[Colonic diverticulitis. Primary clinical and ultrasound diagnosis--report of 47 cases from general practice]

Clinical and sonographic diagnosis-Report on 47 cases From 1993 to 1996, 47 patients with/after acute diverticulitis were examined in our practice by abdominal ultrasound. In all 36 cases with acute diverticulitis, a dolent non-echous wall thickening of descendent/sigmoid colon was seen. In five cases, we found other sonographic signs suspicious of penetration. Elevation of CRP and sometimes leukocytosis assisted the diagnosis in acute cases. In 39 of the 47 patients, colonoscopy was performed in the practice mostly during intermissions. Diverticula were confirmed in 31 patients whereas sigmoid stenosis from chronic diverticulitis could not be passed in 6 cases. 32 patients were treated with antibiotics and 10-including those with stenosis-underwent surgery. Except in one particular case (tubar abscess involving the sigmoid), operation confirmed sonographic findings of severe inflammation (stenosis and sealed perforation, respectively, in five cases). In patients presenting with pain in the left lower quadrant of the abdomen, colonic diverticulitis has to be considered especially if signs of inflammation are present. After clinical examination the first diagnostic measures should be venopuncture (CRP, leukocytes) and at the same time abdominal ultrasound by an experienced clinician. Due to its high accuracy, abdominal ultrasound is sufficient for primary diagnosis and evaluation of the course of colonic diverticulitis. Colonoscopy and barium enema follow after resolution of acute inflammation.

[Ultrasonography in acute diverticulitis of the colon: semiologic features]

To assess the ultrasonographic (US) patterns of acute colonic diverticulitis, we prospectively examined 21 patients. US was performed in all of them, CT in 13/21, contrast enema in 18/21 and endoscopy in 2/21 patients. US follow-up was carried out in 15/17 patients managed with conservative treatment. To analyze the US patterns of simple diverticula, we carried out an in vitro study of two surgical specimens with simple colonic diverticulosis. Wall thickening was seen in 21/21 cases, diverticula in 19/21, changes in pericolic fat in 11/21, local tenderness on gradual compression in 19/21 and changes in peristaltic activity in 21/21 cases. Even though diverticula may appear differently, we found 4 main patterns: round or linear hyperechoic pericolic outpouchings with no definite wall, usually with shadowing or reverberation artifacts (pattern 1), a saccular focus with a well-defined wall and various contents (pattern 2), a tubular structure with no content but with central linear echoes (pattern 3), and a flask-like or arrowhead-like hypoechoic focus (pattern 4). Patterns 1, 2 and 3 were shown in inflamed colic segments and in unaffected adjacent tracts, both in the acute phase and at follow-up, with no relevant morphological changes. In contrast, pattern 4 was observed in 10/19 patients, always in the acute phase and in affected colic tracts. The follow-up showed a decrease in size in 3 cases and a change to patterns 1, 2 or 3 in 7 patients. The authors believe pattern 4 to represent inflamed diverticula, while patterns 1, 2 and 3 indicate simple diverticula. Moreover the detection of diverticula and thickened wall segments does not necessarily indicate diverticulitis: thus, the diagnosis of this condition must rely on the presence of several signs, the most specific of which were, in our series, the flask-like and arrowhead-like patterns, presumptively expressing peridiverticular abscess.

CT evaluation of the acute abdomen: bowel pathology spectrum of disease

CT has become the primary imaging modality for the evaluation of the patient with clinical symptoms of an acute abdomen and a confusing clinical picture. Because these patients may have a range of various pathologies, CT has been used successfully to define the presence of disease and localize it to a specific organ or organ system. In this article, we review the various processes that resulted in acute abdomen focusing on the small bowel and colon. Specific entities discussed include appendicitis, diverticulitis, Crohn disease, and ulcerative colitis. Other less common processes, including pseudomembranous colitis, intussusception, and bowel ischemia are also discussed. The specific role of CT scanning and specific CT signs are discussed and addressed. The value of CT in relationship to other modalities and clinical evaluation is discussed and key statistics provided.

Colouterine fistula: computed tomography and vaginography findings

Colouterine fistulas are difficult to demonstrate radiologically. The authors present a case in which such a fistula was observed with computed tomography and confirmed by vaginography.

Septic thrombophlebitis of the inferior mesenteric vein associated with diverticulitis CT diagnosis

Septic thrombophlebitis of a mesenteric vein can occur as a rare complication of diverticulitis. We report a case of septic thrombophlebitis of the inferior mesenteric vein diagnosed with computed tomography, in a patient with sigmoid diverticulitis.

