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PubMed2000

Acute diverticulitis in patients 40 years of age and younger.

Acute colonic diverticulitis typically occurs in patients older than 60 years of age but is uncommon in patients under the age of 40, which may lead to a delay in diagnosis. Because abdominal pain is a very common presenting symptom in emergency department patients, we retrospectively analyzed the cases of 21 patients 40 years of age and younger diagnosed with acute diverticulitis and characterized the presenting signs and symptoms, laboratory and radiographic findings, treatment, and outcome. There were 17 men and 4 women with a mean age of 34.1 +/-5.9 years. All patients had abdominal pain, with 14 (67%) patients noting pain in the left lower quadrant (LLQ) and 5 (24%) patients noting right lower quadrant (RLQ) pain. Nausea was present in 18 (86%) patients and fever in 15 (71%) patients. The mean pulse rate was 103 +/- 16 and the mean temperature was 100.7 +/- 1.4 F. Leukocytosis was present in 19 (90%) patients. Plain abdominal radiographs were obtained in 19 (91%) patients and were normal in 15 (79%) of these cases. Computed tomographic (CT) scans were obtained in 15 (71%) patients which revealed findings consistent with acute diverticulitis in 14 (93%) patients. The admitting diagnosis was diverticulitis in 10 of the 12 patients with LLQ tenderness and appendicitis in 4 of the 6 patients with RLQ tenderness. Overall, six patients were taken to surgery: three patients had cecal diverticulitis and three patients had perforated colonic diverticulitis. General treatment measures included bowel rest in 18 (86%) patients, and intravenous fluids and antibiotics in all patients. All patients survived. In conclusion, acute diverticulitis is uncommon in patients under 40 years of age; however, this condition may be confused with other conditions, usually acute appendicitis. As a result, clinicians should consider acute diverticulitis in young patients with acute abdominal pain, especially if they are male with nausea, fever, tachycardia, and leukocytosis, and consider obtaining a CT scan to aid in the diagnosis.

Abdominal Pain↗
PubMed2004

Association between sigmoid diverticulitis and left-sided colon cancer: a nested, population-based, case control study.

BACKGROUND: An increased risk of left-sided colon cancer in patients with diverticular disease of the sigmoid colon has been reported. The aim of this study was to investigate to what extent patients with diverticulitis of the sigmoid colon differ in long-term risk of colon cancer compared to patients with diverticulosis of the colon without any clinical signs of diverticulitis. METHODS: A total of 7159 patients (2478 M, 4681 F) discharged with a diagnosis of diverticulosis or diverticulitis in 1965-83 in the Uppsala Health Care Region were followed-up with the Swedish Cancer Registry. Sixty-four cases with colon cancer were identified and compared with 123 controls without cancer matched for sex, age and year of first discharge. Based on information from the patients' charts, an independent observer blinded to the outcome assigned a clinical diagnosis of diverticulitis or not diverticulitis to cases and controls. RESULTS: In patients classified as having sigmoid diverticulitis there was an increased risk of left-sided colon cancer compared with patients with diverticulosis without any clinical signs of diverticulitis (odds ratio = 4.2, 95% CI 1.3-13.0) which remained after mutually adjusting for several clinical parameters in a multivariate conditional logistic regression analysis. CONCLUSION: The results of the study indicate a causal association between sigmoid diverticulitis and a long-term increased risk of left-sided colon cancer.

Aged↗
PubMed2005

Assessment of small intestinal bacterial overgrowth in uncomplicated acute diverticulitis of the colon.

