r t i n g o n 758
recovered a n d the c o l o s t o m y was closed, one d e v e l o p e d a
TABLE7. Age Distribution oJ Diverticulitis
c o l o c u t a n e o u s fistula, a n d o n e d i e d f r o m sepsis. O n e
p a t i e n t w h o h a d a p e r f o r a t e d s e g m e n t exteriorized d i e d Right-sided Left-sided
f r o m sepsis. T h e o p e r a t i v e m o r t a l i t y rate for the emer- Patient Age diverticulitis diverticulitis Total
(Years) (Per Cent) (Per Cent) (Per Cent)
TABLE6. Frequency of Diverticulitis --<19 1 (33.3) -- 1 (33.3)
20-29 15 (44.1) -- 15 (44.1)
Right-sided Left-sided
30-39 12 (14.3) -- 12 (14.1)
diverticulitis diverticulitis Total
40-49 14 (7.5) 2 (18.2) 16 (13.6)
(Per Cent) (Per Cent) (Per Cent) 50-59 9(8.7) 5(13.9) 14 (11,4)
Solitary 10 (7.3) 1 (13.3) 11 (7.3) 60-69 7 (6.0) 5 (9.1) 12 (7.5)
Scattered 41 (12.5) 3 (2.5) 44 (11.2) 70-79 3 (5.2) 3 (5.7) 6 (7.2)
Grouped 10 (18.2) 12 (22.2) 22 (26.8) 80 --> 1 (16.7) 1 (12.5)
 Volume27
Number8 COLONIC DIVERTICULARDISEASE 535

ri~t-sided diverticulitis
61

I I
emergency operation medical treatment
25 36
I I I
I I
FIG. 4. Outcome of treatment for I
patients with right-sided diverticulitis. resection and appendectomy and not improved improved
anastomosis drainage
3 22 I 35
a I I
I I I I
colocutanous no further treatment resection and elective operation no further treatment
fistula anastomosis
1 21 l 9 26

patients with diverticular disease, found the right-sided
type in 14.4 per cent, the left-sided type in 69.8 per cent,
and the bilateral type in 16.1 per cent. Podesth and Pace t~
reported the right-side colon to be involved in 52 per cent
of patients, the right-sided type in 27.6 per cent, the left-
sided type in 41.2 per cent, and the bilateral type in 20.8
per cent. They thought diverticula of the right-side colon
was not a rare condition. Apart from Japan and Japanese
in Hawaii,n only in Korea 12and Thailand 13is right-sided
diverticular disease more c o m m o n than left-sided. In
other countries, such as Israel, 14 Iran, 15 Jordan, 16 and
Brazil, 17 left-sided diverticular disease is predominant, as
well as in the United States, United Kingdom, Europe,
and Australia.
In this study the left-sided type in Japan showed the
same trend as diverticular disease reported in western
countries 5,~8-2~ in terms of average age, age distribution,
and sex ratio, whereas the right-sided type was more
c o m m o n in the younger age group and more predomi-
nant in men.
Painter ~2 suggested that diverticula were regarded as
primary in the sigmoid colon and secondary in the prox-
imal colon, spreading toward the cecum. Parks ~3thought
that if a segment of the colon was going to be affected by
disease, this was often determined early in its course, and
progress of the disease was more often within the segment
or segments initially affected rather than by spread from
one segment to another. However, as the right-sided type
is more c o m m o n in y o u n g people and the bilateral type
has characteristics of both the right-sided and left-sided
type (the sex ratio being the same as that of the right-sided
type and the age distribution being similar to that of the
left-sided type), it is assumed that patients with the right-
sided type may develop diverticula in the sigmoid or
descending colon with the passage of time and finally
show the bilateral type.
Clinically, it is important to distinguish diverticulitis
from disturbed bowel function or painful diverticular
diseaseY 4 T h e frequency of diverticulitis is not related to
the location but to the number of diverticula, Parks ~
estimated that between 10 and 25 per cent of patients with
colonic diverticula developed peridiverticular inflamma-
tion and Miangolarra 9 found 13.4 per cent of patients
with right-sided diverticular disease were complicated by
inflammation. Horner 7 reported that the frequency of
diverticulitis increased in proportion with increasing
follow-up time. In this study, 12.5 per cent of patients
were associated with diverticulitis.
It is very difficult to make a correct diagnosis of right-
sided diverticulitis before operation, the rate of correct
diagnosis being between 0 and 24.2 per cent in the litera-
ture0, 25-3~and 16.4 per cent in this study. T h e most corn-

