Diagnosis Of Diverticulitis Research Articles

Prevalence of Colonic Neoplasia in Patients with a Clinical Diagnosis of Diverticulitis

Prevalence of Colonic Neoplasia in Patients with a Clinical Diagnosis of Diverticulitis Kalyani Maganti, Kent Anderson, Joseph Leung Background: Diverticulosis of the colon is common in developed countries, and the prevalence increases with age. Diverticulitis is a major clinical complication of diverticular disease affecting 10-25% of patients. Although the American College of Gastroenterology recommends elective colonoscopy after resolution of acute inflammation to exclude neoplasia, evidence for this practice guideline is lacking. This retrospective study evaluates the prevalence of colonic neoplasia in patients with a recent clinical diagnosis of diverticulitis. Because of limited resources, we determine if elective colonoscopy impacts on the outcome of this specific group of patients. Methods: We identified all patients with a diagnosis of diverticulitis by ICD-9 codes between 1996 and 2005 at our institution and those who had undergone colonoscopy within one year of the diagnosis. Patient demographics, indications, colonoscopy findings and location of significant pathology were reviewed. Primary outcomes included finding of polyps and advanced neoplasia defined as tubular adenoma O/Z 1 cm, villous histology, high grade dysplasia or cancer. Statistical analysis was performed using exact binomial 95% two-sided confidence interval. Results: A total of 16964 colonoscopies were performed during this period. 2305 patients with a ICD-9 diagnosis of diverticulitis were identified. Of these, 239 patients underwent colonoscopy within 1 year of the diagnosis. 25 patients had a poor preparation, 22 of whom had adequate examinations. Of the 236 patients, 139 were female, 97 male. Mean age was 59 years. 9 patients (3.8%) had family history of colon cancer, and 17 (7.2%) patients had history of prior colonic polyps. Significant findings on colonoscopy were 74 (31.3%) patients with polyps, 38 (16.1%) had tubular adenomas, 5 (2.1%) O10 mm. There was no cancer and no villous histology or high grade dysplasia noted on any polyps in this series. 17 patients had hyperplastic polyps. Based on analysis of our data, the probability of cancer being found at colonoscopy in this group of patients with a diagnosis of diverticulitis is !1%. Conclusions: Our data indicated that the coexistence of colonic neoplasia with diverticulitis is not significant compared to the general population. Considering the limited resources, a clinical diagnosis of uncomplicated diverticulitis in and by itself does not warrant a colonoscopy to rule out neoplasia. However, the standard screening expectations still apply.

Diagnosis of diverticulitis by bedside Ultrasound in the Emergency Department

This case report describes a potential novel indication for the use of bedside ultrasound in the Emergency Department. The patient in this case had some of the signs and symptoms of diverticulitis. The “pseudo-kidney” sign, which was thought to represent acute diverticulitis, was appreciated on a rapid, bedside ultrasound and confirmed by computed tomography. Knowledge of the sonographic appearance of diverticulitis may aid emergency physicians in making this diagnosis promptly, and facilitate the appropriate disposition.

Recurrent Complicated Colon Diverticulitis in Renal Transplanted Patient

Colon perforation due to diverticulitis is a life-threatening complication in the postoperative course of kidney transplantation. In the immunocompromised patient a diagnosis of diverticulitis is difficult to make. We report a 53-year-old woman being kidney transplanted 14 years ago with known diverticulosis. She was admitted with acute severe pain in the lower left abdomen. Abdominal computed tomography (CT) scan indicated a diagnosis of intestinal abscess in the small pelvis. Laparotomy showed a covered sigma perforation with abscess located in the small pelvis (Hinchey-I). Because of the immunocompromised situation of the patient we performed a Hartmann procedure. Her postoperative course was uneventful. In a 6-month interval the intestinal continuity restoration was performed. Twelve days after discharge the patient was readmitted with reduced renal function and increased infection parameters. During physical examination the abdomen was tender. The patient complained of abdominal pain in the left upper abdomen and additional pain in the left shoulder. An antibiotic therapy using ciprofloxacin was already initiated owing to a urinary tract infection. An abdominal CT scan was performed and indicated an intestinal abscess in the left upper abdomen. Laparotomy showed an abscess involving transverse colon, distal jejunum, and proximal ileum (Hinchey-II). Segmental resection of the left colonic flexure, proximal jejunum, and ileum was performed. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. The present casuistry emphasizes that the immunocompromised patient can undergo diverticulitis twice, and that primary anastomosis is a feasible option for patients with localized peritonitis due to complicated diverticulitis.