AIM: Small intestinal bacterial overgrowth (SIBO) may contribute to the appearance of several gastrointestinal nonspecific symptoms. Acute diverticulitis is affected by some similar symptoms and bacterial colonic overgrowth. We assessed the prevalence of SIBO in acute uncomplicated diverticulitis and evaluated its influence on the clinical course of the disease. METHODS: We studied 90 consecutive patients (39 males, 51 females, mean age 67.2 years, range 32-91 years). Sixty-one patients (67.78%) and 29 patients (32.22%) were affected by constipation-or diarrhea-prevalent diverticulitis respectively. All subjects were investigated by lactulose H2-breath test at the entry and at the end of treatment. We also studied a control group of 20 healthy subjects (13 males, 7 females, mean age 53 years, range 22-71 years). RESULTS: Oro-cecal transit time (OCTT) was delayed in 67/90 patients (74.44%) (range 115-210 min, mean 120 min). Fifty-three of ninety patients (58.88%) showed SIBO, while OCTT was normal in 23/90 patients (25, 56%). In the control group, the mean OCTT was 88.2 min (range 75-135 min). The difference between diverticulitic patients and healthy subjects was statistically significant (P<0.01). OCTT was longer in constipation-prevalent disease than in diarrhea-prevalent disease (180.7 min (range 150-210 min) vs 121 min (range 75-180 min) (P<0.001)), but no difference in bacterial overgrowth was found between the two forms of diverticulitis. After treatment with rifaximin plus mesalazine for 10 d, followed by mesalazine alone for 8 wk, 70 patients (81.49%) were completely asymptomatic, while 16 patients (18.60%) showed only slight symptoms. Two patients (2.22%) had recurrence of diverticulitis, and two other patients (2.22%) were withdrawn from the study due to side-effects. Seventy-nine of eighty-six patients (91.86%) showed normal OCTT (range 75-105 min, mean 83 min), while OCTT was longer, but it was shorter in the remaining seven (8.14%) patients (range 105-115 min, mean of 110 min). SIBO was eradicated in all patients, while it persisted in one patient with recurrence of diverticulitis. CONCLUSION: SIBO affects most of the patients with acute diverticulitis. SIBO may worsen the symptoms of patients and prolong the clinical course of the disease, as confirmed in the case of persistence of SIBO and diverticulitis recurrence. In this case, we can hypothesize that bacteria from small bowel may re-colonize in the colon and provoke recurrence of symptoms.

Acute Disease↗
PubMed2006

High-resolution sonographic spectrum of diverticulosis, diverticulitis, and their complications.

OBJECTIVE: The purpose of this study was to evaluate the high-resolution sonographic features of diverticulosis, diverticulitis, and their complications. METHODS: During a period of about 4 years 8 months, there were 25 patients with sonographic features of diverticulosis, uncomplicated diverticulitis, and complicated diverticulitis. The clinical symptoms, sonographic features, follow-up investigations, and management details were recorded. RESULTS: The common symptoms were pain in the left lower quadrant and fever. Sonographic features of uncomplicated diverticulitis were a varying appearance of the diverticulum with pericolic inflammation. Colonic wall thickening was not a consistent sign. Complications seen were pericolic, mesocolic, and intraperitoneal abscesses, colovesical fistulas, colouterine fistulas, perforation, and small-bowel obstruction. Uninflamed diverticula were seen in all patients with left-sided disease. They had 7 types of sonographic appearances. CONCLUSIONS: Uncomplicated diverticulitis is seen as a diverticulum of variable echogenicity with pericolic inflammation. An inflamed diverticulum is not visualized in complicated diverticulitis. Visualization of uninflamed diverticula helps reinforce the diagnosis of uncomplicated diverticulitis and predict the cause in complicated diverticulitis.

Adult↗
PubMed2000

[The role of spiral computed tomography in sigmoid diverticulitis and the diagnostic-therapeutic implications].