left-sided diverticulitis
16
I
I I I
emergency operation elective operation medical treatment
for fistula
FIG. 5. Outcome of treatment for
~,patients with left-sideddiverticulitis. 5 1 10
I I
I I I I
exteriorization suture, diainage elective operation no further treatment
and colostomy
4 4 6
 536 SlSGIHARA, E T AL.
mon incorrect diagnosis was acute appendicitis. Many
a u t h o r s 26,29-3z d e s c r i b e d t h a t i n p a t i e n t s w i t h r i g h t - s i d e d
d i v e r t i c u l i t i s t h e d u r a t i o n of s y m p t o m s was l o n g e r , n a u -
sea a n d v o m i t i n g o c c u r r e d less f r e q u e n t l y t h a n i n p a t i e n t s
w i t h a c u t e a p p e n d i c i t i s , a n d t h e site of t e n d e r n e s s was
s o m e w h a t a p a r t f r o m M c B u r n e y ' s spot. R i g l e r a n d
C h e r r y 26 r e c o m m e n d e d b a r i u m - e n e m a e x a m i n a t i o n i n
o r d e r to m a k e a c o r r e c t d i a g n o s i s i n p a t i e n t s w i t h r i g h t
lower quadrant pain.
M o s t a u t h o r s 27-sl r e c o m m e n d e d d i v e r t i c u l e c t o m y for
minimal inflammation and partial or complete right
h e m i c o l e c t o m y for m o r e e x t e n s i v e i n f l a m m a t i o n a n d for
a m a s s s u s p i c i o u s of c a r c i n o m a . S c h a p i r a 25 t h o u g h t t h a t ,
w i t h n o n o p e r a t i v e s u p p o r t i v e t h e r a p y , m o s t cecal divertic-
ulitis w o u l d p r o b a b l y s u b s i d e a n d the o p e r a t i v e t r e a t m e n t
of c h o i c e w a s t h e o n e t h a t w a s m o s t c o n s e r v a t i v e a n d yet
adequate. This study confirmed Schapira's suggestion.
W h e n r i g h t - s i d e d d i v e r t i c u l i t i s is c l i n i c a l l y suspected,
m e d i c a l t h e r a p y m u s t be s t a r t e d a n d a l m o s t all p a t i e n t s
w o u l d r e c o v e r f r o m this c o n d i t i o n . O n c e l a p a r o t o m y
discloses the i n f l a m e d c o l o n i c w a l l w i t h the n o r m a l
a p p e n d i x , o n l y d r a i n a g e of t h e i n f l a m e d area, w i t h s u p -
p l e m e n t a l a p p e n d e c t o m y , is a d e q u a t e . C o m p l i c a t i o n s of
r i g h t - s i d e d d i v e r t i c u l i t i s are n o t as severe as t h o s e o f left-
sided d i v e r t i c u l i t i s . If c a r c i n o m a c a n n o t be r u l e d o u t at
operation, barium-enema examination and/or colono-
o s c o p y after r e c o v e r y f r o m t h e a c u t e p h a s e resolve the
q u e s t i o n . W h e n c a r c i n o m a is c o n f i r m e d by b i o p s y w i t h
c o l o n o s c o p y , d e f i n i t e o p e r a t i o n w i t h l y m p h - n o d e dissec-
t i o n c a n be p e r f o r m e d after g o o d b o w e l p r e p a r a t i o n .
M o r t a l i t y a n d m o r b i d i t y ~5,z7,3~,32 of e m e r g e n c y r e s e c t i o n
of the d i s e a s e d s e g m e n t is n o t so low. S u p p l e m e n t a l
a p p e n d e c t o m y is r e c o m m e n d e d i n o r d e r to a v o i d c o n f u -
s i o n w i t h a p p e n d i c i t i s in s u b s e q u e n t attacks. P a t i e n t s
h a v i n g r e p e a t e d attacks of d i v e r t i c u l i t i s s h o u l d receive
r i g h t h e m i c o l e c t o m y after i n f l a m m a t i o n has subsided.
T h e p a t h o g e n e s i s of r i g h t - s i d e d d i v e r t i c u l a r disease is
u n c l e a r . S o m e a u t h o r s 2s,32 d e s c r i b e a t h e o r y of c o n g e n i t a l
o r i g i n of s o l i t a r y cecal d i v e r t i c u l u m b a s e d o n the trans-
c i e n t a p p e n d i x s3 i n e m b r y o n i c life. H o w e v e r , i n this
study, a s o l i t a r y d i v e r t i c u l u m of the c e c u m was n o t pres-
e n t at the c o n s t a n t site. T h e r e are m a n y reports 5,8,34,35 t h a t
d i v e r t i c u l a of the c e c u m a n d a s c e n d i n g c o l o n are false.
I n t r a l u m i n a l p r e s s u r e s t u d y 36 of the a s c e n d i n g c o l o n
s h o w s t h a t the c o l o n i c m o t i l i t y i n d e x of p a t i e n t s w i t h
r i g h t - s i d e d d i v e r t i c u l a r disease is s i g n i f i c a n t l y g r e a t e r
t h a n t h a t of n o r m a l subjects. F r o m these o b s e r v a t i o n s , it
