We reviewed the radiology department records of our hospital for imaging studies of patients with a final diagnosis of right colon diverticulitis obtaining a list of six patients from 2005 to 2012,
all with definite diagnosis obtained by surgery,
follow-up imaging (CT,
barium enema),
clinical follow-up or colonoscopy.
In all patients an emergency CT study was performed,
additionally,
an abdominal ultrasound was also performed as the initial study in four of them.
Technical parameters of the acquired studies:
- 4 of the CT studies were obtained using a 64 slice CT scanner,
1 in a 128 slice CT scanner and the remaining in a 16 slice CT equipment.
- Acquisition in a venous (60 to 80 seconds) and/or delayed (180 seconds) phase.
Total administered contrast: 100 - 150 ml of with a concentration of 300 mg / mL.
- Non contrast study in 2 patients.
CLINICAL SPECTRUM
Of the total patients,
4 were women and 2 men,
aged 29 to 53 years (mean 40.8 years).
All patients presented to the emergency department with acute abdominal pain lasting between 12 hours and 5 days,
5 of them focusing the pain in the right lower quadrant.
None of the patients had fever,
being the rest of the vital signs within normal range.
Table 1 depicts the clinical parameters and blood work of all the patients.
- The average leukocyte count was 12,766 per mL,
with a range between 8200 per mL and 16,700 per mL,
with values within the normal range in 33.3% patients.
- The CRP was elevated in 83.3% of patients,
with a range between 3.46 and 15.4 mg/dL.
IMAGING FINDINGS. Table 2
1.
The inflammatory changes: Mild to moderate inflammatory changes in
the pericolonic fat in all patients (Fig.
1,
2).
2.
The diverticula: Visualized in all studies,
being located between the
ileocecal valve and the hepatic flexure of the colon.
3.
The diverticular content: As reported in previous studies,
the
diverticula contained high-density material in most patients (83.3%)
[5].
4.
The location: The right colon was the only location of diverticular
disease in 4 out of 6 patients.
- Of the remaining two patients,
one had additional diverticular disease in the sigmoid colon and the other to the fullest extent of the colon (Fig.
3),
which may mean that some of the right colon diverticula are acquired and not congenital as has been described in the literature. [6,7]
5.
The Size: The average size of the diverticulum was 18.5 mm with a
range between 12 and 27 mm,
similar to that reported in other
series. [8]
6.
The appendix: An appendix of normal characteristics was identified in
3 of the 6 patients.
(Fig.
4)
- In a fourth patient,
a man aged 43,
the inflamed diverticulum was erroneously assessed as an acutely inflamed appendix in the emergency CT report undergoing surgery without complications,
identifying a non-inflamed appendix and a unique right colon diverticulum displaying inflammatory changes. Retrospectively,
the emergency CT study was assessed by radiologists experienced in abdominal imaging,
confirming the findings that suggested the right colonic diverticulitis as the most likely diagnosis. (Fig.
5)
In one of the patients,
an exploratory laparoscopy was performed with the clinical diagnosis of acute abdomen prior to any imaging studies.
Intraoperative findings reported an “inflammatory plastron with some fibrin remainings in the transverse colon at the duodenal level.
Normal cecal appendix,
gallbladder and ovaries".
In the post surgically acquired TC study,
the diverticulum located in the hepatic flexure of the colon with hyperdense content and inflammatory changes in the adjacent fat was clearly visualized (Fig.
6).
The appendix was not identified.
Based on the CT studies,
right colonic diverticulitis was correctly diagnosed initially in 83.3% of patients.
Retrospectively,
all patients presented with suspicious findings of RCD on CT.
PATIENT OUTCOME
Both the patients who received initial conservative -4- as well as surgically intervened patients -2- had a satisfactory outcome with a hospital stay no longer than 6 days.
The final diagnosis of right colon diverticulitis was obtained by:
- Intraoperative findings in 1 patient (patient operated with the diagnosis of acute appendicitis).
- Additional follow-up studies in 4 patients: barium enema (Fig.
7) and colonoscopy in 2 and only colonoscopy in the fifth patient.
- Clinical follow up and initian emergency CT scan only in one of the patients.