A Case of Complicated Diverticulitis
Transcript of A Case of Complicated Diverticulitis
![Page 1: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/1.jpg)
A Case of Complicated Diverticulitis
Brian Clair8/25/08
![Page 2: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/2.jpg)
Agenda
1. Introduction to Our Patient2. Diverticulitis
-Review of Diverticular Disease-Pathogenesis of Diverticulitis-Radiologic Findings-Treatment
3. Complications of Diverticulitis4. Wrap-up of Our Patient
![Page 3: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/3.jpg)
Our Patient: Mr. L
• 55 y/o male with a history of fevers, chills, right lower quadrant pain, pneumaturia, and passing stool in his urine.
![Page 4: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/4.jpg)
Differential Diagnosis of Pneumaturia (i.e. Air in the Bladder Lumen)
• Air from the “outside”– Iatrogenic
• S/P cystoscopy• Suprapubic cystostomy• Foley catheter• Post-operative
– Penetrating trauma
• Air from the “inside”– Enterovesical Fistula
• Bladder cancer• Bowel cancer• Crohn’s Disease• Diverticulitis• S/P radiation• TB
• Air from gas forming organisms– Emphysematous cystitis
CT is the primary imaging modality for suspected enterovesical fistulas.
Lieberman, G. “Male Imaging” Lieberman’s Primary Care Radiology. http://eradiology.bidmc.harvard.edu
![Page 5: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/5.jpg)
Mr. L: Enterovesical Fistula on CT
BIDMC (PACS)
Bladder
Rectum
Rectal contrast material administered without IV contrast is when enterovesical fistula is suspected.
Air is present in the bladder above urine fluid level.
Contrast within the bladder.
CT Pelvis. Rectal contrast without IV contrast.
![Page 6: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/6.jpg)
Mr. L: CT Sagittal View
Bladder
Rectum
BIDMC (PACS)
Communication between the sigmoid colon and the bladder
CT Sagittal Reconstruction. Rectal contrast without IV contrast.
![Page 7: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/7.jpg)
Differential Diagnosis of Enterovesical Fistula
• Bladder cancer• Bowel cancer• Crohn’s Disease• Diverticulitis• S/P radiation• TB
![Page 8: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/8.jpg)
Mr. L: Sigmoid Diverticulitis on CT
BIDMC (PACS)
CT demonstrates diverticulitis of the sigmoid colon
How do we make this diagnosis?
Mr. L: CT Pelvis. Rectal contrast without IV contrast.
![Page 9: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/9.jpg)
Diverticular Disease
• Diverticula: colonic outpouchings consisting only of mucosa and submucosa– Most commonly appear in the sigmoid
colon
• Diverticulosis: describes presence of uninflamed diverticula– Incidence increases with age, from less
than 5% before age 40 years to greater than 65% by age 85 years
• Diverticulitis: inflammation of a diverticulum or diverticula, commonly accompanied by gross or microscopic perforation– Estimated to occur in 10-15% of people
with diverticulosisHorton KM, Corl FM, Fishman EK.
![Page 10: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/10.jpg)
Imaging of Diverticular Disease
Source: Schwartz SI, Shires GT, Spencer FC (eds): Principles of Surgery. 5th ed. New York: McGraw-Hill, 1989, p 1256
Horton KM, Corl FM, Fishman EK.
Companion Patient #1 Barium Enema
Companion Patient #2CT scan with oral and IV contrast material
Sigmoid colon
Air-filled outpuchings = diverticula
![Page 11: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/11.jpg)
Diverticulitis: Pathogenesis
Obstruction at neck of colonic diverticula by
stool, inflammation, or food particles
Bacterial overgrowth, vascular comprimise and microperforation
Pericolicinflammation
![Page 12: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/12.jpg)
Diverticulitis: Diagnosis
• Typical Presentation– Fever– Left lower quadrant abdominal pain– Leukocytosis
• Menu of Diagnostic Tests– Barium enema
• Used in the past– CT scan
• Most accurate and readily available imaging study in diagnosis of acute diverticulitis
![Page 13: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/13.jpg)
Companion Patient #3: Uncomplicated Diverticulitis
BIDMC (PACS)
Companion Patient #3: Ms. C
S. colon
CT Findings:1. Diverticula
2. Bowel wall thickening
3. Fat stranding
C+ CT Pelvis
![Page 14: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/14.jpg)
Diverticulitis: Complications
• Abscess• Hemorrhage• Stricture• Fistula• Phlegmon• Purulent peritonitis• Fecal peritonitis• Perforation• Obstruction
![Page 15: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/15.jpg)
Complicated Diverticulitis: Staging by CT
Stage Modified Hinchey Classification
CT Findings
0 Mild clinical diverticulitis Diverticuli ±colonic wall thickening
Ia Confined pericolic inflammation/phlegmon
Colonic wall thickening with pericolic soft tissue changes
Ib Pericolic/mesocolic abscess Ia changes + pericolic/mesocolic abscess
II Pelvic, distant intraabdominal orretroperitoneal abscess
Ia changes + distant abscess (generally deep in the pelvis or in interloop regions)
III Generalized purulent peritonitis Free gas associated with localized or generalized ascites and possible peritoneal wall thickening
IV Generalized fecal peritonitis Same findings as III
Staging system used to classify severity of complicated diverticulitis
Baker ME.
Emergency operative treatment
CT-guided percutaneous drainage of abscesses larger than 4 cm in diameter
![Page 16: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/16.jpg)
Diverticulitis: Treatment
• Mild uncomplicated diverticulitis: 7-10 days oral broad-spectrum antibiotics– Hospitalization indicated if unable to tolerate
oral intake or pain requires narcotic analgesia• Surgical consultation indicated when:
– There is no response to medical management– Repeated attacks– Complications such as abscess, fistula,
obstruction, or free air
![Page 17: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/17.jpg)
Companion Patient #4: Mr. D
• 38 y/o male who developed left lower quadrant pain with some mild fever the day prior to admission
![Page 18: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/18.jpg)
Complicated Diverticulitis: Perforation
Companion Patient #4: Mr. DC+ CT Pelvis
BIDMC (PACS)
Extraluminal pocket of air
![Page 19: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/19.jpg)
Companion Patient #5: Ms. F
• 68 y/o female presents to the ED with malodorus vaginal discharge.
![Page 20: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/20.jpg)
Complicated Diverticulitis: Abscess & Colovaginal Fistula
Companion Patient #5: Ms. F
Images from BIDMC (PACS)
Vagina
Small pockets of air and a tiny trace of contrast suggest fistulous connection
5.7 x 4.6 perisigmoid abscess filled with stool and air
C+ CT Pelvis
![Page 21: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/21.jpg)
Back to Our Patient
What happened to Mr. L?
![Page 22: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/22.jpg)
Complicated Diverticulitis: Colovesical Fistula
Images from BIDMC (PACS)
Mr. L’s diagnosis: Sigmoid diverticulitis and colovesical fistula
CT Pelvis. Rectal contrast without IV contrast.
![Page 23: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/23.jpg)
Mr. L’s Initial Treatment
• Started on amoxicillin-clavulanate (Augmentin)
• Colonoscopy to rule out colon cancer
• Surgical procedure– Open sigmoidectomy with primary
coloproctostomy
![Page 24: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/24.jpg)
Mr. L’s Further Treatment
• Six days later, Mr. L had fecal material in his urine and was sent emergently to the operating room.– Colorectal anastomosis taken down and
end-colostomy created
![Page 25: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/25.jpg)
Acknowledgments
• Dr. James Kang, BIDMC Radiology• Dr. Gillian Lieberman, BIDMC Radiology• Maria Levantakis, BIDMC Radiology
![Page 26: A Case of Complicated Diverticulitis](https://reader031.fdocuments.us/reader031/viewer/2022022417/5880866d1a28ab7c108bd2cf/html5/thumbnails/26.jpg)
Works Cited• Baker ME. Imaging and interventional techniques in acute left-sided diverticulitis. J
Gastrointest Surg. 2008 Aug;12(8):1314-7.• Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease.
Radiographics. 2000 Mar-Apr;20(2):399-418.• Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007 Nov 15;357(20):2057-
66. • Lieberman, G. “Male Imaging” Lieberman’s Primary Care Radiology.
http://eradiology.bidmc.harvard.edu• Novelline RA. Squire’s Fundamentals of Radiology 6th Ed. Harvard University Press.
Cambridge, MA. 2004.• Schwartz SI, Shires GT, Spencer FC (eds): Principles of Surgery. 5th ed. New York:
McGraw-Hill, 1989, p 1256.• Sheth AA, Longo W, Floch MH. Diverticular disease and diverticulitis. Am J
Gastroenterol. 2008 Jun;103(6):1550-6.• Yu NC, Raman SS, Patel M, Barbaric Z. Fistulas of the genitourinary tract: a
radiologic review. Radiographics. 2004 Sep-Oct;24(5):1331-52.