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Small-Bowel Diverticulitis by bcs24005



                                                          Small-Bowel                                            Diverticulitis:                                          CT

                           Susan      Greenstein1            Three patients         with subsequently        proven       small-bowel       diverticulitis    were studied    with
                               Bronwyn      Jones1        preoperative   CT. In all three cases,     an inflammatory       mass was present, two involving
                             Elliot K. Fishman1           the terminal  ileum and cecum and one involving the jejunum.               While the findings in the
                                                          two cases of ileal diverticulitis  simulated    appendicitis,    in the case of jejunal diverticulitis
                            John L. Cameron2
                                                          the diagnosis    was suggested      on the basis of CT findings.          Small-bowel   diverticulitis
                      Stanley      S. Siegelman1
                                                          should be included    in the differential    diagnosis     if an inflammatory     mass involving the
                                                          small bowel is demonstrated       on CT.

                                                              CT has become           increasingly       important        in the evaluation         of inflammatory     diseases
                                                          of the gastrointestinal            tract,   especially          in those       diseases      with the potential       for
                                                          abscess formation:     Crohn’s    disease    [1             ,   2], appendicitis    [3], and diverticulitis          [4].
                                                          Owing to its superiority     in demonstrating                      the extracolonic     extent of disease,            CT
                                                          has been          used as an adjunct        and, under certain             circumstances,           as an alternative
                                                          to barium          studies.   We present  the CT findings   in three cases of small-bowel
                                                          diverticulitis,       two in the ileum and one in the jejunum.       In all three cases, CT
                                                          delineated        the location and extent of disease, and in the case ofjejunal  diverticulitis,
                                                          the diagnosis           was suggested       preoperatively          based on the CT findings.

                                                          Materials         and    Methods

                                                             The patients         were imaged on either a Siemens              (Iselin, NJ) DR-3 or a Pfizer (Cambridge,
                                                          MA) AS&E 0500 scanner. The scanning           parameters were either 5.2 sec, 450 mAs, and 4-
                                                          mm collimation       or 10-sec, 200 mAs, and 10 mm, respectively.    The patients received    oral
                                                          contrast     medium     (four divided doses of 250 ml each) over a 90-mm period before the
                                                          examination.      IV contrast  medium (100 ml of 60% hypaque [meglumine diatrizoate])    adminis-
                                                          tered as a drip infusion was used as needed.                    All patients     were scanned       at 1 .5-cm intervals
                                                          from the diaphragm          to the symphysis       pubis   with additional       scans     as needed.

                                                          Case     1

                                                             A 50-year-old    woman    presented  with a 1 -day history of epigastnc pain. On physical
                                                          examination,    she was febrile with abdominal tenderness below the umbilicus more marked
                                                          on the left side with questionable             rebound. White-blood count was 15,700/mm3 with a left
      Received March 7, 1986; accepted   April 3, 1986.   shift. A plain radiograph    of the abdomen        was unremarkable.       The preliminary    diagnosis   was
     ‘Department   of Radiology and Radiological Sci-     sigmoid diverticulitis.   CT performed      to further delineate    the extent of disease demonstrated
ence, The Johns Hopkins Medical Institutions, Bal-        an inflammatory       mass containing    a few small air bubbles involving several loops of jejunum
timore, MD 21205. Address reprint requests to B.
                                                          in the left-lower quadrant. A contrast-filled         diverticulum (Fig. 1) was present in the jejunum
Jones, Dept. of Radiology, The Johns Hopkins Hos-
pital, 600 N. Wolfe St., Baltimore, MD 21205.             adjacent to the inflammatory        mass, and the diagnosis       of jejunal diverticulitis  was suggested
     2              of Surgery, The Johns Hopkins         on the basis of the CT findings. A gastrografin            enema performed     the following    day revealed
Medical Institutions, Baltimore, MD 21205.                extrinsic compression     of the distal sigmoid colon with scattered diverticula in the hepatic
                                                          flexure. At surgery a perforated jejunal diverticulum with associated abscess was found, and
AJR    147:271-274,   August   1986
0361-803X/86/1472-0271                                    resection with end-to-end small-bowel anastomosis was performed. Gross pathology revealed
C American Roentgen Ray Society                           a single perforated  jejunal diverticulum  with a 3 x 3 x 0.5 cm mesenteric abscess.
272                                                                                 GREENSTEIN           ET     AL.                                                       AJR:147, August 1986

    Fig. 1 -50-year-old woman with left-lower-quadrant   pain, which was considered consistent with sigmoid diverticulitis. A, Inflammatory mass adjacent to loops
of jejunum. A small bubble (arrow) is seen within inflammatory mass. B, Scan 2 cm caudal to image A shows inflammatory mass adjacent to jejunal loop. Small-
bowel diverticulum suggested (arrow).