[Contribution of Doppler sonography in inflammatory pathology of the large bowels]

At the end of the eighties, Doppler equipment added to conventional ultrasonography a new dynamic dimension. On the basis of radiological (US, CT, barium studies), clinical, biological, surgical and/or pathological correlations in 30 cases, the following considerations were emphasized. In case of intestinal obstruction, viability of the obstructed segment is compromised when Doppler parietal flow remains undetectable. In Crohn's disease or ulcerative colitis, as well as in acute appendicitis, presence of Doppler parietal flow throughout the affected thickened segment indicates an acute condition; similarly, abnormally high mean portal velocity (30-48 cm/sec; normal: 15 +/- 7 cm/sec), and abnormally low resistive index in the superior mesenteric artery (0.58-0.78; normal: 0.908 = 0.026) are detected. In colonic diverticulitis, similar characteristics can be observed, but are subtle and usually predominant at the mesenteric side of the affected segment in moderate diverticulitis. These abnormal Doppler findings disappear with successful therapy.

[The computed tomography of acute sigmoid diverticulitis]

PURPOSE

To study the ranking of CT in the diagnosis of sigma diverticulitis. Comparison of results of the colon monocontrast enema with those obtained via CT and histopathology as gold standard.

MATERIAL AND METHODS

32 patients were included who were operated on for sigma diverticulitis. In 30 patients both CT and monocontrast enema were performed and in two patients CT only.

RESULTS

Acute inflammatory wall alterations are identified by CT with a sensitivity of 89.7% vs 96.3% via contrast enema. Pericolic reactions of the environment were seen via CT with 89.7% sensitivity. In case of covered perforations CT yielded a sensitivity of 76.5% vs 46.7% via contrast enema. Sensitivity for abscesses and fistulas was in each case 100% with CT.

RESULTS

CT may help to identify extraluminal inflammatory changes and complications in diverticulitis. The degree of the inflammation can be classified and the surgical approach suitably influenced, respectively modified.

Diagnosis of acute flank pain: value of unenhanced helical CT

OBJECTIVES

The purpose of our study was to determine the value of unenhanced CT in the diagnosis of acute flank pain. We determined the accuracy of unenhanced Ct for stone detection as well as the detection of abnormalities unrelated to stone disease.

MATERIALS AND METHODS

During an 18-month interval, 292 patients with acute flank pain were imaged with unenhanced CT. Confirmation of the CT diagnosis was obtained for 210 patients: One hundred patients were proved to have ureteral stones based on other imaging studies (58 patients), lithotripsy (seven patients), ureteroscopic stone extraction (five patients), and stone recovery (30 patients). One hundred ten patients were proved not to have ureteral stones based on other imaging studies (24 patients), failure to recover a stone (56 patients), or a confirmed diagnosis unrelated to stone disease (30 patients). This latter group of 30 patients included diagnoses of adnexal masses (eight patients), appendicitis (five patients), diverticulitis (four patients), and common bile duct stones (three patients), as well as other diagnoses.

RESULTS

Unenhanced CT findings were falsely negative for stone disease in three patients and falsely positive for stone disease in four patients. These data yield a sensitivity of 97%, a specificity of 96%, and an accuracy of 97% for diagnosing ureteral stone disease. Of 31 patients with a CT abnormality unrelated to stone disease, there was one false-negative diagnosis of acute appendicitis.

CONCLUSION

Unenhanced CT is a valuable technique for examining patients with acute flank pain in whom a clinical diagnosis is uncertain. It can accurately determine the presence or absence of ureteral stones as well as extraurinary causes of acute flank pain. In most cases, other imaging studies are not required.

[Effect of intestinal ultrasound on choice of surgical procedure in acute abdominal pain]

Differential diagnosis in patients with acute abdominal pain represents a difficult assignment in surgery involving the indication for urgent operation and the operation technique.

AIM

The value of sonography in diseases of the bowels for correct indication for early laparotomy was investigated.

METHOD

In a retrospective analysis we compared the result of sonography on 159 patients with acute abdominal pain with the first clinical assessment.

RESULTS

The sensitivity of this technique was found to be 38.9% for acute appendicitis, 57.1% for diverticulitis and 76.9% for obstructive ileus. The specificity ranged above 90% in each case. In consideration of more than two sonomorphological criterias for pathological alterations of the intestines the positive predictive value achieved 100%.

CONCLUSION

Low diagnostic sensitivity with high specificity implies the necessity to intensity routine ultrasonic investigation of the gut.

Technetium-99m-pyrophosphate scintigraphic findings of intestinal perforation in dermatomyositis

Gastrointestinal complications are more common in children than in adults and present a serious problem with dermatomyositis. We report on a 66-yr-old man with dermatomyositis who suffered from intestinal perforation. The abdominal plain radiograph revealed only dilatation of the intestinal loops; increased radioactivity, however, was clearly demonstrated in the early 5-min and delayed 3-hr 99mTc-pyrophosphate images.