PURPOSE: Colonic diverticula are saccules made of colonic mucosa and submucosa that herniate from the colonic lumen through the muscular layer of the wall where straight vessels penetrate. Diverticula are localized in the sigmoid colon in 95% of cases. Bacteria pooling in the lumen may cause lumen erosion and eventually perforation. CT is a useful technique in this condition because it can demonstrate intra- and/or extramural inflammation. Aim of this retrospective study was to assess the capabilities of contrast-enhanced helical Computed Tomography (CT) in sigmoid diverticulitis, especially relative to selection of the appropriate treatment. MATERIAL AND METHODS: We retrospectively reviewed the findings of 41 patients referred to our emergency department for diverticulitis. CT scans were performed 65 seconds after i.v. injection of nonionic contrast material (3 mL/s, 120 mL in all) administered by a CT-power injector. The following 7 CT findings were considered at least suggestive of acute diverticulitis: focal wall thickening, intramural abscess, inflammatory changes in the sigmoid mesentery root, pericolic fat inflammation or pericolic abscess formation, fistula, peritonitis. CT results were compared with surgical and physical findings. RESULTS: Based on CT findings, diverticulitis was classified as mild (25 patients) or severe (15 patients). In mild diverticulitis we found: focal sigmoid wall thickening (6 patients), intramural abscess (3 patients), sigmoid mesentery root thickening (5 patients), edema fluid (8 patients) and phlegmon (3 patients). In severe diverticulitis we found: sigmoid mesentery abscess (6 patients), fistula (5 patients) and peritonitis (4 patients). CT findings were questionable in 1 case and thus we could not exclude a perforated carcinoma. CONCLUSION: Contrast-enhanced helical CT is the imaging modality of choice in assessing mild or severe acute diverticulitis because it provides useful information for appropriate treatment planning in the emergency setting. This technique is most useful in questionable cases and in patients with suspected severe diverticulitis where a choice must be made between different treatment options.

Colon, Sigmoid↗
PubMed2001

Diverticulitis in the young patient.

Although predominantly a disease in older adults diverticulitis does affect younger patients. The disease has been described as not only rare but virulent by some authors, and a young patient age is considered to be a relative indication for early sugery. The goal of this study was to evaluate the experience of the Louisiana State University Health Sciences Center-Shreveport and affiliated hospitals with diverticulitis in young patients. This study was a retrospective chart review of 22 patients with diverticulitis age 40 years and younger over the past 20 years. Inclusion criteria were either a diagnosis of diverticulitis confirmed at surgery or positive CT findings and/or a positive contrast enema. The mean age in this study was 32.1 years (range 16-40). All 22 patients presented with abdominal pain. The next most common symptom was nausea and/or vomiting in 45 per cent followed by fever and chills in 36 per cent. Twelve patients had abdominal CTs on admission, and 87 per cent had positive findings. Eighteen patients underwent an operation. Four patients were treated nonoperatively. Nineteen patients had diverticulitis of the sigmoid colon. The remaining three had right-sided diverticulitis. Two patients underwent right hemicolectomy, and one underwent cecectomy. Of the 15 patients with sigmoid diverticulitis 12 (80%) underwent a two-stage procedure of sigmoid colectomy, end colostomy, and Hartmann's pouch. Three patients (20%) underwent a one-stage procedure of sigmoid colectomy and primary anastomosis. Two of three patients undergoing a one-stage procedure required reoperation. Postoperative complications occurred in 10 of 18 patients for an overall incidence of 56 per cent. Two of these patients had septic complications. Both of these patients had a delay in time from admission until operation: one for 7 days and the other for 10 days. There was one death in the series. Colostomy closure was performed successfully in nine of 12 (75%) patients. The mean time interval before closure was 7.7 months, (range 3-14). Patients with two-stage procedures on initial admission fared better than those with one-stage procedures. The overall mortality was 4.5 per cent. There was a high overall complication rate of 56 per cent in patients undergoing an operation. Two patients who had a delay in time from admission to operation had septic complications. Early surgical intervention should be considered in this clinical setting. In summary, although rare, diverticulitis in the young patient is often a fulminant illness requiring operation early in the disease process.

Adolescent↗
PubMed2004

[Computed tomography (CT) of acute diverticulitis of the cecum and ascending colon].

