Volume
35
Diseases
of the
CozoN R.creM
Number
12
DECEMBER 1992 ORIGINAL CONTRIBUTIONS
Computed Tomography in the Initial Management of Acute Left-Sided Diverticulitis Mark P. Hachigian, M.D., Steven Honickman, M.D., Theodore E. Eisenstat, M.D., RobertJ. Rubin, M.D., Eugene P. Salvati, M.D. From the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School Affiliated Hospitals Program in Colon and Rectal Surgery, Plainfield, New Jersey, and the University of California at Irvine School of Medicine, Irvine, California 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. Thirtyseven 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. [Key words: Diverticulitis; Computed tomography; Percutaneous drainage; CT]
Hachigian MP, Honickman S, Eisenstat TE, Rubin RJ, Salvati EP. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992;35:1123-1129. sing c o m p u t e d t o m o g r a p h y (CT) to evaluate h o l l o w viscera is a recent application compared with its role in the evaluation of solid intraabdominal organs. Several investigators have reported on the effectiveness of CT in detecting the extraluminal events of both c o m p l i c a t e d and uncomplicated diverticulitis. 1' 2 Cross-sectional imaging holds several advantages over traditional contrast e n e m a s in evaluating patients with acute diverticulitis. Contrast e n e m a s require the indirect evidence of a mass effect or extravasation of contrast to diagnose the condition with a high degree of certainty. These specific radiologic findings are frequently not evident, even in patients with c o m p l i c a t e d disease? CT is superior at delineating colonic and pericolic inflammation, and it does so without risking extravasation of contrast. It is capable of displaying direct evid e n c e of extracolonic disease such as adjacent or distant abscess formation, fistula to adjacent organs, and urinary tract involvement. Lastly, CT has b e e n e m p l o y e d as a therapeutic modality allowing percutaneous drainage of localized abscesses. 4 This treatment s e q u e n c e may avoid e m e r g e n t surgery,
U
Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989. Address reprint requests to Dr. Salvati: 1010 Park Avenue, Plainfield, New Jersey 07060. 1123
1124
HACHIGIAN ET AL
circumvent the need for a colostomy, and safely allow an elective resection with primary anastomosis. 5 For over 289 years, CT was used instead of a contrast enema as the sole initial imaging study to evaluate patients with acute left-sided diverticulitis. The utility of CT was further established by following patients prospectively to determine whether CT had any predictive value with regard to clinical outcome.
MATERIALS AND METHODS In this evaluation, CT was the only radiologic study used to image patients during an acute attack of left-sided diverticulitis. The usual symptoms and signs of acute diverticulitis were relied upon to make the clinical diagnosis: left lower quadrant abdominal pain or tenderness, a palpable mass, fever, and leukocytosis. During each patient's course, up to six surgeons had the opportunity to examine the patient and confirm the clinical diagnosis. Sixty-one patients were studied, but two were excluded because the CT scan was not performed during the acute phase of their illness. This was arbitrarily defined as within seven days of their presentation. Fifty-nine patients are included in this report. There were 32 males and 37 females ranging in age from 20 to 91 years (average, 63.2 years). Two patients had CT scans while being managed as outpatients. The remaining 57 patients were studied during their hospitalization. All imaging was performed within seven days (average, 2.4 days) of the patient's admission. Determination of clinical outcome was concluded at the time of surgery or discharge from the hospital. All examinations were performed on a General Electric 9800 CT Scanner. Ten-millimeter-thick slices were taken at 20-mm intervals from the diaphragm to the umbilicus, while 10-mm sections were taken at 10-mm intervals from the umbilicus to the pubis. An intravenous bolus of 100 cc of 60 percent contrast was given to all patients except one who had a mildly elevated creatinine. All patients received oral water-soluble contrast. To avoid distention of the diseased colon, it was not our practice to use either air or positive contrast rectally for delineation of the bowel wall. Acute u n c o m p l i c a t e d diverticulitis was diagnosed radiographically only by identifying effacement of the pericolic fat (Fig. 1). The presence of
Dis Colon Rectum, December 1992
diverticula and/or localized thickening of the coionic wall without changes in the pericolic fat was considered to be compatible with, but not diagnostic of, uncomplicated diverticulitis. Acute comp l i c a t e d diverticulitis was confirmed radiographically by identifying an adjacent or distant abscess, peritonitis, fistula formation, or evidence of coIonic obstruction.
