Dr ahmed esawy 8 bowel imaging colonic diverticulum disease
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Transcript of Dr ahmed esawy 8 bowel imaging colonic diverticulum disease
بسم هللا الرحمن الرحيم
Dr. Ahmed Abdallah Eisawy
MBBS M.Sc MD
THE ROLE OF COMPUTERIZED
TOMOGRAPHY(CT)
IN INVESTIGATION OF
COLONIC DIVERTICULUM DISEASE
Evaluation of colonic diverticulum and
its sequence like
(peridivcrticulitis,abscesses,
stricture,fistula) is piont of our study
• In recent years, CT scanning has been
assuming an increasing role. Most now
consider it the procedure of choice
• both for its ability to image
transmural/extraluminal disease and
adjacent structures, as well as its
therapeutic potential in the drainage of
abscesses
NORMAL APPEARANCES OF
COLON BY COMPUTERIZED
TOMOGRAPHY(CT)
CT CRITERIA OF COLONIC
WALL • Measurement of colonic wall at different levels in normal
individuals have shown thickness between 0.9 and 2.6 mm with a standard deviation of 0.4 mm.
• A slight increase in the wall thickness of collapsed colonic segments is often seen.
• It is safe to assume that when the colon is distended its wall thickness does not exceed 3 mm, while on a collapsed colon it is not greater than 5 mm .
• The pericolic fat, connective tissue, and mesentric attachments appear as homogenous structures, having a fat density and a few thin enhancing vascular channels (Mori et al., 1992).
caecum
• The caecum and
ascending colon can
be seen anterior to
the muscles of the
posterior abdominal
wall on the right side.
• Its average axial
length is about 6 cm.
hepatic flexure
• The hepatic flexure
can be seen lateral to
the second part of the
duodenum
ASCENDING COLON
• About 15 cm. long and is narrower than the caecum.
Relations:
• Anteriorly: Coils of Small Intestine, Greater Omentum, and Anterior abdominal wall.
• Posteriorly: Iliacus, Iliac crest, Quadratus Lumborum, Lower pole of right kidney
Iliohypogastric and Ilioinguinal nerves cross behind it. Snell, 1995)
splenic flexure
• The splenic flexure is
seen behind the
greater curvature of
the stomach and the
anterior splenic tip.
The Transverse Colon
• About 50 cm
• T axial view shows the transverse colon extending from the liver on the right, to the splenic tip on the left side crossing the duodenum and head of pancreas (Charnsangavej et af., 1993)
descending colon
• The descending colon
is seen on the
muscles of the
posterior abdominal
wall on the left side
• Is less than 30 cm.
long
SIGMIOD COLON
• Relations:
• Anteriorly: urinary
bladder in male; uterus
and vagina in female.
• Posteriorly: Rectum,
Sacrum and lower coils of
terminal part of ileum
.(Snell. 1995)
• It is usually less than 4.5 cm long
rectum
• The rectum measures approximately 12 to 15 cm. in length
• lower third is related to urinary bladder, vas deferens, seminal vesicles, and prostate
• The lower third is related to posterior surface of vagina.
• PATHOLOGY
AND IMAGING OF
COLONIC DIVERTICULUM
EPIDEMIOLOGY OF DIVERTICULAR DISEASE
• GEOGRAPHIC DISTRIBUTION
Epidemiologic studies indicate that
diverticular disease is essentially unheard
in Non-developed areas of Africa and
Asia(Joseph T.ferrrucci) Diverticulosis coli
is one of the most common disease seen
in western civilization than in Africa and
Asia
AGING EFFECTS
• 1%: before 30th year
• 3%:before 40"'year
• 5% from 40lh - 50th year
• 10%:in the 50-70 year
• >30%; older than 70 years
• Both sexes are affected with equal frequency.
• DISTRIBUTION OF DIVERTICULA IN THE COLON
• Most divcrticula are in
the sigmoid colon
(80-90%)
ETIOLOGICAL FACTORS
• DIETARY FACTORS
high dietary fiber content of native diets results in
large volume semisolid stools,
• LIFESTYLE
Defecation using standard western society toilets
generates much greater intracolonic pressures
than seen in the third world
• 3) COLLAGEN ALTERATION IN AN ANIMAL
MODEL OF COLONIC DIVERTICULOSIS
. PATHOGENESIS OF
DIVERTlCULAR DISEASE • 1)MUSCULAR CHANGES
Muscular Weakening. (simple massed diverticulitis)
Muscular Hypertrophy. (spastic colon diverticulosis).
• 2)1NCREASE IN INTRALUMINAL
PRESSURE.
• 3)LOCAL WEAKNESS
Diverticula arise at locations in the colonic wall where large branches of the vasa recta penetrate the muscle layer
PATHOLOGICAL
TERMS,SEOUANCE • DIVERTICULAR DISEASE
Diverticular disease is characterized by clinical symptoms, where by surgical specimens show the characteristic abnormal musculature usually with diverticula, which, however, can be absent or inflamed .
• DIVERTICULOSIS:
Multiple occurrence of pseudodiverticula or (rarely) true diverticula
• DIVERTICULITIS:
Acute or chronic inflammation of one or more diverticula, intermittent with remission and reactivation; mirco or macroperforations with peridiverticulitis.
SEQUENCE AND STAGING
• STAGE OF DIVERTICULITIS AND PERIDIVERTICULITIS are often classified in stages : (Neffand VanSonnenberg, 1989).
• STAGE 0
The inflammation remains beneath the serosa. Cellulitis of the sigmoid wall. Colonic wall phlegmon is also possible.