Acute diverticulitis of the cecum and ascending colon, also called right-sided diverticulitis, represents a relatively rare disorder in the western hemisphere. Pseudodiverticula and, less frequently, solitary congenital diverticula are regarded as the underlying causes of acute diverticulitis. We report the helical CT findings in four patients with acute right-sided colonic diverticulitis. The CT was performed with a collimation of 8 mm, a pitch of 1.5 and an increment of 8 mm, and with variable administration of intravenous, oral and rectal contrast material. In two of the four patients, the acute diverticulitis was detected in the cecum and ascending colon, respectively. In two patients, the diagnosis could be confirmed during surgery and subsequent histologic examination of the resected specimen. On the initial CT studies, acute diverticulitis was correctly diagnosed in two patients and suspected in one patient without identifying an inflamed diverticulum. In one patient, the offending diverticulum in the ascending colon caused an inflammatory pseudotumor at the level of the ileocecal region. This process was initially mistaken as Crohn's disease. The CT diagnosis of a right-sided colonic diverticulitis is based on an inflamed diverticulum in the center of pericolic inflammatory changes and a preserved wall enhancement (target sign). Other CT findings, such as fatty pericolic infiltration and colon wall thickening, are rather non-specific and can also be found in a number of different ileocolic disorders, especially in colon cancer. In selected cases, the diagnosis can only be established by follow up CT after the pericolic infiltration has markedly subsided and an offending diverticulum has emerged.

Acute Disease↗
PubMed2000

Acute left colonic diverticulitis--compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients.

PURPOSE: The most valuable radiologic examination to be done initially when acute left colonic diverticulitis is suspected is still a matter of controversy. This study compares the performance between water-soluble contrast enema and computed tomography. METHODS: From 1986 to 1997, all patients admitted in our emergency center with clinically suspected left-colonic diverticulitis had a contrast enema and a computed tomography within 72 hours of their admission, unless clinical findings required immediate laparotomy. They were prospectively included in the study if one or both radiologic examinations showed signs of acute diverticulitis or diverticulitis was surgically removed and histologically proven or both. Diverticulitis was considered moderate when computed tomography showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat and contrast enema showed segmental lumen narrowing and tethered mucosa; it was considered severe when abscess or extraluminal air or contrast or all three were observed on computed tomography and when one or both of the last two signs were seen on contrast enema. Of 542 patients, 420 who had both computed tomography and contrast enema entered the study. RESULTS: The performance of computed tomography was significantly superior to contrast enema in terms of sensitivity (98 vs. 92 percent; P = 0.01), which was calculated from patients who had their colon removed and whose diverticulitis was histologically proven, and in the evaluation of the severity of the inflammation (26 vs. 9 percent; P = 0.02). Moreover, of 69 patients who had an associated abscess seen on computed tomography, only 20 (29 percent) had indirect signs of this complication on contrast enema. CONCLUSIONS: In the diagnostic evaluation of acute left-colonic diverticulitis, computed tomography should be preferred to contrast enema as the initial radiologic examination because of its statistically significant superiority in sensitivity and for its significantly better performance in the detection of severe infection, especially when an abscess is associated with the disease.

Abscess↗
PubMed1992

Computed tomography in the initial management of acute left-sided diverticulitis.

Computed tomography (CT) was used in place of contrast enemas as the initial imaging study to evaluate patients with the clinical diagnosis of acute sigmoid diverticulitis. This report attempts to clarify the role of CT in the management of acute sigmoid diverticulitis by reviewing its usefulness in the diagnosis and treatment of 59 patients. CT established that three patients (5 percent) were hospitalized with an incorrect clinical diagnosis. Thirty-seven patients (62.7 percent) were identified as having uncomplicated acute diverticulitis. These patients were all treated successfully with nonsurgical therapies and were discharged in an average of 6.8 days. In the remaining 19 patients (32.2 percent), CT revealed complicated acute diverticulitis by identifying abscess, fistula, peritonitis, or obstruction. Eleven of these 19 patients required urgent surgery or CT-guided percutaneous drainage of an abscess. The four patients whose abscesses were drained percutaneously responded favorably and underwent an elective single-stage resection. The average hospital stay for patients with complicated diverticulitis was 13.6 days. Computed tomography is a useful aid in the initial management of patients with acute diverticulitis. It is a noninvasive test that recognizes and stratifies patients according to the severity of their disease. It has the further advantage of providing information about extracolonic pathology and anatomic variation useful for surgical planning. Additionally, early CT-guided needle drainage allowed downstaging of complicated diverticulitis, avoided emergent surgery, and permitted single-stage elective surgical resection.

