Refining the Diagnosis of Appendiceal Diverticulitis: An Intraoperative Protocol for Surgical Precision and case report

Refining the Diagnosis of Appendiceal Diverticulitis: An Intraoperative Protocol for Surgical Precision and case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Refining the Diagnosis of Appendiceal Diverticulitis: An Intraoperative Protocol for Surgical Precision and case report Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8418183/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Introduction Appendiceal diverticulitis is an uncommon pathology known by the acute inflammation of a diverticulum emerging from the vermiform appendix. A true appendiceal diverticulum refers to a protrusion involving all layers of the appendix. A 2021 case report (3) showed approximately 50 cases published to date. This pathological anatomic variant increases the risk of appendiceal neoplasms, principally neuroendocrine tumors (48%) (5), which makes a detailed pathological analysis important after surgery. The purpose of this research is to analyze the diagnosis of appendiceal diverticulitis by a case report and establish an intraoperative algorithm to accurately identify this type of diverticulum, optimizing surgical decision-making. Case report A 26-year-old woman from Florencia, Colombia, treated at Corpomedica clinic (rural area), presented a 36-hour history of right lower abdominal pain without vomiting or fever. Abdominal ultrasound revealed no significant findings. Due to inadequate pain progression, the patient was transferred to the operating room for intervention. Dissection revealed a firm, 2.5 cm mass at the base, immobile, with a contained 5 mm perforation and minimal contamination. Pathology reports a cecal appendix accompanied by a true diverticulum with acute diverticulitis. Conclusion Like appendiceal diverticulitis, most of these neoplasms are detected incidentally in a surgical specimen after an appendectomy for suspected appendicitis (13). Their intraoperative differentiation is of great importance since their management varies considerably and impacts the patient's disease burden and quality of life. Further studies are needed to standardize its timely diagnosis in order to avoid patient morbidity and mortality. Appendiceal diverticulitis true appendiceal diverticulum appendiceal neoplasms intraoperative algorithm case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Appendiceal diverticulitis is an uncommon pathology known by the acute inflammation of a diverticulum emerging from the vermiform appendix. Historically, it has been considered an uncommon etiology of acute abdomen, with an incidence ranging from 0.004% to 2.1% of appendicitis cases ( 1 ). These diverticula are principally false diverticula, composed by protrusions of the mucosa and submucosa through a muscle defect. The clinical presentation mimics the scenario of acute appendicitis, which can confuse and delay the diagnosis ( 2 ). Even less frequently, a true appendiceal diverticulum refers to a protrusion involving all layers of the appendix. These are usually located on the antimesenteric border of the appendix and may be associated with developmental abnormalities such as trisomy 13 and 15 ( 3 ). A 2021 case report ( 2 ) reported approximately 50 cases published to date. Research on this area is essential due to its low prevalence, to the diagnosis challenge it presents and the potential severe complications, such as perforation and subsequently peritonitis. Scientific research proves that appendiceal diverticulitis has a higher risk of perforation compared to acute appendicitis, occurring in up to 66% of cases, a rate four times greater than that in acute appendicitis ( 4 ). Additionally, this pathological anatomic variant increases the risk of appendiceal neoplasms, principally neuroendocrine tumors (48%) ( 5 ), which makes a detailed pathological analysis important after surgery. The purpose of this research is to analyze the diagnosis of appendiceal diverticulitis by a case report and establish an intraoperative algorithm to accurately identify this type of diverticulum, optimizing surgical decision-making. Intraoperative proposal include developing a protocol in which, upon identifying a protuberance in the vermiform appendix, it must be opened to distinguish between a true diverticulum or a potential neoplasia. This distinction is such a life changing decision, as a neoplastic suspicion would warrant a hemicolectomy, whereas confirmation of a true diverticulum would only require an appendectomy. Case report A 26-year-old woman from Florencia, Colombia, treated at Corpomedica clinic (rural area), presented with a 36-hour history of right lower abdominal pain without vomiting or fever. Physical examination showed no clear signs of peritoneal irritation. The Alvarado score was negative for acute appendicitis. The paraclinical tests on admission did not show anemia, leukocytosis, or neutrophilia. Abdominal ultrasound revealed no significant findings. Due to inadequate pain progression, treatment was started