一例复杂型憩室炎影像学表现

A Case of Complicated Diverticulitis Brian Clair 8/25/08 Agenda 1. Introduction to Our Patient 2. Diverticulitis -Review of Diverticular Disease -Pathogenesis of Diverticulitis -Radiologic Findings -Treatment 3. Complications of Diverticulitis 4. Wrap-up of Our Patient Our Patient: Mr. L • 55 y/o male with a history of fevers, chills, right lower quadrant pain, pneumaturia, and passing stool in his urine. Differential Diagnosis of Pneumaturia (i.e. Air in the Bladder Lumen) • Air from the “outside” – Iatrogenic • S/P cystoscopy • Suprapubic cystostomy • Foley catheter • Post-operative – Penetrating trauma • Air from the “inside” – Enterovesical Fistula • Bladder cancer • Bowel cancer • Crohn’s Disease • Diverticulitis • S/P radiation • TB • Air from gas forming organisms – Emphysematous cystitis CT is the primary imaging modality for suspected enterovesical fistulas. Lieberman, G. “Male Imaging” Lieberman’s Primary Care Radiology. http://eradiology.bidmc.harvard.edu Mr. L: Enterovesical Fistula on CT BIDMC (PACS) Bladder Æ RectumÆ Rectal contrast material administered without IV contrast is when enterovesical fistula is suspected. Air is present in the bladder above urine fluid level. Contrast within the bladder. CT Pelvis. Rectal contrast without IV contrast. Mr. L: CT Sagittal View Bladder Æ ÅRectum BIDMC (PACS) Communication between the sigmoid colon and the bladder CT Sagittal Reconstruction. Rectal contrast without IV contrast. Differential Diagnosis of Enterovesical Fistula • Bladder cancer • Bowel cancer • Crohn’s Disease • Diverticulitis • S/P radiation • TB Mr. L: Sigmoid Diverticulitis on CT BIDMC (PACS) CT demonstrates diverticulitis of the sigmoid colon How do we make this diagnosis? Mr. L: CT Pelvis. Rectal contrast without IV contrast. Diverticular Disease • Diverticula: colonic outpouchings consisting only of mucosa and submucosa – Most commonly appear in the sigmoid colon • Diverticulosis: describes presence of uninflamed diverticula – Incidence increases with age, from less than 5% before age 40 years to greater than 65% by age 85 years • Diverticulitis: inflammation of a diverticulum or diverticula, commonly accompanied by gross or microscopic perforation – Estimated to occur in 10-15% of people with diverticulosis Horton KM, Corl FM, Fishman EK. Imaging of Diverticular Disease Source: Schwartz SI, Shires GT, Spencer FC (eds): Principles of Surgery. 5th ed. New York: McGraw-Hill, 1989, p 1256 Horton KM, Corl FM, Fishman EK. Companion Patient #1 Barium Enema Companion Patient #2 CT scan with oral and IV contrast material Sigmoid colon Air-filled outpuchings = diverticula Diverticulitis: Pathogenesis Obstruction at neck of colonic diverticula by stool, inflammation, or food particles Bacterial overgrowth, vascular comprimise and microperforation Pericolic inflammation Diverticulitis: Diagnosis • Typical Presentation – Fever – Left lower quadrant abdominal pain – Leukocytosis • Menu of Diagnostic Tests – Barium enema • Used in the past – CT scan • Most accurate and readily available imaging study in diagnosis of acute diverticulitis Companion Patient #3: Uncomplicated Diverticulitis BIDMC (PACS) Companion Patient #3: Ms. C ÅS. colon CT Findings: 1. Diverticula 2. Bowel wall thickening 3. Fat stranding C+ CT Pelvis Diverticulitis: Complications • Abscess • Hemorrhage • Stricture • Fistula • Phlegmon • Purulent peritonitis • Fecal peritonitis • Perforation • Obstruction Complicated Diverticulitis: Staging by CT Stage Modified Hinchey Classification CT Findings 0 Mild clinical diverticulitis Diverticuli ±colonic wall thickening Ia Confined pericolic inflammation/ phlegmon Colonic wall thickening with pericolic soft tissue changes Ib Pericolic/mesocolic abscess Ia changes + pericolic/mesocolic abscess II Pelvic, distant intraabdominal or retroperitoneal abscess Ia changes + distant