Abscess↗
PubMed2006

One-stage sigmoid colon resection for perforated sigmoid diverticulitis (Hinchey stages III and IV).

INTRODUCTION: Guidelines for the treatment of complicated sigmoid diverticulitis recommend Hartmann's procedure or anastomosis with protective colostomy for Hinchey stage III diverticulitis and Hartmann's procedure only for Hinchey stage IV diverticulitis. We evaluated the outcome of patients with perforated sigmoid diverticulitis Hinchey III/IV undergoing one-stage colon resection and primary anastomosis without protective colostomy. METHODS: After implementation of a protocol to treat Hinchey III/IV diverticulitis with primary anastomosis without protective ileocolostomy, the patients' data were recorded prospectively between August 2001 and August 2003 and analyzed retrospectively from a computer-related database. RESULTS: Of 41 patients, 34 (81%) underwent one-stage sigmoid resection and primary anastomosis, 3 of 41 patients (7%) underwent primary anatomosis with protective ileostomy, and 5 of 41 patients (12%) had a Hartmann's procedure. The mortality was 11% in patients undergoing primary anastomosis and 60% in patients with Hartmann's procedure. The relative risk of co-morbidity factors for lethal outcome after sigmoid resection was 6.94 for preceding operations, 3.75 for renal failure or renal transplantation, and 3.25 for immunosuppression. CONCLUSIONS: One-stage sigmoid resection and primary anastomosis can be performed safely in nearly 90% of all patients with perforated sigmoid diverticulitis (Hinchey III/IV) by surgeons of different training levels. Patients with immunosuppression, chronic renal failure, liver cirrhosis, or previous organ transplantation or complex cardiovascular reconstructive procedures have a significantly increased risk of dying after sigmoid resection for perforated diverticulitis.

Anastomosis, Surgical↗
PubMed2004

Laparoscopic colectomy for diverticulitis is not associated with increased morbidity when compared with non-diverticular disease.

BACKGROUND AND AIMS: It was the aim of this prospective study to compare the outcome of laparoscopic sigmoid and anterior resection for diverticulitis and non-diverticular disease. PATIENTS AND METHODS: All patients who underwent laparoscopic colectomy for benign and malignant disease within a 10-year period were entered into the prospective PC database registry. For outcome analysis, patients who underwent laparoscopic sigmoid and anterior resection for diverticular disease were compared with patients who underwent the same operation for non-inflammatory (non-diverticular) disease. The parameters analyzed included age, gender, co-morbid conditions, diagnosis, procedure, duration of surgery, transfusion requirements, conversion, morbidity including major (requiring reoperation), minor (conservative treatment) and late-onset (postdischarge) complications, stay in the ICU, hospitalization, and mortality. For objective evaluation, only laparoscopically completed procedures were analyzed. Statistics included Student's t-test and chi-square analysis (p<0.05 was considered statistically significant). RESULTS: A total of 676 patients were evaluated including 363 with diverticular disease and 313 with non-inflammatory disease. There were no significant differences in conversion rates (6.6 vs. 7.3%, p>0.05), so that the laparoscopic completion rate was 93.4% (n=339) in the diverticulitis group and 92.7% (n=290) in the non-diverticulitis group. The two groups did not differ significantly in age or presence of co-morbid conditions (p>0.05). In the diverticulitis group, recurrent diverticulitis (58.4%), and complicated diverticulitis (27.7%) were the most common indications, whereas in the non-diverticulitis group, outlet obstruction by sigmoidoceles (30.0%) and cancer (32.4%) were the main indications. The most common procedure was laparoscopic sigmoid resection, followed by sigmoid resection with rectopexy and anterior resection. No significant differences were documented for major complications (7.4 vs. 7.9%), minor complications (11.5 vs. 14.5%), late-onset complications (3.0 vs. 3.5), reoperation (8.6 vs. 9.3%) or mortality (0.6 vs. 0.7%) between the two groups (p>0.05). In the postoperative course, no differences were noted in terms of stay in the ICU, postoperative ileus, parenteral analgesics, oral feeding, and length of hospitalization (p>0.05). CONCLUSION: These data indicate that laparoscopic sigmoid and anterior resection can be performed with acceptable morbidity and mortality for both diverticular disease and non-diverticular disease. The results show in particular that laparoscopic resection for inflammation is not associated with increased morbidity.

