Tai Van Le M.D
Nhan Vo Nguyen Thanh M.D
Hai Thanh Phan M.D
Medic Medical Center, HCM City, Vietnam
INTRODUCTION
Acute abdominal pain with rebound tenderness, particularly in cases of right-sided abdominal pain which are usually underwent surgery because of almost cases of acute appendicitis. However, acute colonic uncomplicated diverticulitis (ACUD), primary epiploic appendagitis, right-sided segmental infarction of omentum could be conservative treatment unnecessary operation. What role of ultrasound has in the diagnosis? Consequently, how to approach acute colonic uncomplicated diverticulitis that has been considered.
OBJECTIVE
The purpose of this study is to describe the sonographic appearance of acute colonic uncomplicated diverticulitis (ACUD), clinical evolution in correlation with conservative therapy. How to improve the accuracy of diagnosis of ACUD. Role of the sonographic appearance of normal colon (haustra pattern appearances) in detecting diverticulitis.
MATERIALS & METHODS
From December 2007 to January 2008, prospectively, 22 cases were suspected acute colonic uncomplicated diverticulitis with ultrasound, 17 male and 5 female, age: 22 – 70 year-old, (mean age 44 year-old), 19 cases of right abdominal pain, 3 cases of left abdominal pain, almost cases with rebound tenderness. All patients were performed with graded compression of Puylaret (1), 12 cases combining with CT.
Ultrasound scans of total colon thanks to normal colon which have haustra pattern appearaces. In practically, the wall of colon containing diverticulitis which became thickening due to reactive inflammation and to lose haustra pattern appearances. However, it could to recognize if there was the continuity with normal colon which has haustra pattern appearances. Thickening of fatty tissue surrounding colon is the important sign that suggests there are inflammation adjacent to colon.
The steps should to do for discover of ACUD (Figure 2): Firstly, to survey total colon to look for segmental colon with wall thickening, then to discover whether there is thickening of fatty tissue adjacent to it, after that detecting ACUM inside fatty tissue. ACUD is small hyperechoic lesion in or adjacent to colonic wall with or without shadowing, or hypoechoic lesion which could to open into colonic lumen. Characteristic ultrasound finding is similar to the appearance of thyroid glands with transverse section so-called “thyroid in the abdomen” appearance (2).
Aloka SSD Prosound 4000, convex probe with frequency 3.8 MHz, and MSCT of Toshiba were used.
RESULTS
Among twenty-two cases were suspected of ACUD, a case with post-operated diagnosis was acute appendicitis, twenty-one cases were true of ACUD (95%) in which ten cases of the cecum (47%) (Figure 3, 6), seven cases of ascending colon (33%) (Figure 2, 4), a case of transverse colon (5%), two cases of descending colon (10%) (Figure 5), a case of sigmoid colon (5%). There was a case of diverticulitis of the cecum with position of the cecum above umbilical level (Figure 6).
Ultrasound revealed a part of colon with thick wall and inflammation of pericolonic fatty tissue in which there was small hyperechoic lesion with or without shadowing that had findings similar to “thyroid in the abdomen” appearance, noncompressible and tenderness, 6 – 15 cm in diameter, 10 – 20 cm long (Figure). Color Doppler could to reveal hyperemia intracolonic wall and diverticular wall (Figure 2B, 3A, 3B, 5A). CT confirmed inflammatory fatty lesion with or without air inside along colonic wall (3, 4), (Figure 4B, 5B, 6C).
Clinical symptoms included acute abdominal pain with rebound tenderness in almost cases. Mild fever, loose stool, only there were some cases with bloody stool. Elevation of the white blood cell count and sedimentary rate.Eighteen cases were conservatively treated with antibiotic (oral or intravenous) (Figures 6A, 6B). Four cases underwent operation because surgeons suspected acute appendicitis, with post-operative diagnoses 3 cases of diverticulitis of the cecum and 1 case of acute appendicitis.
DISCUSSION Almost cases in our study with acute colonic uncomplicated diverticulitis on the right-sided colon involving cecum and ascending colon according to Vietnamese who are Oriental (2) and could be patients scared of appendicitis.