RESULTS CT was not diagnostic of acute diverticulitis in 14 of the 59 patients (24 percent). Three of these patients had a normal CT, eight had scans that showed no abnormality except diverticulosis, and three had localized colonic thickening along with diverticula, but there was no altered density in the pericolic fat to suggest acute inflammation. This group of patients all responded promptly to dietary restriction and antibiotics. There were no septic complications, and all were discharged successfully without operative intervention. One patient's hospital course was complicated by a urinary tact infection, and one suffered a complicated subendocardial myocardial infarction. Both responded promptly to medical management of their suspected diverticulitis. Two patients were managed throughout their course as outpatients. The remaining 10 patients were hospitalized from 4 to 11 days (average, 7.1 days) and were discharged with the clinical diagnosis of acute uncomplicated diverticulitis though it was not substantiated by CT. CT revealed that 3 of the 59 patients (5 percent) had been clinically'misdiagnosed. One patient had left-sided pyelonephritis with an edematous kidney, inflammatory changes in the perinephric fat, and thickening of Gerota's fascia (Fig. 2). The second patient had free pelvic fluid and an abnormal left ovary establishing the diagnosis of a ruptured ovarian cyst. The third patient had a thickened rectal wall with increased density in the perirectal fat. Rigid proctoscopy confirmed the diagnosis of proctitis. CT identified either complicated or uncomplicated inflammatory changes in 42 patients (71 percent). Disease was limited to the descending or sigmoid colon in all cases. Twenty-three patients (39 percent) had radiographic features of uncomplicated diverticulitis with increased density of the pericolic fat. One of these patients did not respond to medical management and refused surgery. She had a known ovarian
Vol. 35, No. 12
CT IN THE MANAGEMENT OF DIVERTICULITIS
1125
Figure 1. A CT scan of the abdomen and pelvis with oral and IV contrast showing uncomplicated diverticulitis. "C" identifies the sigmoid colon lumen, and the arrows depict the effacement of the pericolic fat. These inflammatory changes are absent from the right side of the abdomen.
carcinoma and acute myelogenous leukemia and died of septic complications after refusing surgery. The remaining 22 patients were hospitalized from 2 to 10 days (average, 6.5 days) and were discharged with the diagnosis of uncomplicated diverticulitis. CT identified 19 patients (32 percent) with features of complicated diverticulitis. Intra-abdominal abscess was the most frequent complication, accounting for 68 percent of all complications seen (Fig. 3). Fistula, peritonitis, and colonic obstruction were also seen but far less frequently.
with an abscess had urgent surgery because of sepsis. Two had Hartmann's procedure, and the third had a left hemicolectomy for a perforated Dukes B carcinoma of the descending colon. The tumor was not detected preoperatively by CT. The remaining six patients responded to medical therapy and were discharged without sequelae. Hospital stay for all patients with an abscess ranged from 5 to 23 days (average, 14 days). There were no deaths.
Abscess (13 Patients)
Fistulization was inferred by the presence of extracolonic contrast in the vagina of two patients and an air contrast level in the bladder of the third. These patients all had primary colon resections after their sepsis was controlled. Hospital stay ranged from 11 to 16 days (average, 12.7 days).
Four patients with an abscess (two paracolic, one hepatic, and one pelvic) underwent successful percutaneous drainage and had an elective singlestage colon resection (Fig. 4). Surgery was performed during the same hospital admission after the sepsis was controlled and the patient received a mechanical and antibiotic bowel preparation. The presence of a colocutaneous fistula created by the drainage did not preclude a single-stage colon resection and anastomosis (Fig. 5). Three patients
Fistula (Three Patients)
Peritonitis (Two Patients) Peritonitis was characterized by an ileus, diffuse inflammatory changes, and free intra-abdominal fluid. One patient resolved in eight days on intra-
1126
HACHIGIAN E T AL
Dis Colon Rectum, December 1992
Figure 2. A CT scan of the abdomen with oral and IV contrast showing left-sided pyelonephritis. "a" identifies inflamed and thickened Gerota's fascia. "b" and "c" depict the effacement of the perinephric fat. "d" delineates the inflammation between the psoas muscle and left kidney. Note the absence of these findings on the contralateral side.
venous antibiotics, and the other underwent Hartmann's resection.
