Diagnosis of diverticulosis and diverticulitis
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Diagnosis of diverticulosis and diverticulitis. Tryggvi Björn Stefánsson Dept of Surgery Landspitali University Hospital. Diverticulosis. Barium Enema. Barium Enema. Diverticulitis. Clinical classification Hinchey classification Ambrosetti classification.

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Diagnosis of diverticulosis and diverticulitis

Diagnosis of diverticulosis and diverticulitis

Tryggvi Björn Stefánsson

Dept of Surgery

Landspitali University Hospital


Diverticulosis
Diverticulosis

  • Barium Enema.



Diverticulitis
Diverticulitis

  • Clinical classification

  • Hinchey classification

  • Ambrosetti classification


Clinical classification european association for endoscopic surgeons
Clinical classification(European association for endoscopic surgeons)

I. Symptomatic uncomplicated disease.

Fever, crampy abdominal pain, CT evidence of phlegmonous diverticulitis.

II. Recurrent symptomatic disease. Recurrence of above.

III. Complicated disease.

(hemorrhage, abscess, perforation, purulent and fecal peritonitis, stricture, fistula, small-bowel obstruction due to postinflammatory adhesions)


Hinchey classification
Hinchey classification

  • Stage 1

  • Pericolic or mesenteric abscesses.

  • Stage 2

  • Walled off pelvic abscess.

  • Stage 3

  • Generalised purulent peritonitis.

  • Stage 4

  • Generalised fecal peritonitis


Ambrosetti s ct staging of diverticulitis
Ambrosetti’s CT Staging of Diverticulitis.

  • Mild Diverticulitis

    Localized sigmoid wall thickening (less than 5 mm)

    Inflammation of pericolic fat.

  • Severe Diverticulitis

    Abscess

    Extraluminal air

    Extraluminal contrast


Complicated diverticulitis
Complicated diverticulitis

  • Abscess

  • Purulent peritonitis

  • Faecal peritonitis

  • Colovaginal fistula

  • Colovesical fistula

  • Colocutan fistula

  • Stricture

  • Hemorrage


Differential diagnosis
Differential diagnosis

  • Appendicitis.

  • Inflammatory bowel disease(Crohn’s disease).

  • Pelvic inflammatory disease.

  • Tubal pregnancy.

  • Tuboovarian abscess.

  • Cystitis.

  • Advanced colonic cancer.

  • Infectious colitis.

  • Colorectal cancer.


Diagnostic tools
Diagnostic tools

  • Clinical symptoms.

  • Lab tests.

  • Barium enema.

  • Ultrasound.

  • MRI.

  • CT.

  • Laparoscopy.


Clinical symptoms
Clinical symptoms

The AVOD study: Chabok A et al, British Journal of Surgery 2012



Computed tomography
Computed Tomography

  • Diverticulas

  • Thickening of the bowel wall >3 mm-5mm.

  • Cloudy fat in the mesentery



CT

  • Sensitivity 93%-98%

  • Specificity 75%-100%

  • Stefánsson T, Acta Radiol. 1997 Mar;38(2):313-9.

  • Doringer E. Crit Rev Diagn Imaging 1992; 33: 421–35

  • Hulnick DH et al, Radiology,1984; 152: 491–95.

  • Cho KC et al, Radiology 1990; 176: 111–15.

  • Ambrosetti P et al Dis Colon Rectum 2000; 43: 1363–67.


Barium enema1
Barium Enema

  • Diverticulas

  • Edema

  • Intramural sinus tract.

  • Extravasated contrast material outlining an abscess cavity.

  • Fistula.


Barium enema2
Barium Enema

  • Sensitivity 0.82 (95% CI: 0.71-0.90)

  • Specificity 0.81 (95% CI: 0.67-0.91)

    Stefánsson T, Acta Radiol. 1997 Mar;38(2):313-9.



Ultrasound1
Ultrasound

  • Inflamed segment.

  • Hypoechogenic thickening of the bowel wall (Hypertrophy of muscularis propria)

  • Hyperechogenic halo (Pericolitis, inflammatory fat)

  • Diverticulum with hyperechogenic halo.

  • Luminal narrowing.

  • Hypoperistalsis.

  • Pericolic abscess.


Ultrasound2
Ultrasound

  • Operator dependent

  • Sensitivity 98.6%

  • Specificity 96.5%

  • Schwerk WB, Zeitschrift für Gastroenerologi 1993


Ultrasound3
Ultrasound

  • Inflammatory target sign in the left lower quadrant,

  • Hyperechogenic halo and diverticula.

  • Highly suggestive of ACD in a symptomatic patient.

  • Surgeons in training showed 84% sensitivity for US diagnosis . Comparable to the results of specialists.

  • A. Zielke, Surgical Endoscopy 1997.


Us vs ct
US vs CT

  • Sensitivity

  • US : 92% (95% CI:80%-97%)

  • CT 94% (95%CI: 87%-97%) (p=0.65).

  • Specificity

  • US 90% (95%CI: 82%-95%)

  • CT 99% (95%CI: 90%-100%) (p=0.07).

  • Alternative diseases sensitivity ranged

  • between 33% and 78% for US and

  • between 50% and 100% for CT

  • Wytze Laméris, Eur Radiol (2008) (metatanalysis)


Magnetic resonance imaging
Magnetic Resonance Imaging

  • Uncomplicated diverticulitis

  • Diverticula

  • Bowel wall thickening ( more than 3-5 mm)

  • Pericolonic fat stranding

  • Complicated diverticulitis

  • Diverticula

  • Bowel wall thickening more than 5 mm

  • Perforation, Abscess

  • fistula





Laparoscopy
Laparoscopy

  • Acute abdomen

  • Acute abdomen due to diverticulitis

    Differentiate between purulent peritonitis and faecal peritonitis.

  • Recurrent diverticulitis or cronic diverticulitis to decide if the patient must be operated or not.


Summary
Summary.

  • Lower abd pain, tenderness and raised CRP.

  • US ? If in doubt CT or MRI.

  • CT or MRI best to diagnose complications and diff diagnosis.

  • 6-8 weeks later colonoscopy if you want to rule out cancer.


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