Case 2                                                                                                gastrografin     studies,   only one revealed clear signs of inflam-
     A 46-year-old       man presented         with a 1 -week history of abdominal
                                                                                                      matory disease,        demonstrating      mass impression  on the me-
pain. Physical examination             revealed right lower quadrant               tenderness         dial wall of the cecum with serosal spiculation.          None of the
with minimal guarding and a temperature                                    The white-blood
                                                             of 38.6#{176}C.                          patients     had small-bowel      studies performed.
count was 8300/mm3.              On clinical grounds,           the provisional      diagnosis           In all three cases CT demonstrated                       an inflammatory             mass,
was appendicitis. An abdominal                  radiograph        was nonspecific         with a      in case      1 in the     left   lower    quadrant        and     in cases      2 and 3 in
few air-fluid       levels in the transverse             colon. CT demonstrated                 an    the right lower quadrant.                In case 1 with jejunal
                                                                                                                                                            ,                      diverticulitis,
inflammatory        process containing          air bubbles in the right-lower            quad-       the inflammatory  mass adjacent   to a loop of jejunum   con-
rant that involved the cecum and was thought to represent                             a sealed-       tamed a small air bubble; superior to the mass, intraluminal
off perforation        (Fig. 2). A differential        diagnosis      of appendicitis        with
                                                                                                      contrast material demonstrated    a single diverticulum.     In the
abscess      or a perforated          right-sided       diverticulum      was suggested.
                                                                                                      remaining two cases, with ileal diverticulitis, the inflammatory
Gastrografin        enema demonstrated              mass impression          on the medial
wall of the cecum             with serosal         spiculation      and a persistent            air
                                                                                                      mass was medial to the cecum, contained a moderate amount
collection    inferior to the cecum. At surgery, an abscess in the region                             of gas centrally (in one case), and involved the cecum in one
of the cecum was found. An ileocecal resection                        was performed          with     case and both cecum and terminal          ileum in the other. The
creation    of an ileostomy         and mucous            fistula. Gross pathology             re-    preoperative    diagnosis based on clinical and CT findings        in
vealed a perforated          ileal diverticulum        with an abscess          involving     the     the first case was small-bowel    diverticulitis  and in the latter
mesenteric       soft tissues adjacent to the terminal ileum and cecum.                               two cases appendicitis.

Case 3                                                                                                Discussion
   An 82-year-old        man presented      with a 2-day history of right lower                          Diverticulosis of the jejunum      and ileum is an uncommon
quadrant      pain and vomiting.        Physical    examination   revealed     right-
                                                                                                      entity, with a reported    prevalence     on conventional  barium
lower-quadrant        tenderness.    White-blood     count was 1 2,800/mm3.        An
                                                                                                      studies      of 0.3-1 .9% [5, 6] and at autopsy                      of 0.3-1 .3% [7].
abdominal      radiograph     was nonspecific    with scattered    air-fluid levels.
                                                                                                      However,        a recently       published    study       using    enterocylsis         found
A preliminary      diagnosis    of acute appendicitis     was made. CT revealed
an inflammatory          mass in the right lower quadrant           involving     the                 diverticula ofthejejunum      and ileum in 2.3% of patients studied
terminal ileum and cecum (Fig. 3). The differential diagnosis was                                     by this technique [8]. Small-bowel        diverticula found inciden-
appendiceal abscess or sealed off cecal perforation.      At surgery,  a                              tally on small-bowel       series or barium enema are usually
perforated ileal diverticulum was found. An ileocecal resection was                                   asymptomatic      [5, 6]. Acute complications      including diverticu-
performed with creation of an end-to-end   ileocolostomy.     On gross                                litis, perforation,        obstruction,       and hemorrhage              are relatively
pathology,  there were            multiple ileal diverticula  with diverticulitis              in-    rare, occurring         in 6.5-1 0.4%        of patients [9].
volving one diverticulum           with perforation    and acute peritonitis.                           There are no pathognomonic       signs or symptoms of small-
                                                                                                      bowel diverticulitis. The clinical spectrum in reported cases
                                                                                                      varies from intermittent          abdominal     pain to an acute abdomen
                                                                                                      with leukocytosis          and fever [6, 9-15].         In the reported       cases
    The clinical presentation in two of the cases was of appen-                                       of ileal diverticulitis,      the most common               clinical presentation
dicitis and in the third case was of sigmoid      diverticulitis. In                                  mimicked    acute appendicitis          [7, 9, 10-12].
none of the cases was the plain film helpful.          Of the two                                        The diagnosis         of small-bowel     diverticulitis,        therefore,  is not
AJR:147, August 1986                                                SMALL-BOWEL       DIVERTICULITIS                                                                      273

