Diverticulitis is one of the presentations of diverticular disease and is most often a complication of colonic diverticulosis. Differentiating one from the other is critical since uncomplicated diverticulosis is mostly asymptomatic and acute diverticulitis is a potentially life-threatening illness.
On imaging, non-complicated diverticulitis is characterized by a focal fat stranding adjacent to a colonic diverticulum, usually the sigmoid. A small amount of extraluminal fluid and gas locules may be present.
Diverticulitis is a complication of diverticulosis, and the demographics of the condition are therefore similar, with elderly patients being most at risk. Of those with diverticulosis, 4% will go on to develop diverticulitis 7.
Symptoms of diverticulitis usually begin in the left iliac fossa with unremitting pain and accompanying tenderness. The pain is accompanied by a fever, leukocytosis and change in bowel movements 8. An ill-defined mass may also be palpable representing the inflammatory phlegmon. Clinical evaluation alone may be insufficient in the initial diagnosis of divertivulitis and radiological evidence of inflammation is necessary for definitive diagnosis 8.
As the disease progresses and becomes more generalized (stage III and IV - see Hinchey classification of acute diverticulitis), signs and symptoms also become widespread and indistinguishable from other causes of generalized peritonitis.
Diverticular development is thought to involve colonic wall abnormality, increased intraluminal pressure and lack of dietary fiber 8. The sigmoid colon has the highest intraluminal pressure and the narrowest caliber, it is therefore the most common site of diverticula formation 8. Diverticulitis is the result of obstruction of the neck of the diverticulum, with subsequent inflammation, perforation, and infection 2. Early changes of local inflammatory phlegmon may later progress to abscess formation and generalized peritonitis.
Although CT is the modality of choice for the diagnosis and staging of diverticulitis with a sensitivity of 94% and specificity of 99%, a dedicated ultrasound study may be able to confidently characterize this condition 8.
- diverticula are characterized as bright bowel outpouching (also referred as bowel bright “ears”) showing some degree of acoustic shadowing due to the presence of gas or inspissated feces 4
- echogenic and non-compressible fat suggesting an inflammatory process of the surrounding fat planes 4
- thickened bowel wall (>4 mm) 4
- presence of organized collections imply abscess and thus complicated diverticulitis, which requires further CT assessment
- pericolic stranding, often disproportionately prominent compared to amount of bowel wall thickening 2,3
- segmental thickening of bowel wall
- enhancement of colonic wall
- usually has inner and outer high-attenuation layers, with a thick middle layer of low attenuation
- diverticular perforation
- extravasation of gas and fluid into pelvis and peritoneal cavity
- abscess formation (seen in up to 30% of cases)
- may contain fluid, gas or both
- fistula formation (usually a chronic complication)
- gas in the bladder
- direct visualization of a fistulous tract
Treatment and prognosis
Treatment depends on a host of factors, especially patient co-morbidities and stage of the disease.
For localized disease (stage I and II) conservative management with IV antibiotics and rehydration usually suffices. If the first attack of diverticulitis is treated successfully without surgery, most patients do not go on to have further episodes (66-75%). But some have multiple repeated attacks and go on to require surgery 1.
If the abscess is large, then percutaneous drainage under CT or US may be beneficial (successful in 70-90% of cases) 1.
Recognized complications include 1-5:
- abscess formation
- fistula formation
- small bowel obstructions from adhesions or bowel wall edema
- perforation resulting in pneumoperitoneum, peritonitis and sepsis
Surgery is the treatment of choice in patients:
- who progress to stage III or IV
- who fail medical management
- in whom carcinoma cannot be excluded
- who have multiple (2 or more) attacks
- who develop fistulas
Surgical options depend on whether surgery is elective or emergent and on the quality of bowel preparation. For elective surgery, the aim is to perform a single-stage segmental colectomy (usually sigmoid colectomy) with a primary end to end anastomosis. In emergent cases, either on-table lavage with primary anastomosis or a two-stage procedure is performed. The two-stage procedure consists of a Hartmann colectomy with end colostomy and rectal stump closure, which is subsequently closed by a second operation. This carries a mortality of less than 5% 1.
General imaging differential considerations include:
- less inflammatory change
- usually shorter segment
acute appendicitis (for right-sided disease)
- younger patients
- no predilection for Asian patients
- epiploic appendagitis
- ischemic colitis
- bowel wall thickening more pronounced than the amount of stranding 3
inflammatory bowel disease
- bowel wall thickening more pronounced than the amount of stranding 3
- tuboovarian abscess 6
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- 3. Pereira JM, Sirlin CB, Pinto PS et-al. Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain. Radiographics. 24 (3): 703-15. doi:10.1148/rg.243035084 - Pubmed citation
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- 5, Mehmet Ruhi Onur, Erhan Akpinar, Ali Devrim Karaosmanoglu, Cavid Isayev, Musturay Karcaaltincaba. Diverticulitis: a comprehensive review with usual and unusual complications. (2017) Insights into Imaging. 8 (1): 19. doi:10.1007/s13244-016-0532-3 - Pubmed \
- 6. JA Naliboff, SJ Longmire-Cook. Diverticulitis mimicking a tuboovarian abscess. Report of a case in a young woman. (1996) The Journal of reproductive medicine. 41 (12): 921. Pubmed
- 7. Shahedi K, Fuller G, Bolus R, Cohen E, Vu M, Shah R, Agarwal N, Kaneshiro M, Atia M, Sheen V, Kurzbard N, van Oijen MG, Yen L, Hodgkins P, Erder MH, Spiegel B. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. (2013) Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 11 (12): 1609-13. doi:10.1016/j.cgh.2013.06.020 - Pubmed
- 8. You, Hayley, Sweeny, Amy, Cooper, Michelle L, Von Papen, Michael, Innes, James. The management of diverticulitis: a review of the guidelines. (2019) The Medical Journal of Australia. 211 (9): n/a. doi:10.5694/mja2.50276