Skip to content

Advertisement

The Ultrasound Journal
The Ultrasound Journal Cover Image

Volume 5 Supplement 1

Topics in emergency abdominal ultrasonography

  • Research
  • Open Access

Sigmoid diverticulitis: US findings

  • †1Email author,
  • †1,
  • †1,
  • †2,
  • †3,
  • †4,
  • †5 and
  • †1
†Contributed equally
Critical Ultrasound Journal20135 (Suppl 1) :S5

https://doi.org/10.1186/2036-7902-5-S1-S5

©  Mazzei et al; licensee BioMed Central Ltd. 2013

  • Published:

Abstract

Acute diverticulitis (AD) results from inflammation of a colonic diverticulum. It is the most common cause of acute left lower-quadrant pain in adults and represents a common reason for acute hospitalization, as it affects over half of the population over 65 years with a prevalence that increases with age. Although 85% of colonic diverticulitis will recover with a nonoperative treatment, some patients may have complications such as abscesses, fistulas, obstruction, and /or perforation at presentation. For these reasons, different classifications were introduced through times to help clinicians to develop a correct diagnosis and guide the treatment and for the same reasons imaging is used in most cases both to realise a differential diagnosis and to guide the therapeutic management. US and CT are both usefull in diagnosis of diverticolitis, and their sensibility and specificity are similar. However CT scanning is essential for investigating complicated diverticular disease especially where there are diffuse signs and clinical suspicion of secondary peritonitis; instead in most uncomplicated cases the experienced sonographer may quickly confirm a diagnosis guided by the clinical signs. US is to be recommended in premenopausal women, and in young people to reduce dose exposure.

Keywords

  • Diverticulitis
  • Bowel Wall
  • Diverticular Disease
  • Compute Tomography Colonography
  • Muscularis Propria

Background

Acute diverticulitis (AD) results from inflammation of a colonic diverticulum. It is the most common cause of acute left lower-quadrant pain in adults and represents a common reason for acute hospitalization, as it affects over half of the population over 65 years with a prevalence that increases with age [1, 2]. Although 85% of colonic diverticulitis will recover with a non operative treatment, some patients may have complications such as abscesses, fistulas, obstruction, and /or perforation at presentation [3] . Moreover clinical differentiation from other causes of abdominopelvic pain is often difficult (Table 1), so imaging is used in most cases both to realise a differential diagnosis and to guide the therapeutic management [4]. Hollerweger A et al realised an alternative diagnosis in 47 out of 175 patients clinically suspected of having diverticulitis, with a relatively high frequency of epiploic appendagitis (8 out of 47 patients), ureterolitihasis (6 out of 47 patients), urinary tract infection and pelvic inflammatory disease (4 out of 47 patients), and other bowel pathologies, as ischemic colitis, infectious enterocolitis and perforated carcinoma (3 out of 47 patients) [5]. Currently, Multidetector Computed tomography (MDCT) of the abdomen is often the diagnostic test of choice, especially in the urgent assessment of patients with AD, with sensitivity, specificity, and positive and negative predictive values all well greater than 95%, allowing the identification of both colonic abnormalities (particularly mural thickening and diverticula) and inflammatory changes in the pericolonic fat planes, grading its severity, and identifying most usual complications [6–8]. The usual MDCT features include segmental wall thickening with spasm, submucosal oedema, diverticula, vascular engorgement, and inflammatory changes in the pericolic fat, plus fascial, mesenteric, and/or peritoneal fluid [6]. Conventional contrast-enhanced MDCT is also highly reliable in excluding an underlying carcinoma [9, 10]. Some Authors claims that CT sensitivity is higher than that of ultrasound (US) in detecting diverticulitis (81% versus 61%, p = 0.048) in unselected patients presenting with acute abdominal pain, but the positive predictive values are comparable, whereas in presence of clinical suspicion of diverticulitis the sensitivity of US reaches the 92% [11–15]. In particular US is highly sensitive and specific for uncomplicated acute diverticulitis and for the primary complication of pericolic abscess [16–18]. In this review, we discuss the US findings of diverticulitis and the role of US in it’s diagnostic management.
Table 1

Possible alternative diagnosis of Left Lower-Quadrant Pain.