A combined flexible sigmoidoscopy and double-contrast barium enema service: initial experience

BACKGROUND

A service has been instituted offering a combined single-stage procedure of flexible sigmoidoscopy and double-contrast barium enema (FS/DCBE). The results have been reviewed in the first 80 patients to undergo this examination (45 male: 35 female; mean age 61.4 years).

METHODS

Indications for investigation were abdominal pain or suspected diverticular disease (22 patients), altered bowel habit (19), rectal bleeding (17), iron deficiency anemia (6), and miscellaneous (16). FS was followed immediately by DCBE. Radiographs were reviewed by two radiologists unaware of the FS findings.

RESULTS

The extent of FS was to the proximal sigmoid or sigmoid descending colon or splenic flexure in 12.5%, and mid or distal sigmoid in 37.5%. Biopsies were performed at FS in 26 patients (33%). In 67 (84%) of DCBEs the barium coating was assessed as satisfactory or better. FS yielded pathological findings not seen at DCBE in 21 patients (26%). DCBE demonstrated additional abnormalities within the range of the FS examination in 15 patients (19%), almost entirely due to its increased sensitivity for diverticular disease.

CONCLUSION

FS/DCBE is feasible as a one-stage combined procedure. The quality of DCBE following FS is satisfactory, and the extra yield of FS and its potential for biopsy make the combined FS/DCBE a useful technique in the investigation of large bowel disease.

Transvaginal sonographic diagnosis of sigmoid diverticulitis

The development of the transvaginal technique has allowed for high-resolution, detailed evaluation of the female pelvis. Although not previously emphasized, gut pathology can also be recognized with this technique. We report two cases of sigmoid diverticulitis which were prospectively diagnosed using endovaginal sonography. In both patients, pelvic sonogram was the first imaging study performed for evaluation of nonspecific abdominal pain.

[Radiological and endoscopic diagnosis of sigmoid diverticulitis]

In emergency, the most commonly used examination, other than plain radiographs of the abdomen, is the water-soluble contrast enema (Gastrografin). It demonstrates three different pictures, which may be more or less associated one to the other: "peridiverticulitis", featuring serrate lesions, abnormal stiffness and fixity and, in some cases, a long narrowing or stricture of the colon; diverticula, mainly in the sigmoid colon, becoming sharp-pointed or spark-liked; spillage of contrast material out of the colic lumen or into a neighbouring organ (fistula). Ultrasonography may be a useful emergency procedure to secure a hesitating diagnosis in a patient with a febrile abdominal pain or with a abdominal-pelvic mass, especially in women. Colonoscopy and barium enema are both usually contra-indicated in the acute setting of diverticulitis because of their potential hazards. On the other hand, after resolution of the acute event, these tests may allow to rule out carcinoma or associated adenomas (which coexist in more than 15% of the patients). Endoscopic control appears more especially important as initial accurate diagnosis in sometimes impossible to assess between adenocarcinoma and diverticulitis. CT scan has found an increasing place in both diagnosis and evaluation of infectious complications of diverticular disease. It is most recommended to assess the diagnosis of severe episodes, failing to clearly improve after medical treatment, and most particularly when an abscess in suspected. CT scan may demonstrate a thickening of the colic wall, high densities of pericolic fat and a tissular mass which may enclose gas bubbles.

CT of inflammatory disease of the colon

CT plays an important role in the evaluation of patients with suspected colonic inflammation. High-resolution, thin-section imaging of the gastrointestinal tract allows assessment of both the intraluminal and extraluminal components of colonic disease, thereby enabling radiologists to detect and stage colonic pathology accurately. In addition, CT can be used to guide percutaneous drainage of abscess collections, often obviating the need for surgical intervention. This article describes CT techniques for diagnosing inflammatory diseases of the colon as well as the typical CT appearances.

[Hydrocolonic sonography in the study of colonic diseases. Comparison with double-contrast enema]