Obstruction (One Patient) Partial colonic obstruction with colonic dilatation was obvious on CT. This patient died from complications of severe long-standing heart disease. When the patients with CT evidence of compli: cated diverticulitis were reviewed collectively, 11 (58 percent) required urgent operative or percutaneous intervention, seven (37 percent) were successfully managed medically, and one (5 percent) died. The average hospital stay was 13.6 days. This contrasts sharply with the 40 patients whose CT scan was normal, showed another disease, or displayed uncomplicated inflammation. These patients were treated medically, and the average hospital stay was 6.8 days except for the previously noted exceptions. Two patients were managed entirely as outpatients. One complication occurred with CT (1.7 per-
cent). Anaphylaxis with hypotension and bronchospasm occurred during the injection of ionic intravenous contrast. Supportive therapy stabilized the patient within 24 hours. DISCUSSION CT has emerged as the best initial imaging study in patients with suspected acute diverticulitis. CT detected disease of other organ systems that was clinically indistinguishable from diverticulitis. It identified a 5 percent error in clinical diagnosis and in each case led to the correct diagnosis. It is a noninvasive test that recognizes and stratifies patients according to the severity of their disease. Where CT findings of acute inflammation were lacking to corroborate the clinical impression of diverticulitis, all patients responded to nonoperative treatment and had a benign clinical course. Presumably these responders had mild diverticulitis with an imperceptible anatomic abnormality, but one could as easily suggest that they never had diverticulitis. Regardless, none of these patients
VO1.35, No. 12
CT IN THE MANAGEMENT OF DIVERTICULITIS
1127
Figure 3. A CT scan of the pelvis with oral and IV contrast showing a large pelvic abscess depicted by the arrow. "R" identifies the lumen of the rectum.
Figure 4. A C T scan of the pelvis with oral and IV contrast in a prone patient undergoing percutaneous drainage of a pelvic abscess. "R" identifies the lumen of the rectum.
1128
HACHIGIAN E T
AL
Dis Colon Rectum, December 1992
Figure 5. A sinogram obtained approximately 10 days after drainage of a diverticular abscess. The colocutaneous fistula did not preclude a bowel preparation and single-stage resection and anastomosis.
required early surgical intervention. Similarly, all patients except one, identified by CT as having uncomplicated pericolic inflammation, were also treated successfully with bowel rest and antibiotics. The exception was a severely immunocompromised patient with ovarian carcinoma and acute myelogenous leukemia. Although this group of patients is small, CT appears able to distinguish between complicated and uncomplicated diverticulitis. Furthermore, in immunocompetent patients, a CT finding of uncomplicated disease seems to predict a successful outcome with medical therapy. CT readily identified acute complicated diverticulitis. CT-guided percutaneous drainage of both distant and adjacent abscesses allowed elective surgical resections in the four instances in which it was attempted. The importance of avoiding an immediate operation for complicated diverticulitis has been well proven. Eisenstat e t al. 6 reported a 2.2 percent mortality rate for primary elective resection, as opposed to a 6.4 percent mortality rate for staged procedures in patients with complicated diverticulitis including diverticular abscesses. The
morbidity of Hartmann's procedure is burdensome as well7 As was illustrated by our case of a perforated cancer, increased soft tissue density in the pericolic fat is a nonspecific sign of inflammation. Subsequent examination with a contrast enema or endoscopy is necessary to exclude other diseases. Lymphoma, perforated carcinoma, inflammatory bowel disease, pseudomembranous colitis, and ischemia can all masquerade on CT as acute diverticulitis. 5 CONCLUSIONS This experience indicates that CT is a safe and effective aid in the initial management of patients with acute diverticulitis. CT has the additional advantage of providing the surgeon with information about the anatomy and function of the urinary tract. Also, early use of CT does not prohibit additional diagnostic studies when the CT itself is not diagnostic. It identifies errors in clinical diagnosis, distinguishes between complicated and uncomplicated disease, and may have predictive value with
Vol. 35, No. 12
CT IN TIlE MANAGEMENT OF DIVERTICULITIS
regard to clinical outcome. Perhaps most importantly, CT-guided p e r c u t a n e o u s intervention can downstage some patients with complicated diverticulitis who in the past have r e q u i r e d multistage procedures. This ultimately avoided urgent surgery and allowed an elective resection with a primary anastomosis.
4.
REFERENCES
6.
1. Labs JD, Sarr MG, Fishman EK, Siegelman SS, Cameron JL. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg 1988;155:331-5. 2. Hulnick DH, MegibowAJ, Dalthazar EJ, Naidich DP, Dosniak MA. Computed tomography in the evaluation of diverticulitis. Radiology 1984;152:491-5. 3. Hackford AW, Schoetz DJ Jr, Coller JA, Veidenhei-
5.
7.
8.
1129
mer MC. Surgical management of complicated diverticulitis: the Lahey Clinic experience, 1967 to 1982. Dis Colon Rectum 1985;28:317-21. vanSonnenberg E, Mueller PR, Ferruci JT Jr. Percutaneous drainage of 250 abdominal abscesses and fluid collections. Radiology 1984;151:337-41. Saini S, Mueller PR, Wittenberg J, Butch RJ, Rodkey GV, Welch CE. Percutaneous drainage of diverticular abscess: an adjunct to surgical therapy. Arch Surg 1986;121:475-8. Eisenstat TE, Rubin RJ, Salvati EP. Surgical management of diverticulitis: the role of the Hartmann procedure. Dis Colon Rectum 1983;26:429-32. Labow SB, Salvati EP, Rubin RJ. The Hartmann procedure in the treatment of diverticular disease. Dis Colon Rectum 1978;16:392-4. Lieberman JM, Haaga JR. Computed tomography of diverticulitis. J Comput Assist Tomogr 1983;7: 431-3.
35
Diseases
of the
CozoN R.creM
Number
12
DECEMBER 1992 ORIGINAL CONTRIBUTIONS
Computed Tomography in the Initial Management of Acute Left-Sided Diverticulitis Mark P. Hachigian, M.D., Steven Honickman, M.D., Theodore E. Eisenstat, M.D., RobertJ. Rubin, M.D., Eugene P. Salvati, M.D. From the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School Affiliated Hospitals Program in Colon and Rectal Surgery, Plainfield, New Jersey, and the University of California at Irvine School of Medicine, Irvine, California 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. Thirtyseven 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. [Key words: Diverticulitis; Computed tomography; Percutaneous drainage; CT]
Hachigian MP, Honickman S, Eisenstat TE, Rubin RJ, Salvati EP. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992;35:1123-1129. sing c o m p u t e d t o m o g r a p h y (CT) to evaluate h o l l o w viscera is a recent application compared with its role in the evaluation of solid intraabdominal organs. Several investigators have reported on the effectiveness of CT in detecting the extraluminal events of both c o m p l i c a t e d and uncomplicated diverticulitis. 1' 2 Cross-sectional imaging holds several advantages over traditional contrast e n e m a s in evaluating patients with acute diverticulitis. Contrast e n e m a s require the indirect evidence of a mass effect or extravasation of contrast to diagnose the condition with a high degree of certainty. These specific radiologic findings are frequently not evident, even in patients with c o m p l i c a t e d disease? CT is superior at delineating colonic and pericolic inflammation, and it does so without risking extravasation of contrast. It is capable of displaying direct evid e n c e of extracolonic disease such as adjacent or distant abscess formation, fistula to adjacent organs, and urinary tract involvement. Lastly, CT has b e e n e m p l o y e d as a therapeutic modality allowing percutaneous drainage of localized abscesses. 4 This treatment s e q u e n c e may avoid e m e r g e n t surgery,
U
Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989. Address reprint requests to Dr. Salvati: 1010 Park Avenue, Plainfield, New Jersey 07060. 1123
1124
HACHIGIAN ET AL
circumvent the need for a colostomy, and safely allow an elective resection with primary anastomosis. 5 For over 289 years, CT was used instead of a contrast enema as the sole initial imaging study to evaluate patients with acute left-sided diverticulitis. The utility of CT was further established by following patients prospectively to determine whether CT had any predictive value with regard to clinical outcome.