Gastrointestinal

Genitourinary/gynecologic

Vascular/Other

Epiploic appendagitis

Ureterolithiasis

Dissection/ruptured aneurysm

Ischemic colitis

Urinary tract infection

Abdominal wall abscess

Infectious enterocolitis

Ectopic pregnancy

Abdominal wall hematoma

Perforated carcinoma

Hemorrhagic or rupture ovarian cyst

Psoas abscess

Small bowel obstruction

Ovarian torsion

Retroperitoneal hemorrhage

Inflammatory bowel disease

Ruptured corpus luteum

 

Appendicitis

Uterine fibroids torsion

 

Small bowel infarction

Pelvic Inflammatory disease

 

Omental infarction

  

Incarcerated hernia

  

Main body

Pathogenesis and classifications

Diverticulitis results from occlusion of a colonic diverticulum by stool, inflammation, or food particles, causing a microperforation and surrounding pericolic inflammation. A colonic diverticulum is a herniation of mucosa and submucosa, corresponding to a weak point where the vasa recti penetrate the tunica muscularis, so most colonic diverticula are “false diverticula” containing no muscularis propria. In 1965 Painter et al. presented the hypothesis that diverticular disease was caused by excess pressure in the colon due to segmentation based on insufficient intake of dietary fibre [19]. In the Western world diverticulosis occurs primarily in the sigmoid colon, corresponding to the highest intraluminal pressure, where they are often associated with other typical findings of diverticular disease (i.e. muscularis propria thickening, shortening and narrowing of the lumen). The incidence for diverticulosis is 33–66%, of these patients, 10–25% will develop an acute episode of diverticulitis [2]. Other risk factors are: obesity (BMI≥30), use of non-steroidal anti-inflammatory drugs or acetaminophen; smoking was not significantly associated with symptomatic diverticular disease, and a genetic predisposition was not proved yet [20]. Diverticula vary in size from tiny intramural and transient phenomena to permanent protrusions up to several centimeters in diameter. Retention of fecal matter within the diverticulum due to an occlusion may produce a mucosal abrasion resulting in infection or inflammation of the diverticulum wall (diverticulitis). The process may realise a focal intramural inflammatory mass or abscess, infiltrate along the bowel wall to produce an inflammatory bowel segment, and perforate into sigmoid mesentery where the process is usually contained. Therefore its presentation may vary greatly per individual patient, from symptomatic diverticulosis to perforated diverticulitis [21–23], even if the majority of individuals with diverticulosis are asymptomatic [24–26]. However, perforation can cause intraperitoneal contamination that is associated with a much higher morbidity and mortality. From 1978 until today different classifications were proposed for the staging of acute complicated diverticolitis; first Hinchey that proposed a classification in 4 stages, developed to predict outcomes following the surgical management of complicated diverticular disease (perforated disease) (stage I: mesocolic/pericolic abscess; stage II: pelvic abscess; stage III generalized peritonitis; stage IV faecal peritonitis) [27]. Then the much more detailed information provided by CT scans led earlier to modifications of the original Hinchey classification. Subcategories could be defined considering the radiological findings. In 1997 Sher et al introduced the first modification for distinguishing between pericolic abscesses (stage I), distant abscesses amendable for percutaneous drainage (stage IIa), and complex abscesses associated with a possible fistula (stage IIb). This modification also implied the use of new treatment strategies such as CT-guided percutaneous drainage of abscesses (Table 2) [28–30] . From these, several other classifications have been made (Wasvary et al. in 1999, Kohler et al in 1999, Siewert et al in 1995), among that deserve mention the Hansen/Stock classification and Kohler et al classification, both based on the clinical severity and presentation of disease (Table 3) [31, 32]. Finally in 2002 Ambrosetti et al. proposed a simplified staging of acute diverticulitis based on CT criteria and showed its prognostic significance in a prospective study: moderate diverticulitis defined by localized sigmoid wall thickening (<5mm) with pericolic fat stranding, and severe diverticulitis defined by wall thickening accompanied by abscess, extraluminal air or extraluminal contrast [33]. More recently Klarenbeek et al have proposed a new classification arranged in three stages of differentiating diverticula disease: a) uncomplicated, b) chronic complicated, and c) acute complicated, and according both clinical and radiological findings in addition to treatment modalities, in order to guide the clinical management and form the basis of a practice parameter for diverticular disease [16].
Table 2

Hinchey classification and modified Hinchey classification by Sher et al.