Impact of CT-Guided Drainage in the Treatment of Diverticular Abscesses: Size Matters

Our objective was to determine whether abscess size can be used as a discriminating factor to guide management of patients with diverticular abscesses. We performed a word search of our CT database between July 2001 and July 2002 for the CT diagnosis of diverticulitis. CTs were retrospectively reviewed as consensus opinion of two reviewers. CTs were evaluated for presence of an abscess, its location, maximum diameter, and feasibility of percutaneous abscess drainage. Abscesses were categorized into smaller than 3 cm and larger than or equal to 3 cm, and the management of these groups was compared. Thirty-one abscesses were noted in 30 (17%) of 181 patients with a CT diagnosis of diverticulitis. Twenty-two (73%) of 30 patients had 23 abscesses, all of which were smaller than 3 cm and were treated and resolved with antibiotics alone (p < 0.001). Eight (36%) of 22 required surgical treatment. Eight (26%) of 31 abscesses had a maximum diameter larger than or equal to 3 cm. Four (50%) of eight patients with abscesses 3.4-4.1 cm were treated with antibiotics alone. Four (50%) of eight abscesses, all larger than 4.1 cm, were treated with CT-guided drainage and one abscess required repeat drainage. After resolution of symptoms, surgery was performed in five (62.5%) of eight of the larger abscesses. Patients with abscesses smaller than 3 cm in size can be treated with antibiotics alone and, in some cases, as outpatients, and may not uniformly require surgery. This is also likely true for patients with abscesses 3-4 cm in size, although our results in this group were limited by a small sample size. Patients with abscesses larger than or equal to 4 cm can be managed with CT-guided abscess drainage followed by referral for surgical treatment.

Differentiating Colonic Diverticulitis from Colon Cancer: The Value of Computed Tomography in the Emergency Setting

The purpose of this study was to establish practical diagnostic criteria to differentiate colonic diverticulitis from colon cancer by computed tomography (CT) in the emergency department (ER). Helical CT scans of 40 patients admitted to the ER with the clinical diagnosis of diverticulitis and 14 patients diagnosed with colon cancer were retrospectively reviewed. In total, 18 imaging parameters were analyzed and were compared between the 2 groups of patients. Thirteen parameters were found to be statistically significant for the diagnosis of colonic diverticulitis in excluding colon cancer: pericolic infiltration (p < 0.001); presence of lymph nodes (p < 0.001); inflamed diverticula (p = 0.001); non-inflamed diverticula (p = 0.001); degree of enhancement (p = 0.001); intestinal obstruction (p = 0.001); involved wall thickness (p = 0.005); lymph node size (p = 0.007); fascial thickening (p = 0.009); pattern of enhancement (p = 0.012); involved length (p = 0.014); free air (p = 0.035); and abscess formation (p = 0.042). Among these parameters, the most valuable imaging findings for diverticulitis were the presence of non-inflamed diverticulum, inflamed diverticulum, mild degree of enhancement, and small lymph node size. Three were found to have high specificity but low sensitivity: target enhancement pattern; abscess formation; and free air. When colonic obstruction is present, colon cancer is more likely than diverticulitis. Specific CT criteria help to differentiate colonic diverticulitis from colon cancer. CT scan with intravenous contrast administration would be the best noninvasive imaging modality in the ER for the accurate diagnosis and appropriate management of such disease.

Sigmoid diverticulitis in patients with Williams–Beuren syndrome: Relatively high prevalence and high complication rate in young adults with the syndrome

In a retrospective survey of 128 adults with Williams-Beuren syndrome (age range 18-62 years) sigmoid diverticulitis was reported in 10 patients (2 f, 8 m). The diagnosis of diverticulitis had been made between the ages of 17.1 and 39.6 years. An additional four patients (age range 23.5-32.2 years) had presented with sigmoid diverticulosis. In eight patients the course of the disease was complicated, some of them having to undergo multiple surgery. Conservative therapy was successful in only one female and one male patient with diverticulitis. Thus, we conclude that there is an increased prevalence of sigmoid diverticulitis in adult patients with Williams-Beuren syndrome (8% vs. 2% in the normal population in the age group below 40 years).

