Escolar Documentos
Profissional Documentos
Cultura Documentos
CT
points of weakness or defects in the colonic wall, and Since Hulnick’s initial description of diverticulitis
consist of the mucosal and submucosal layers of the bowel using CT scan,8 multiple studies have shown high sensitivity
wall. It is interesting to note that these points coincide with (79% to 99%)2,9 and specificity9–13 in diagnosing diverti-
the locations of penetrating vessels such as the vasa recta.1 culitis with a CT scan. In 1990, Cho et al6 showed a
Colonic diverticulosis is very common, affecting 5% to 10%
of people of the age of 45 years and 80% of the age of 80
years.2 Up to 30% of patients with diverticulosis develop
acute diverticulitis, in which diverticula become inflamed.
In the setting of diverticulitis, 25% of patients develop
complicated disease resulting in hospital admission.3 The
most common location of diverticulitis is in the sigmoid
colon, although it can occur anywhere. Right-sided diverti-
culitis is more likely to affect patients under the age of 50
years and the Asian population.4 Before routine imaging
became a part of the workup of patients with left lower
quadrant pain, 25% to 30% of surgical specimens showed no
inflammation.5
Before the clinical implementation of computed
tomography (CT) in the 1980s, fluoroscopic barium enema
was the primary method of diagnosing diverticulitis. A CT
scan has now replaced barium enema in the evaluation of
left lower quadrant pain. In select circumstances, ultra-
From the *MR Center; and wSmilow Cancer Hospital, Yale University
School of Medicine, New Haven, CT.
No conflicts of interest.
Reprints: Gary Israel, MD, Professor of Diagnostic Radiology, Smilow
Cancer Hospital, Yale University School of Medicine, 2nd Floor FIGURE 1. Axial computed tomographic image performed with
North Pavilion in Room 2-245, New Haven, CT 06520 (e-mail: intravenous and oral contrast depicts thickening of the wall of the
gary.israel@yale.edu). sigmoid colon (short arrows) with surrounding stranding of
Copyright r 2011 by Lippincott Williams & Wilkins pericolonic fat (long arrows) consistent with diverticulitis.
FIGURE 2. Axial (A) and coronal reformatted (B) computed tomographic images taken with oral contrast shows mild thickening of the
fascia at the base of the sigmoid mesocolon (long arrow in A) and minimal pericolonic fat stranding (short arrows in A and B), consistent
with mild diverticulitis.
sensitivity of 93% and specificity of 100% using single-slice reported in 16% of cases.16 Microperforation can lead to
nonhelical CT scan. Today, with the latest multidetector the formation of an abscess. Initially, a phlegmon may be
CT scanners obtaining volumetric datasets in which images identified, which manifests as ill-defined soft tissue attenua-
can be reconstructed into any viewing plane, sensitivity and tion material in the adjacent pericolic fat. In some cases,
specificity may be higher than reported earlier. The this resolves with antibiotics but can progress to an abscess,
American College of Radiology advocates CT scanning of which appears as a well-defined fluid collection that may
the abdomen and pelvis with oral and/or rectal contrast as contain gas (Fig. 4A) and may have an enhancing wall
the modality of choice in the evaluation of diverticulitis.14 (Fig. 4B). Abscess occurs in a minority of cases of acute
diverticulitis, but has been reported to occur in 45% to 59%
Technique of cases in the literature.4,6,16 Most commonly, they occur
At Yale New Haven Hospital, CT scans for diverti- within (intramural abscess) or adjacent to the inflamed
culitis are performed with oral and intravenous contrast. colonic wall. However, abscesses can occur remotely from
Oral contrast helps to mark and distend the bowel to
minimize artifactual wall thickening from underdisten-
sion.15 The role of intravenous contrast is to evaluate the
differences in bowel wall enhancement and to help identify
complications of acute diverticulitis such as abscess and
fistula. Some experts advocate rectal contrast to increase
distal colonic distension, which may not have occurred after
oral contrast, to opacify fistulae and increase accuracy.12
We do not routinely administer rectal contrast at our
institution to minimize patient discomfort and avoid
complications such as iatrogenic perforation.
Findings
Most commonly, diverticulitis manifests as a short
segment of focal eccentric or circumferential bowel wall
thickening (70% to 94% of cases) with adjacent infiltration
of the pericolonic fat (98%)16 (Fig. 1). In approximately
30% of cases,16 the inflamed diverticulum can be identified.