   Fig. 2-46-year-old   man with a 1-week history of abdominal pain. Physical           cecum (arrows). B, Scan caudal to A demonstrates inflammatory mass with
exam was remarkable for right-lower-quadrant      tenderness consistent with            central air bubbles (arrow). This suggested perforation of a viscus, probably
appendicitis. A, Inflammatory process seen in right lower quadrant medial to            the appendix or cecum.

                                                                                        for a possible   intraabdominal           inflammatory      process.     The CT
                                                                                        findings in small-bowel        diverticulitis     have not previously         been
                                                                                        described.   However,      the value of CT in the workup of patients
                                                                                        with other inflammatory         diseases        of the gastrointestinal       tract
                                                                                        is well documented        [1 -4, 1 6, 17]. In inflammatory              diseases
                                                                                        that have the propensity        for phlegmon         and abscess formation,
                                                                                        such as Crohn’s      disease, sigmoid diverticulitis,            and appendi-
                                                                                        citis, CT has proved          to be superior           to barium      studies      in
                                                                                        demonstrating        the mural,        serosal,    and mesentenc         extent     of
                                                                                        disease [1-4].
                                                                                            When an abscess     is present,   CT findings     may include
                                                                                        relatively smooth margins, areas of low attenuation       within the
                                                                                        mass, nm enhancement      after IV contrast  administration,     gas
                                                                                        within the mass, displacement               of surrounding        structures,     and
                                                                                       edema of thickening        of the surrounding     fat or fascial planes
    Fig. 3-82-year-old   man with a 2-day history of right-lower-quadrant  pain        [3, 1 6, 1 7]. Unfortunately,    these findings     are not specific for
radiating to the left lower quadrant. Preliminary diagnosis was appendicitis.          abscess,    as low-attenuation      areas may be found in necrotic
Inflammatory mass in right lower quadrant involving terminal ileum (arrow) and
cecum (arrowhead).                                                                     tumor or hematoma,         rim enhancement       may be found in neo-
                                                                                       plasm or phlegmon,        and thickening    of the fascial planes may
                                                                                       be seen with neoplastic            invasion,       hemorrhage,       and radiation
often made preoperatively.            In most of the previously         reported       change [3, 16, 1 7]. The most specific sign of an abscess          is
cases of small-bowel         diverticulitis,     the presumptive       diagnosis       probably    the presence    of gas within the mass. However,      in
before surgery included perforated                 ulcer, appendicitis,     or co-     two reported series evaluating the CT findings in abdominal
Ionic diverticulitis   [9, 1 1 1 2]. There are reports in the surgical
                                  ,                                                    abscesses, gas was found in only two (1 1 %) of 19 patients
literature   stressing    the difficulty       of recognizing     small-bowel          in one series   [1 6] and in 1 1 (38%) of 29 patients in the other
diverticula   at surgery,     including      cases where a missed perfo-                [17].
rated   diverticulum     was     responsible        for the death    of the patient       In the patient under discussion      with jejunal diverticulitis
[9]. The reported       mortality for perforated   small-bowel     divertic-           (case 1), CT revealed   an inflammatory      mass containing        air
ula is 21-40%      [9].                                                                with     edema    of the    mesentery        and    intraluminal     contrast      ma-
    Plain-film diagnosis        has not been helpful [15]. There are                   terial outlining    an adjacent      jejunal diverticulum.          Although      the
only isolated     reports       in the literature where     barium    study            clinical diagnosis      was sigmoid         diverticulitis,     CT localized      the
suggested       the diagnosis,        with   findings   including    extravasation     inflammatory       process      to the jejunum,             and the CT findings
of barium into an abscess      cavity adjacent    to a diverticulum,                   were thought to be suggestive              of jejunal diverticulitis.      Included
mucosal edema and luminal narrowing         with associated       diver-               in the differential      diagnosis      would be a small-bowel                 tumor
ticula, an omental    mass displacing     small-bowel     loops, and                   with sealed-off       perforation,      although        the findings     of a gas-
serosal changes    in the colon [10, 14, 15].                                          containing      mass associated          with a nearby diverticulum               are
    In the cases under discussion,    CT was performed          to look                more suggestive         of small-bowel          diverticulitis.    Based on the
274                                                                            GREENSTEIN     ET AL.                                                             AJR:147, August 1986

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