IS Case 572: Ruptured diverticulitis with interval resolution to colonic diverticulosis

Katherine Kaproth-Joslin, MD

Imaging Sciences URMC


Imaging Sciences URMC 2010
Publication Date: 2011-11-17

History

Patient is a 59-year-old male with history of perforated diverticulum seen for pre-operative assessment.

Findings

CT findings showed a ruptured diverticulum with abdominal free air. Follow- up fluoroscopy showed multiple sac-like outpouchings arising from the sigmoid and transverse colon.

Diagnosis

Ruptured diverticulitis with interval resolution to colonic diverticulosis

Discussion

Diverticulosis is typically an acquired condition of the bowel found primarily in Westernized countries, felt to occur secondarily to the low-fiber, high-fat diet of these regions [1]. The number of diverticula found in the colon tend to increase with age, such that less then 2% of patients under age 30 are found to have this condition, 40% are found to have diverticula at age 60, and 60% of individuals acquire diverticula by age 802. 95% of bowel diverticula occur in the sigmoid and descending colon and tend to progress proximally with age [2]. Diverticula of the colon are considered pseudodiverticula, with herniation of only the mucosal and submucosal layers. Only 10-25% of patients with diverticulosis will develop diverticulitis with a range of symptoms from mild flares to life-threatening complications [1,2].

Diverticulitis refers to the inflammation of a diverticular sac. The pathophysiology underlying inflammation is felt to be secondary narrowing of the neck of the diverticulum or impaction of fecal matter in the diverticulum, leading to stasis of fecal material, bacterial proliferation, toxin and gas production, diverticular inflammation, mucosal injury, and potentially to microperforation [2].

Computed tomography (CT) is the imaging modality of choice for acute diverticulitis, assessing both intraluminal and extraluminal colonic pathology, ruling out other etiologies with similar presentations, and evaluating for extension of pathology into adjacent tissues [1]. Following resolution of a diverticulitis flare, confounding diagnoses need to be evaluate which may mimic acute diverticulitis, including adenocarcinomas which are found in 3-5% of cases assessed for diverticulitis [1]. Modalities used for follow up evaluation include fluoroscopy, repeat CT scan, and colonoscopy, through the later is difficult with extensive diverticulosis. Fluoroscopy can be used to assess the extent of the diverticular disease, as well as complications associated with the condition, including fistula, stricture, perforation, or abscess.

References

  1. Lopez DE, Brown CV. Diverticulitis: the most common colon emergency for the acute care surgeon. Scand J Surg. 2010;99(2):86-9. PMID: 20679043
  2. Touzios JG, Dozois EJ. Diverticulosis and acute diverticulitis. Gastroenterol Clin North Am. 2009 Sep;38(3):513-25. PMID: 19699411

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