Haustra pattern findings of normal colon on ultrasound were useful for exact determination of colon. Thanks to this the diverticulitis was loclated exactly position and corresponding with CT. Specially, diverticulitis of the cecum which had symptoms similar to acute appendicitis. We diagnosed ten cases of cecal diverticulitis in which a case with position of cecum above umbilical level. According to authors, the diagnosis of diverticulitis of the cecum has been the challenge to imaging diagnosis.
Basically, hemicolonic removed for therapy of diverticulitis. However, in our study, eighteen cases were conservatively treated with antibiotic. Four cases were underwent operation because surgeons suspected acute appendicitis, with post-operative diagnoses three cases of diverticulitis of the cecum and a case of acute appendicitis.
To differentiate ACUD from acute appendicitis (in cases of acute appendicitis and wall-off formation surrounded by thick fatty tissue), primary epiploic appendagitis, right-sided segmental infartcion of omentum. The appendicitis is longer than diverticulitis and acute appendicitis has characteristic ultrasound finding so-called finger sign (1) (Figure 7A, 7B). Primary epiploic appendagitis are small, oval, hyperechoic lesion, tenderness and uncompressible, 3-5 cm in size (5) (Figure 7C). Right-sided segmental infarction of omentum are oval, hyperechoic, tenderness, noncompressible with large-size, often bigger 5 cm, which are usually localized at right lower abdomen at the level of umbilicus (6) (Figure 7D).
CONCLUSION
Haustra pattern findings of normal colon on ultrasound were useful for exact determination of colon. Thanks to this the diverticulitis was loclated exactly position and corresponding with CT. Specially, diverticulitis of the cecum which had symptoms similar to acute appendicitis. We diagnosed ten cases of cecal diverticulitis in which a case with position of cecum above umbilical level. According to authors, the diagnosis of diverticulitis of the cecum has been the challenge to imaging diagnosis.
Basically, hemicolonic removed for therapy of diverticulitis. However, in our study, eighteen cases were conservatively treated with antibiotic. Four cases were underwent operation because surgeons suspected acute appendicitis, with post-operative diagnoses three cases of diverticulitis of the cecum and a case of acute appendicitis.
To differentiate ACUD from acute appendicitis (in cases of acute appendicitis and wall-off formation surrounded by thick fatty tissue), primary epiploic appendagitis, right-sided segmental infartcion of omentum. The appendicitis is longer than diverticulitis and acute appendicitis has characteristic ultrasound finding so-called finger sign (1) (Figure 7A, 7B). Primary epiploic appendagitis are small, oval, hyperechoic lesion, tenderness and uncompressible, 3-5 cm in size (5) (Figure 7C). Right-sided segmental infarction of omentum are oval, hyperechoic, tenderness, noncompressible with large-size, often bigger 5 cm, which are usually localized at right lower abdomen at the level of umbilicus (6) (Figure 7D).
CONCLUSION Acute colonic uncomplicated diverticulitis has fairly characteristic sonographic features, therefore US enable diagnosis. Exact determination of colon and cecum thanks to haustra pattern appearances that could to improve the accuracy of diagnosis of colonic diverticulitis. Conservative therapy of ACUD are quite safe no require surgery.
REFERENCES
1. Puylaert JBCM. Acute appendicitis: US evaluation using graded compression. Radiology 158:355, 1986.
2. Khanh t. Nguyen. Bowel and Mesentery, Abdominal Sonography: 253-255.
3. Ruedi F. Thoeni, MD and John P. Cello, MD. CT Imaging of Colitis. Radiology 2006;240:623-638.
1. Puylaert JBCM. Acute appendicitis: US evaluation using graded compression. Radiology 158:355, 1986.
2. Khanh t. Nguyen. Bowel and Mesentery, Abdominal Sonography: 253-255.
3. Ruedi F. Thoeni, MD and John P. Cello, MD. CT Imaging of Colitis. Radiology 2006;240:623-638.
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