MATERIALS AND METHODS In this evaluation, CT was the only radiologic study used to image patients during an acute attack of left-sided diverticulitis. The usual symptoms and signs of acute diverticulitis were relied upon to make the clinical diagnosis: left lower quadrant abdominal pain or tenderness, a palpable mass, fever, and leukocytosis. During each patient's course, up to six surgeons had the opportunity to examine the patient and confirm the clinical diagnosis. Sixty-one patients were studied, but two were excluded because the CT scan was not performed during the acute phase of their illness. This was arbitrarily defined as within seven days of their presentation. Fifty-nine patients are included in this report. There were 32 males and 37 females ranging in age from 20 to 91 years (average, 63.2 years). Two patients had CT scans while being managed as outpatients. The remaining 57 patients were studied during their hospitalization. All imaging was performed within seven days (average, 2.4 days) of the patient's admission. Determination of clinical outcome was concluded at the time of surgery or discharge from the hospital. All examinations were performed on a General Electric 9800 CT Scanner. Ten-millimeter-thick slices were taken at 20-mm intervals from the diaphragm to the umbilicus, while 10-mm sections were taken at 10-mm intervals from the umbilicus to the pubis. An intravenous bolus of 100 cc of 60 percent contrast was given to all patients except one who had a mildly elevated creatinine. All patients received oral water-soluble contrast. To avoid distention of the diseased colon, it was not our practice to use either air or positive contrast rectally for delineation of the bowel wall. Acute u n c o m p l i c a t e d diverticulitis was diagnosed radiographically only by identifying effacement of the pericolic fat (Fig. 1). The presence of
Dis Colon Rectum, December 1992
diverticula and/or localized thickening of the coionic wall without changes in the pericolic fat was considered to be compatible with, but not diagnostic of, uncomplicated diverticulitis. Acute comp l i c a t e d diverticulitis was confirmed radiographically by identifying an adjacent or distant abscess, peritonitis, fistula formation, or evidence of coIonic obstruction.
RESULTS CT was not diagnostic of acute diverticulitis in 14 of the 59 patients (24 percent). Three of these patients had a normal CT, eight had scans that showed no abnormality except diverticulosis, and three had localized colonic thickening along with diverticula, but there was no altered density in the pericolic fat to suggest acute inflammation. This group of patients all responded promptly to dietary restriction and antibiotics. There were no septic complications, and all were discharged successfully without operative intervention. One patient's hospital course was complicated by a urinary tact infection, and one suffered a complicated subendocardial myocardial infarction. Both responded promptly to medical management of their suspected diverticulitis. Two patients were managed throughout their course as outpatients. The remaining 10 patients were hospitalized from 4 to 11 days (average, 7.1 days) and were discharged with the clinical diagnosis of acute uncomplicated diverticulitis though it was not substantiated by CT. CT revealed that 3 of the 59 patients (5 percent) had been clinically'misdiagnosed. One patient had left-sided pyelonephritis with an edematous kidney, inflammatory changes in the perinephric fat, and thickening of Gerota's fascia (Fig. 2). The second patient had free pelvic fluid and an abnormal left ovary establishing the diagnosis of a ruptured ovarian cyst. The third patient had a thickened rectal wall with increased density in the perirectal fat. Rigid proctoscopy confirmed the diagnosis of proctitis. CT identified either complicated or uncomplicated inflammatory changes in 42 patients (71 percent). Disease was limited to the descending or sigmoid colon in all cases. Twenty-three patients (39 percent) had radiographic features of uncomplicated diverticulitis with increased density of the pericolic fat. One of these patients did not respond to medical management and refused surgery. She had a known ovarian
Vol. 35, No. 12
CT IN THE MANAGEMENT OF DIVERTICULITIS
1125
Figure 1. A CT scan of the abdomen and pelvis with oral and IV contrast showing uncomplicated diverticulitis. "C" identifies the sigmoid colon lumen, and the arrows depict the effacement of the pericolic fat. These inflammatory changes are absent from the right side of the abdomen.