with cefazolin-metronidazole, analgesics, and transfer to the operating room for intervention. Under general anesthesia, a Rockey-Davis incision was made, revealing an edematous cecal appendix with a plastron at its base and minimal fibrinopurulent membranes (Fig. 1 ). Dissection revealed a firm, 2.5 cm mass at the base, immobile, with a contained 5 mm perforation and minimal contamination. The base of the appendix was opened and three fecaliths of 23, 6, and 5 mm were removed (Fig. 2). The orifice and appendiceal stump were closed and the soft tissues of the plastron were repositioned. Postoperative recovery was uneventful. The patient completed 72 hours of intravenous antibiotics and analgesics. Pathology reports a cecal appendix measuring 8 cm in length and 1 cm in diameter accompanied by a true diverticulum with acute diverticulitis (Fig. 3 ). Discussion Regarding epidemiology, appendiceal diverticulitis is more common in males, typically occurring in the third decade of life, and has a higher mortality rate than acute appendicitis due to its insidious clinical course, delayed diagnosis, and potentially complications ( 6 , 7 ). Notably, imaging techniques do not have a diagnostic value in this case, leading to late diagnosis, which is principally confirmed through histopathological examination of intraoperatively excised specimens. The treatment of choice is principally appendectomy ( 6 , 7 ). Neoplasms of the appendix represent approximately 0.5% of all gastrointestinal neoplasms. According to the World Health Organization (WHO) in 2019, they are divided into adenomas and sessile serrated lesions, mucinous neoplasms, adenocarcinomas, goblet cell adenocarcinomas of the appendix, and neuroendocrine neoplasms ( 8 ). These occur at an average age of 62 to 65 years and have a slight preference for the male gender. Together, they constitute a heterogeneous group of conditions that differ in treatment depending on their recognition and tumor stage ( 9 ). Mucinous tumors of the appendix are also a rare pathology, with a prevalence under 0.5% ( 10 , 11 , 12 ). The average age of onset is in the sixth decade of life and is more common in males ( 12 ). Clinical presentation as in the appendiceal diverticulitis can mimic the scenario of an acute appendicitis, with the difference that this pathology has a high risk of peritoneal dissemination of mucin and so metastasis ( 12 ). Diagnosis rate is also low, as it is made by histopathological specimens according to the American Joint Committee on Cancer (AJCC) classification. ( 13 ) Given the risks associated with this pathology, the treatment of choice is surgery, ranging from appendectomy to right hemicolectomy, depending on the histological diagnosis. The principal goal is to achieve complete resection of compromised tissue, which may require reoperation in cases of surgical margin invasion. If the condition is incidentally discovered during surgery, conversion from laparoscopy to laparotomy is recommended due to the risk of mucin dissemination and the need to assess areas such as the colon and ovaries. ( 13 ) The presented clinical case joins others that have reported the intraoperative finding of appendicular diverticulitis in a patient with an initial suspicion of appendicitis. ( 1 , 2 , 3 , 5 , 6 , 10 ) However, the current report documents a true diverticulum, which given its low prevalence, adds uniqueness to the case. As previously described, the abdominal ultrasound image did not show significant changes at the level of the vermiform appendix, which necessitated a surgical approach due to the lack of improvement in the patient's clinical condition. Intraoperatively, a 2.5 cm mass was found at the base of the appendix, which corresponded to a true diverticulum of the vermiform appendix. This dilation can be incorrectly misinterpreted as an appendiceal neoplasm, leading the surgeon to perform a hemicolectomy, as occurred in a case reported in 2021 ( 2 ). Due to its low frequency, there is currently no surgical consensus on how to manage this situation. Therefore, we propose an intraoperative algorithm to enable surgeons to promptly distinguish between these conditions, ensuring optimal decision-making and improve clinical outcomes for the patient (Fig. 4 ). Further studies are needed to help standardize the diagnosis and management of this condition, which will influence patients morbidity and quality of life. Conclusion The diagnosis of appendiceal diverticulitis supposes a surgical challenge due to its nonspecific clinical features, the limited usefulness of imaging in this setting and the importance of its intraoperative differentiation from appendiceal neoplasia. Further studies are needed to standardize its timely diagnosis that influences patient morbidity and mortality. Declarations Funding – Not applicable Conflicts of interest - As authors, we declare that there are no conflicts of interest Ethics approval - We have the patient's informed consent for the publication of the article Consent to participate - Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Written Consent for publication : Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and material - We declare that the images and diagrams are our own work. Code availability - Not applicable Authors' contributions 1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. Responsibles: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. - Study design and conception: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. - Data acquisition: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. - Data analysis and interpretation: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. - Manuscript writing: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. 