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Fig. 15.5 Sagittal view of sinogram through a percutaneous drain demonstrated connection between the diverticular abscess and vagina. (From Rook JM, Dworsky JQ, Curran T, et al. Elective surgical management of diverticulitis. Curr Prob Surg. 2020:100876 [Fig. 4]. ISSN 0011-3840, https://doi.org/10.1016/j.

cpsurg.2020.100876, http://www.sciencedirect.com/science/article/pii/S0011384020301465.)

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BOX 15.1’Hinchley Classification of Diverticulitis

Pericolic abscess or phlegmonStage I Pelvic, intraabdominal, or retroperitoneal abscessStage II Generalized purulent peritonitisStage III Generalized fecal peritonitisStage IV

percutaneously, or if significant perforation, fistula, or bowel obstruction is present, emergent surgical treatment consisting of primary bowel resection is indi-

Fig. 15.9). Occasionally, a diverting colostomy will be required to allow

cated ( resolution of severe diverticulitis (Fig. 15.10).

COMPLICATIONS AND PITFALLS

Diverticulitis is a common cause of acute abdominal pain. Its clinical presentation can range from a mild self-limited disease to a life-threatening illness. Because of

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Fig. 15.6 Acute uncomplicated sigmoid diverticulitis in four different patients. (a) Axial contrastenhanced computed tomography (CECT) image shows wall thickening of the sigmoid colon and fat strandi ng centered arou nd a diverticulum (arrow) in a 65-year-old man. (b) Axial CECT shows inflammatory pericolic fat stranding (arrows) around the sigmoid colon with several hyperdense diverticula (arrowheads) in a 76-year-old wom an. (c) Axi al CECT shows e ngorgem ent o f the mesenteric veins (white arrow) draining a mildly inflamed segment of sigmoid colon (black arrow) in a 57-year-old man. (d) Coronal CECT shows m ultip le diverticula arising from the sigmoid colon, which is mildly thickened, with confluent inflammatory stranding of the pericolic fat (arrow- heads) in a 37-year-old woman. (From Sugi MD, Sun DC, Menias CO, et al. Acute diverticulitis: key features for guiding clinical management. Eur J Radiol. 2020;128:109026 [Fig. 3]. ISSN 0720-048X,

article/pii/S0720048X20302151.)

https://doi.org/10.1016/j. ejrad .2020 .10902 6, http://www.sciencedirect.com/science/

the number of other diseases that mimic diverticulitis, diagnosis and treatment may be delayed, leading to increased morbidity and rarely, mortality. Early implementationof broad-spectrum antibiotics and identification and drainage of pericolonic abscess are mandatory to decrease more severe complications.

Many other causes of an acute abdomen can mimic the presentation of diverticulitis. The failure to correctly identify the source of the patient’s abdominal

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Fig. 15.7 Diverticulitis on ultrasonography. The arrow indicates a diverticulum with associated bowel wall edema. The star indicates pericolonic infiltration observed as hyperechoic fat. (From Cohen A, Li T, Stankard B, et al. A prospective evaluation of point-of-care ultrasonographic diagnosis of diverticulitis in the emergency department. Ann Emerg Med. 2020 [Fig. 1]. ISSN 0196-0644,

https://doi.org/10.1016/j.annemergmed.2020.05.017, http://www.sciencedirect.com/science/article/ pii/S0196064420303656.)

15—A 64-YEAR-OLD WAITRESS WITH LEFT-SIDED ABDOMINAL PAIN AND FEVER

BOX 15.2’Diseases That May Mimic Acute Diverticulitis

Appendicitis Inflammatory bowel disease Irritable bowel syndrome Colorectal malignancies Acute gastroenteritis Ectopic pregnancy Ischemic colitis Abdominal angina Tuboovarian abscess Pelvic inflammatory disease Ureteral calculi Volvulus Ovarian torsion Endometriosis

symptoms can lead to significant morbidity and mortality. It should be remembered that right-sided diverticulitis is common in patients of Asian descent and may present identically to acute appendicitis. Early identification and drainage of abscess is essential to avoid more serious complications when treating diverticulitis.

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Fig. 15.8 Computed tomography of the pelvis demonstrates a transgluteal percutaneous drain within a diverticular pelvic abscess (arrows).(FromRookJM,DworskyJQ,CurranT,etal.Elective surgical management of diverticulitis. Curr Prob Surg. 2020:100876 [Fig. 2]. ISSN 0011- 3840,

https://doi.org/10.1016/ j.c psurg. 202 0.1008 76, http://www.sciencedirect.com/science/article/pii/ S0011384020301465.)

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Fig. 15.9 Surgical treatment of diverticular abscess. (A) Diagnostic computed tomography. (B) Percutaneous drain placed. (C) Intraoperative resection of bowel with percutaneous drain in place. (From Chapman JR, Wolff BG. The management of complicated diverticulitis. Adv Surg. 2006;40:285297.)

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15—A 64-YEAR-OLD WAITRESS WITH LEFT-SIDED ABDOMINAL PAIN AND FEVER

Fig. 15.10 Diverting transverse colostomy. (From Sugarbaker PH. Diverting transverse colostomy in a midline incision, a case report. Int J Surg Open. 2019;16:14-17 [Fig. 2]. ISSN 2405-8572, https://doi.

org/10.1016/j.ijso.2018.11.007, http://www.sciencedirect.com/science/article/pii/S2405857218300998.)

HIGH-YIELD TAKEAWAYS

• The patient is febrile, which is always a concern in a patient with abdominal

pain.

• The patient’s symptomatology is most consistent with acute diverticulitis, and

physical examination and testing should focus on the confirmation of this working diagnosis and to rule out other diseases that may mimic the clinical presentation of diverticulitis.

• The patient has left lower quadrant tenderness, which is highly suggestive of

diverticulitis.

• There is a mass in the left lower quadrant, which in this clinical setting is most

likely an abscess.

(Continued)

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• CT scanning will provide high-yield information regarding th e source of the

patient’s signs and symptoms and is highly accurate in confirming the diagnosis of diverticulitis, as well as identifying associated complications such as abscess and fistula formation.