This study was aimed at assessing the diagnostic value of hydrocolonic sonography (HS), a new technique of US examination of the colon during water enema, in colonic diseases. HS was performed on 120 clinically selected patients and was followed by double contrast barium enema (DCBE) in all patients, by endoscopy in 85, by pathology in 50 and by surgery in 36 patients. We obtained good quality images in 86% of cases, middle quality findings in 10% and poor results in 4% of cases. HS allowed the 5 layers of the colonic wall to be visualized. Forty of 50 polyps bigger than 1 cm, 9/10 cases of granulomatous colitis and diverticulitis were recognized and distinguished from cancer and 31/32 carcinomas were found--3 of them were locally invasive tumors, even though endoscopic biopsy had diagnosed them as adenomas. Compared with DCBE, HS exhibited lower sensitivity in recognizing small polyps (80% vs. 92%) but higher specificity (100% vs. 92.8%); in the diagnosis of carcinoma, HS exhibited higher sensitivity (96.8% vs. 90.6%) and the same specificity (about 100%); the depiction of parietal layers allowed also tumor staging. At present, HS cannot be proposed as the examination of choice to study polyps because of its limitations in recognizing them; nevertheless, HS appears to exhibit some advantages over DCBE in tumor detection and staging. HS is a simple, fast and safe technique which is well tolerated and easily repeatable, which calls for further investigation of its potentials, also because improved operator's experience is sure to increase HS reliability.

Serial assessment of adnexal masses with transvaginal color Doppler sonography

Transvaginal color Doppler sonography (TV-CDS) was performed on 64 women with adnexal masses at 3, 6 and 12 weeks after initial presentation. In 47 (72% of patients studied), the pelvic mass demonstrated a decrease in size and increase in pulsatility index (PI) after 12 weeks. Of the patients undergoing surgery in this group, one had a tubo-ovarian abscess, one diverticular abscess and one hydrosalpinx. In seven patients (10%), there was no change in size or PI. Three in this group had an endometrioma, whereas two had a peritoneal cyst. In five (7%), there was no change in size and an increase in PI. One of these patients had a mucinous cystadenoma. In three (5%), there was a decrease in size and PI. Two of these patients had a tubo-ovarian abscess. In two (3%) patients studied, the mass showed an increase in size and decrease in PI; both had corpora luteum cysts with acute hemorrhage. Seventy-two percent of masses with high impedance underwent regression, whereas only 21% of lesions with low impedance did. Only 20% of masses demonstrating low impedance or morphologically complex structure regressed. Sixty-five percent of lesions that regressed had a significant drop in PI, whereas all the lesions that showed no change in size or enlargement had either no change or decrease in PI. Probability of regression was the greatest in young women (less than 40 years of age) and in masses < 5 cm. Ninety-three percent of women with persistent masses that underwent progestational suppression demonstrated regression with decrease of PI and peak systolic velocity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis of acute colonic diverticulitis: comparison with echography and tomodensitometry]

The sensitivity of ultrasonography (US) as the initial imaging procedure in acute diverticulitis of the left colon was retrospectively compared with that of computed tomography (CT) in 34 patients. Final diagnosis was based on clinical findings and follow-up in a first group of 20 patients with mild diverticulitis, and was proved by surgery in a second group of 14 patients with severe diverticulitis. In the first group, US showed findings consistent with diverticulitis in 19 patients, as did CT. The image of an inflamed diverticulum was shown by US in 10 patients. In the surgical group, findings consistent with diverticulitis were shown by US in 11 cases, and by CT in 13 cases. An inflamed diverticulum was not detected at US in this group of patients, presumably because the diverticulum was incorporated in the inflammatory process. These results suggest that US is a valuable technique in the initial evaluation of patients suspected of having acute diverticulitis, especially when the disease is not severe. The image of an inflamed diverticulum shown at US strongly suggests the diagnosis of mild diverticular disease. When diverticulitis is severe, CT should be performed in addition to US.

[Ultrasonography of acute diverticulitis of the colon]

Ultrasonographic findings in two patients with acute diverticulitis of the left colon are described. Echographic identification of diverticula and thickened (> 4 mm) hypoechoic bowel wall were common findings. The final diagnosis was confirmed by contrast enema and colonoscopy. Patients had clinical signs and symptoms of acute diverticulitis. Diverticula were visualized as echogenic shadowing foci in thickened bowel wall (1 case) or as outpouches of the intestinal wall in the pericolonic soft tissues (1 case). One patient had edema of the pericolic fat. Additional studies are needed to confirm the usefulness of ultrasounds in the diagnosis of colonic diverticulitis.

CT of appendicitis and diverticulitis

CT scans have made a significant impact on the diagnosis and staging of those gastrointestinal disorders that are associated with perienteric inflammatory extension. Appendicitis and diverticulitis are examples of such diseases, and this article reviews the current role of CT scans in the diagnosis and management of patients with these conditions.

Sonography of appendicitis and diverticulitis

Graded compression sonography has gained widespread acceptance as a useful technique to evaluate patients with atypical signs and symptoms of appendicitis. When positive, early surgery can be performed prior to perforation. When there is no sonographic evidence of appendicitis, other alternative diagnoses may be established. CT scans and the contrast enema remain the primary imaging modalities to evaluate suspected diverticulitis; however, sonography may be useful in selected patients with an atypical clinical presentation.