2. Drafting the work or reviewing it critically for important intellectual content: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. 3. Final approval of the version to be published: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. 4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: Fernando Escobar-Castañeda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas. References Arenas-García V, Santos-Seoane SM, Delgado-Sevillano RJ. Appendiceal diverticulitis: An uncommon cause of acute abdomen. Rev Gastroenterol Mex. 2019;84(2):243-244. Available from: https://www.revistagastroenterologiamexico.org/en-appendiceal-diverticulitisan-uncommon-cause-articulo-S2255534X1930012X Kristopher Bujold-Pitre, Olivier Mailloux, Diverticulitis of the appendix—case report and literature review, Journal of Surgical Case Reports, Volume 2021, Issue 10, October 2021, rjab488, https://doi.org/10.1093/jscr/rjab488 Liu Y, Zhang Y, Zhang Y, et al. Perforated appendiceal diverticulitis mimicking appendicitis. Am Coll Surg. 2018;226(1):e1-e3. Available from: https://www.facs.org/for-medical-professionals/newspublications/journals/case-reviews/issues/v4n1/liu-appendiceal-diverticulitis/ Lee JH, Lee HS, Park SH, et al. Appendiceal diverticulitis: diagnosis and differentiation from usual acute appendicitis using computed tomography. J Comput Assist Tomogr. 2007;31(5):763-769. Available from: https://pubmed.ncbi.nlm.nih.gov/17805147/ Escobar F, Vega NV, Valbuena E, Barón M. Diverticulitis apendicular, revisión de la literatura científica y presentación de dos casos. Rev Colomb Cir. 2013;28(3):223-228. Fé FS, Cadena M, López R, Cardoso L, Universidad de los Andes, García D, et al. Acute diverticulitis of the appendix: A case report. Annals of Mediterranean Surgery [Internet]. 2023;6(2):17–22. Disponible en: https://edicions.uib.es/ojs/index.php/AMS/article/download/1027/1127 Lobo-Machín I, Delgado-Plasencia L, Hernández-González I, Brito-García A, Burillo-Putze G, Bravo-Gutiérrez A, et al. Appendiceal diverticulitis and acute appendicitis: differences and similarities. Rev Esp Enferm Dig. 2014;106:452-8. PMID: 25490164. [ Links ] Van de Moortele M, De Hertogh G, Sagaert X, Van Cutsem E. Appendiceal cancer : a review of the literature. Acta Gastroenterol Belg. 2020 Jul-Sep;83(3):441-448. PMID: 33094592. Sandoval G, Rojas M, Segovia J. Manejo de la diverticulitis apendicular: una patología poco común. 2023;75(2). http://dx.doi.org/10.35687/s2452-454920230021667 Abdullgaffar B. Diverticulosis and diverticulitis of the appendix. Int J Surg Pathol. 2009;17(3):231-237. doi:10.1177/1066896909332728. Köhler F, Matthes N, Rosenfeldt M, Kunzmann V, Germer CT, Wiegering A. Neoplasms of the Appendix. Dtsch Arztebl Int. 2023 Aug 7;120(31-32):519-525. doi: 10.3238/arztebl.m2023.0136. PMID: 37282595; PMCID: PMC10534129. Kelly KJ. Management of appendix cancer. Clin Colon Rectal Surg [Internet]. 2015;28(4):247–55. Disponible en: http://dx.doi.org/10.1055/s-0035-1564433 Nutu OA, Marcacuzco AA, Manrique A, Justo I, Calvo J, García-Conde M, et al. Tumores mucinosos del apéndice: incidencia, diagnóstico y tratamiento quirúrgico. Cir Esp. 2017;95(6):321-327. doi:10.1016/j.ciresp.2017.05.008. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 26 Jan, 2026 Reviews received at journal 25 Jan, 2026 Reviews received at journal 23 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers invited by journal 21 Jan, 2026 Editor assigned by journal 21 Jan, 2026 Submission checks completed at journal 21 Jan, 2026 First submitted to journal 21 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8418183","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":578397931,"identity":"127c1262-6fce-443f-9666-5b69d1bee670","order_by":0,"name":"Fernando Escobar-Castañeda","email":"","orcid":"","institution":"Corpomedica clinic","correspondingAuthor":false,"prefix":"","firstName":"Fernando","middleName":"","lastName":"Escobar-Castañeda","suffix":""},{"id":578397934,"identity":"68420f91-d226-48fc-9f58-b7db127c3907","order_by":1,"name":"Juan Pablo 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09:43:07","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":42496,"visible":true,"origin":"","legend":"","description":"","filename":"21a903a88ff64ef1abfa8cc43a2aa2111structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8418183/v1/a5d87e9af3a93719acc0f990.xml"},{"id":101203931,"identity":"7cd915b1-df1c-43a3-9231-1644d6ffb423","added_by":"auto","created_at":"2026-01-27 