What radiologists should know about tomographic evaluation of acute diverticulitis of the colon

Acute diverticulitis of the colon is a common indication for computed tomography, and its diagnosis and complications are essential to determining the proper treatment and establishing the prognosis. The adaptation of the surgical classification for computed tomography has allowed the extent of intestinal inflammation to be established, the computed tomography findings correlating with the indication for treatment. In addition, computed tomography has proven able to distinguish among the main differential diagnoses of diverticulitis. This pictorial essay aims to present the computed tomography technique, main radiological signs, major complications, and differential diagnoses, as well as to review the classification of acute diverticulitis.

Keywords:
Diverticulitis, colonic; Abdomen, acute; Tomography, X-ray computed

Authorship

Aline de Araújo Naves

Full Member of the Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Specialist Student at the Center for Imaging Sciences and Medical Physics of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, BrazilColégio Brasileiro de Radiologia e Diagnóstico por ImagemBrazilBrazilFull Member of the Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Specialist Student at the Center for Imaging Sciences and Medical Physics of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil

Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Ribeirão Preto, SP, BrazilUniversidade de São PauloBrazilRibeirão Preto, SP, BrazilUniversidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Ribeirão Preto, SP, Brazil

Giuseppe D'Ippolito

Tenured Professor in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM/Unifesp), São Paulo, SP, BrazilUniversidade Federal de São PauloBrazilSão Paulo, SP, BrazilTenured Professor in the Department of Diagnostic Imaging of the Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM/Unifesp), São Paulo, SP, Brazil

Luis Ronan Marquez Ferreira Souza

PhD, Associate Professor of Radiology at the Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, BrazilUniversidade Federal do Triângulo MineiroBrazilUberaba, MG, BrazilPhD, Associate Professor of Radiology at the Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil

Sílvia Portela Borges

Medical Student at the Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, BrazilUniversidade Federal do Triângulo MineiroBrazilUberaba, MG, BrazilMedical Student at the Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil

Glênio Moraes Fernandes

Specialist in Coloproctology, Preceptor at the Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, BrazilUniversidade Federal do Triângulo MineiroBrazilUberaba, MG, BrazilSpecialist in Coloproctology, Preceptor at the Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil

Mailing address: Dr. Luis Ronan Marquez Ferreira Souza. UFTM – Disciplina de Radiologia e Diagnóstico por Imagem. Avenida Claricinda Alves de Rezende, 1650, L9Q9. Uberaba, MG, Brazil, 38081-793. E-mail: luisronan@gmail.com

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (14)

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Figure 1
Inflamed diverticulum. Intravenous contrast-enhanced axial CT of the abdomen, showing the diverticulum with discrete wall thickening (arrow) and increased attenuation of pericolonic fat.

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Figure 2
Wall thickening. Intravenous and rectal contrast-enhanced coronal CT scan of the abdomen, showing colonic diverticula associated with thickening of the intestinal wall to > 1.0 cm, with an extent of 8.0 cm (arrow).

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Figure 3
Inflammatory signs in pericolonic fat. Intravenous and rectal contrastenhanced axillary CT, in the axial plane, showing increased mesenteric fat attenuation (arrow) adjacent to the inflammatory process in the diverticula.

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Figure 4
A,B: Rectal contrast-enhanced CT of abdomen showing signs of acute diverticulitis, characterized by sigmoid wall thickening, diverticula, and increased regional fat density (arrow in A), as well as extraluminal gas, indicating pneumoperitoneum (arrows in B). C: Signs of intestinal perforation. Intravenous contrast-enhanced abdominal CT, in the axial plane, showing pneumoretroperitoneum (arrows) secondary to diverticulitis.

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Figure 5
Pericolonic/distal abscess. Intravenous contrast-enhanced abdominal CT, in the axial plane, showing heterogenous fluid collections (arrows) surrounded by a hyperintense halo with contrast enhancement.

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Figure 6
Fistulas to adjacent organs. Rectal contrast-enhanced CT of the abdomen, in the sagittal plane, showing a fistulous pathway between the inflamed colonic segment and the vagina (colovaginal fistula). The diagnostic hypothesis of fistula can be suggested when there is inflammatory tissue or obliteration and increased density of the fat between the colon and the adjacent organs, as well as intraluminal gas (in the bladder, vaginal canal, or other lumen).

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Figure 7
Hinchey stage 0. Intravenous contrast-enhanced abdominal CT, in the axial plane, showing colonic diverticula (arrow), with discrete wall thickening.

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Figure 8
Hinchey stage Ia. Abdominal CT, in the coronal plane, without contrast. Note the wall thickening of the descending colon, accompanied by a perforated diverticulum at the mesenteric border (arrow) and increased density of the adjacent fat, without any fluid collections.

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Figure 9
Hinchey stage Ib. Intravenous contrast-enhanced abdominal CT, in the coronal plane, showing wall thickening of the sigmoid, with an adjacent pericolonic abscess (arrows).

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Figure 10
Hinchey stage II. Intravenous and rectal contrast-enhanced axial CT of the abdomen. Note the thickened and finely heterogeneous walls of the sigmoid (arrows in A) and the hepatic abscess (arrows in B) related to the inflammatory process in the colon.