Hinchey classification

Modified Hinchey classification by Sher et al

I pericolic abscess or phlegmon

I pericolic abscess

II pelvic, intrabdominal or retroperitoneal abscess

IIa distant abscess amendable to percutaneous drainage

 

IIb Complex absess associated with fistula

III Generalized purulent peritonitis

III Generalized purulent peritonitis

IV Generalized fecal peritonitis

IV Fecal peritonitis

Table 3

Köhler and Hansen/Stock classification.

Köhler Classification

Hansen/Stock classification

Symptomatic uncomplicated disease

0 Diverticulosis

Recurrent symptomatic disease

I Acute uncomplicated diverticulitis

Complicated disease:

II Acute complicated diverticulitis

Hemorrhage, Abscess, Phlegmon

   a. Phlegmon, peridiverticulitis

Fistula, Perforation, Stricture

   b. Abscess, sealed perforation

Purulent and fecal peritonitis, Small bowel

   c. Free perforation

obstruction due to post-inflammatory adhesions

III Chronic recurrent diverticulitis

Clinical presentation and treatment

From a clinical point of view, comparing patients with non specific abdominal pain to those with diverticulitis, they are more likely to have a subacute onset of pain (>1 hr), tenderness to palpation only in the left lower quadrant, and raised inflammatory markers; and are less likely to have nausea and vomiting [34]. Other symptoms are: fever, absence of peristalsis, and defence muscularis. Diverticular bleeding and pneumaturia (pathognomic for a colovesical fistula) are rare.

The wide spectrum of diverticular disease requires a differentiated therapeutic approach to the different manifestations. Moderate cases of diverticular disease (phlegmon or small abscess) can be treated conservatively, generally with antibiotics and an easily digestible diet. Large abscesses, if amendable and usually larger than 5 cm, should be good candidates for CT-guided percutaneous drainage [35]. This procedure may relieve symptoms or function as a bridge to (elective) surgery. In cases of fecal peritonitis resulting from a perforation acute surgical intervention should be warranted because it is associated with high morbidity and mortality (10–35%) [36]. It is now thought that after a conservatively treated episode, diverticular disease usually follows a rather benign course and that complications occur mostly at first presentation [37, 38]. Therefore, elective sigmoid resections should be restricted for use in treating complicated disease, such as symptomatic stenosis, fistulas to a hollow organ, or recurrent diverticular bleeding [39].

Imaging

Imaging may not be necessary in patients with the classic triad of left lower-quadrant pain, fever, and leukocytosis, and in whom uncomplicated diverticulitis is suspected. Imaging also may not be necessary in patients with a history of diverticulitis who present with relatively mild clinical symptoms of recurrent disease. However, considering the wide spectrum of diverticular disease , also depending on the age of patients (clinical presentation may differ significantly in older patients where a reduction in symptom severity causing a misdiagnosis could be present), and the possibile difficult differential diagnosis from other causes of abdominopelvic pain, imaging often plays a definitive role both to realise a differential diagnosis and to guide the therapeutic management [1, 8, 40]. As reported above, today contrast-enhanced CT has a pivotal role in the clinical practice regarding diverticular disease, and because of their superior sensitivity and specificity up to 100%, replaced the most important imaging modality [40]. Especially when an associated abscess is suspected, a CT scan can be very helpful to demonstrate its presence, and also for evaluate the possibility of a percutaneous drainage [41]. In the case of diverticular bleeding, a contrast-enhanced CT examination may demonstrate a contrast blush; and even if it has to be considered that 80% of all diverticular bleeding is self-limiting, occasionally successes of highly selective arterial embolization are described. Although the role of interventional radiology is yet to be determined. Conventional contrast-enhanced MDCT is also highly reliable in excluding other diagnoses of acute abdomen and an underlying carcinoma (Figure 1) [14, 15, 42–44]. A colonoscopy is indicated when there is doubt about cancer, persisting or recurrent complaints in the left lower quadrant, and suspicion of a stenosis or recurrent blood loss. Follow-up colonoscopy for ruling out malignancy is usually performed 6 weeks after an episode of acute diverticulitis. Moreover the computed tomography colonography (CTC) seems to be a reasonable alternative in follow-up of patients with symptomatic diverticular disease [45]. In recent years, magnetic resonance imaging (MRI) has gained popularity, because it lacks the ionizing radiation and even if CT remains the modality of choice; however MRI can similarly demonstrate findings of diverticulitis and could be useful in diagnosis of ischemic colitis [46, 47]. Although, colonic diverticulitis is easily diagnosed and classified (graded) by CT than by ultrasound (US), it is important to be aware of the US signs of diverticulitis considering that US is often used as a first modality in the diagnostic approach to the acute abdomen.
Figure 1
Figure 1