09:41:04","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53072,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8418183/v1/40e68eaa6ab06c90525ed42a.html"},{"id":101018706,"identity":"79d16f7e-3699-442c-981a-75403213335d","added_by":"auto","created_at":"2026-01-24 00:34:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":93051,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eVermiform appendix of 8 cm in length and 1 cm in diameter with a 2.5 cm proximal dilation with attached omentum. Grasped with Bancock forceps\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418183/v1/2d31b93cb41c6fd403160b12.jpg"},{"id":101018710,"identity":"468b6117-c2c3-4f8d-b02d-20c040e5dc78","added_by":"auto","created_at":"2026-01-24 00:34:03","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":190836,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eA. Vertical view of cecal appendix of 8 cm in length and 1 cm in diameter containing a 2.5 cm mass inside, accompanied by 3 fecaliths of 23, 6 and 5 mm; B. Longitudinal view of appendix with evidence of a 2.5 cm mass at the base; C. Opposite longitudinal view of appendix with fecaliths of 23, 6 and 5 mm extracted\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418183/v1/a278031ceb04ca8d776851ca.jpg"},{"id":101204804,"identity":"7f622046-018f-40ad-b46c-4b71817fecba","added_by":"auto","created_at":"2026-01-27 09:43:58","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":136670,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePathology 10x hematoxylin and eosin showing invagination of the mucosa and submucosa of the cecal appendix\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418183/v1/c4db66906da9d94e26fe350a.jpg"},{"id":101203929,"identity":"3dc5f524-e9d0-40b7-b0f8-e6502548f15d","added_by":"auto","created_at":"2026-01-27 09:41:02","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":61397,"visible":true,"origin":"","legend":"\u003cp\u003eintraoperative algorithm to promptly distinguish between a true diverticulum or a potential neoplasia.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8418183/v1/4bd34052d13d1a64f1ef0383.jpg"},{"id":101751224,"identity":"5fe6b006-94b5-4c54-9ed0-f973101864c4","added_by":"auto","created_at":"2026-02-03 10:18:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1108183,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8418183/v1/b5e0fc71-d57c-40a3-a0cb-d0b34f52a5af.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Refining the Diagnosis of Appendiceal Diverticulitis: An Intraoperative Protocol for Surgical Precision and case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAppendiceal diverticulitis is an uncommon pathology known by the acute inflammation of a diverticulum emerging from the vermiform appendix. Historically, it has been considered an uncommon etiology of acute abdomen, with an incidence ranging from 0.004% to 2.1% of appendicitis cases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). These diverticula are principally false diverticula, composed by protrusions of the mucosa and submucosa through a muscle defect. The clinical presentation mimics the scenario of acute appendicitis, which can confuse and delay the diagnosis (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Even less frequently, a true appendiceal diverticulum refers to a protrusion involving all layers of the appendix. These are usually located on the antimesenteric border of the appendix and may be associated with developmental abnormalities such as trisomy 13 and 15 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A 2021 case report (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) reported approximately 50 cases published to date.\u003c/p\u003e \u003cp\u003eResearch on this area is essential due to its low prevalence, to the diagnosis challenge it presents and the potential severe complications, such as perforation and subsequently peritonitis. Scientific research proves that appendiceal diverticulitis has a higher risk of perforation compared to acute appendicitis, occurring in up to 66% of cases, a rate four times greater than that in acute appendicitis (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Additionally, this pathological anatomic variant increases the risk of appendiceal neoplasms, principally neuroendocrine tumors (48%) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), which makes a detailed pathological analysis important after surgery. The purpose of this research is to analyze the diagnosis of appendiceal diverticulitis by a case report and establish an intraoperative algorithm to accurately identify this type of diverticulum, optimizing surgical decision-making. Intraoperative proposal include developing a protocol in which, upon identifying a protuberance in the vermiform appendix, it must be opened to distinguish between a true diverticulum or a potential neoplasia. This distinction is such a life changing decision, as a neoplastic suspicion would warrant a hemicolectomy, whereas confirmation of a true diverticulum would only require an appendectomy.