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Figure 11
Hinchey stage III. Intravenous and rectal contrast-enhanced axial CT of the abdomen showing diverticulitis with multiple abscesses (arrow) in the inframesocolic region and pneumoperitoneum, together with generalized peritonitis.

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Figure 12
Intravenous contrast-enhanced axial CT of the abdomen showing diverticulitis with perforation and pelvic abscesses with heterogeneous content (arrow) in a patient who subsequently underwent surgery, during which a large amount of pus and feces were found in the peritoneal cavity.

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Figure 13
Thrombosis of the portal vein. Intravenous and rectal contrast-enhanced axial CT of the abdomen showing a thrombus within the superior mesenteric vein (arrow in A), together with acute perforated and blocked diverticulitis (arrow in B), in a patient with diabetes.

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Figure 14
Adenocarcinoma of the colon. Intravenous and rectal contrast-enhanced coronal CT of the abdomen, showing asymmetric wall thickening in the descending colon (arrow), with an abrupt transition to the normal loop (the shoulder sign)

Figure 1 Inflamed diverticulum. Intravenous contrast-enhanced axial CT of the abdomen, showing the diverticulum with discrete wall thickening (arrow) and increased attenuation of pericolonic fat.

Figure 2 Wall thickening. Intravenous and rectal contrast-enhanced coronal CT scan of the abdomen, showing colonic diverticula associated with thickening of the intestinal wall to > 1.0 cm, with an extent of 8.0 cm (arrow).

Figure 3 Inflammatory signs in pericolonic fat. Intravenous and rectal contrastenhanced axillary CT, in the axial plane, showing increased mesenteric fat attenuation (arrow) adjacent to the inflammatory process in the diverticula.

Figure 4 A,B: Rectal contrast-enhanced CT of abdomen showing signs of acute diverticulitis, characterized by sigmoid wall thickening, diverticula, and increased regional fat density (arrow in A), as well as extraluminal gas, indicating pneumoperitoneum (arrows in B). C: Signs of intestinal perforation. Intravenous contrast-enhanced abdominal CT, in the axial plane, showing pneumoretroperitoneum (arrows) secondary to diverticulitis.

Figure 5 Pericolonic/distal abscess. Intravenous contrast-enhanced abdominal CT, in the axial plane, showing heterogenous fluid collections (arrows) surrounded by a hyperintense halo with contrast enhancement.

Figure 6 Fistulas to adjacent organs. Rectal contrast-enhanced CT of the abdomen, in the sagittal plane, showing a fistulous pathway between the inflamed colonic segment and the vagina (colovaginal fistula). The diagnostic hypothesis of fistula can be suggested when there is inflammatory tissue or obliteration and increased density of the fat between the colon and the adjacent organs, as well as intraluminal gas (in the bladder, vaginal canal, or other lumen).

Figure 7 Hinchey stage 0. Intravenous contrast-enhanced abdominal CT, in the axial plane, showing colonic diverticula (arrow), with discrete wall thickening.

Figure 8 Hinchey stage Ia. Abdominal CT, in the coronal plane, without contrast. Note the wall thickening of the descending colon, accompanied by a perforated diverticulum at the mesenteric border (arrow) and increased density of the adjacent fat, without any fluid collections.

Figure 9 Hinchey stage Ib. Intravenous contrast-enhanced abdominal CT, in the coronal plane, showing wall thickening of the sigmoid, with an adjacent pericolonic abscess (arrows).

Figure 10 Hinchey stage II. Intravenous and rectal contrast-enhanced axial CT of the abdomen. Note the thickened and finely heterogeneous walls of the sigmoid (arrows in A) and the hepatic abscess (arrows in B) related to the inflammatory process in the colon.

Figure 11 Hinchey stage III. Intravenous and rectal contrast-enhanced axial CT of the abdomen showing diverticulitis with multiple abscesses (arrow) in the inframesocolic region and pneumoperitoneum, together with generalized peritonitis.

Figure 12 Intravenous contrast-enhanced axial CT of the abdomen showing diverticulitis with perforation and pelvic abscesses with heterogeneous content (arrow) in a patient who subsequently underwent surgery, during which a large amount of pus and feces were found in the peritoneal cavity.

Figure 13 Thrombosis of the portal vein. Intravenous and rectal contrast-enhanced axial CT of the abdomen showing a thrombus within the superior mesenteric vein (arrow in A), together with acute perforated and blocked diverticulitis (arrow in B), in a patient with diabetes.

Figure 14 Adenocarcinoma of the colon. Intravenous and rectal contrast-enhanced coronal CT of the abdomen, showing asymmetric wall thickening in the descending colon (arrow), with an abrupt transition to the normal loop (the shoulder sign)

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What radiologists should know about tomographic evaluation of acute diverticulitis of the colon

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[1] Mailing address: Dr. Luis Ronan Marquez Ferreira Souza. UFTM – Disciplina de Radiologia e Diagnóstico por Imagem. Avenida Claricinda Alves de Rezende, 1650, L9Q9. Uberaba, MG, Brazil, 38081-793. E-mail: luisronan@gmail.com