Contrast-enhanced MDCT 2D reconstruction on axial –oblique (a) and coronal oblique (b) planes shows a neoplastic thickening of the colonic wall (sigmoid tract) in presence of diverticulitisis.

US: techinique and findings

US is an imaging modality widely available in the Emergency Department. The lower cost and in particular the lack of radiation exposure are the most important advantages of US compared to CT. Furthermore US is a real-time dynamic examination and this characteristic conveys dynamic information about bowel motility and changes in position, and to depict blood flow. Another important advantage of US examination is the possibility to correlate the US findings with the point of maximal tenderness. Besides, in not too obese patients, US may be superior to CT, and it is most useful in early, uncomplicated diverticulitis. From a technical point of view , both curved (3.5–5.0-MHz) and linear (5.0 –12.0-MHz) transducers are most commonly used, in particular the higher frequency probes are useful for detailed investigation of the large bowel wall, identifying its typical haustral pattern. Focal bowel masses, segments of wall thickening, and dilated loops may be evident even at lower frequencies, but high-frequency probes are essential to identify and chracterize changes in the layers of the bowel wall. At higher frequencies, US images the bowel wall as five alternating bands (gut signature) of high and low echogenicity to produce a characteristic sonographic signature approximating to the concentric layered histologic structure [48]. Visualization of the fine inner and outer bright layers (interface echoes) is highly dependent on the echogenicity of adjacent structures and is most easily seen where there is fluid in the bowel lumen or ascites between bowel loops. Even at lower diagnostic frequencies in loops further from the probe, at least the two most prominent layers are evident due to their relative thickness and high contrast: the bright submucosa (third layer) and the dark muscularis propria (fourth layer) [34]. Doppler scanning demonstrates no signal in normal bowel wall [49, 50].

A thinned diverticular wall may be demonstrated at higher probe frequencies with a reduced gut signature due to the absence of muscularis propria. Diverticula appear as bright “ears” out of the bowel wall with acoustic shadowing due to the presence of gas or inspissated feces; furthermore the neck of diverticulum may be identified as an echogenic band traversing hypoechoic muscularis propria that is often thickened. The diagnostic criteria for diverticulitis that has been used in US and CT are the same: 1) at least one diverticulum, 2) signs of inflammation of periodic fat (dirty fat/stranding) and 3) thickened bowel wall > 4-5 mm [33]. An isolated inflamed diverticulum is identified as an enlarged echo-poor protrusion from the colon wall, with an ill-defined margin surrounded by echogenic noncompressible fat, which represents the inflamed mesentery and omentum 'sealing off' the imminent perforation. The diverticulum wall signature is lost. A central shadowing echogenicity may indicate the presence of fecalith (Figure 2) [51]. Often the inflammation will have extended into the bowel producing asymmetrical or circumferential hypoechoic mural thickening that may demonstrate hyperemia on Doppler scanning. Diverticulitis may progress to an intramural or pericolic abscess indicated by an anechoic collection that may contain pockets of air or debris (Figure 3) [4]. Right-sided colonic diverticulitis in many respects differs from its left-sided cousin. Diverticula of the right colon are usually congenital, solitary, true diverticula containing all bowel wall layers. The fecoliths within these diverticula are larger and the diverticular neck is wider. There is no hypertrophy of the muscularis of the right colonic wall . Puylaert JB in a study of 110 patients with right colonic diverticulitis clearly show, through US and CT, that it invariably has a favorable course and never leads to free perforation or large abscesses. Although relatively rare (left:right = 15:1), it is crucial to make a correct diagnosis since the clinical symptoms of acute right lower quadrant pain may lead to an unnecessary appendectomy or even right hemicolectomy.
Figure 2
Figure 2

Sonographic features of uncomplicated diverticulitis: diverticula appear as bright “ear” out of the bowel wall (a); a central shadowing echogenicity may indicate the presence of fecalith (b).