Laparoscopic sigmoid colectomy after acute diverticulitis: When to operate?

Laparoscopic sigmoid colectomy has become an acceptable method of surgical treatment for diverticulitis. However, an optimal waiting period before attempting elective laparoscopic colectomy has not been established. We sought to evaluate the relationship between the time interval from an acute episode of diverticulitis to laparoscopic colectomy and surgical outcomes. All patients undergoing laparoscopic colectomy during a period of 10 years in a single institution were studied. Retrospectively collected data included patient demographics, American Society of Anesthesiologists score, prior episodes of diverticulitis, interval between last attack and operation, operative time, complications, conversion, and recovery period. A total of 120 patients were included; 89 had a primary diagnosis of diverticulitis. Mean interval from acute diverticulitis to operation was 64 days (range, 1 to 240). Median number of episodes of diverticulitis before colectomy was 3 (range, 1 to 10). Ten patients (11%) required conversion from laparoscopic to open colectomy. Neither interval from acute attack to operation nor number of prior episodes of diverticulitis was associated with any significantly increased rate of conversion to open colectomy, complication rate, operative time, or recovery period (P=not significant). Our study showed no direct relationship between surgical timing after acute diverticulitis and complication or conversion rates after elective laparoscopic sigmoid colectomy.

Is a Recent Episode of Diverticulitis an Acceptable Indication for Colonoscopy?

Purpose: Patients are routinely referred for colonoscopy after experiencing an episode of diverticulitis. There is no evidence supporting this practice. The goal of this study is to compare the incidence of clinically significant lesions found during colonoscopy between a group of patients referred after an episode of diverticulitis and a group of average risk individuals undergoing screening colonoscopy. Method: Patients referred for colonoscopy after receiving the clinical diagnosis of diverticulitis were identified from our database (diverticulitis group). As our reference group we used consecutive average risk patients referred for screening colonoscopy without a history of diverticulitis (screening group). For this study, we considered all adenomatous polyps (small and large) and adenocarcinoma as significant lesions. The study was powered to detect a 10% difference in the incidence of significant lesions with an alpha of 95% and a beta of 80%. Results: From 1997 to 2003, we found 119 patients referred for colonoscopy after an episode of diverticulitis (75 females, 44 males, mean age 61, range 29-89). In this group, 16 patients (13.4%) had adenomas <1 cm, 8 (6.7%) had adenomas ≥1 cm and 2 (1.7%) had adenocarcinoma. The screening group consisted of 440 patients (294 females, 145 males, mean age 60, range 50-74). We found that 68 patients (15.5%) had adenomas <1 cm, 19 (4.3%) had adenomas ≥1 cm and 3 (0.7%) had adenocarcinoma. There was no statistical difference in the frequency of findings between both groups. In our subgroup analysis we noted that the prevalence of significant lesions was significantly greater in males when compared to females (p value = 0.04). This observation held true in both study groups. Conclusions: There is no difference in the prevalence of significant lesions identified during colonoscopy in patients with previous diverticulitis compared with average risk individuals. Patients with previous diverticulitis should therefore follow the normal colorectal screening guidelines.

Association between sigmoid diverticulitis and left‐sided colon cancer: a nested, population‐based, case control study

Background: An increased risk of left‐sided colon cancer in patients with diverticular disease of the sigmoid colon has been reported. The aim of this study was to investigate to what extent patients with diverticulitis of the sigmoid colon differ in long‐term risk of colon cancer compared to patients with diverticulosis of the colon without any clinical signs of diverticulitis. Methods: A total of 7159 patients (2478 M, 4681 F) discharged with a diagnosis of diverticulosis or diverticulitis in 1965–83 in the Uppsala Health Care Region were followed‐up with the Swedish Cancer Registry. Sixty‐four cases with colon cancer were identified and compared with 123 controls without cancer matched for sex, age and year of first discharge. Based on information from the patients' charts, an independent observer blinded to the outcome assigned a clinical diagnosis of diverticulitis or not diverticulitis to cases and controls. Results: In patients classified as having sigmoid diverticulitis there was an increased risk of left‐sided colon cancer compared with patients with diverticulosis without any clinical signs of diverticulitis (odds ratio = 4.2, 95% CI 1.3–13.0) which remained after mutually adjusting for several clinical parameters in a multivariate conditional logistic regression analysis. Conclusion: The results of the study indicate a causal association between sigmoid diverticulitis and a long‐term increased risk of left‐sided colon cancer.