abscess (generally deep in the pelvis or in interloop regions) III Generalized purulent peritonitis Free gas associated with localized or generalized ascites and possible peritoneal wall thickening IV Generalized fecal peritonitis Same findings as III Staging system used to classify severity of complicated diverticulitis Baker ME. Emergency operative treatment CT-guided percutaneous drainage of abscesses larger than 4 cm in diameter Diverticulitis: Treatment • Mild uncomplicated diverticulitis: 7-10 days oral broad-spectrum antibiotics – Hospitalization indicated if unable to tolerate oral intake or pain requires narcotic analgesia • Surgical consultation indicated when: – There is no response to medical management – Repeated attacks – Complications such as abscess, fistula, obstruction, or free air Companion Patient #4: Mr. D • 38 y/o male who developed left lower quadrant pain with some mild fever the day prior to admission Complicated Diverticulitis: Perforation Companion Patient #4: Mr. D C+ CT Pelvis BIDMC (PACS) Extraluminal pocket of air Companion Patient #5: Ms. F • 68 y/o female presents to the ED with malodorus vaginal discharge. Complicated Diverticulitis: Abscess & Colovaginal Fistula Companion Patient #5: Ms. F Images from BIDMC (PACS) Vagina Æ Small pockets of air and a tiny trace of contrast suggest fistulous connection 5.7 x 4.6 perisigmoid abscess filled with stool and air C+ CT Pelvis Back to Our Patient What happened to Mr. L? Complicated Diverticulitis: Colovesical Fistula Images from BIDMC (PACS) Mr. L’s diagnosis: Sigmoid diverticulitis and colovesical fistula CT Pelvis. Rectal contrast without IV contrast. Mr. L’s Initial Treatment • Started on amoxicillin-clavulanate (Augmentin) • Colonoscopy to rule out colon cancer • Surgical procedure – Open sigmoidectomy with primary coloproctostomy Mr. L’s Further Treatment • Six days later, Mr. L had fecal material in his urine and was sent emergently to the operating room. – Colorectal anastomosis taken down and end-colostomy created Acknowledgments • Dr. James Kang, BIDMC Radiology • Dr. Gillian Lieberman, BIDMC Radiology • Maria Levantakis, BIDMC Radiology Works Cited • Baker ME. Imaging and interventional techniques in acute left-sided diverticulitis. J Gastrointest Surg. 2008 Aug;12(8):1314-7. • Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics. 2000 Mar-Apr;20(2):399-418. • Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007 Nov 15;357(20):2057- 66. • Lieberman, G. “Male Imaging” Lieberman’s Primary Care Radiology. http://eradiology.bidmc.harvard.edu • Novelline RA. Squire’s Fundamentals of Radiology 6th Ed. Harvard University Press. Cambridge, MA. 2004. • Schwartz SI, Shires GT, Spencer FC (eds): Principles of Surgery. 5th ed. New York: McGraw-Hill, 1989, p 1256. • Sheth AA, Longo W, Floch MH. Diverticular disease and diverticulitis. Am J Gastroenterol. 2008 Jun;103(6):1550-6. • Yu NC, Raman SS, Patel M, Barbaric Z. Fistulas of the genitourinary tract: a radiologic review. Radiographics. 2004 Sep-Oct;24(5):1331-52. A Case of Complicated Diverticulitis Agenda Our Patient: Mr. L Differential Diagnosis of Pneumaturia (i.e. Air in the Bladder Lumen) Mr. L: Enterovesical Fistula on CT Mr. L: CT Sagittal View Differential Diagnosis of �Enterovesical Fistula Mr. L: Sigmoid Diverticulitis on CT Diverticular Disease Imaging of Diverticular Disease Diverticulitis: Pathogenesis Diverticulitis: Diagnosis Companion Patient #3: Uncomplicated Diverticulitis Diverticulitis: Complications Complicated Diverticulitis: Staging by CT Diverticulitis: Treatment Companion Patient #4: Mr. D Complicated Diverticulitis: Perforation Companion Patient #5: Ms. F Complicated Diverticulitis:�Abscess & Colovaginal Fistula Back to Our Patient Complicated Diverticulitis: Colovesical Fistula Mr. L’s Initial Treatment Mr. L’s Further Treatment Acknowledgments Works Cited