Adult↗
PubMed2001

Emergency surgery for colonic diverticulitis: differences between right-sided and left-sided lesions.

BACKGROUND AND AIMS: Right-sided diverticulitis is rare in Western societies but is not uncommon in Asian countries. Many of the patients are operated with the presumptive diagnosis of appendicitis. This study compared the results of emergency surgery for patients with right-sided and left-sided diverticulitis. PATIENTS AND METHODS: Demographic data, type of operation, and surgical outcome were recorded in 60 patients who had undergone emergency surgery for colonic diverticulitis (37 right-sided, 23 left-sided). RESULTS: Patients with right-sided disease were significantly younger (mean age 41.9 vs. 74.2), and there was a tendency to male predominance (78.4% vs. 56.5%). All patients with right-sided disease had localized peritonitis while 74% of patients with perforated left-sided diverticulitis had generalized faecal or purulent peritonitis. Mortality rates for right-sided disease and left-sided disease were 0% and 13%, respectively, and morbidity was 14.2% and 61%, respectively. Longer hospital stay was also found in patients with left-sided diverticulitis. CONCLUSIONS: There are major differences in the demographics, presentation, type of operation and outcome of patients who had emergency surgery for colonic diverticulitis, with emergency operation for left-sided diverticulitis being associated with higher mortality and morbidity.

Adult↗
PubMed2006

Laparoscopic vs. hand-assisted laparoscopic sigmoidectomy for diverticulitis.

INTRODUCTION: Sigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left-lower quadrant and pelvis. We hypothesized that hand-assisted laparoscopic technique may facilitate laparoscopic completion of this surgery while retaining the short-term benefits associated with "pure" laparoscopic surgery, in which an incision is made only for extracting the specimen. This study was designed to compare the outcomes of patients who underwent totally laparoscopic or hand-assisted laparoscopic sigmoidectomy for diverticulitis. METHODS: We reviewed our prospectively collected patient database from July 2001 to June 2004 and compared the intraoperative data and postoperative outcomes of patients who underwent elective laparoscopic or hand-assisted laparoscopic sigmoidectomies for diverticulitis. Complicated patients (with abscess or fistulas) also were separately analyzed. RESULTS: The hand-assisted laparoscopic (mode age, 57 years; 48 percent male) and laparoscopic sigmoidectomy (mode age, 56 years; 90 percent male) groups were similar with regard to age and gender. Overall, patients who underwent laparoscopic (n = 21) vs. hand-assisted laparoscopic (n = 21) sigmoidectomies had a significantly longer operative time (197 +/- 42 vs. 171 +/- 34 minutes, P = 0.04) and shorter incision length (5 +/- 2.1 vs. 9.3 +/- 4.1 cm, P = 0.0001). Patients with complicated diverticulitis (n = 14; abscess, colovesical fistula, enterocolic fistula) who underwent laparoscopic sigmoidectomies (n=4) had a significantly longer operative time compared with hand-assisted laparoscopic sigmoidectomy (n = 10) group (255 +/- 18 vs. 177 +/- 34 minutes, P = 0.001). Conversion rate for the laparoscopic group was significantly higher (3/4 vs. 1/10, P = 0.04, Fisher exact) when complicated diverticulitis was present. There were no differences in postoperative outcomes or incision lengths in the complicated group. CONCLUSIONS: Outcomes after hand-assisted laparoscopic sigmoidectomy for diverticulitis are similar to those seen in the pure laparoscopic method, with lower conversion rates and shorter operative times. Hand-assisted laparoscopic sigmoid resection for diverticulitis is an attractive alternative to a "pure" laparoscopic method in complicated cases.