Spectrum of disease and outcome of complicated diverticular disease

Background Diverticular disease is a common entity. The presentation, investigations performed, and management are variable. Our objectives were to assess the presentation, extent of disease, and treatment of a cohort of patients with colonic diverticulitis. Methods All patients with a diagnosis of diverticulitis over a 9-year period were reviewed. Patients were assessed as to age, sex, presenting symptoms, diagnostic studies, extent of disease, treatment, and outcome. Results Over a 9-year period (1992 to 2001), 192 patients were admitted with a diagnosis of colonic diverticulitis. The mean age was 61 years (range 28 to 90); 113 of 192 (59%) were female. The mean duration of symptoms prior to presentation was 14 days (range 1 to 270 days). One hundred eighteen of 192 (61%) had a previous documented attack of diverticulitis. Of the investigations performed 128 of 192 (66.7%) had a computed tomography (CT) scan of the abdomen and pelvis, 37 of 192 (20%) underwent a contrast enema, 61 of 192 (32%) underwent colonoscopy and 2 of 192 (1%) underwent a small bowel series. The abnormal findings on the CT scan were as follows: diverticular abscess (16%), diverticulitis (37%), diverticulosis without inflammation (15%), free air (10%) and fistula (1%). The locations of the diverticular abscesses were: pelvic (36%), pericolic sigmoid (36%), and “other,” which included interloop (28%). Preoperative abscess drainage occurred in 10 of 192 (5%), which were either percutaneous, 6 of 192 (3%), or transrectal, 4 of 192 (2%). Nine of 192 (6%) presented with a fistula, colovesical fistulae (3%), colocutaneous (1%), enterocolic (1%), or colovaginal (1%). Overall, 73 of 192 (38%) underwent surgery. All patients undergoing surgery had a resection of their colon. The operative findings were localized abscess in 16 of 73 (22%), purulent/feculent peritonitis in 12 of 73 (17%), and phlegmon in 10 of 73 (14%). Sixty-seven of 73 (92%) had a primary resection with anastomosis; 38 of 67 (56%) had a protecting stoma. Five of 73 (7%) patients were found to have an unsuspected carcinoma. Overall, 29 of 192 (15%) developed a complication related to diverticulitis. Morbidity was 15.1%, of which 34% was infection related. Four of 192 patients (2%) died. Conclusions In our experience, most patients presented with abdominal pain predominantly in the left lower quadrant. The symptoms were present on average of 14 days, most were female (59%), and most patients had a previous attack of diverticulitis. The commonest investigation performed was a CT scan (66.7%); however, other investigations were performed, for example, barium enemas. The practice of resection and primary anastomosis for acute diverticulitis has an acceptable morbidity and mortality. For high-risk anastomoses, a covering loop ileostomy and not a Hartmann's procedure is preferred. Surgery remains safe for the majority of patients and is associated with resolution of symptoms. We believe that because of the high number of patients in our series who had a previous attack of diverticulitis, therapy should be focused on preventing recurrent and virulent attacks by earlier operative intervention.

Diverticulitis in the younger patient

Background The purpose of this study was to examine the presentation of diverticulitis at an urban county hospital serving predominantly indigent patients and to analyze the differences, if any, in presentation and treatment in younger patients. Methods A retrospective review of medical records from 1995 to 2001 was performed at a single institution to identify patients admitted to the surgical service with the diagnosis of diverticular disease. Inclusion criteria were either diverticulitis confirmed at operation or radiographic findings consistent with the disease. Patient demographics, history, pertinent physical findings, and treatment were recorded. The data were analyzed after dividing the patients into two populations: a younger population 50 years of age or less, and a second population of patients older than 50. Results During the interval, a total of 64 patients were admitted to the surgical service with the diagnosis of diverticulitis. The mean age of this population was 45.5 years (range 21 to 86). Forty-six patients were under 50 years of age (72%). Analysis of sex differences, type and timing of surgical procedure, and complication rate with respect to age showed no significant difference between the two age groups. Conclusions We are clearly treating a younger patient population than previous reports on patients with diverticulitis. Although there was a trend toward increased surgical intervention in the younger population, this number did not reach statistical significance. Diverticulitis in young patients at our institution does not appear to take a more aggressive course than the same disease in older patients.

