憩室疾病的影像学诊断

Diverticular Disease Christopher Gross Gillian Lieberman, MD March 2008 Goals … Definitions … Epidemiology … Anatomy … Pathophysiology … Symptoms … Menu of Diagnostic Modalities Definitions … Diverticulum– sac-like protrusion of the colonic wall that consists of mucosa, submucosa, serosa … Diverticulosis– the presence of diverticula, often an incidental finding … Diverticulitis– inflammation resulting from a perforation of a diverticulum … Diverticular Hemorrhage– Diverticular bleeding usually not associated with diverticulitis Epidemiology … Age: † Affects <5% before 40yoÆ 30% at 60yoÆ 65% at 80yo † 20% of those present with sxs … Risk factors: † “disease of Western Civilization” „ low fiber Æ constipation „ obesity, lack of physical activity „ NSAIDs „ smoking Anatomy … Pseudodiverticula– Herniations of mucosa and submucosa covered by serosa where vasa rectae penetrate the circular muscle layer † Between each side of the mesenteric taenia, and on one side of antimesenteric taeniae www.accesssurgery.com “Current Surgical Diagnosis and Treatment” http://www.meddean.luc.edu/ Pathophysiology … 95% of diverticuli occur in the sigmoid † In Asians, 70% present as R-sided pain … Laplace’s law: (P=T/r), sigmoid has the smallest diameter and largest pressures … Segmentation exaggeratedÆ increase in intralumenal P www.webmd.com Patient: KB 51 yo M who presents to ED with left lower abdominal pain and anorexia. History of Present Illness … LLQ pain x 3wks; +distension and pressure … PCP Rx Levofloxacin + Ciprofloxacin 2 wks prior … No Nausea/Vomiting … +Bowel Movements, no BRPRP, no diarrhea … Afebrile, HR: 96, BP: 156/89 More information . . . … PMH †HTN †Hyperlipidemia † ?Sleep apnea † ?GERD †Hiatal Hernia … Medications †HCTZ 25mg QD † Atenolol 25mg QD Physical Exam … Significant findings: † tender LLQ to palpation †Distended, +rebound … Labs † Electrolytes, LFTs nl † CBC: 16.0\___/336 /44.3\ Differential DDx: Differential Diagnosis Appendicitis, cholecystitis Ischemic colitis Colorectal CA Mesenteric infarction Cystitis Ovarian torsion IBD PID, endometriosis IBS Renal disease Incarcerated Hernia SBO, LBO … Colorectal CA can have microperforations and become 2o infected … Follow-up colonoscopy is recommended in 6-8wks in a suspicious CT. Clinical Presentation Clinical Presentation Incidence LLQ pain 93-100% Fever, chills 57-100% Leukocytosis 69-83% Nausea /Vomiting 20% Mass Constipation Diarrhea Urinary Sxs What should we order for our patient? Menu of Imaging … Goals: establish Dx and demonstrate the extent and severity of diverticulitis; ?complications … Menu: † Barium Enema–largely outdated † CT—test of choice †US—in pregnancy „ Can be used in initial eval of lower abd pain, esp w/ females „Will see hyperechogenicity surrounding bowel wall Companion Pt 1: Diverticulosis on Barium Enema … Double contrast used to be gold standard † Sensitivity: 82% † Specificity: 81% … Shows divertics, with sigmoid narrowing, extravasation … (+) Provided info on presence and degree of diverticula … ( - ) Cannot discern clinical relevance, missed Dx in 33% † C/I in cases of suspected perforation and emergencies Luminal narrowingwww.radiologychannel.net/diverticuliti CT: Test of Choice … Triple contrast (IV, PO, rectal) now standard … Sensitivity– 85-97% … (+) Can quantify diverticulitis to direct management, see presence of complications CT based scoring system for diverticulitis Management Stage 0 Mural thickening and diverticulae Conservative Stage 1 Abscess/phlegmon <3cm in diam Conservative in low risk patients Stage 2 Abscess 5-15cm in diam CT-guided percutaneous drainage or Surgery Stage 3 Abscess beyond the confines of pelvis Surgery Stage 4 Fecal peritonitis Surgery Companion Pt 2: CT Manifestations of Diverticulitis … Pericolic fat infiltration (98%) … Thickened fascia, wall thickening >4mm (78.9%) … Muscular Hypertrophy (26.3%) … “Arrowhead” sign (23.7%) … Other signs of complications † Abscess (35%) „ Intramural sinus tract (with air or contrast) with thickened wall † Fistulas † Perforation † Obstruction Fat stranding Wall thickening http://www.learningradiology.com/caseofweek/caseoftheweekpix2006/cow228arr.jp Companion Pt 3 + 4: Percutaneous Drainage of Diverticular Abscess • Percutaneous Drainage: Seldenger Technique with 12 French gauge locking pigtail catheter 5cm abscess, Stage 2 Pigtail catheter Halligan, et al. “Imaging Diverticular Disease” http://www.emedicine.com/radio/images/336139‐367320‐6366.jpg Thickened walls, sigmoid abscess What does our patient’s CT show? Our Pt KB: Pelvic Fistula on Pelvic CT small sinus tract in pelvis communicating w/ rectosigmoid colon, dilated sigmoid Small sinus tract Enteroenteric fistula Colocolonic fistula PACS 6cm Companion Pt 5 + 6: Fistulas on CT and Abd Plain Film … 2-10% of cases: Colovesical > colovaginal > coloenteric > colouteral Air, stool, oral contrast in bladder Air in bladder http://myweb.lsbu.ac.uk/dirt/museum/margaret/838-2454a-1480410.jpghttp://brighamrad.harvard.edu/Cases/bwh/hcache/124/full.html Companion Pt 7: Perforation on Abd CT • Mortality for Stage III is 13% and Stage IV is 43% Extraluminal air Stollman, et al. “Diverticular Disease of the Colon” Treatment Recommendations … Elective Surgery: 6-8wks later † One episode of complicated † 2 confirmed episodes that require hospitalization † Immunocompromised CT scoring Management Stage 0 Conservative– Flagyl +/- Cipro; hospitalize if severe Stage 1 Conservative Stage 2 Drainage or Surgery Stage 3 Surgery (Sigmoid resection with 1o anastamosis) Stage 4 Surgery (Hartmann procedure) Our Pt KB: Hospital Course … Hospital course of Amp, Levo, Flagyl … Pt was scheduled for a hemicolectomy … Found to have rectosigmoid stricture during ex-lap † Low anterior resection (L hemicolectomy) with 1o anastamosis to the rectum Conclusion … Diverticulosis vs. diverticulitis … Initial Presentation of Diverticulitis … Diagnostic Menu: know the CT manifestations and their associated treatments Thanks to: • Dr. Gillian Lieberman • Dr. Andrew Hines-Peralta • Dr. James Kang Works Cited … Boulos PB “Complicated Diverticulitis” Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):649- 662. Review … Buchanan GN, Kenefick NJ, Cohen CR. “Diverticulitis”. Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):635-47. Review … Ferzoco LB, Raptopofhdfulos V, Silen W. “Acute diverticulitis”. N Engl J Med. 1998 May 21;338(21):1521-6. Review. … Halligan S, Saunders B. “Imaging Diverticular Disease”. Best Pract Res Clin Gastroenterol. 2002 Aug;16(4):595-610. Review … Johnson CD, Baker M, Rice R, Silverman P, Thompson W. “Diagnosis of Acute Colonic Diverticulitis: Comparison of Barium Enema and CT” AJR 1987 March; 148: 541-546 … Makela J, Vuolio S, Kiviniemi H, Laitinen S. “Natural history of diverticular disease: when to operate? “Dis Colon Rectum. 1998 Dec;41(12):1523-8. … Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons. “Practice parameters for sigmoid diverticulitis”. Dis Colon Rectum 2006 Jul;49(7):939-44. … Salzman H, Lillie D. “Diverticular Disease: Diagnosis and Treatment” American Family Physician. 2005 Oct 1; 72(7): 1229-1233 … Shen SH, Chen JD, Tiu CM, Chou YH, Chang CY, Yu C. “Colonic diverticulitis diagnosed by computed tomography in the ED”. Am J Emerg Med 2002;20:552. … Stollman N, Raskin J. “Diverticular Disease of the Colon”. The Lancet. 2004 Feb 21; 363: 631- 639 Diverticular Disease Goals Definitions Epidemiology Anatomy Pathophysiology Patient: KB History of Present Illness More information . . . Physical Exam Differential DDx: Clinical Presentation What should we order for our patient? Menu of Imaging Companion Pt 1: �Diverticulosis on Barium Enema CT: Test of Choice Companion Pt 2: �CT Manifestations of Diverticulitis Companion Pt 3 + 4:�Percutaneous Drainage of Diverticular Abscess What does our patient’s CT show? Our Pt KB:�Pelvic Fistula on Pelvic CT Companion Pt 5 + 6:�Fistulas on CT and Abd Plain Film Companion Pt 7:�Perforation on Abd CT Treatment Recommendations Our Pt KB: �Hospital Course Conclusion Thanks to: Works Cited