When mild diverticulitis involves the sigmoid colon, fascial
thickening at the base of the sigmoid mesocolon adjacent
to the left pelvic side wall may be a helpful sign to confirm
the diagnosis (Fig. 2).16,17 Pericolic lymphadenopathy may
occur but is most common in the right-sided diverticulitis,
in which it is reported to be present in 90% of cases.18 FIGURE 3. Axial computed tomographic image taken with
intravenous and oral contrasts shows diverticulosis (arrowheads)
Complications with pericolic inflammation (black arrow) and a small bubble of
Microperforation (Fig. 3), with the resulting small foci extraluminal gas (white arrow), consistent with a microperfora-
of extraluminal free air is the most common complication, tion from acute sigmoid diverticulitis
FIGURE 4. A, Axial computed tomographic (CT) image performed without contrast shows pericolic inflammation (arrowheads) and a
fluid and gas collection (arrow), consistent with sigmoid diverticulitis. B, Axial CT image of the same patient taken 2 days later but with
intravenous (i.v.) and oral contrasts shows a pericolic fluid collection with a well-defined enhancing wall, consistent with an abscess
(arrow). The use of i.v. and oral contrasts helps define and diagnose the abscess that is not as apparent in (A), carried out without
contrast material. The patient was treated with antibiotics and the abscess subsequently resolved.
the site of diverticulitis and may involve the psoas muscle 23%27 of cases of diverticulitis, a CT scan does not always
and musculature of the pelvic floor, uterus, and adnexa. identify the fistula. CT findings of a fistula include an air-
Most cases of microperforation can be treated con- filled or fluid-filled tract extending from the colon to the
servatively, but some progress to frank perforation. When a affected organ (Figs. 5–7). In some cases, the fistula cannot
perforation is large, extraluminal oral contrast, fecal material, be definitely identified using a CT scan but secondary
or both may be present. Peritonitis may occur, which findings such as focal thickening of the bladder wall,
manifests as generalized haziness of the peritoneal fat and tethering of the sigmoid colon to the bladder, and gas
increased enhancement of the peritoneal lining. within the lumen of the bladder are hints of a colovesical
Fistulas may complicate diverticulitis and have been fistula (Fig. 5).
reported to be present in the bladder,19 vagina,20 skin,21 Giant diverticula of the colon are defined as being larger
small bowel,22 uterus,23 ovary,24 psoas muscle,25 and the than 4 cm in diameter and are usually located in the sigmoid
hip.26 A review of the fistulas related to diverticulitis over a colon.28 There are 2 theories on how these diverticula form.
20-year period found that colovesical and colovaginal One hypothesis is that an untreated abscess fistulizes to the
fistulas account for approximately 90% of all fistulae.22 colon. After the abscess drains into the colon, the remaining
Although colovesical fistula has been reported in 2% to wall of the abscess forms a diverticulum-like structure that
FIGURE 5. Computed tomographic images with intravenous and oral contrasts in the axial (A) and coronal reconstructed (B) planes
depict a colovesical fistula secondary to diverticulitis. Imaging findings include focal thickening of the bladder wall (arrow in A),
tethering to the sigmoid colon (arrow in B) to the bladder, and gas (G) within the bladder lumen.
FIGURE 6. A 63-year-old woman who is status post hysterectomy with acute diverticulitis and a colovaginal fistula. A, Axial computed
tomographic image taken with intravenous and oral contrast shows oral contrast and gas within the vaginal cuff (arrow), suggestive of a
colovaginal fistula. B, A water-soluble contrast enema shows the fistula (arrow) from the sigmoid colon (*) to the vaginal cuff (arrow).
