急性乙状结肠憩室炎和并发症影像学表现

1 Acute Sigmoid Diverticulitis and its Complications Jasmine Barrow, Harvard Medical School Year III Gillian Lieberman, MD April 2011 Jasmine Barrow, year III Gillian Lieberman, MD 2 Agenda  What Acute Sigmoid Diverticulitis is  Role and Goals of Imaging Why image? Menu of Tests  Strength/weaknesses  Findings and Complications Jasmine Barrow, year III Gillian Lieberman, MD 3 Diverticulosis 1  Diverticulosis- presence of many diverticula  Diverticulum- pouch or a pocket-like opening in the bowel wall  Mucosa/submucosa/serosa  2/3 of 65 years and older  ¼ of those will get diverticulitis accessmedicine.net Jasmine Barrow, year III Gillian Lieberman, MD 4 Diverticulosis 2 •Usually left sided- descending colon and sigmoid •Can be anywhere •Asian population right sided predominence •Diverticulum bleed accessmedicine.net Jasmine Barrow, year III Gillian Lieberman, MD 5 Diverticulitis  Location Most diverticulitis- sigmoid  Inflammation or infection of the diverticulum Microperforations  Intraluminal pressure, inspissated stool Edema  Wall thickening Pericolic inflammation- inflamed fat Jasmine Barrow, year III Gillian Lieberman, MD 6 Diverticulitis: Complications  Anatomy Pericolonic, intraperitoneal, retroperitoneal  Abscess  Fistula  Macroperforation Jasmine Barrow, year III Gillian Lieberman, MD 7 Clinical diagnosis vs. Imaging  Many patients present with typical clinical picture LLQ pain, fever, and leukocytosis-  Most common cause is acute sigmoid diverticulitis Age, history of diverticulosis or diverticulitis Many patients can then be managed medically with antibiotics  Why image? Jasmine Barrow, year III Gillian Lieberman, MD 8 Goal of Imaging  Narrow differential diagonses to a diagonsis  Management Jasmine Barrow, year III Gillian Lieberman, MD 9 Differential Diagonsis Hammond, Nancy. Paul, Nikolaidis. Frank, Miller. Left lower-quadrant pain: guidelines from the american college of radiology appropriateness criteria. American Family Physician.2010; 82(7):766-70. Jasmine Barrow, year III Gillian Lieberman, MD 10 Goal of Imaging  Narrow differential diagonses to a diagonsis  Management Extent of disease  Staging (CT)  Complications 15-30% will need surgery– imaging helps decide Jasmine Barrow, year III Gillian Lieberman, MD 11 Menu of Tests  Computed Tomography With Contrast  Compression Ultrasonography (U/S)  Barium Enema (BE) radiography Jasmine Barrow, year III Gillian Lieberman, MD 12 CT with Contrast  Direct examination of lumen, wall, pericolonic, intraperitoneal and retroperitoneal spaces  Ability to diagnose other conditions  Abitlity to stage extent of disease and presence of complications  79-99% sensitivity  High specificity  Pitfall– perforated colon cancer can mimic diverticulitis clinically and radiographically  f/u BE or colonoscopy Jasmine Barrow, year III Gillian Lieberman, MD 13 CT Staging- Hinchey’s Criteria  Stage 0- bowel wall thickening  Medical manganement  Stage 1- small pericolonic abscess  medical management  Stage 2- large abscess not extending beyond pelvis  Drain percutaneously/surgery  Stage 3- abscess beyond pelvis  surgery  Stage 4- free rupture of diverticulum into peritoneal cavity- fecal peritonitis  surgery Jasmine Barrow, year III Gillian Lieberman, MD 14 Now Let’s Look at a Patient Jasmine Barrow, year III Gillian Lieberman, MD 15 Our Patient: Classic CT findings 1  53 yr old man with mild LLQ abdominal pain for 2 days and low grade fever  Axial CT with contrast  Inflammed divertculum- air pockets with surrounding edema  Wall thickening Jasmine Barrow, year III Gillian Lieberman, MD PACS, BIDMC 16 Our Patient: Classic CT findings 2 •Axial CT with contrast •Fat stranding •Pericolonic inflammation abutting/adherant to bladder Jasmine Barrow, year III Gillian Lieberman, MD PACS, BIDMC 17 Now Let’s Look at Complications of Diverticulitis seen in Our Patient Jasmine Barrow, year III Gillian Lieberman, MD 18 Our Patient: Complications on CT 1 •Axial CT with contrast •Pericolonic rim-enhancing gas and fluid collection consistent with a diverticular abscess •Air within bladder suggestive of colovesical fistula Jasmine Barrow, year III Gillian Lieberman, MD PACS, BIDMC 19 More on Abscess Complication  Most common complication of diverticulitis  Presence, size, and location used to determine staging  Plegmnon and/or abscess seen on 35% of cases of diverticulitis imaged with CT  Can be drained percutaneously with CT guidance or surgically Jasmine Barrow, year III Gillian Lieberman, MD 20 More on Fistula Complication  20% of surgically treated diverticulitis  Colovesical- most common (65%)  Male predominance  Uterus protects bladder  Colovaginal (25%)  Coloenteric (<10%)  Colouterine- rare  Colocutaneous- rare Jasmine Barrow, year III Gillian Lieberman, MD 21 Our Patient: Complications on CT 2 •Axial CT with contrast •Contrast in bladder, further evidence of colovesical fistula •Pericolonic inflammation •Large inflammed diverticulum Jasmine Barrow, year III Gillian Lieberman, MD PACS, BIDMC 22 Our Patient: Colovesical Fistula •Axial CT with contrast •Contrast in bladder, further evidence of colovesical fistula Jasmine Barrow, year III Gillian Lieberman, MD PACS, BIDMC 23 Our Patient: More history  Pneumaturia with dysuria, consistent with colovesical fistula seen on CT  History of known diverticulosis  Third episode of diverticulitis week prior to presentation  managed conservatively as an outpatient.  