Acute diverticulitis

Ferzoco L B et al 1998 Acute diverticulitis. New England Journal of Medicine 338 1521-1526 Goyal R K, Hirano 11996 The enteric nervous system. New England Journal of Medicine 334 1106-1115... 

Wada M, Kikuchi Y, Doy M (1990) Uncomplicated acute diverticulitis of the cecum and ascending colon. Sonographic findings in 18 patients. Am J Roentgenol 155 283-287... 

Gynaecological disorders, such as ruptured ovarian cysts, ovarian torsion,ectopic pregnancy or pelvic inflammatory disease, can resemble acute diverticulitis in female patients, but often these patients are younger. Transvaginal sonography maybe helpful in obtaining an accurate diagnosis. Stone of the ureter on the left side may simulate diverticulitis. 

The differential diagnosis of acute diverticulitis is wide (Gritzmann et al. 2002). One important reason for left lower quadrant pain can be a torsion or necrosis of appendices epiploicae of the left colon. A well-defined point of pain is typical, and is the effect of a local peritonitis. 

Performed by an experienced investigator, sonography shows results comparable to those of CT in diagnosing acute diverticulitis, and an accuracy of more than 90% can be reached. If complications, such as abscess formation or fistulas, are suspected, CT should be performed. In distal sigmoid localisation, transrectal examination provides high-resolution images with a high specificity. 

Brengman ML, Otchy DP (1998) Timing of computed tomography in acute diverticulitis. Dis Colon Rectum 41 1023-1028... 

Farag Soliman M, Wustner M et al (2004) Primary diagnostics of acute diverticulitis of the sigmoid. Sonography versus computed tomography a prospective study. Ultraschall Med 25 342-347... 

Fig. 17.16 Sigmoid diverticulitis. Multiple air-containing diverticula are found along the sigmoid colon. In this patient with acute pelvic pain, focal wall thickening, stenosis, and paracolic fat stranding (arrow) are signs of acute diverticulitis involving the distal sigmoid colon. R, rectum...

Labs JD, Sarr MG, Fishman EK et al (1988) Complications of acute diverticulitis of the colon improved early diagnosis with computerized tomography. Am J Surg 155 331-336... 

In selected cases stents may also be used for preoperative decompression of obstruction in acute diverticulitis (Baron et al. 1998 Binkert et al. 1998 Knopfle et al. 1998 Camunez et al. 2000 Tamim et al. 2000). The goal is to relieve the patient immediately from symptomatic ileus and to treat the inflammation with antibiotics prior to surgery. Since it is often difficult to distinguish diverticulitis from a malignant tumour as the cause of obstruction even on endoscopy, preoperative stenting should be performed anyway to allow cleansing prior to resection. 

Failed colonoscopy Change in bowel habits Acute diverticulitis... 

The contraindications to CTC are few and, in general, different than these encountered with conventional colonoscopy (Rex et al. 1987). Weight and girth limitations of the scanner, artifacts from metal prosthesis and claustrophobia are examples of contraindications unique to CT. Absolute contraindications to instrumentation of the colon include presence of an acute abdomen, recent abdominal or pelvic surgery, colonic hernia, and acute diverticulitis (Fig. 2.3). Relative contra-indications include pregnant patients, patients with hip replacements, claustrophobia and an incompetent ileocecal valve (Fig. 2.4). 

Presently, CT colonography has no role in the diagnosis of acute diverticulitis, and, in addition, the distension of the colon may lead to perforation. In selected cases, CTC may help in the differential diagnosis between diverticulitis and cancer after the acute inflammatory episode has subsided. 

Streptokinase is contraindicated in patients with nlcerative wounds, active internal bleeding, recent trauma with possible internal injuries, visceral or intracranial malignancy, ulcerative cohtis, diverticulitis, severe hypertension, acute or chronic hepatic or renal insufficiency, uncontrolled hypoco-agnlation, chronic pulmonary disease with cavitation, sub-acnte bacterial endocarditis or rheumatic valvular disease, recent cerebral embolism, thrombosis, or hemorrhage, and diabetic hemorrhagic retinopathy, becanse excessive bleeding may occur. 

Traditionally,contrast enemahasbeen the mainstayin the evaluation of patients suspected of having diverticulosis or acute colonic diverticulitis (Fig. 3.1). 

Diverticulosis can also be diagnosed by endoscopy (Fig. 3.2) however, when diverticulits is suspected clinically, endoscopy is contraindicated. After the acute phase of inflammation, the colon should be examined to exclude a colon carcinoma. So a complete colonic evaluation should generally be performed 6-8 weeks after the resolution of a diverticulitis. In cases of inflammation, coloscopy is often incomplete and painful for the patient. The risk for perforation is also higher because of the air insufflation. 

Acute colonic diverticulitis is a common cause of acute abdominal symptoms, especially in elderly patients. In turn, diverticulitis develops in 10-25% of the population vyith diverticulosis (Roberts et al. 1995). It is, in virtually all cases, the result of a micro-perforation of a single diverticulum (Fig. 3.5). 

The clinical diagnosis and assessment of acute colonic diverticulitis can be difficult (Chappuis and Cohn 1988). The classic pattern of left lower quadrant pain, tenderness, fever, and leukocytosis is suggestive of acute colonic diverticulitis but can be mimicked by numerous acute abdominal conditions. Symptoms such as nausea, vomiting, constipation or diarrhoea lead to a high rate of wrong diagnosis up to 34% of cases. 

At most hospitals, CT has replaced barium enema examination of the colon for diagnosis of suspected diverticulitis. Compared with sonography, the operator dependency is less (Ambrosetti et al. 1997). One of the reasons is that diverticulitis is primarily an extramural process, and barium enema diagnosis depends on the secondary effects on the barium column caused by the extramucosal manifestations of acute inflammation. 

Any form of colitis, such as pseudomembranous, acute ulcerative colitis or Crohn s colitis can also mimic diverticulitis. Usually, pseudomembranous colitis is associated with antibiotic therapy. In most cases a significant thickening of the colon is found. 

Ambrosetti P, Grossholz M, Becker C et al (1997) Computed tomography in acute left colonic diverticulitis. Br J Surg 84 532-534... 

Chappuis CW, Cohn I (1988) Acute colonic diverticulitis. Surg Clin North Am 68 301-313... 

Fig. 17.15a,b. Right-sided diverticulitis. Trans-axial CT scans at the level of the pelvic crest at the initial presentation (a) and after 3 weeks (b). In a 33-year-old woman who presented with acute right quadrant pain and laboratory signs of inflammation, a diffuse inflammatory process (arrow) in the pericecal region is demonstrated. It was diagnosed as acute retrocecal appendicitis (a). At surgery, there was no evidence of inflammatory changes of the appendix. The follow-up 3 weeks later demonstrated complete resolution of the inflammatory reaction and revealed several diverticula (arrow) of the cecum (b)... 

Epiploic appendagitis and omental infarction are causes of acute pelvic pain that are often misdiagnosed clinically as acute appendicitis or diverticulitis. Based on the imaging findings, especially CT allows a definite diagnosis in most cases and patients can be managed conservatively. 

Indications appendicitis, diverticulitis, pelvic pain, acute abdomen ... 

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