Adult↗
PubMed1999

Surgical approach to cecal diverticulitis.

BACKGROUND: Cecal diverticulitis is a rare condition in the Western world, with a higher incidence in people of Asian descent. The treatment for cecal diverticulitis has ranged from expectant medical management, which is similar to uncomplicated left-sided diverticulitis, to right hemicolectomy. STUDY DESIGN: A retrospective chart review was conducted of the 49 patients treated for cecal diverticulitis at Olive View-UCLA Medical Center from 1976 to 1998. This was the largest-ever single-institution review of cecal diverticulitis reported in the mainland US. RESULTS: The clinical presentation was similar to that of acute appendicitis, with abdominal pain, low-grade fever, nausea/vomiting, abdominal tenderness, and leukocytosis. Operations performed included right hemicolectomy in 39 patients (80%), diverticulectomy in 7 patients (14%), and appendectomy with drainage of intraabdominal abscess in 3 patients (6%). Of the 7 patients who had diverticulectomy, 1 required right hemicolectomy at 6 months followup for continued symptoms. Of the three patients who underwent appendectomy with drainage, all required subsequent hemicolectomy for continued inflammation. Of the 39 patients who received immediate hemicolectomies, there were complications in 7 (18%), with no mortality. CONCLUSIONS: We endorse an aggressive operative approach to the management of cecal diverticulitis, with the resection of all clinically apparent disease at the time of the initial operation. In cases of a solitary diverticulum, we recommend the use of diverticulectomy when it is technically feasible. When confronted with multiple diverticuli and cecal phlegmon, or when neoplastic disease cannot be excluded, we advocate immediate right hemicolectomy. This procedure can be safely performed in the unprepared colon with few complications. Excisional treatment for cecal diverticulitis prevents the recurrence of symptoms, which may be more common in the Western population.

Adolescent↗
PubMed2004

[CT findings in acute small bowel diverticulitis].

Small bowel diverticulitis is a rare cause of an acute abdomen. Originating from acquired diverticula of the jejunum, less often of the ileum, or Meckel diverticulum, the symptoms are nonspecific, simulating other acute inflammatory disorders, such as appendicitis, cholecystitis or colonic diverticulitis. The diagnosis of small bowel diverticulitis is solely based on radiologic findings, with computed tomography (CT) regarded as the method of choice. In recent years, a number of case reports have described the spectrum of the CT features in acute small bowel diverticulitis and its dependence on the severity of the inflammatory process. Typical findings are an inflamed diverticulum, inflammatory mesenteric infiltration, extraluminal gas collection and mural edema of adjacent small bowel loops with resultant separation of bowel loops. An enterolith is rarely found in an inflamed diverticulum. Complications include abscesses, fistulae, small bowel obstruction and free perforation with peritonitis. Small bowel diverticulitis can be a diagnostic problem if it involves the terminal ileum or Meckel's diverticulum. For preoperative confirmation of the presumed diagnosis of small bowel diverticulitis on CT, an enteroclysis for acquired diverticula or a technetium scan for Meckel's diverticulum should be performed. We present the CT findings in three patients of acute small bowel diverticulitis, two affecting the jejunum and one a Meckel's diverticulum.