Was not imaged at that time Jasmine Barrow, year III Gillian Lieberman, MD 24 We will now examine other complications using images of companion patients 25 Companion Patient 1: Colocutaneous Fistula Stocchi, Luca. Current indications and role of surgery in the management of sigmoid diverticulitis. World Journal of Gastroenterology. 2010;16(7): 804-817. •Axial CT with contrast •Fistula track from colon through subcutaneous tissue to cutaneous tissue Jasmine Barrow, year III Gillian Lieberman, MD 26 Companion Patient 2: Perforation  Axial CT with contrast  Pneumoperitoneum (Extraluminal air ) http://brighamrad.harvard.edu/Cases/bwh/hcache/124/full.html Jasmine Barrow, year III Gillian Lieberman, MD 27 Other Imaging Modalities  Graded Compression Ultrasonography  Barium Enema Jasmine Barrow, year III Gillian Lieberman, MD 28 Graded Compression U/S  Women of childbearing age or pregnant patients Best for GYN differential No radiation  Sensitivity- 77-98%  Specificity- 80-99%  Operator dependent Direct physician involvement in examination recommended Jasmine Barrow, year III Gillian Lieberman, MD 29 U/S Findings  Wall thickness (hypoechoic)  Pericolonic fat inflammation (echogenic)  Identify abscess (hypoechoic)  Identify fistula (hypoechoic, bubbles •Echogenic material filling inflammed diverticulum- air, fecal material, enterolith •Hypoechoic colonic wall thickening •Echogenic pericolonic fat inflammation www.radbazaar.com Jasmine Barrow, year III Gillian Lieberman, MD 30 Barium Enema  Former primary imaging modality  Differential limited  Only detects secondary affects of inflammation on colon  Not sensitive to primary pericolonic inflammation  Not sensitive to complications  Sensitivity- 59-90%  More invasive  Can be follow up study if CT is equivocal Jasmine Barrow, year III Gillian Lieberman, MD 31 BE Findings  Fold thickening  Segmental spasm  Sinus tract  Fistula  Mass effect from abscess or free air •Segmental spasm http://radiology.healthcommunities.com/diverticulitis/index.shtml Jasmine Barrow, year III Gillian Lieberman, MD 32 Summary  Acute inflammation and infection of diverticulum  Microperforations leading to extraluminal inflammation  Abscess, Fistula, Macroperforation complications  CT with constrast imaging modality of choice Jasmine Barrow, year III Gillian Lieberman, MD 33 References  American College of Radiology. Lower Left Quadrant Pain. ACR Appropriateness Criteria. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelon GastrointestinalImaging/LeftLowerQuadrantPainDoc8.aspx. Accessed 4/12/2011.  Destigter, Kristen. David, Keating. Imaging update: acute colonic diverticulitis. Clincal Colon Rectal Surgery. 2009; 22(3):147-55  Hammond, Nancy. Paul, Nikolaidis. Frank, Miller. Left lower-quadrant pain: guidelines from the american college of radiology appropriateness criteria. American Family Physician.2010; 82(7):766-70.  O’Malley, Martin. Stephanie, Wilson. Ultrasonography and computed tomography of appendicitis and diverticulitis. Seminars in Roentgenology. 2001; 36(2);138-147.  Sarma, Deba. Walter, Longo. Diagnostic imaging for diverticulitis. Journal of Clinical Gastroenterology. 2008; 42(10):1139-1141.  Stocchi, Luca. Current indications and role of surgery in the management of sigmoid diverticulitis. World Journal of Gastroenterology. 2010;16(7): 804-817.  Young-Fadok, Tonia. John, Pemberton. Acute diverticulitis complicated by fistula formation. Uptodate. http://www.uptodate.com/contents/acute-diverticulitis-complicated-by-fistula- formation?source=search_result&selectedTitle=1%7E150. Accessed 4/14/2011.  Young-Fadok, Tonia. John, Pemberton. Clinical manifestation and diagnosis of colonic diverticular disease. Uptodate. http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of- colonic-diverticular-disease?source=search_result&selectedTitle=2%7E15. Accessed 4/14/2011. Jasmine Barrow, year III Gillian Lieberman, MD 34 Acknowledgments  Dr. Gillian Lieberman  Dr. Tamuna Chadashvili Jasmine Barrow, year III Gillian Lieberman, MD Acute Sigmoid Diverticulitis and its Complications Agenda Diverticulosis 1 Slide Number 4 Diverticulitis Diverticulitis: Complications Clinical diagnosis vs. Imaging Goal of Imaging Differential Diagonsis Goal of Imaging Menu of Tests CT with Contrast CT Staging- Hinchey’s Criteria Slide Number 14 Our Patient: Classic CT findings 1 Our Patient: Classic CT findings 2 Slide Number 17 Our Patient: Complications on CT 1 More on Abscess Complication More on Fistula Complication Our Patient: Complications on CT 2 Our Patient: Colovesical Fistula Our Patient: More history We will now examine other�complications using images of�companion patients Companion Patient 1: Colocutaneous Fistula Companion Patient 2: Perforation Other Imaging Modalities Graded Compression U/S U/S Findings Barium Enema BE Findings Summary References Acknowledgments