case of the week

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A patient Rehman said presented to us With complaint of alternative
diarrhea and constipation from last 3months with abdominal pain and
nausea, The symptoms worsen day by day and not relieved with
medication.
No other associated history and co-morbidities noted.
→this medical physician advised CT Abdomen & pelvis with contrast
→ No previous Radiological investigation provided

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Diverticulosis
1.Definition
Out pouching of colonic mucosa and submucosa

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2.Epidemiology
Diverticulosis is very common in westernized countries
and Found in order individuals At 40 years of age ~ 5% of population
have diverticula : At 60 years ~ 30% increasing to 50-80 % by the
age of 80

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Etiology
. Peptic ulcers
. Sedentary life style
.high fat
. Irritatable bowel
.Low fiber diet predispose to diabetes

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 Obesity
 Smoking
 Diverticulosis among other elements

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4.Clinical features
.Most often asymptomatic
.Symptoms are bloating stomach pain, chlis, abdmonial
camping, abdmonial tenderon,fever .
.Alternatively constipation and diarrhea

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 Alternating constipation and diarrhea
 Diverticulitis or abscess
 Most common case of rectal bleeding in patients >40 years
age

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5.Imaging
General features
→ Best Diagnostic clue
Rounded or oval colonic wall outpouching
→Location
Primarily sigmoid colon, but may occur in any segment except rectum.

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→ size
5-10mm in diameter
→ Morphology
Oval or rounded
Imaging Recommendation
→ Best imaging Tool
CT and braium Enema

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→ Protocol advice
Good bowel preparation is necessary to avoid
misdiagnosis of poly vs diverticula on air .
Contrast barium enema

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Fluoroscopic finding
→contrast Enema
1. Diverticula project out beyond wall of colon
2. circular muscle hypertrophy (myoclcosis coli) cause
irregularly spaced indentations and narrowing of lumen of
colon
3. Easier To distinguish colonic diverticula from polyp on
single contrast barium enema

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4. Diverticula fills with barium on single contrast barium enema
5. Diverticulum with large Neck may resemble sessile polyp on air contrast
barium enema

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 → saw_tooth appearance to the colon, with shortening of bowel, cronding Of
haustra and picket-fencing of folds

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Radiographic findings
Radiography
→ ‘’Bubbly‘’ Appearance of sigmoid in 56% of cases
→ Associated with calcified pleboliths
→ Diverticula arise adjacent wall due to weakness in bowel wall de
to penetration of vasa rectea

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CT findings
→outpouching (Diverticula) filled with air, stool or contrast agent.
→Mural thicknessing due to myoclcosis ( circular muscle hypertrophy)
usually >4mm
→ Cause irregular narrowing of colonic lumen
→ No pericolonic fluid, gas or fat standing

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Ultrasonographic findings :
Echogenic
focus from colon wall casting acoustic shadow
represents diverticulum
L

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6. Treatment
Treatment depends on a host of factors especially patient
comorbidites and stage of disease
→ For localized disease ( stage 1 and 2 ) conservative treatment
→ If the abscess is large , then percutaneous Drainage under CT or us
may be beneficial
→ Stage 3and 4 disease requires emergency surgery

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Complication
1. Abscess formation
2. Fistola formation colovesical – bladder colovaginal – vagina coloenteric fistula
bowel colouterine uterus colocultaneous - skin
3. Small bowel obstruction
4. Performation
5. Lower GI Homorrage
6. Secondary abscess formation liver tubo – ovarian abscess

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 8. Differential Dignosis
 Acute appendicitis
 Acute cholecystitis
 Colorecatal CA
 Cystits
 IBD
 IBS
 Ischemic colitis

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 Epiploic Appendagitis
 Tubi_ ovarian abscess
 Pseudomembranous colitis

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