Tryggvi Björn Stefánsson Dept of Surgery Landspitali University Hospital Diverticulosis Barium Enema Barium Enema Diverticulitis Clinical classification Hinchey classification Ambrosetti classification ID: 916471
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Slide1
Diagnosis of diverticulosis and diverticulitis
Tryggvi Björn Stefánsson
Dept of Surgery
Landspitali University Hospital
Slide2Diverticulosis
Barium Enema.
Slide3Barium Enema
Slide4Diverticulitis
Clinical classification
Hinchey classification
Ambrosetti classification
Slide5Clinical 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)
Slide6Hinchey classification
Stage 1
Pericolic or mesenteric abscesses.
Stage 2
Walled off pelvic abscess.
Stage 3
Generalised purulent peritonitis.
Stage 4
Generalised fecal peritonitis
Slide7Ambrosetti’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
Slide8Complicated diverticulitis
Abscess
Purulent peritonitis
Faecal peritonitis
Colovaginal fistula
Colovesical fistula
Colocutan fistula
Stricture
Hemorrage
Slide9Differential diagnosis
Appendicitis.
Inflammatory bowel disease(Crohn’s disease).
Pelvic inflammatory disease.
Tubal pregnancy.
Tuboovarian abscess.
Cystitis.
Advanced colonic cancer.
Infectious colitis.
Colorectal cancer.
Slide10Diagnostic tools
Clinical symptoms.
Lab tests.
Barium enema.
Ultrasound.
MRI.
CT.
Laparoscopy.
Slide11Clinical symptoms
The AVOD study: Chabok A et al,
British Journal of Surgery 2012
Slide12WBC, CRP
Slide13Computed Tomography
Diverticulas
Thickening of the bowel wall >3 mm-5mm.
Cloudy fat in the mesentery
Slide14Abscess
Slide15CT
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.
Slide16Barium Enema
Diverticulas
Edema
Intramural sinus tract.
Extravasated contrast material outlining an abscess cavity.
Fistula.
Slide17Barium 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.
Slide18Ultrasound
Slide19Ultrasound
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.
Slide20Ultrasound
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.
Slide21US 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)
Slide22Magnetic 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
Slide23MR
Slide24MR
Slide25MR
Slide26Laparoscopy
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.
Slide27Summary.
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.