is s u s p e c t e d t h a t d i v e r t i c u l a of the c e c u m a n d a s c e n d i n g
c o l o n m a y be a n a c q u i r e d c o n d i t i o n .
References
1. Ohmori M, Akimoto S, Kameoka S, Yazawa T, Hamano K. Diver-
ticular disease of the colon. J Jpn Soc Colo-Proct 1979;32:502-11.
2. Kubo A, Ishiwata J, Maeda Y, Kida T, Yamabe K, Shimosegawa T.
Clinical studies on diverticular disease of the colon. Jpn J Med
1983;22:185-9.
august 1984
3. Slack WW. The anatomy, pathology and some clinical featm'es of
diverticulitis of the colon. Br J Surg 1962;50:185-90.
4. Parks TG. Post-mortem studies on the colon with special reference
to diverticular disease. Proc R Soc Med 1968;61:30-2.
5. Hughes LE. Postmortem survey of diverticular disease of the
colon. Gut 1969;10:336-51.
6. Smith CC, Christensen WR. The incidence of colonic diverticulo-
sis. AJR 1959;82:996-9.
7. Homer J. Natural history of diverticulosis of the colon. Am J Dig
Dis 1958;3:343-50.
8. Williams KL. Acute solitary ulcer and acute diverticulitis of the
cecum and ascending colon. Br J Surg 1960;47:351-8.
9. Miangolarra CJ. Diverticulitis of the right colon: an important
surgical problem. Ann Surg 1961;153:861-70.
10. Podesta MT, Pace JL. Distribution of diverticula of the large
intestine based on postmortem studies. Internat Surg 1975;
60:395-6.
11. Stemmermann GN, Yatani R. Diverticulosis and polyps of the
large intestine: a necropsy study of Hawaii Japanese. Cancer
1973;31:1261-70.
12. Munakata A, Nakaji S, Yoshida Y, Han MC, Choi WK. Study on
the diverticular disease of the colon in Korea. J Jap Soc Colo-
proct 1982;35:224-31.
13. Vajrabukka T, Saksornchai K, Jimakorn P. Diverticular disease of
the colon in a far-eastern community. Dis Colon Rectum
1980;23:151-4.
14. Levy N, Luboshitzk R, Shiratzki Y, Ghivarello M. Diverticulosis of
the colon in Israel. Dis Colon Rectum 1977;20:477-81.
15. Dabestani A, Aliabadi P, Shah-Rookh FD, Borhanmanesh FA.
Prevalence of colonic diverticular disease in southern Iran. Dis
Colon Rectum 1981;24:385-7.
16. Fatayer W. A-Khalaf MM, Shalan KA, Toukan A, Daker M,
Arnaout MA. Diverticular disease of the colon in Jordan. Dis
Colon Rectum 1983;26:247-9.
17. Paulino F, Roselli A, Martins U. Pathology of diverticular disease
of the colon. Surgery 1971;69:63-9.
18. Debray C, Hardouin JP, Besancon F. Frbquence de la diverticulose
colique selon l'age etude statistique a partir de 500 lavements
barytes. Sem Hop Paris 1961;37:1743-5.
19. Manousos ON, Truelove SC, Lumsden K. Prevalence of colonic
diverticulosis in general population of Oxford area. Br Med J
1967;3:762-3.
20. Parks TG. Natural history of diverticular disease of the colon. A
review of 521 cases. Br Med J 1969;4:639-42.
21. Eide TJ, Stalsberg H. Diverticular disease of the large intestine in
northern Norway. Gut 1979;20:609-15.
22. Painter NS. Diverticulosis of the colon--fact and speculation. Am
J Dig Dis 1969;12:222-7.
23. Parks TG. Natural history of diverticular disease of the colon. Clin
Gastroenterol 1975;4:53-69.
24. Painter NS. Diverticular disease of the colon--a deficiency disease
of Western civilization. London: William Heinemann, 1975:
175 -9.
25. Schapira A, Leichtling J J, Wolf BS, Marshak RH, Janawitz HD.
Diverticulitis of the cecum and right colon: clinical and radio-
graphic features. Am J Dig Dis 1958;3:351-83.
26. Rigler RG, Cherry JW. Diverticulitis of the cecum: preoperativ%
diagnosis. Am Surg 1960;26:405-8.
27. Nicholas EE, Frymark WB, Raffensperger JR. Acute cecal divertic-
ulitis. JAMA 1962;182:157-60.
28. Ash M, Markowitz AM. Cecal diverticulitis: report of 16 cases and a
review of the literature. Surgery 1969;65:906-10.
29. Magness LJ, Sanfelippo PM, van Heerden JA, Judd ES. Diverticu-
lar disease of the right colon. Surg Gynecol Obstet 1975;
140:30-2.
30. Arrington P, Judd CS. Cecal diverticulitis. Am J Surg 1981;142:
56-9.
31. McFee AS, Sutton PG, Ramos R. Diverticulitis of tile right colon.
Dis Colon Rectum 1982;25:254-6.
32. Lauridson J, Ross FP. Acute diverticulitis of the cecum. Arch Surg
1952;64:320-30.
33. Goldstone R J, Wakeley CPG. The relative frequency of the various
 V o l u m e 27
Number 8 COLONIC DIVERTICULAR DISEASE 537

