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Likelihood Ratio (LR) in Emergency Medicine

4/10/2013

Imaging strategies of suspected acute colonic diverticulitis: how does it work?

Clinical scenario

A 66 yo man complains of left lower quadrant (LLQ) pain, anoressia and fever, it is the first time. The pain is acute, there is not vomit, temperature is 38°C. Abdomen is treatable, with severe pain and tenderness localized at LLQ , there is not history of prior abdominal surgery. Probably this patient suffers of an acute colonic diverticulitis (ACD).



Is Computer Thomography (CT) the imaging procedure of choice for this patient? 













Conclusion 

In a recent post we saw that the clinical diagnosis of diverticulitis has a high specificity but a poor sensitivity.
The Guidelines for sigmoid diverticulitis from the American Society of Colon and Rectal Surgeons say: “CT scan is tipically the examination of choice for patients with suspected diverticulitis who require diagnostic imaging.” 
Recent systematic reviewes demostrated that US has yelded similar results those of CT. Furthermore the costs are lower, doesn’t use contrast e doesn’t use ionizing radiation (the patient that suffers of ACD is prone at recurrence and conseguently at multiple abdominal CT). 
Obviously the enemies of US are fat and inexperience of operator.
In summary, if an imaging is necessary US could be the first test.
When is abdominal CT necessary?
When US is inconclusive, when there is a generalized peritonitis, when there is a large abscess.

Enjoy Ultrasound!!!!

Bibliography

J Rafferty
Practice parameters for sigmoid diverticulitis.
Dis Colon Rectum 2006 49 930-944

N de Korte
Suspected left sided diverticulitis.
BMJ 2013; 346 f928

W Lameris
Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta analysis of test accuracy.
Eur Radiol 2008 18: 2498-2511

Ciro Paolillo

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