communicates with the colon.29 Alternatively, preexisting these cases can cause free peritoneal perforation.33 The typical
diverticula grow in size through a ball-valve effect as trapped treatment is surgical resection of the diverticulum or partial
air causes the divertculum to grow.30 Giant diverticula can colectomy.34
present secondary to complications in up to 19% of cases.31 Other rare complications include small bowel obstruc-
They can become infected and develop acute diverticulitis. On tion35 and pyelophlebitis.36,37 In patients with small bowel
CT scanning, the findings are a large gas-filled cavity with obstruction, secondary to diverticulitis, the inflammation
wall thickening, enhancement of the diverticular wall, and related to diverticulitis extends to a small bowel loop and its
peridiverticular fat stranding (Fig. 8).32 These features are adjacent mesentery, resulting in focal peritonitis, spasm, and
also found with large abscesses and therefore differentiating possibly adhesions. Pyelophlebitis may occur in approxi-
the 2 processes can be difficult. Importantly, up to half of mately 3% of cases of diverticulitis.36,37 This begins as
thrombophlebitis of small veins draining the infected segment
of the colon, which can then propagate into the portal vein
(Fig. 9). Rarely, this process can progress to suppurative
pyelophlebitis, a condition in which the venous thrombus is
associated with bacteremia. Suppurative pyelophlebitis can be
life threatening as it can be unresponsive to antibiotics.38
Limitations in Diagnosis
Perforated colonic adenocarcinoma may be difficult to
differentiate from diverticulitis using a CT scan. Both
conditions can present with focal colonic wall thickening,
pericolic inflammation, and perforation. Imaging findings
that suggest carcinoma (Fig. 10) and not diverticulitis include
wall thickening >2 cm, eccentric wall thickening, a homo-
geneously enhanced bowel wall, and pericolic adenopa-
thy.39,40 Colonic obstruction should raise the concern for
neoplasm.41 A long segment (>10 cm) of colonic involvement
and a striated pattern of bowel wall enhancement (the target
sign) suggest diverticulitis.42,43 Given the overlap in CT
findings, some researchers advocate follow-up colonoscopy in
patients diagnosed with diverticulitis using a CT scan.44
Alternative Diagnoses
Right-sided diverticulitis (Fig. 11) can clinically mimic
appendicitis, epiploic appendagitis, omental infarct, and
inflammatory bowel disease.45 In most cases, this differentia-
tion can be made by using a CT scan. Acute appendicitis
FIGURE 7. Axial computed tomography image taken with oral
contrast shows sigmoid diverticulosis (black arrow) and a gas- (Fig. 12) manifests as a distended appendix with appendiceal
filled fistula (white arrows) between the sigmoid colon and left wall thickening, edema at the base of the cecum, and
psoas muscle (*), which contains an abscess (*). The lack of periappendiceal fat stranding. However, in cases of perfo-
significant pericolic inflammation suggests that the fistula may rated appendicitis in which the appendix is not visualized by
have been formed from an earlier episode of diverticulitis. imaging, differentiation from diverticulitis can be difficult.
FIGURE 8. A, Coronal scout computed tomography (CT) image shows a gas-filled (G) cavity in the mid-pelvis. B, CT with intravenous
and oral contrasts reformatted in the coronal plane depicts the giant diverticulum (*) with an enhancing thickened wall and surrounding
inflammation (arrow).
FIGURE 9. A, Axial computed tomographic (CT) image obtained with intravenous and oral contrasts in a patient with sigmoid
diverticulitis shows a thrombus within the inferior mesenteric vein (arrow). B, Axial CT image obtained at the level of the portal vein
shows that thrombus has propagated into the portal vein (arrow).
FIGURE 10. A 54-year-old woman referred for computed tomography (CT) who was thought to have diverticulitis. A, Axial CT image
obtained with intravenous and oral contrast shows diverticulosis of the transverse colon and pericolic inflammation (arrow). These
findings suggest diverticulitis. B, Coronal reformatted image of the same CT scan shows a short segment of very focal concentric
transverse colonic wall thickening that enhances homogeneously (arrow) with pericolic inflammation. Although the findings can be
seen with diverticulitis, adenocarcinoma was diagnosed at subsequent colonoscopy followed by surgical resection.
FIGURE 16. Patient with left lower quadrant pain who underwent computed tomography (CT) colonography. A, The 3-dimensional
endoluminal view showed a linear abnormality that spanned the lumen of the sigmoid colon. B, A reconstructed sagittal CT image with
bone windowing depicts a thin linear radiodense foreign body consistent with a bone in the sigmoid colon. This was removed at optical
colonscopy and a fishbone was confirmed.
FIGURE 17. Magnetic resonance imaging was performed on a patient with left lower quadrant pain. Axial T2-weighted (A) and gadolinium-
enhanced fat-suppressed T1-weighted (B) images shows diverticulosis with associated thickening of the wall of the sigmoid colon (white
arrowhead), pericolic stranding (white arrow), and a fluid and gas (G) collection, consistent with sigmoid diverticulitis and abscess.