positions of the vermiform appendix: an ascertained analysis of
3000 cases: with an account of its development. Br J Surg
1924;11:503-20.
34. Pen'y PM, Morson BC. Right-sided diverticulosis of the colon. Br J
Surg 1971;58:902-4.
85. Meyers MA, Volberg F, Katzen B, Alonso D, Abbot G. The
angioarchitecture of colonic diverticula. Radiology 1973;108:
249-61.
36. Sugihara K, Muto T, Morioka Y. Motility study in right-sided
diverticular disease of the colon. Gut 1983;24:1130-4.

Announcement

XIXTH CZECHOSLOVAK CONGRESS OF GASTROENTEROLOGY

The Congress will be held November 12-16, 1984 in Karlovy Vary Czech-
oslovakia. The scientific program will include review lectures, symposia,
round table discussions, short communications, posters and scientific films.
Congress languages are English, Czech, or Slovak with simultaneous trans-
lation. Main topics will include: early diagnosis of digestive malignancies
and possibilities of prevention, inflammatory bowel diseases, therapeutic
endoscopy, recent developments in the diagnosis and therapy of gallstones,
chronic pancreatitis, advances in the surgical treatment of digestive diseases,
and endocrine tumors of the digestive system. A social program will be
arranged for participants and post-congress tours will be available. For
further information, contact Czechoslovak Medical Society, J. E. Purkyn~,
Czechoslovak Congress of Gastroenterology, Vi't~zn~ho finora 31, 120 26
Praha 2, Czechoslovakia. Telephone: 294145. Telex: 121293. Cable:
purkynemedical praha.