1. Diverticulitis Ultrasound
Nicholas Kurtzman, MS4
EM Ultrasound
Thomas Jefferson University Hospital
September 19, 2016

2. Epidemiology Diverticulosis 60% of people by age 60
95% have sigmoid diverticula
In Asia prevalence is 13-25% and right sided
4-15% of pt w/ diverticulosis develop diverticulitis
Mean age is 63 years
Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut 1969; 10:336.

3. Pathogenesis Micro- or macroscopic perforation of a diverticulum.
Previously believed that obstruction of diverticula increased diverticular pressure and caused perforation (known to be rare)
Erosion of the diverticular wall by increased intraluminal pressure or inspissated food particles. Inflammation and focal necrosis ensue, resulting in perforation.
Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg 1989; 26:133.

4. Clinical features Subacute onset of pain (>1 hour)
Tenderness to palpation in LLQ
Raised inflammatory markers
Fever
Absence of peristalsis

5. Workup
Imaging not necessary in patients w/ left lower quadrant pain, fever, leukocytosis, or history of diverticulitis with symptoms of recurrent disease
Contrast enhanced CT
Rules out other sources of pain or underlying diagnoses
Follow up colonoscopy 6 weeks after episode of diverticulitis

7. Approach to exam Curvilinear 3.5-5.0 MHz probe
Can use linear probe in pediatrics, elderly, decreased muscle mass
Can use endocavitary probe for evaluation of difficult to access areas
Focus on most painful area
Perform systemic evaluation of colon starting in RUQ w/ ascending colon
Visualize all sections of colon
Attempt to visualize rectum using bladder as a window (half full bladder is optimal)
J Ultrasound Med Oct;32(10): doi: /ultra
Sonography: first-line modality in the diagnosis of acute colonic diverticulitis?
Helou N1, Abdalkader M, Abu-Rustum RS.

8. Colon Normal wall thickness: <3mm
Colonic wall > 5mm assume underlying disease
Colon lacks vulvulae conniventes
Colon is aperistaltic

9. Diagnostic criteria Signs of inflammation of periodic fat Diverticulum
Thickened bowel wall >4-5 mm

10. Sonographic features
Thick hypoechoic wall with central hyperechoic center
40% of cases (pseudokidney)
Diverticula (50% of cases)
Thin wall due to lack of muscularis propria
“bright ears” out of the bowel wall with acoustic shadowing
Changes in pericolic fat
Rigid hyperechoic zone surrounding colon
Enlarged fluid filled loops of bowel
Air containing diverticula
Hyperechoic areas within lumen w/ acoustic shadowing
Abscess
Local pain and tenderness on compression

11. Use of US in diagnosis of Diverticulitis
Lameris et al meta analysis w/ 630 patients evaluated with US and 684 evaluated with CT
US sensitivity 92%
CT sensitivity 94%
No statistical significance
US cheaper than CT
No radiation
Correlates point of maximal tenderness with visuals

12. Limitations Area obscured by overlying gas Obesity Operator
Statistically significant difference in detection of operator between >500 and <500 scans
Difficult to determine between diverticulitis alternative causes of abdominal pain
J Ultrasound Med Oct;32(10): doi: /ultra
Sonography: first-line modality in the diagnosis of acute colonic diverticulitis?
Helou N1, Abdalkader M, Abu-Rustum RS.
Sigmoid diverticulitis: US findings. Maria Antonietta Mazzei† author, Nevada Cioffi Squitieri†, Susanna Guerrini†, Amato Antonio Stabile Ianora†, Lucio Cagini†, Luca Macarini†, Melchiore Giganti† and Luca Volterrani†

13. References
J Ultrasound Med Oct;32(10): doi: /ultra Sonography: first-line modality in the diagnosis of acute colonic diverticulitis? Helou N1, Abdalkader M, Abu-Rustum RS.
Sigmoid diverticulitis: US findings. Maria Antonietta Mazzei† author, Nevada Cioffi Squitieri†, Susanna Guerrini†, Amato Antonio Stabile Ianora†, Lucio Cagini†, Luca Macarini†, Melchiore Giganti† and Luca Volterrani
Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg 1989; 26:133.
Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut 1969; 10:336.