Left Lower Quadrant Pain. [online publication]. Reston (VA): 38. Domajnko B, Kumar A, Salloum RM. Mesenteric venous
American College of Radiology (ACR); 2008:5. thrombophlebitis—septic thrombophlebitis of the inferior
15. Rhea JT. CT evaluation of appendicitis and diverticulitis. II. mesenteric vein: an unusual manifestation of diverticulitis.
Diverticulitis. Emerg Radiol. 2000;7:237–244. Am Surg. 2007;73:404–406.
16. Kircher MF, Rhea JT, Kihiczak D, et al. Frequency, sensitivity, 39. Padidar AM, Jeffrey RB Jr, Mindelzun RE, et al. Differentiat-
and specificity of individual signs of diverticulitis on thin-section ing sigmoid diverticulitis from carcinoma on CT scans:
helical CT with colonic contrast material: experience with 312 mesenteric inflammation suggests diverticulitis. AJR Am J
cases. AJR Am J Roentgenol. 2002;178:1313–1318. Roentgenol. 1994;163:81–83.
17. Werner A, Diehl SJ, Farag-Soliman M, et al. Multislice spiral 40. Goh V, Halligan S, Taylor SA, et al. Differentiation between
CT in routine diagnosis of suspected acute leftsided colonic diverticulitis and colorectal cancer: quantitative CT perfusion
diverticulitis: a prospective study of 120 patients. Eur Radiol. measurements versus morphologic criteria–initial experience.
2003;13:2596–2603. Radiology. 2007;242:456–462.
18. Lee IK, Jung SE, Gorden DL, et al. The diagnostic criteria for 41. Shen SH, Chen JD, Tiu CM, et al. Differentiating colonic
right colonic diverticulitis: prospective evaluation of 100 diverticulitis from colon cancer: the value of computed tomo-
patients. Int J Colorectal Dis. 2008;23:1151–1157. graphy in the emergency setting. J Chin Med Assoc. 2005;68:
19. Goldman SM, Fishman EK, Gatewood OM, et al. CT 411–418.
demonstration of colovesical fistulae secondary to diverticuli- 42. Chintapalli KN, Chopra S, Ghiatas AA, et al. Diverticulitis
tis. J Comput Assist Tomogr. 1984;8:462–468. versus colon cancer: differentiation with helical CT findings.
20. Williams SM, Nolan DJ. Colosalpingeal fistula: a rare Radiology. 1999;210:429–435.
complication of colonic diverticular disease. Eur Radiol. 43. Jang HJ, Lim HK, Lee SJ, et al. Acute diverticulitis of the
1999;9:1432–1433. cecum and ascending colon: the value of thin-section helical
21. Fazio VW, Church JM, Jagelman DG, et al. Colocutaneous CT findings in excluding colonic carcinoma. AJR Am J
fistulas complicating diverticulitis. Dis Colon Rectum. 1987;30: Roentgenol. 2000;174:1397–1402.
89–94. 44. Wolff JH, Rubin A, Potter JD, et al. Clinical significance
22. Vasilevsky CA, Belliveau P, Trudel JL, et al. Fistulas complicating of colonoscopic findings associated with colonic thickening
diverticulitis. Int J Colorectal Dis. 1998;13:57–60. on computed tomography: is colonoscopy warranted when
23. Davis AG, Posniak HV, Cooper RA. Colouterine fistula: thickening is detected? J Clin Gastroenterol. 2008;42:472–475.
computed tomography and vaginography findings. Can Assoc 45. Hoeffel C, Crema MD, Belkacem A, et al. Multi-detector row
Radiol J. 1996;47:186–188. CT: spectrum of diseases involving the ileocecal area. Radio-
24. Vermeulen J, van Hout N, Klaasen R. Fistula formation to the
graphics. 2006;26:1373–1390.
bladder and to a corpus alienum as a rare complication of
46. Lee SS, Kim AY, Yang SK, et al. Crohn disease of the small
diverticulitis: a case report. J Emerg Med. 2009.
bowel: comparison of CT enterography, MR enterography,
25. Green BR, Joypaul V. Left sided diverticulitis presenting as a
and small-bowel follow-through as diagnostic techniques.
right lumbar fistula: a case report. Cases J. 2009;2:7146.
Radiology. 2009;251:751–761.
26. Haleem S, Clifton R, Quraishi NA, et al. “Pointing” in the
47. Osada H, Ohno H, Watanabe W, et al. Multidetector
wrong direction: a case of diverticulitis presenting at the hip.
Hip Int. 2008;18:58–60. computed tomography diagnosis of primary and secondary
27. Najjar SF, Jamal MK, Savas JF, et al. The spectrum of epiploic appendagitis. Radiat Med. 2008;26:582–586.
colovesical fistula and diagnostic paradigm. Am J Surg. 2004; 48. Rioux M, Langis P. Primary epiploic appendagitis: clinical, US,
188:617–621. and CT findings in 14 cases. Radiology. 1994;191:523–526.
28. Singh AK, Raman S, Brooks C, et al. Giant colonic 49. Rao PM, Wittenberg J, Lawrason JN. Primary epiploic
diverticulum: percutaneous computed tomography-guided appendagitis: evolutionary changes in CT appearance. Radio-
treatment. J Comput Assist Tomogr. 2008;32:204–206. logy. 1997;204:713–717.
29. Harris RD, Anderson JE, Wolf EA. Giant air cyst of the 50. Velitchkov NG, Grigorov GI, Losanoff JE, et al. Ingested
sigmoid complicating diverticulitis: report of a case. Dis Colon foreign bodies of the gastrointestinal tract: retrospective
Rectum. 1975;18:418–424. analysis of 542 cases. World J Surg. 1996;20:1001–1005.
30. Gallagher JJ, Welch JP. Giant diverticular of the sigmoid 51. Li SF, Ender K. Toothpick injury mimicking renal colic: case
colon: a review of differential diagnosis and operative manage- report and systematic review. J Emerg Med. 2002;23:35–38.
ment. Arch Surg. 1979;114:1079–1083. 52. Eisen GM, Baron TH, Dominitz JA, et al; American Society for
31. Havenstrite KA, Harris JA, Rivera DE. Giant colonic Gastrointestinal Endoscopy. Guideline for the management of
diverticulum: report of a case. Am Surg. 1999;65:578–580. ingested foreign bodies. Gastrointest Endosc. 2002;55:802–806.
32. Sugihara S, Fujii S, Kinoshita T, et al. Giant sigmoid colonic 53. Wilson SR. The value of sonography in the diagnosis of acute
diverticulitis: case report. Abdom Imaging. 2003;28:640–642. diverticulitis of the colon. AJR. 1990;154:1199.
33. Abou-Nukta F, Bakhos C, Ikekpeazu N, et al. Ruptured giant 54. Lee MW, Kim YJ, Jeon HJ, et al. Sonography of acute right
colonic diverticulum. Am Surg. 2005;71:1073–1074. lower quadrant pain: importance of increased intraabdominal
34. Chaiyasate K, Yavuzer R, Mittal V. Giant sigmoid diverticu- fat echo. AJR Am J Roentgenol. 2009;192:174–179.
lum. Surgery. 2006;139:276–277. 55. Cobben LP, Groot I, Blickman JG, et al. Right colonic
35. Kim AY, Bennett GL, Bashist B, et al. Small-bowel obstruc- diverticulitis: MR appearance. Abdom Imaging. 2003;28:794–798.
tion associated with sigmoid diverticulitis: CT evaluation in 16 56. Ajaj W, Ruehm SG, Lauenstein T, et al. Dark-lumen magnetic
patients. AJR Am J Roentgenol. 1998;170:1311–1313. resonance colonography in patients with suspected sigmoid
36. Klinefelter HF Jr, Grose WE, Crawford HJ. Pylephlebitis. diverticulitis: a feasibility study. Eur Radiol. 2005;15:2316–2322.
Bull Johns Hopkins Hosp. 1960;106:65–73. 57. Heverhagen JT, Sitter H, Zielke A, et al. Prospective
37. Kaewlai R, Nazinitsky KJ. Acute colonic diverticulitis in a evaluation of the value of magnetic resonance imaging in
community-based hospital: CT evaluation in 138 patients. suspected acute sigmoid diverticulitis. Dis Colon Rectum. 2008;
Emerg Radiol. 2007;13:171–179. 51:1810–1815.