Radiographic Pictorial Review of Diverticular disease v/s Carcinoma

1. Dr. Naveed AshrafRadiologic Pictorial Review
Diverticular Disease Vs
Carcinoma
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2. Dr. Naveed AshrafRadiologic Pictorial Review
TEACHING POINTS
Absence of visualized diverticula within the thickened sigmoid segment is
the most useful discriminator in the diagnosis of cancer rather than
diverticular disease.
Shoulder phenomenon showed high positive predictive value for
carcinoma).
Segments affected by carcinoma often showed straightened and
eccentric growth patterns,and there were more and larger local-regional
lymph nodes , while diverticular disease show curved growth pattern with
tapering margins.
Degree of wall thickening and pericolonic fat infiltration were not
significant .
Combination of absence of diverticula and presence of shouldering show a
high diagnostic certainty (93%) regarding carcinoma.
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3. Dr. Naveed AshrafRadiologic Pictorial Review
Diverticulum formation and
vascular relationships.
A. The vas rectum penetrates
the colon wall from the
serosa to the submucosa
through an obliquely
oriented connective tissue
septum in the circular
muscle (CM). This
penetration occurs near
the mesenteric side of the
taenia (T).
B. The diverticulum develops
through and widens this
connective tissue cleft. The
mucosal protrusion begins
to elevate the artery.
C. As the diverticulum
extends transmurally, the
vas rectum is placed over
its dome, penetrating to
the submucosa on the
antimesenteric border of
its neck and orifice.
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4. Dr. Naveed AshrafRadiologic Pictorial Review
Diverticulosis: CT findings. CT scan at the level of the sigmoid colon shows
multiple air and contrast filled diverticula (arrows).
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5. Dr. Naveed AshrafRadiologic Pictorial Review
Diverticulitis. Double-contrast barium enema shows mass effect on the
medial aspect of the junction of the descending colon and sigmoid
(arrows). There is distortion of the lumen, but the extent of extracolonic
disease cannot be assessed.
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6. Dr. Naveed AshrafRadiologic Pictorial Review
Spot image from a barium enema shows filling of an abscess (A) and a
sinus tract (arrows) along the inferior aspect of the sigmoid colon
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7. Dr. Naveed AshrafRadiologic Pictorial Review7