Abdomen, Acute↗
PubMed2003

Patterns of pain in diverticular disease and the influence of acute diverticulitis.

BACKGROUND: While the association of recurrent bouts of abdominal pain with colonic diverticulosis is well recognized, the cause of this pain is obscure since in most cases it occurs without obvious diverticulitis or other potential causes. AIMS: To define the patterns of pain in diverticular disease and the influence of acute diverticulitis. METHODS: Two studies were undertaken to establish the relationship between bouts of prolonged abdominal pain (> 24 h) presumed to be due to inflammatory diverticulitis and recurrent short-lived pain. In Study 1, 261 patients with a barium enema showing diverticulosis completed a postal questionnaire concerning episodes of both prolonged and short-lived pain. In Study 2, 26 patients previously admitted to hospital with a firm diagnosis of diverticulitis were interviewed for details of their bowel habits since discharge. RESULTS: Study 1: 94/261 patients experienced recurrent, short-lived pain on a median of five days a month, with a median duration of 3 h. In addition, 51/261 patients described episodes of prolonged pain with a median duration of three days. Of these, 31/51 (61%) experienced recurrent, short-lived pain compared with 63/210 (30%) who had not had an episode of prolonged pain. More specifically, 12/17 (71%) who received antibiotic treatment for presumed acute diverticulitis during their bout of prolonged pain experienced recurrent pain compared with 82/244 (34%) who did not experience such an episode. Study 2: 18/26 patients hospitalized for acute diverticulitis developed new, recurrent, short-lived abdominal pain following discharge, with a median duration of 4 h. CONCLUSION: Episodes of prolonged, presumed inflammatory pain due to diverticulitis are frequently followed by recurrent, short-lived pain similar to that seen in irritable bowel syndrome.

Abdominal Pain↗
PubMed2005

The management of complicated diverticulitis and the role of computed tomography.

PURPOSE: Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis. METHODS: We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis. RESULTS: In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%. CONCLUSIONS: CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

Abdominal Abscess↗
PubMed2000

Sigmoid diverticulitis: value of transrectal sonography in addition to transabdominal sonography.

OBJECTIVE: Overlying intestinal gas often impairs transabdominal sonographic assessment of the lower sigmoid colon. The aim of this study was to investigate the usefulness of transrectal sonography in addition to transabdominal sonography for the evaluation of sigmoid diverticulitis. SUBJECTS AND METHODS: Eighty-six consecutive patients with clinically suspected acute sigmoid diverticulitis were referred for transabdominal sonography as the initial imaging method. In 46 patients, transrectal sonography was performed in addition to transabdominal sonography if pain was localized to the mid lower abdomen and if a disease process could not be visualized or could be only partially visualized on transabdominal examination. An end-firing 5-9-MHz endocavitary probe was used for transrectal sonography. RESULTS: Thirty-four of 50 patients with a final diagnosis of sigmoid diverticulitis underwent both transabdominal and transrectal sonography. In 20 patients, transrectal sonography showed relevant additional information: six diagnoses of diverticulitis were established on transrectal sonography alone. Transrectal sonography revealed one perforation, five abscesses, and three fistulous complications that were not shown on transabdominal sonography. In the remaining five patients, correct diagnoses were supported on transabdominal examinations, but only transrectal sonography could show an inflamed diverticulum. In 10 patients, transrectal sonography revealed signs of diverticulitis but no relevant information in addition to the results from transabdominal sonography. Four false-negative and two false-positive results were revealed with transrectal sonography. CONCLUSION: Transrectal sonography is accurate for confirming clinically suspected acute colonic diverticulitis when the lower sigmoid colon is affected. It helps avoid false-negative results and defines the severity of disease in the lower sigmoid colon better than transabdominal sonography alone. Transrectal sonography can increase the sensitivity of sonography for diagnosing sigmoid diverticulitis.

Abdomen↗