Value of CT for Acute Left-Colonic Diverticulitis: The Surgeon’s View

Abstract

Aim: To determine the immediate and later role(s) of initial CT in patients presenting with their first episode of acute left-colonic diverticulitis. Methods: Prospective inclusion of 542 patients hospitalized in the University Hospital of Geneva between 1986 and 1997. 465 (86%) patients had a CT. CT grading of diverticulitis was divided between moderate diverticulitis (no sign of colonic perforation) and severe diverticulitis (signs of colonic perforation). Results: During the index hospitalization, surgical treatment of the first episode of acute diverticulitis was needed in 26% of patients with CT-severe diverticulitis compared to 4% for patients with CT-moderate diverticulitis. At 5 years of follow-up after medical treatment of the first episode, incidence of remote complications was the highest (49%) for patients with CT-severe diverticulitis and the lowest (22%) for patients with CT-moderate diverticulitis. Finally, we found that the location of the diseased segment, which is important to guide the type of resection in case of elective surgery, varies in 35% of patients who had 2 episodes of acute diverticulitis. Conclusion: CT is the indispensable tool both to confirm the suspected diagnosis of acute diverticulitis and to appreciate the risk of surgical treatment during the initial acute episode. Moreover, CT grading of diverticulitis is a statistically significant prognostic parameter of the chance of secondary complicated outcome after a first acute diverticulitis episode successfully treated medically. Finally, CT gives the exact location of diverticulitis. In case of elective surgery this colonic segment should be removed.

Minimally invasive and surgical management strategies tailored to the severity of acute diverticulitis

“…The diagnostic modality of choice is CT as it has a high sensitivity and specificity for diverticulitis, and can accurately stage disease to guide management. The reported sensitivity and specificity for CT in diagnosing diverticulitis are 91 and 77 per cent respectively.…”

“…Based on computed tomography (CT) criteria, diverticulitis can be classified as mild (uncomplicated; for example sigmoid thickening, pericolonic fat stranding on CT) ( Fig . ) or moderate severe (complicated; sigmoid thickening and abscess, free air or contrast extravasation on CT) ( Figs and ).…”

Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?

“…A CT scan is the tool that best directs treatment during the initial acute episode of diverticulitis and is less subject to operator interpretation than an ultrasound. 17 Early diagnosis guides prompt therapy and is the most important variable at disease onset, particularly for IS patients.…”

Diagnostik und Klassifikation der Divertikelkrankheit

“…Für die Sensitivität der Kolonkontrastverfahren werden Werte von 71-94% und für die Spezifität von 61-72% angegeben [48]. Viele Autoren sehen daher die Kolonkontrastdarstellung als eine insbesondere durch die CT überholte und nur noch in Reservesituationen indizierte diagnostische Modalität an [16,29,51] [53] verspricht hier eine Verbesserung durch den Einsatz der CT-Perfusionsbildgebung. Insgesamt wird für die CT eine Sensitivität von 90-95% und eine Spezifität von 72% berichtet; die Rate falsch-negativer Befunde liegt bei 7-21% [29].…”

“…Ambrosetti [51,54] schlägt aufgrund der in der CT zu erhebenden Befunde eine Einteilung in eine moderate und eine Tursi [65] votiert in einem «Letter to the editor» aus drei Gründen für die Beibehaltung der Koloskopie nach Divertikulitis: (i) Ausschluss anderer Diagnosen; (ii) Charakterisierung der Divertikulose bezüglich Lokalisation und Konfiguration der Divertikel wegen möglicher Konsequenzen für das therapeutische (insbesondere chirurgische) Vorgehen; (iii) Erfassung des entzündlichen Status der Divertikel wegen möglicher therapeutischer Konsequenzen im Sinne einer Rezidivprophylaxe. Bezüglich des Zeitpunkts der Koloskopie spricht sich Tursi [65] im Fall der AUD, aber nicht der ACD für eine frühe Untersuchung 7-10 Tage nach adäquater Therapie aus.…”