Figure 3
Figure 3

Sonographic features of complicated diverticulitis: the images show the presence of diveticula, thickening of the bowel wall and pericolic fluid (a,b)

Conclusions

US and CT are both useful in diagnosis of diverticolitis, and their sensibility and specificity are similar. However, CT may be more likely to identify alternative causes of abdominal pain and it is essential for investigating complicated diverticular disease especially where there are diffuse signs and clinical suspicion of secondary peritonitis. [52] Instead in most uncomplicated cases the experienced sonographer may quickly confirm a diagnosis guided by the clinical signs. US is to be recommended in premenopausal women, and in young people to reduce dose exposure.

Notes

Declarations

Acknowledgements

We thank Ms Julia Hassall for reviewing the english and Dr. Palmino Sacco for helping in the preparation of the images.

Declarations

This article has been published as part of Critical Ultrasound Journal Volume 5 Supplement 1, 2013: Topics in emergency abdominal ultrasonography. The full contents of the supplement are available online at http://www.criticalultrasoundjournal.com/supplements/5/S1. Publication of this supplement has been funded by the University of Molise, University of Siena, University of Cagliari, University of Ferrara and University of Turin.

Authors’ Affiliations

(1)
Department of Medical, Surgical and Neuro Sciences, Section of Radiological Sciences, Siena, Italy
(2)
University of Bari, Diagnostic Imaging Section, Bari, Italy
(3)
University of Perugia, Thoracic Surgery Unit, Perugia, Italy
(4)
University of Foggia, Department of Radiology, Foggia, Italy
(5)
University of Ferrara, Dipartimento di Scienze Chirurgiche, Ferrara, Italy

