A 66-year-old female presents with 24 hours of LIF pain and fever.
She has a background of multiple myeloma and is currently receiving chemotherapy in preparation for autologous stem cell transplant.
Her vital signs include a temperature of38.5°C, HR 80, BP 125/75, RR 16, and Sats 98% RA
On examination there is focal tenderness to the left iliac fossa (LIF) with no signs of peritonism.
Laboratory investigations reveal neutropenia with WCC 0.3 x 109/L and neutrophils 0.0 x 109/L
An abdominal CT scan was performed
Describe and interpret the CT scans
There are multiple sigmoid diverticulum with associated inflammation.
Signs of inflammation that we see here are mural thickening and pericolic fat stranding.
The mural thickening is centred around the diverticula. The wall thickening involves hyper enhancement of the inner and outer layers and hypodense oedematous middle layer.
All of these features are classical of acute diverticulitis.
There is also a small localised collection along the colon. This probably represents a small contained perforation with abscess formation.
A close differential for acute diverticulitis is colonic malignancy, however this tends to have mural thickening which is not centred around a diverticulum.
This is a case of complicated diverticulitis.
Assessing whether the patient has complicated vs uncomplicated diverticulitis is important, as this has implications for management.
Features of uncomplicated diverticulitis include;
- Thickened and enlarged diverticula
- Surrounding fat stranding (tissues appear hazy)
- There may be inflammation of the nearby structures e.g., bladder (reactive inflammation)
Features of complicated diverticulitis include;
- Diverticular perforation. Extraluminal free air – easiest to see on bone or lung windows
- Abscess formation. Contrast enhancing collection of fluid +/- air
- Fistula formation
Treatment will depend on a number of factors, especially patient comorbidities and severity of the disease.
For localised disease, intravenous antibiotics therapy is usually sufficient. If there is complicated diverticulitis, emergency surgery is often required.
For this patient, given her co-morbidities and concurrent neutropenia, she was initially managed with broad spectrum IV antibiotics. However, due to failure to improve, both clinically and on repeat CT imaging, she went on to require a Hartmann’s procedure.
- Hartung MP. Abdominal CT: diverticulitis. LITFL
TOP 100 CT SERIES
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.