8. Dr. Naveed AshrafRadiologic Pictorial Review8

9. Dr. Naveed AshrafRadiologic Pictorial Review
Diverticulitis: MDCT findings on non–contrast-enhanced scans. Sagittal (A)
and axial (B) images show the hyperdense offending diverticulum (curved
arrow) at the center of the pericolonic inflammation. Note the thickening
of the anterior (small straight arrow) and lateroconal (large straight arrow)
interfascial planes. C. Coronal reformatted image in a different patient
demonstrates a hyperdense diverticulum with surrounding inflammatory
change (arrow).
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10. Dr. Naveed AshrafRadiologic Pictorial Review
MDCT of diverticulitis: early changes. A. Axial CT scan of the sigmoid colon
demonstrates mural thickening with haziness of the sigmoid mesocolon
(arrows) associated with engorged vasa recta. B. Axial postcontrast CT scan
shows mural thickening and pericolic inflammatory change in the
transverse colon, with hyperdense diverticulum (arrow).
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11. Dr. Naveed AshrafRadiologic Pictorial Review
MDCT of diverticulitis: intramural abscess. Axial CT of the sigmoid colon
shows mural thickening, pericolonic inflammatory changes, and fascial
thickening with the presence of an intramural abscess (arrow).
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12. Dr. Naveed AshrafRadiologic Pictorial Review
Surgical staging of diverticular abscesses.
Stage I, A small (<3 cm) pericolic abscess is contained within the
sigmoid mesocolon.
Stage II, A pelvic abscess has broken out of the sigmoid mesocolon
but is contained by the pelvic organs.
Stage III, The large pelvic abscess has spread into the rest of the
peritoneal cavity. Stage
IV, Large diverticular perforation occurs with fecal contamination
of the peritoneal cavity.
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13. Dr. Naveed AshrafRadiologic Pictorial Review
MDCT of diverticulitis: abscess. Axial image in one patient demonstrates a
large abscess with an air-fluid level (A) identified in the pelvis.
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14. Dr. Naveed AshrafRadiologic Pictorial Review
Colon cancer versus diverticulitis: imaging considerations.
Line drawings showing features that suggest diverticulitis (inflammation,
pericolic edema, fluid in the root of the mesentery–combined interfascial
plane, extraluminal fluid and air) versus carcinoma (eccentric thickening,
luminal mass).
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15. Dr. Naveed AshrafRadiologic Pictorial Review
Barium enema examination demonstrates an indeterminate stricture in
the sigmoid colon. Multiple diverticula are present but there is an abrupt,
overhanging edge (arrows) along the proximal margin of this lesion. This
patient had diverticulitis and carcinoma of the sigmoid colon.
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16. Dr. Naveed AshrafRadiologic Pictorial Review
Focal, symmetric mural thickening of the sigmoid colon is present. There
are inflammatory changes in the fat of the sigmoid mesocolon. Several
diverticula are evident just distal to the region of thickening. This patient
had diverticulitis.
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17. Dr. Naveed AshrafRadiologic Pictorial Review
There is a mass identified within the lumen of the sigmoid colon, with only
minimal haziness of the adjacent fat. This patient had carcinoma of the
sigmoid colon.
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18. Dr. Naveed AshrafRadiologic Pictorial Review
Axial CT demonstrates an intraluminal mass with diverticula seen along the
margins of the mass, but not in the segment with the mass. There are
equivocal surrounding inflammatory changes. This patient had carcinoma
of the sigmoid colon
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19. Dr. Naveed AshrafRadiologic Pictorial Review
CT colonographic image in a 62-yearold woman who presented with
nonspecific abdominal pain shows chronic diverticular disease mimicking
colonic carcinoma. Note the presence of multiple air- and barium-filled
diverticula, tapered ends of the segment, and curved growth pattern.
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20. Dr. Naveed AshrafRadiologic Pictorial Review
Image in 73-year-old woman who underwent CT colonography because of
changed bowel habits. Typical appearance of chronic diverticular disease
that did not manifest as a mass and therefore was not included in this
study. Image shows long-segment moderate wall thickening with tapered
ends and presence of diverticula within the involved segment.
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21. Dr. Naveed AshrafRadiologic Pictorial Review
Typical appearance of colonic carcinoma on CT colonographic image in an
89-year-old woman with changed bowel habits. Image shows no
diverticula but does show shoulder phenomenon (arrow tip), complete
distortion of fold pattern, and straightened growth pattern.
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22. Dr. Naveed AshrafRadiologic Pictorial Review
CT colonographic image in 81-year-old woman with anemia shows sigmoid
carcinoma with an atypical appearance, mimicking the appearance of
chronic diverticular disease. Note the presence of diverticula in the
segment (arrowhead), as well as shouldering and the straightened growth
pattern
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23. Dr. Naveed AshrafRadiologic Pictorial Review
A 47-year-old man underwent CT colonography because impression on the
bladder at cystoscopy appeared to be chronic diverticular disease. (a)
Coronal view shows short-segment wall thickening with diverticula
(arrowhead). (b) Sagittal view shows pericolonic fat infiltration and a small
lymph node (arrow).
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24. Dr. Naveed AshrafRadiologic Pictorial Review
A 75-year-old woman with rectal blood loss underwent CT colonography
because of incomplete colonoscopy. Image shows poorly distended long
segment of chronic diverticular disease with tapered ends (arrow tip),
diverticula within the segment (arrowhead), complete distortion of
mucosal folds, curved growth pattern, and some pericolic fat infiltration
(*).
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25. Dr. Naveed AshrafRadiologic Pictorial Review
CT colonographic images in a 78-year-old man with changed bowel habits
show chronic diverticular disease in a long curved segment with
circumferential wall thickening, complete distortion of the mucosal fold
pattern, some fat infiltration, and thickened fascia (arrow tip); however, no
diverticula was seen in either the (a) axial view or the (b) sagittal view.
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26. Dr. Naveed AshrafRadiologic Pictorial Review
Chronic diverticulitis. Axial CT image shows pericolonic inflammatory
changes, with extensive long segment wall thickening.
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27. Dr. Naveed AshrafRadiologic Pictorial Review
Right-sided diverticulitis: imaging considerations. A. Coronal reformatted
image shows the hyperdense offending diverticulum (arrows) associated
with considerable inflammatory change in the adjacent fat. B. Axial scan of
different patient shows contrast filling a normal appendix (curved arrow)
and the offending diverticulum (straight arrow). C. Postcontrast coronal
reformatted CT image demonstrates focal pericolic inflammatory changes,
with wall thickening and suggestion of the inflamed diverticulum (arrow).
D. Note the contrast-filled posterior to the cecum on the axial image
(arrow).
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28. Dr. Naveed AshrafRadiologic Pictorial Review
Colovesical fistula caused by diverticulitis. A, B. Indirect evidence of a
fistula with inflammatory changes of the sigmoid colon and adjacent
eccentric bladder wall thickening (arrow).73 C, D. Direct evidence of a
colovesical fistula with an air-filled tract between the sigmoid colon and
bladder (arrow), with gas seen in the bladder
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29. Dr. Naveed AshrafRadiologic Pictorial Review
Free intraperitoneal perforation. A. Lateral scout image demonstrates free
intraperitoneal gas (arrow). B. Axial image of the pelvis demonstrates the
gascontaining region of perforation (arrows). C. Several bubbles of gas are
evident anterior to the liver (arrows).
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30. Dr. Naveed AshrafRadiologic Pictorial Review
Large bowel obstruction caused by diverticulitis. A. Scout image
demonstrates large and small bowel distention. B. CT scan demonstrates
transition point (arrows) with pericolonic inflammatory change, fascial
thickening, and luminal narrowing.
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