References

  1. Hammond NA, Nikolaidis P, Miller FH: Left lower-quadrant pain: guidelines from the American College of Radiology appropriateness criteria. Am Fam Physician 2010, 82: 766–70. ReviewPubMedGoogle Scholar
  2. Jacobs DO: Clinical practice. Diverticulitis. N Engl J Med 2007, 357: 2057–66. Review 10.1056/NEJMcp073228View ArticlePubMedGoogle Scholar
  3. Laméris W, van Randen A, van Gulik TM, Busch OR, Winkelhagen J, Bossuyt PM, Stoker J, Boermeester MA: A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum 2010, 53: 896–904. 10.1007/DCR.0b013e3181d98d86View ArticlePubMedGoogle Scholar
  4. Reginelli A, Pezzullo MG, Scaglione M, Scialpi M, Brunese L, Grassi R: Gastrointestinal disorders in elderly patients. Radiol Clin North Am 2008, 46(4):755–71. 10.1016/j.rcl.2008.04.013View ArticlePubMedGoogle Scholar
  5. Hollerweger A, Macheiner P, Rettenbacher T, Brunner W, Gritzmann N: Colonic diverticulitis: diagnostic value and appearance of inflamed diverticula-sonographic evaluation. Eur Radiol 2001, 11: 1956–63. 10.1007/s003300100942View ArticlePubMedGoogle Scholar
  6. Cuccurullo V, Cioce F, Sica A, Iasiello F, Capasso R, Gatta G, Rubini G: Gastroenteric diseases in the third millennium: a rational approach to optimal imaging technique and patient selection. Recenti Prog Med 2012, 103(11):426–30.PubMedGoogle Scholar
  7. Tack D, Bohy P, Perlot I, De Maertelaer V, Alkeilani O, Sourtzis S, Gevenois PA: Suspected acute colon diverticulitis: imaging with low-dose unenhanced multi-detector row CT. Radiology 2005, 237: 189–96. 10.1148/radiol.2371041432View ArticlePubMedGoogle Scholar
  8. Horton KM, Corl FM, Fishman EK: CT evaluation of the colon: inflammatory disease. Radiographics 2000, 20: 399–418. 10.1148/radiographics.20.2.g00mc15399View ArticlePubMedGoogle Scholar
  9. Jang HJ, Lim HK, Lee SJ, Lee WJ, Kim EY, Kim SH: Acute diverticulitis of the cecum and ascending colon: the value of thin-section helical CT findings in excluding colonic carcinoma. Am J Roentgenol 2000, 174: 1397–402. 10.2214/ajr.174.5.1741397View ArticleGoogle Scholar
  10. Sai VF, Velayos F, Neuhaus J, Westphalen AC: Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review. Radiology 2012, 263: 383–90. Review. Erratum in: Radiology 2012, 264:306 10.1148/radiol.12111869PubMed CentralView ArticlePubMedGoogle Scholar
  11. Reginelli A, Mandato Y, Cavaliere C, Pizza NL, Russo A, Cappabianca S, Brunese L, Rotondo A, Grassi R: Three-dimensional anal endosonography in depicting anal-canal anatomy. Radiol Med 2012, 117(5):759–71. 10.1007/s11547-011-0768-4View ArticlePubMedGoogle Scholar
  12. Reginelli A, Mandato Y, Solazzo A, Berritto D, Iacobellis F, Grassi R: Erros in the rediological evaluation of the alimentary tract: part II. Semin Ultrasound CT MR 2012, 33(4):308–311. 10.1053/j.sult.2012.01.016View ArticlePubMedGoogle Scholar
  13. Angelelli G, Moschetta M, Sabato L, Morella M, Scardapane A, Stabile Ianora AA: Value of "protruding lips" sign in malignant bowel obstructions. Eur J Radiol 2011, 80(3):681–5. 10.1016/j.ejrad.2010.09.034View ArticlePubMedGoogle Scholar
  14. Russo M, Martinelli M, Sciorio E, Botta C, Miele E, Vallone G, Staiano A: Stool Consistency, but Not Frequency, Correlates with Total Gastrointestinal Transit Time in Children. J Pediatr 2013.Google Scholar
  15. Esposito F, Senese R, Salvatore P, Vallone G: Intrahepatic portal-vein gas associated with rotavirus infection. J Ultrasound 2011, 14(1):10–3. 10.1016/j.jus.2011.01.001PubMed CentralView ArticlePubMedGoogle Scholar
  16. van Randen A, Laméris W, van Es HW, van Heesewijk HP, van Ramshorst B, Ten Hove W, Bouma WH, van Leeuwen MS, van Keulen EM, Bossuyt PM, Stoker J, Boermeester MA: OPTIMA Study Group. A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain. Eur Radiol 2011, 21: 1535–45. 10.1007/s00330-011-2087-5PubMed CentralView ArticlePubMedGoogle Scholar