carcinoma and acute myelogenous leukemia and died of septic complications after refusing surgery. The remaining 22 patients were hospitalized from 2 to 10 days (average, 6.5 days) and were discharged with the diagnosis of uncomplicated diverticulitis. CT identified 19 patients (32 percent) with features of complicated diverticulitis. Intra-abdominal abscess was the most frequent complication, accounting for 68 percent of all complications seen (Fig. 3). Fistula, peritonitis, and colonic obstruction were also seen but far less frequently.
with an abscess had urgent surgery because of sepsis. Two had Hartmann's procedure, and the third had a left hemicolectomy for a perforated Dukes B carcinoma of the descending colon. The tumor was not detected preoperatively by CT. The remaining six patients responded to medical therapy and were discharged without sequelae. Hospital stay for all patients with an abscess ranged from 5 to 23 days (average, 14 days). There were no deaths.
Abscess (13 Patients)
Fistulization was inferred by the presence of extracolonic contrast in the vagina of two patients and an air contrast level in the bladder of the third. These patients all had primary colon resections after their sepsis was controlled. Hospital stay ranged from 11 to 16 days (average, 12.7 days).
Four patients with an abscess (two paracolic, one hepatic, and one pelvic) underwent successful percutaneous drainage and had an elective singlestage colon resection (Fig. 4). Surgery was performed during the same hospital admission after the sepsis was controlled and the patient received a mechanical and antibiotic bowel preparation. The presence of a colocutaneous fistula created by the drainage did not preclude a single-stage colon resection and anastomosis (Fig. 5). Three patients
Fistula (Three Patients)
Peritonitis (Two Patients) Peritonitis was characterized by an ileus, diffuse inflammatory changes, and free intra-abdominal fluid. One patient resolved in eight days on intra-
1126
HACHIGIAN E T AL
Dis Colon Rectum, December 1992
Figure 2. A CT scan of the abdomen with oral and IV contrast showing left-sided pyelonephritis. "a" identifies inflamed and thickened Gerota's fascia. "b" and "c" depict the effacement of the perinephric fat. "d" delineates the inflammation between the psoas muscle and left kidney. Note the absence of these findings on the contralateral side.
venous antibiotics, and the other underwent Hartmann's resection.
Obstruction (One Patient) Partial colonic obstruction with colonic dilatation was obvious on CT. This patient died from complications of severe long-standing heart disease. When the patients with CT evidence of compli: cated diverticulitis were reviewed collectively, 11 (58 percent) required urgent operative or percutaneous intervention, seven (37 percent) were successfully managed medically, and one (5 percent) died. The average hospital stay was 13.6 days. This contrasts sharply with the 40 patients whose CT scan was normal, showed another disease, or displayed uncomplicated inflammation. These patients were treated medically, and the average hospital stay was 6.8 days except for the previously noted exceptions. Two patients were managed entirely as outpatients. One complication occurred with CT (1.7 per-
cent). Anaphylaxis with hypotension and bronchospasm occurred during the injection of ionic intravenous contrast. Supportive therapy stabilized the patient within 24 hours. DISCUSSION CT has emerged as the best initial imaging study in patients with suspected acute diverticulitis. CT detected disease of other organ systems that was clinically indistinguishable from diverticulitis. It identified a 5 percent error in clinical diagnosis and in each case led to the correct diagnosis. It is a noninvasive test that recognizes and stratifies patients according to the severity of their disease. Where CT findings of acute inflammation were lacking to corroborate the clinical impression of diverticulitis, all patients responded to nonoperative treatment and had a benign clinical course. Presumably these responders had mild diverticulitis with an imperceptible anatomic abnormality, but one could as easily suggest that they never had diverticulitis. Regardless, none of these patients
VO1.35, No. 12
CT IN THE MANAGEMENT OF DIVERTICULITIS
1127
Figure 3. A CT scan of the pelvis with oral and IV contrast showing a large pelvic abscess depicted by the arrow. "R" identifies the lumen of the rectum.
Figure 4. A C T scan of the pelvis with oral and IV contrast in a prone patient undergoing percutaneous drainage of a pelvic abscess. "R" identifies the lumen of the rectum.