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 26-year-old woman from Florencia, Colombia, treated at Corpomedica clinic (rural area), presented with a 36-hour history of right lower abdominal pain without vomiting or fever. Physical examination showed no clear signs of peritoneal irritation. The Alvarado score was negative for acute appendicitis. The paraclinical tests on admission did not show anemia, leukocytosis, or neutrophilia. Abdominal ultrasound revealed no significant findings. Due to inadequate pain progression, treatment was started with cefazolin-metronidazole, analgesics, and transfer to the operating room for intervention. Under general anesthesia, a Rockey-Davis incision was made, revealing an edematous cecal appendix with a plastron at its base and minimal fibrinopurulent membranes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Dissection revealed a firm, 2.5 cm mass at the base, immobile, with a contained 5 mm perforation and minimal contamination. The base of the appendix was opened and three fecaliths of 23, 6, and 5 mm were removed (Fig.\u0026nbsp;2). The orifice and appendiceal stump were closed and the soft tissues of the plastron were repositioned. Postoperative recovery was uneventful. The patient completed 72 hours of intravenous antibiotics and analgesics. Pathology reports a cecal appendix measuring 8 cm in length and 1 cm in diameter accompanied by a true diverticulum with acute diverticulitis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eRegarding epidemiology, appendiceal diverticulitis is more common in males, typically occurring in the third decade of life, and has a higher mortality rate than acute appendicitis due to its insidious clinical course, delayed diagnosis, and potentially complications (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Notably, imaging techniques do not have a diagnostic value in this case, leading to late diagnosis, which is principally confirmed through histopathological examination of intraoperatively excised specimens. The treatment of choice is principally appendectomy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNeoplasms of the appendix represent approximately 0.5% of all gastrointestinal neoplasms. According to the World Health Organization (WHO) in 2019, they are divided into adenomas and sessile serrated lesions, mucinous neoplasms, adenocarcinomas, goblet cell adenocarcinomas of the appendix, and neuroendocrine neoplasms (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These occur at an average age of 62 to 65 years and have a slight preference for the male gender. Together, they constitute a heterogeneous group of conditions that differ in treatment depending on their recognition and tumor stage (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMucinous tumors of the appendix are also a rare pathology, with a prevalence under 0.5% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The average age of onset is in the sixth decade of life and is more common in males (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Clinical presentation as in the appendiceal diverticulitis can mimic the scenario of an acute appendicitis, with the difference that this pathology has a high risk of peritoneal dissemination of mucin and so metastasis (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Diagnosis rate is also low, as it is made by histopathological specimens according to the American Joint Committee on Cancer (AJCC) classification. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Given the risks associated with this pathology, the treatment of choice is surgery, ranging from appendectomy to right hemicolectomy, depending on the histological diagnosis. The principal goal is to achieve complete resection of compromised tissue, which may require reoperation in cases of surgical margin invasion. If the condition is incidentally discovered during surgery, conversion from laparoscopy to laparotomy is recommended due to the risk of mucin dissemination and the need to assess areas such as the colon and ovaries. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe presented clinical case joins others that have reported the intraoperative finding of appendicular diverticulitis in a patient with an initial suspicion of appendicitis. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) However, the current report documents a true diverticulum, which given its low prevalence, adds uniqueness to the case. As previously described, the abdominal ultrasound image did not show significant changes at the level of the vermiform appendix, which necessitated a surgical approach due to the lack of improvement in the patient's clinical condition. Intraoperatively, a 2.5 cm mass was found at the base of the appendix, which corresponded to a true diverticulum of the vermiform appendix.