  17. Laméris W, van Randen A, Bipat S, Bossuyt PM, Boermeester MA, Stoker J: Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol 2008, 18: 2498–511. 10.1007/s00330-008-1018-6View ArticlePubMedGoogle Scholar
  18. Schwerk WB, Schwarz S, Rothmund M: Sonography in acute colonic diverticulitis. A prospective study. Dis Colon Rectum 1992, 35: 1077–84. 10.1007/BF02252999View ArticlePubMedGoogle Scholar
  19. Painter NS, Truelove SC, Ardran GM, Tuckey M: Segmentation and the localization of intraluminal pressures in the human colon, with special reference to the pathogenesis of colonic diverticula. Gastroenterology 1965, 49: 169–77.PubMedGoogle Scholar
  20. Andersen JC, Bundgaard L, Elbrønd H, Laurberg S, Walker LR, Støvring J: Danish Surgical Society. Danish national guidelines for treatment of diverticular disease. Dan Med J 2012, 59: C4453.PubMedGoogle Scholar
  21. Klarenbeek BR, de Korte N, van der Peet DL, Cuesta MA: Review of current classifications for diverticular disease and a translation into clinical practice. Int J Colorectal Dis 2012, 27: 207–14. Review 10.1007/s00384-011-1314-5PubMed CentralView ArticlePubMedGoogle Scholar
  22. Grassi R, Rambaldi PF, Di Grezia G, Mansi L, Cuccurullo V, Cirillo A, Riegler G, Cappabianca S, Rotondo A: Inflammatory bowel disease: value in diagnosis and management of MDCT-enteroclysis and 99mTc-HMPAO labeled leukocyte scintigraphy. Abdom Imaging 2011, 36(4):372–81. 10.1007/s00261-010-9652-2View ArticlePubMedGoogle Scholar
  23. Lorusso F, Fonio P, Scardapane A, Giganti M, Rubini G, Ferrante A, Stabile Ianora AA: Gatrointestinal imaging with multidetector CT and MRI. Recenti Prog Med 2012, 103(11):493–9.PubMedGoogle Scholar
  24. Niccoli Asabella A, Renna MA, Stabile Ianora AA, Rubini D, Rubini G: Role of imaging techniques in the evaluation of chyluria. Recenti Prog Med 2012, 103(11):555–8.PubMedGoogle Scholar
  25. Stabile Ianora AA, Moschetta M, Pedote P, Scardapane A, Angelelli G: Preoperative local staging of colosigmoideal cancer: air versus water multidetector-row CT colonography. Radiol Med 2012, 117(2):254–67. 10.1007/s11547-011-0782-6View ArticlePubMedGoogle Scholar
  26. Ambrosetti P, Gervaz P, Fossung-Wiblishauser A: Sigmoid diverticulitis in 2011: many questions; few answers. Colorectal Dis 2012, 14: e439–46. Review 10.1111/j.1463-1318.2012.03026.xView ArticlePubMedGoogle Scholar
  27. Sher ME, Agachan F, Bortul M, Nogueras JJ, Weiss EG, Wexner SD: Laparoscopic surgery for diverticulitis. Surg Endosc 1997, 11: 264–7. 10.1007/s004649900340View ArticlePubMedGoogle Scholar
  28. Hughes ES, Cuthbertson AM, Carden AB: The surgical management of acute diverticulitis. Med J Aust 1963, 50: 780–2.PubMedGoogle Scholar
  29. Wasvary H, Turfah F, Kadro O, Beauregard W: Same hospitalization resection for acute diverticulitis. Am Surg 1999, 65: 632–5. discussion 636PubMedGoogle Scholar
  30. Köhler L, Sauerland S, Neugebauer E: Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999, 13: 430–6. Review 10.1007/s004649901007View ArticlePubMedGoogle Scholar
  31. Hansen O, Graupe F, Stock W: Prognostic factors in perforating diverticulitis of the large intestine. Chirurg 1998, 69: 443–9. German 10.1007/s001040050436View ArticlePubMedGoogle Scholar
  32. Siewert JR, Huber FT, Brune IB: Early elective surgery of acute diverticulitis of the colon. Chirurg 1995, 66: 1182–9. Review. GermanPubMedGoogle Scholar
  33. Ambrosetti P, Jenny A, Becker C, Terrier TF, Morel P: Acute left colonic diverticulitis--compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients. Dis Colon Rectum 2000, 43: 1363–7. 10.1007/BF02236631View ArticlePubMedGoogle Scholar
  34. Rodgers PM, Verma R: Transabdominal ultrasound for bowel evaluation. Radiol Clin North Am 2013, 51: 133–48. Review 10.1016/j.rcl.2012.09.008View ArticlePubMedGoogle Scholar
  35. Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F: Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 2005, 48: 787–91. 10.1007/s10350-004-0853-zView ArticlePubMedGoogle Scholar