1128
HACHIGIAN E T
AL
Dis Colon Rectum, December 1992
Figure 5. A sinogram obtained approximately 10 days after drainage of a diverticular abscess. The colocutaneous fistula did not preclude a bowel preparation and single-stage resection and anastomosis.
required early surgical intervention. Similarly, all patients except one, identified by CT as having uncomplicated pericolic inflammation, were also treated successfully with bowel rest and antibiotics. The exception was a severely immunocompromised patient with ovarian carcinoma and acute myelogenous leukemia. Although this group of patients is small, CT appears able to distinguish between complicated and uncomplicated diverticulitis. Furthermore, in immunocompetent patients, a CT finding of uncomplicated disease seems to predict a successful outcome with medical therapy. CT readily identified acute complicated diverticulitis. CT-guided percutaneous drainage of both distant and adjacent abscesses allowed elective surgical resections in the four instances in which it was attempted. The importance of avoiding an immediate operation for complicated diverticulitis has been well proven. Eisenstat e t al. 6 reported a 2.2 percent mortality rate for primary elective resection, as opposed to a 6.4 percent mortality rate for staged procedures in patients with complicated diverticulitis including diverticular abscesses. The
morbidity of Hartmann's procedure is burdensome as well7 As was illustrated by our case of a perforated cancer, increased soft tissue density in the pericolic fat is a nonspecific sign of inflammation. Subsequent examination with a contrast enema or endoscopy is necessary to exclude other diseases. Lymphoma, perforated carcinoma, inflammatory bowel disease, pseudomembranous colitis, and ischemia can all masquerade on CT as acute diverticulitis. 5 CONCLUSIONS This experience indicates that CT is a safe and effective aid in the initial management of patients with acute diverticulitis. CT has the additional advantage of providing the surgeon with information about the anatomy and function of the urinary tract. Also, early use of CT does not prohibit additional diagnostic studies when the CT itself is not diagnostic. It identifies errors in clinical diagnosis, distinguishes between complicated and uncomplicated disease, and may have predictive value with
Vol. 35, No. 12
CT IN TIlE MANAGEMENT OF DIVERTICULITIS
regard to clinical outcome. Perhaps most importantly, CT-guided p e r c u t a n e o u s intervention can downstage some patients with complicated diverticulitis who in the past have r e q u i r e d multistage procedures. This ultimately avoided urgent surgery and allowed an elective resection with a primary anastomosis.
4.
REFERENCES
6.
1. Labs JD, Sarr MG, Fishman EK, Siegelman SS, Cameron JL. Complications of acute diverticulitis of the colon: improved early diagnosis with computerized tomography. Am J Surg 1988;155:331-5. 2. Hulnick DH, MegibowAJ, Dalthazar EJ, Naidich DP, Dosniak MA. Computed tomography in the evaluation of diverticulitis. Radiology 1984;152:491-5. 3. Hackford AW, Schoetz DJ Jr, Coller JA, Veidenhei-
5.
7.
8.
1129
mer MC. Surgical management of complicated diverticulitis: the Lahey Clinic experience, 1967 to 1982. Dis Colon Rectum 1985;28:317-21. vanSonnenberg E, Mueller PR, Ferruci JT Jr. Percutaneous drainage of 250 abdominal abscesses and fluid collections. Radiology 1984;151:337-41. Saini S, Mueller PR, Wittenberg J, Butch RJ, Rodkey GV, Welch CE. Percutaneous drainage of diverticular abscess: an adjunct to surgical therapy. Arch Surg 1986;121:475-8. Eisenstat TE, Rubin RJ, Salvati EP. Surgical management of diverticulitis: the role of the Hartmann procedure. Dis Colon Rectum 1983;26:429-32. Labow SB, Salvati EP, Rubin RJ. The Hartmann procedure in the treatment of diverticular disease. Dis Colon Rectum 1978;16:392-4. Lieberman JM, Haaga JR. Computed tomography of diverticulitis. J Comput Assist Tomogr 1983;7: 431-3.
![[Computed tomography of colonic diverticulitis].](/assets/img/hold.png)