\u003c/p\u003e \u003cp\u003eThis dilation can be incorrectly misinterpreted as an appendiceal neoplasm, leading the surgeon to perform a hemicolectomy, as occurred in a case reported in 2021 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Due to its low frequency, there is currently no surgical consensus on how to manage this situation. Therefore, we propose an intraoperative algorithm to enable surgeons to promptly distinguish between these conditions, ensuring optimal decision-making and improve clinical outcomes for the patient (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Further studies are needed to help standardize the diagnosis and management of this condition, which will influence patients morbidity and quality of life.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe diagnosis of appendiceal diverticulitis supposes a surgical challenge due to its nonspecific clinical features, the limited usefulness of imaging in this setting and the importance of its intraoperative differentiation from appendiceal neoplasia. Further studies are needed to standardize its timely diagnosis that influences patient morbidity and mortality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding \u0026ndash;\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest -\u0026nbsp;\u003c/strong\u003eAs authors, we declare that there are no conflicts of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e- We have the patient\u0026apos;s informed consent for the publication of the article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u0026nbsp; - Written informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWritten Consent for publication\u003c/strong\u003e: Written informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e - We declare that the images and diagrams are our own work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e - Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. Responsibles: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e- Study design and conception: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u003c/p\u003e\n\u003cp\u003e- Data acquisition: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u003c/p\u003e\n\u003cp\u003e- Data analysis and interpretation: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u003c/p\u003e\n\u003cp\u003e- Manuscript writing: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u003c/p\u003e\n\u003cp\u003e2. Drafting the work or reviewing it critically for important intellectual content: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u003c/p\u003e\n\u003cp\u003e3. Final approval of the version to be published: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u003c/p\u003e\n\u003cp\u003e4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: Fernando Escobar-Casta\u0026ntilde;eda, Juan Pablo Torregroza-Castilla, Sara Restrepo-Vivas, Alvaro Silva-Redondo, Luis Felipe Cabrera-Vargas.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArenas-Garc\u0026iacute;a V, Santos-Seoane SM, Delgado-Sevillano RJ. Appendiceal diverticulitis: An uncommon cause of acute abdomen. Rev Gastroenterol Mex. 2019;84(2):243-244. Available from: https://www.revistagastroenterologiamexico.org/en-appendiceal-diverticulitisan-uncommon-cause-articulo-S2255534X1930012X \u003c/li\u003e\n\u003cli\u003eKristopher Bujold-Pitre, Olivier Mailloux, Diverticulitis of the appendix\u0026mdash;case report and literature review, Journal of Surgical Case Reports, Volume 2021, Issue 10, October 2021, rjab488, https://doi.org/10.1093/jscr/rjab488\u003c/li\u003e\n\u003cli\u003eLiu Y, Zhang Y, Zhang Y, et al. Perforated appendiceal diverticulitis mimicking appendicitis. Am Coll Surg. 2018;226(1):e1-e3. Available from: https://www.facs.org/for-medical-professionals/newspublications/journals/case-reviews/issues/v4n1/liu-appendiceal-diverticulitis/ \u003c/li\u003e\n\u003cli\u003eLee JH, Lee HS, Park SH, et al. Appendiceal diverticulitis: diagnosis and differentiation from usual acute appendicitis using computed tomography. J Comput Assist Tomogr. 2007;31(5):763-769. Available from: https://pubmed.ncbi.nlm.nih.gov/17805147/\u003c/li\u003e\n\u003cli\u003eEscobar F, Vega NV, Valbuena E, Bar\u0026oacute;n M. Diverticulitis apendicular, revisi\u0026oacute;n de la literatura cient\u0026iacute;fica y presentaci\u0026oacute;n de dos casos. Rev Colomb Cir. 2013;28(3):223-228.\u003c/li\u003e\n\u003cli\u003eF\u0026eacute; FS, Cadena M, L\u0026oacute;pez R, Cardoso L, Universidad de los Andes, Garc\u0026iacute;a D, et al. Acute diverticulitis of the appendix: A case report. Annals of Mediterranean Surgery [Internet]. 2023;6(2):17\u0026ndash;22. Disponible en: https://edicions.uib.es/ojs/index.php/AMS/article/download/1027/1127\u003c/li\u003e\n\u003cli\u003eLobo-Mach\u0026iacute;n I, Delgado-Plasencia L, Hern\u0026aacute;ndez-Gonz\u0026aacute;lez I, Brito-Garc\u0026iacute;a A, Burillo-Putze G, Bravo-Guti\u0026eacute;rrez A, et al. Appendiceal diverticulitis and acute appendicitis: differences and similarities. Rev Esp Enferm Dig. 2014;106:452-8. PMID: 25490164. [ Links ] \u003c/li\u003e\n\u003cli\u003eVan de Moortele M, De Hertogh G, Sagaert X, Van Cutsem E. Appendiceal cancer : a review of the literature. Acta Gastroenterol Belg. 2020 Jul-Sep;83(3):441-448. PMID: 33094592.\u003c/li\u003e\n\u003cli\u003eSandoval G, Rojas M, Segovia J. Manejo de la diverticulitis apendicular: una patolog\u0026iacute;a poco com\u0026uacute;n. 2023;75(2). http://dx.doi.org/10.35687/s2452-454920230021667\u003c/li\u003e\n\u003cli\u003eAbdullgaffar B. Diverticulosis and diverticulitis of the appendix. Int J Surg Pathol. 2009;17(3):231-237. doi:10.1177/1066896909332728. \u003c/li\u003e\n\u003cli\u003eK\u0026ouml;hler F, Matthes N, Rosenfeldt M, Kunzmann V, Germer CT, Wiegering A. Neoplasms of the Appendix. Dtsch Arztebl Int. 2023 Aug 7;120(31-32):519-525. doi: 10.3238/arztebl.m2023.0136. PMID: 37282595; PMCID: PMC10534129.\u003c/li\u003e\n\u003cli\u003eKelly KJ. Management of appendix cancer. Clin Colon Rectal Surg [Internet]. 2015;28(4):247\u0026ndash;55. Disponible en: http://dx.doi.org/10.1055/s-0035-1564433\u003c/li\u003e\n\u003cli\u003eNutu OA, Marcacuzco AA, Manrique A, Justo I, Calvo J, Garc\u0026iacute;a-Conde M, et al. Tumores mucinosos del ap\u0026eacute;ndice: incidencia, diagn\u0026oacute;stico y tratamiento quir\u0026uacute;rgico. Cir Esp. 2017;95(6):321-327. doi:10.1016/j.ciresp.2017.05.008.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Appendiceal diverticulitis, true appendiceal diverticulum, appendiceal neoplasms, intraoperative algorithm, case report","lastPublishedDoi":"10.21203/rs.3.rs-8418183/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8418183/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAppendiceal diverticulitis is an uncommon pathology known by the acute inflammation of a diverticulum emerging from the vermiform appendix. A true appendiceal diverticulum refers to a protrusion involving all layers of the appendix. A 2021 case report (3) showed approximately 50 cases published to date. This pathological anatomic variant increases the risk of appendiceal neoplasms, principally neuroendocrine tumors (48%) (5), which makes a detailed pathological analysis important after surgery. The purpose of this research is to analyze the diagnosis of appendiceal diverticulitis by a case report and establish an intraoperative algorithm to accurately identify this type of diverticulum, optimizing surgical decision-making.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase report\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 26-year-old woman from Florencia, Colombia, treated at Corpomedica clinic (rural area), presented a 36-hour history of right lower abdominal pain without vomiting or fever. Abdominal ultrasound revealed no significant findings. Due to inadequate pain progression, the patient was transferred to the operating room for intervention. Dissection revealed a firm, 2.5 cm mass at the base, immobile, with a contained 5 mm perforation and minimal contamination. Pathology reports a cecal appendix accompanied by a true diverticulum with acute diverticulitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLike appendiceal diverticulitis, most of these neoplasms are detected incidentally in a surgical specimen after an appendectomy for suspected appendicitis (13). Their intraoperative differentiation is of great importance since their management varies considerably and impacts the patient's disease burden and quality of life. Further studies are needed to standardize its timely diagnosis in order to avoid patient morbidity and mortality.\u003c/p\u003e","manuscriptTitle":"Refining the Diagnosis of Appendiceal Diverticulitis: An Intraoperative Protocol for Surgical Precision and case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-24 00:33:58","doi":"10.21203/rs.3.rs-8418183/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-26T12:00:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T20:20:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-23T17:26:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330663271569258680701080744164869045532","date":"2026-01-23T09:45:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198882398794632271443168810692625078628","date":"2026-01-21T23:44:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91565209886432911431604696715017400757","date":"2026-01-21T21:04:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155916990615143610114757587901974424810","date":"2026-01-21T19:10:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242274765649208154341584967160741086488","date":"2026-01-21T09:42:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-21T09:14:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T07:36:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-21T07:02:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2025-12-21T15:12:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2db3d262-19db-43bb-b26f-9bc5bdbf3842","owner":[],"postedDate":"January 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-04T12:40:56+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-24 00:33:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8418183","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8418183","identity":"rs-8418183","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}