  36. Oomen JL, Engel AF, Cuesta MA: Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors. Colorectal Dis 2006, 8: 112–9. 10.1111/j.1463-1318.2005.00848.xView ArticlePubMedGoogle Scholar
  37. Salem TA, Molloy RG, O'Dwyer PJ: Prospective, five-year follow-up study of patients with symptomatic uncomplicated diverticular disease. Dis Colon Rectum 2007, 50: 1460–4. 10.1007/s10350-007-0226-5View ArticlePubMedGoogle Scholar
  38. Collins D, Winter DC: Elective resection for diverticular disease: an evidence-based review. World J Surg 2008, 32: 2429–33. Review 10.1007/s00268-008-9705-7View ArticlePubMedGoogle Scholar
  39. Ambrosetti P: Acute diverticulitis of the left colon: value of the initial CT and timing of elective colectomy. J Gastrointest Surg 2008, 12: 1318–20. Review 10.1007/s11605-008-0489-8View ArticlePubMedGoogle Scholar
  40. Le Pennec V, Hourna E, Schmutz G, Pelage JP: Imaging in infections of the left iliac fossa. Diagn Interv Imaging 2012, 93: 466–72. Review 10.1016/j.diii.2012.03.006View ArticlePubMedGoogle Scholar
  41. Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA: Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum 2006, 49: 1533–8. 10.1007/s10350-006-0613-3View ArticlePubMedGoogle Scholar
  42. Mazzei MA, Guerrini S, Cioffi Squitieri N, Imbriaco G, Mazzei FG, Volterrani L: Non-obstructive mesenteric ischemia after Cardiovascular Surgery: not so uncommon. Ann Thorac Cardiovsc Surg, in press.Google Scholar
  43. Mazzei MA, Guerrini S, Cioffi Squitieri N, Genovese EA, Mazzei FG, Volterrani L: Diagnosis of acute mesenteric ischemia/infarction in the era of multislice CT. Recenti Prog Med 2012, 103: 435–7.PubMedGoogle Scholar
  44. Mazzei MA, Mazzei FG, Marrelli D, Imbriaco G, Guerrini S, Vindigni C, Civitelli S, Roviello F, Grassi R, Volterrani L: Computed tomographic evaluation of mesentery: diagnostic value in acute mesenteric ischemia. J Comput Assist Tomogr 2012, 36: 1–7. 10.1097/RCT.0b013e31823b4465View ArticlePubMedGoogle Scholar
  45. Hjern F, Jonas E, Holmström B, Josephson T, Mellgren A, Johansson C: CT colonography versus colonoscopy in the follow-up of patients after diverticulitis a prospective, comparative study. Clin Radiol 2007, 62: 645–50. 10.1016/j.crad.2007.01.019View ArticlePubMedGoogle Scholar
  46. Hammond NA, Miller FH, Yaghmai V, Grundhoefer D, Nikolaidis P: MR imaging of acute bowel pathology: a pictorial review. Emerg Radiol 2008, 15: 99–104. Review 10.1007/s10140-007-0686-xView ArticlePubMedGoogle Scholar
  47. Mazzei MA, Guerrini S, Cioffi Squitieri N, Imbriaco G, Chieca R, Civitelli S, Savelli V, Mazzei FG, Volterrani L: MRI: is there a role in clinical management for acute ischemic colitis? World J Gastroenterol 2013, 19: 1256–63. 10.3748/wjg.v19.i8.1256PubMed CentralView ArticlePubMedGoogle Scholar
  48. Kimmey MB, Martin RW, Haggitt RC, Wang KY, Franklin DW, Silverstein FE: Histologic correlates of gastrointestinal ultrasound images. Gastroenterology 1989, 96: 433–41.PubMedGoogle Scholar
  49. Esteban JM, Maldonado L, Sanchiz V, Minguez M, Benages A: Activity of Crohn's disease assessed by colour Doppler ultrasound analysis of the affected loops. Eur Radiol 2001, 1: 1423–8.View ArticleGoogle Scholar
  50. Wilson SR, Toi A: The value of sonography in the diagnosis of acute diverticulitis of the colon. Am J Roentgenol 1990, 154: 1199–202. 10.2214/ajr.154.6.2110728View ArticleGoogle Scholar
  51. Puylaert JB: Ultrasound of colon diverticulitis. Dig Dis 2012, 30: 56–9. Review 10.1159/000336620View ArticlePubMedGoogle Scholar
  52. Marrelli D, Mazzei MA, Pedrazzani C, Di Martino M, Vindigni C, Corso G, Marrelli E, Volterrani L, Roviello F: High accuracy of multislices computed tomography (MSCT) for para-aortic lymph node metastases from gastric cancer: a prospective single-center study. Ann Surg Oncol 2011, 18: 2265–2272. Epub 2011 Jan 26 10.1245/s10434-010-1541-yView ArticlePubMedGoogle Scholar

Copyright

© Mazzei et al; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement