1. Diagnosis of diverticulosis and diverticulitis
Tryggvi Björn Stefánsson
Dept of Surgery
Landspitali University Hospital

2. Diverticulosis
Barium Enema.

3. Barium Enema

4. Diverticulitis Clinical classification Hinchey classification
Ambrosetti classification

5. Clinical classification (European association for endoscopic surgeons)
I. Symptomatic uncomplicated disease.
Fever, crampy abdominal pain, CT evidence of phlegmonous diverticulitis.
II. Recurrent symptomatic disease. Recurrence of above.
III. Complicated disease.
(hemorrhage, abscess, perforation, purulent and fecal peritonitis, stricture, fistula, small-bowel obstruction due to postinflammatory adhesions)

6. Hinchey classification
Stage 1
Pericolic or mesenteric abscesses.
Stage 2
Walled off pelvic abscess.
Stage 3
Generalised purulent peritonitis.
Stage 4
Generalised fecal peritonitis

7. Ambrosetti’s CT Staging of Diverticulitis.
Mild Diverticulitis
Localized sigmoid wall thickening (less than 5 mm)
Inflammation of pericolic fat.
Severe Diverticulitis
Abscess
Extraluminal air
Extraluminal contrast

8. Complicated diverticulitis
Abscess
Purulent peritonitis
Faecal peritonitis
Colovaginal fistula
Colovesical fistula
Colocutan fistula
Stricture
Hemorrage

9. Differential diagnosis
Appendicitis.
Inflammatory bowel disease(Crohn’s disease).
Pelvic inflammatory disease.
Tubal pregnancy.
Tuboovarian abscess.
Cystitis.
Advanced colonic cancer.
Infectious colitis.
Colorectal cancer.

10. Diagnostic tools Clinical symptoms. Lab tests. Barium enema.
Ultrasound.
MRI.
CT.
Laparoscopy.

11. Clinical symptoms
The AVOD study: Chabok A et al, British Journal of Surgery 2012

12. WBC, CRP

13. Computed Tomography Diverticulas
Thickening of the bowel wall >3 mm-5mm.
Cloudy fat in the mesentery

14. Abscess

15. CT Sensitivity 93%-98% Specificity 75%-100%
Stefánsson T, Acta Radiol Mar;38(2):313-9.
Doringer E. Crit Rev Diagn Imaging 1992; 33: 421–35
Hulnick DH et al, Radiology,1984; 152: 491–95.
Cho KC et al, Radiology 1990; 176: 111–15.
Ambrosetti P et al Dis Colon Rectum 2000; 43: 1363–67.

16. Barium Enema Diverticulas Edema Intramural sinus tract.
Extravasated contrast material outlining an abscess cavity.
Fistula.

17. Barium Enema Sensitivity 0.82 (95% CI: 0.71-0.90)
Specificity (95% CI: )
Stefánsson T, Acta Radiol Mar;38(2):313-9.

18. Ultrasound

19. Ultrasound Inflamed segment.
Hypoechogenic thickening of the bowel wall (Hypertrophy of muscularis propria)
Hyperechogenic halo (Pericolitis, inflammatory fat)
Diverticulum with hyperechogenic halo.
Luminal narrowing.
Hypoperistalsis.
Pericolic abscess.

20. Ultrasound Inflammatory target sign in the left lower quadrant,
Hyperechogenic halo and diverticula.
Highly suggestive of ACD in a symptomatic patient.
Surgeons in training showed 84% sensitivity for US diagnosis . Comparable to the results of specialists.
A. Zielke, Surgical Endoscopy 1997.

21. US vs CT Sensitivity US : 92% (95% CI:80%-97%)
CT 94% (95%CI: 87%-97%) (p=0.65).
Specificity
US 90% (95%CI: 82%-95%)
CT 99% (95%CI: 90%-100%) (p=0.07).
Alternative diseases sensitivity ranged
between 33% and 78% for US and
between 50% and 100% for CT
Wytze Laméris, Eur Radiol (2008) (metatanalysis)

22. Magnetic Resonance Imaging
Uncomplicated diverticulitis
Diverticula
Bowel wall thickening ( more than 3-5 mm)
Pericolonic fat stranding
Complicated diverticulitis
Bowel wall thickening more than 5 mm
Perforation, Abscess
fistula

23. MR

24. MR

25. MR

26. Laparoscopy Acute abdomen Acute abdomen due to diverticulitis
Differentiate between purulent peritonitis and faecal peritonitis.
Recurrent diverticulitis or cronic diverticulitis to decide if the patient must be operated or not.

27. Summary. Lower abd pain, tenderness and raised CRP.
US ? If in doubt CT or MRI.
CT or MRI best to diagnose complications and diff diagnosis.
6-8 weeks later colonoscopy if you want to rule out cancer.