Diagnosis and management of diverticulitis in women

Diverticular disease is thought to be related to dietary fiber deficiency and has a higher incidence in developed countries and in older patients, especially women. Diverticulitis is an inflammatory process of colonic diverticula that commonly presents with lower abdominal pain, fever, and leukocytosis. The differential diagnosis of diverticulitis includes ruptured ovarian cyst, ovarian torsion, tubo-ovarian abscess, ectopic pregnancy, pelvic inflammatory disease, appendicitis, Crohn's disease, colon cancer, ischemic colitis, pseudomembranous colitis, complicated ulcer disease, and urologic disease. Treatment may be medical or surgical, depending upon the severity of the episode and the presence or absence of complications.

Patterns of pain in diverticular disease and the influence of acute diverticulitis.

While the association of recurrent bouts of abdominal pain with colonic diverticulosis is well recognized, the cause of this pain is obscure since in most cases it occurs without obvious diverticulitis or other potential causes. To define the patterns of pain in diverticular disease and the influence of acute diverticulitis. Two studies were undertaken to establish the relationship between bouts of prolonged abdominal pain (> 24 h) presumed to be due to inflammatory diverticulitis and recurrent short-lived pain. In Study 1, 261 patients with a barium enema showing diverticulosis completed a postal questionnaire concerning episodes of both prolonged and short-lived pain. In Study 2, 26 patients previously admitted to hospital with a firm diagnosis of diverticulitis were interviewed for details of their bowel habits since discharge. Study 1: 94/261 patients experienced recurrent, short-lived pain on a median of five days a month, with a median duration of 3 h. In addition, 51/261 patients described episodes of prolonged pain with a median duration of three days. Of these, 31/51 (61%) experienced recurrent, short-lived pain compared with 63/210 (30%) who had not had an episode of prolonged pain. More specifically, 12/17 (71%) who received antibiotic treatment for presumed acute diverticulitis during their bout of prolonged pain experienced recurrent pain compared with 82/244 (34%) who did not experience such an episode. Study 2: 18/26 patients hospitalized for acute diverticulitis developed new, recurrent, short-lived abdominal pain following discharge, with a median duration of 4 h. Episodes of prolonged, presumed inflammatory pain due to diverticulitis are frequently followed by recurrent, short-lived pain similar to that seen in irritable bowel syndrome.

LaparoscopicVersusOpen Sigmoid Colectomy for Diverticulitis

This study compared laparoscopic with open sigmoid colectomy for patients with a diagnosis of diverticulitis. Increased use of less invasive techniques makes it vitally important to evaluate outcomes of these techniques as compared with standard open procedures. Patients undergoing sigmoid colectomy for diverticulitis without hemorrhage (code 56211) between January 1997 and December 2001 were reviewed. Two groups were identified: those undergoing open sigmoid colectomy and those undergoing laparoscopic sigmoid colectomy; American Society of Anesthesiologists (ASA) scores, operative time, intensive care unit (ICU) and hospital length of stay, morbidity/mortality, and hospital charges were compared. During the study period 271 sigmoid colectomies were performed for diverticulitis without hemorrhage: 56 laparoscopically and 215 with the standard open technique. Four patients required conversion from laparoscopic to open colectomy. Mean ASA scores were: open group 2.4; laparoscopic group, 1.9 ( P &lt; 0.001). Mean operative times were: laparoscopic group, 170 ± 45 minutes; open group, 140 ± 49 minutes ( P &lt; 0.001). In the open group 39 patients required transfer to the ICU; one patient in the laparoscopic group required transfer to the ICU. Average hospital lengths of stay for the open and laparoscopic groups were 9.06 and 4.12 days, respectively ( P &lt; 0.001). Complications were recorded in 57 (27%) of 215 patients who underwent an open procedure versus 5 (9%) of 56 patients who underwent laparoscopic sigmoid colectomy ( P &lt; 0.01). There were three deaths in the open group and none in laparoscopic group. Average total hospital charges were $25,700 for open sigmoid colectomy and $17,414 for laparoscopic colectomy. Laparoscopic sigmoid colectomy compares favorably with open sigmoid colectomy for patients with a diagnosis of diverticulitis.

Epiploic Appendagitis: MR Appearance

Epiploic appendices are peduncultaed adipose protrusions from the serosal surface of the colon. An epiploic appendix may undergo infarction followed by secondary inflammatory changes, a proces which has been named epiploic appendagitis. Presenting symptoms are non-specific, leading to a presumed clinical diagnosis of diverticulitis or appendicitis in most cases [1]. Misdiagnosis may result in unwarranted surgical procedures and hospitalization, as epiploic appendagitis is a self-limiting disease [2, 3]. Ultrasound (US) and computed tomography (CT) are capable of a reliable diagnosis of epiploic appendagitis [2-4]. This is the first report of the magnetic resonance (MR) imaging features of epiploic appendagitis, in two patients.

Conservative management of epiploic appendagitis based on CT scan findings

Dear Editor, Epiploic appendagitis is a relatively rare, often underdiagnosed condition affecting young adults. A 31-year-old male presented with a 12-hour history of acute left iliac fossa pain of increasing severity, which had become constant and aggravated by movement. There was no history of gastrointestinal disturbance. On examination, there was marked tenderness and guarding in the left iliac fossa. The white cell count was raised (11.23x10/l) with a neutrophilia (7.9x10/l). Initially, a clinical diagnosis of diverticulitis was made in spite of the patient’s age. An abdominal CT showed an abnormality of the descending and sigmoid junction with a peripheral hyperattenuated ring, a central area of hypoattenuation of the anterior peritoneal lining and thickening and stranding of fat surrounding the lesion (see Figures 1 and 2). These findings confirmed the diagnosis of epiploic appendagitis. The patient was managed conservatively and by day 5 his symptoms had resolved and he was discharged home. Primary epiploic appendagitis (PEA) results from torsion and inflammation of an epiploic appendix, or less commonly following spontaneous venous thrombosis. While formerly thought to be relatively rare, recent literature suggests it is being underdiagnosed. Patients present with localised abdominal tenderness which may mimic the acute surgical emergencies of diverticulitis or appendicitis. Gastrointestinal symptoms are uncommon. The patient is typically apyrexial with a normal leucocyte count. Clinical diagnosis is difficult. Previously diagnosed at laparotomy for presumed diverticulitis or appendicitis, and treated by ligation and excision of the appendage, it may now be diagnosed reliably on characteristic CT findings. PEA should be considered in the differential diagnosis of acute abdominal pain, particularly in young patients presenting with atypical features.

Diverticulitis causing a high serum level of carbohydrate antigen 19-9: report of a case.

We report herein a rare case of diverticulitis causing a high serum level of carbohydrate antigen (CA) 19-9. A 52-year-old man was admitted to our hospital with lower abdominal pain. Laboratory data showed evidence of inflammation and a high serum level of CA 19-9 (370 U/ml). Computed tomography demonstrated thickening of the wall of the sigmoid colon. He was diagnosed as having diverticulitis of the sigmoid colon and was treated with antibiotics. Although his symptoms improved, the presence of a malignancy such as colorectal cancer could not be completely ruled out because of the persistently high serum level of CA 19-9. A laparotomy was performed and the sigmoid colon was found to be adherent to the bladder. Under a diagnosis of diverticulitis, a sigmoidectomy was performed. Pathological examination revealed diverticulitis of the sigmoid colon, but there was no evidence of malignancy in the resected specimen. The serum CA 19-9 level decreased to normal postoperatively and immunohistochemical staining revealed CA 19-9 antigen in the cytoplasm of the diverticular epithelium. Therefore, a possible explanation for the high level of this tumor marker was diverticulitis of the sigmoid colon.

Diverticulitis in the Young Patient

Although predominantly a disease in older adults diverticulitis does affect younger patients. The disease has been described as not only rare but virulent by some authors, and a young patient age is considered to be a relative indication for early sugery. The goal of this study was to evaluate the experience of the Louisiana State University Health Sciences Center-Shreveport and affiliated hospitals with diverticulitis in young patients. This study was a retrospective chart review of 22 patients with diverticulitis age 40 years and younger over the past 20 years. Inclusion criteria were either a diagnosis of diverticulitis confirmed at surgery or positive CT findings and/or a positive contrast enema. The mean age in this study was 32.1 years (range 16-40). All 22 patients presented with abdominal pain. The next most common symptom was nausea and/or vomiting in 45 per cent followed by fever and chills in 36 per cent. Twelve patients had abdominal CTs on admission, and 87 per cent had positive findings. Eighteen patients underwent an operation. Four patients were treated nonoperatively. Nineteen patients had diverticulitis of the sigmoid colon. The remaining three had right-sided diverticulitis. Two patients underwent right hemicolectomy, and one underwent cecectomy. Of the 15 patients with sigmoid diverticulitis 12 (80%) underwent a two-stage procedure of sigmoid colectomy, end colostomy, and Hartmann's pouch. Three patients (20%) underwent a one-stage procedure of sigmoid colectomy and primary anastomosis. Two of three patients undergoing a one-stage procedure required reoperation. Postoperative complications occurred in 10 of 18 patients for an overall incidence of 56 per cent. Two of these patients had septic complications. Both of these patients had a delay in time from admission until operation: one for 7 days and the other for 10 days. There was one death in the series. Colostomy closure was performed successfully in nine of 12 (75%) patients. The mean time interval before closure was 7.7 months, (range 3-14). Patients with two-stage procedures on initial admission fared better than those with one-stage procedures. The overall mortality was 4.5 per cent. There was a high overall complication rate of 56 per cent in patients undergoing an operation. Two patients who had a delay in time from admission to operation had septic complications. Early surgical intervention should be considered in this clinical setting. In summary, although rare, diverticulitis in the young patient is often a fulminant illness requiring operation early in the disease process.

Sonographic features of acute colonic diverticulitis: the "dome sign".

This study was performed to clarify the sonographic features of acute colonic diverticulitis to enable its differentiation from appendicitis. Of 119 patients who were referred to our hospitals for lower abdominal pain between June 1997 and December 1998 and underwent sonography, 12 patients had a definitive diagnosis of acute colonic diverticulitis and 4 patients a tentative diagnosis. Seventy-eight patients were diagnosed as having acute appendicitis, confirmed by appendectomy. In the 16 patients with diagnoses of diverticulitis, the sonographic and clinical features of acute colonic diverticulitis were studied. Among the 12 patients with definitive diagnoses of acute colonic diverticulitis, sonographic findings included localized thickening of the colonic wall (100%) and a hemispheric mass (the "dome sign") protruding at the thickened colonic wall (100%) and consisting of a hypoechoic wall (100%) and a central echogenic area (66%). The presence of diverticula was confirmed by barium-enema x-ray study in all 12 patients. The 4 patients with tentative diagnoses of acute colonic diverticulitis all had colonic wall thickening but no dome sign. Colonoscopy revealed colitis in 3 of these patients. All 16 patients recovered with conservative treatment, without laparotomy. Sonography was useful for differentiating acute colonic diverticulitis from appendicitis. The sonographic finding of the dome sign seems to be specific for acute colonic diverticulitis.

CT of diverticulitis and alternative conditions

The clinical diagnosis of diverticulitis is often uncertain and frequently incorrect. Diagnostic imaging such as with helical CT offers a rapid and accurate diagnosis of diverticulitis and its complications as well as alternative conditions. In particular, helical CT combined with contrast material administered through the colon is highly accurate and can be obtained quickly. CT signs of diverticulitis include focal inflammatory wall thickening and paracolic inflammation superimposed on diverticular disease (diverticula, muscular wall hypertrophy). Common alternative conditions that can clinically mimic diverticulitis include small bowel obstruction, primary epiploic appendagitis, acute cholecystitis, appendicitis, ileitis, ovarian cystic disease, and ureteral stone disease. Early and frequent use of diverticular CT promises to improve diagnosis and treatment of patients with clinically suspected diverticulitis.