• STAGE I
Small abscess or phlegmon up to 3 cm in diamter, limited to the mesentery (pericolic abscess).Inflammatory infiltration of the pericolic fat.
• STAGE II
Perforation of pericolic abscess through the mesentery, limited by structures such as the greater omentum, small intestines, colon or fallopian tubes. Abscesses with a diameter of 5-15 cm.
• STAGE III Spread of abscess to the minor pelvis, to other regions of the abdominal
cavity, or to the retroperitonium.
• STAGE IV
Through a large perforation of a diverticulum, faeces enters the abdominal cavity acute peritonitis and sepsis
COMPLICATIONS OF
DIVERTICULAR DISEASE
• 1-DIVERTICULAR BLEEDING
• 2-FISTULA
• 3-OBSTRUCTION
• 4-INTRA-ABDOMINAl ABSCESS
• 5-PERFORATION AND PERITONITIS
C.T. CRITERIA OF DIVERTICULITIS
• MURAL SIGNS
1) Thickening of the bowel wall
(concentric,homogenous)
2)stricture formation
3) intramural air loculi
4) Diverticula
• EXTRAMURAL SIGNS
1) exophytic fat permeation
2) Pericolic inflammation
3) Pericolic abscesses
4) fistula
• CT scanning shows: CT scan demonstrate right-sided diverticulitis in association with obvious pericolic inflammatory changes consistent with acute diverticulitis (right sided diverticulitis) exophytic fat permeation stricture, wall thickening (concentric, heterogenous))
• Provisional diagnosis: right side diverticulitis
• CT scanning shows::
• diffuse inflammation of the
wall of the sigmoid colon
with no extraserosal fluid
• (sigmiod diverticulitis
stricture,wall thickening
(concentric,heterogenous)
exophytic fat permeation)
• Provisional diagnosis:
acute sigmioid diverticulitis
• CT scanning shows: CT. scan shows multiple air-filled sigmoid diverticulitis.a focal region of pericolic inflammatory reaction is seen adjacent to the anterior wall of the sigmoid colon (arrow).
• CT. findings are consistent with early perforation of a single diverticulum at this site mild sigmiod diverticulitis ,perforation, stricture,wall thickening (concentric heterogenous)exophytic fat permeation
• Provisional diagnosis: mild diverticulitis with perforation
• CT scan shows pericolic inflammation predominantly involving The medial all of the cecum as well as severeal small right-sided diverticula
• Provisional diagnosis:. cecal diverticulitis
• CT scanning shows: • moderate wall thickening in the
sigmoid colon (S) with adjacent inflammatory changes and stranding of the pericolic fat. Focal wall thickening is seen in the left posterior part of the bladder adjacent to the inflamed sigmoid(arrow)
• A moderate amount of air is also present in the bladder, a finding compatible with a colovesical fistula.
• Small collections of retained barium are identified within diverticula (colovesical fistula stricture,wall thickening
(concentric,heterogenous) exophytic fat permeation sigmoid diverticulitis)
• CT scanning shows:. Transverse contrast-enhanced CT scans in a case with pneumaturia and prior diverticulitis show air (arrowhead) in the bladder and the site of fistulous communication (arrow) between sigmoid colon and bladder. Note diverticulosis of the sigmoid colon (colovesical fistula, stricture, wall thickening, concentric, heterogenous)
• Provisional diagnosis: Colovesical fistula
• CT scanning shows: large pericolic abscess due to diverticulitis.a debris and air filled abscess(arrow) has a thick,contrast enhancing wall large pericolic abscess, stricture, wall thickening, concentric, heterogenous exophytic fat permeation
• Provisional diagnosis: sigmoid diverticulitis with abscess
• CT scanning shows: Peridiverticular Abscess in a. The sigmoid colon in this CT scan has a thickened wall (S). A small fluid collection (arrow) indicates an intramural abscess extending to a contained extraluminal perforation and an organized inflammatory reaction posteriorly. Multiple diverticula are present acute sigmoid diverticulitis (intramural abscess)stricture,wall thickening ,concentric,heterogenous exophytic fat permeation
• CT scanning shows: extensive diverticulosis of the sigmoid colon there is hypertrophy of the central muscularis propria,which often accompanies severe colonic diverticulosis ,stricture wall thickening, concentric, heterogenous
• Provisional diagnosis: sigmiod diverticulosis
• CT scanning shows: • (A) show asymmetric inflammatory wall
thickening diverticula, fat stranding, and fascial thickening Note contained perforation with formation of phlegmon and extraluminal air.No free intraperitoneal extravasation of colonic contrast material is seen
• (B) Axial CT scans show asymmetric inflammatory wall thickening superimposed on muscular wall hypertrophy diverticula, fat stranding, and fascial thickening Note contained perforation with formation of phlegmon and extraluminal air No free intraperitoneal extravasation of colonic contrast material is seen. acute sigmiod diverticulitis,stricture wall thickening (concentric,heterogenous) exophytic fat permeation, perforation
• Provisional diagnosis: . acute diverticulitis of sigmoid colon
•On sonography, inflamed diverticula appear as bright echogenic foci
with acoustic shadowing or a ring-down artifact within or beyond the
thickened gut wall.
56-year-old man with acute
sigmoid diverticulitis.
Transverse gray-scale
image through left lower
quadrant shows wall
thickening of sigmoid colon
(arrowheads) with
associated diverticulum
(calipers). Adjacent
mesenteric and omental fat
(F) is abnormally echogenic
and attenuating, obscuring
deeper structures.