Acute diverticulitis of the appendix.

Acute diverticulitis of the appendix (ADA), though uncommon, often presents similarly to acute appendicitis but carries a higher risk of complications such as perforation and malignancy. We report the case of a male patient in his 50s with acute right iliac fossa abdominal pain, diagnosed via CT scan with ADA. Urgent laparoscopic appendicectomy was performed, and the patient was discharged without further issues. This case highlights the importance of promptly identifying and managing such conditions to minimise complications and improve outcomes. Despite the overlap in symptoms between appendiceal diverticulitis and acute appendicitis, accurate diagnosis is crucial for appropriate treatment. Healthcare providers should maintain a high index of suspicion, particularly in older patients presenting with an acute appendicitis, like clinical picture to ensure timely intervention and optimal patient care.

Diverticulosis morphology is associated with risk of diverticulitis.

The size, number and distribution of diverticula vary greatly in patients with diverticulosis. We aimed to study the association between the morphology of diverticulosis assessed on colonoscopy and the risk of diverticulitis. We performed a retrospective, case-control study of cases with a history of diverticulitis and controls with diverticulosis without diverticulitis matched on sex, age (within 5 years) and year of colonoscopy. Diverticulosis characteristics were obtained from endoscopy reports and were categorized according to severity, extent, number and size. We used conditional logistic regression on matched pairs to calculate the odds of diverticulitis among patients with diverticulosis according to differing morphologic characteristics. We identified 85 cases with computed tomography-documented diverticulitis and 85 matched controls with diverticulosis without a diagnosis of diverticulitis. In cases, 60% had left-sided only diverticulosis, 2% had right-sided only and 38% had both right and left-sided diverticulosis; whereas in controls, the distribution was 53%, 18% and 29%, respectively. Cases were more likely to have large diverticula [odds ratio (OR), 3.33; 95% confidence interval (CI), 1.30-8.56 for left colon only and 1.89, 95% CI, 0.78-4.57 for both right and left]. Similarly, when the severity of diverticulosis was compared between the groups, cases were more likely to have moderate or severe diverticulosis (OR, 3.44; 95% CI, 1.51-7.84 for moderate and OR, 8.87; 95% CI, 2.98-26.37 for severe). Diverticulitis cases were more likely to have large diverticula and severe diverticulosis when compared to controls suggesting that size and severity are novel risk factors for diverticulitis.

Is reassessment of Computed Tomography Reports Worthwhile in Acute Diverticulitis?

INTRODUCTION: Since the assessment of the disease severity in acute diverticulitis (AD) is of utmost importance to determine the optimal treatment and the need for follow-up investigations, we wanted to investigate whether the first CT report is compatible with daytime reassessment report and whether the value of initial report changes according to the experience of the radiologist. METHODS: Consecutive patients from tertiary referral centre with AD were included. CT images done in the emergency department were initially analysed by either resident radiologists or consultant radiologists and then later reanalysed by consultant abdominal radiologists. Discrepancies between reports were noted. RESULTS: Of total of 562 patients with AD, CT images were reanalysed in 439 cases. In 22 reports (5.0%) the final report was significantly different from the initial report and management changed in 20 cases. In reports of uncomplicated acute diverticulitis, reanalysis changed initial assessment in 4.0% of the cases and in complicated acute diverticulitis (CAD) in 9.1%. When consultant and resident radiologists were compared, there was no significant difference. CONCLUSION: Although no statistical difference could be noted between residents and consultants, the final report was significantly different in overall 5% of the cases when reanalysed at normal working hours by an experienced consultant abdominal radiologist. Therefore, we conclude that reassessment of CT reports is worthwhile in AD.

Emergency medicine updates: Acute diverticulitis.

INTRODUCTION: Acute diverticulitis is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease. OBJECTIVE: This paper evaluates key evidence-based updates concerning acute diverticulitis for the emergency clinician. DISCUSSION: Diverticulitis is a complication of diverticulosis and most commonly affects the sigmoid and descending colon in Western countries. History and examination can suggest the diagnosis, with abdominal pain and tenderness in the left lower quadrant being the most common symptom and sign, respectively. Change in bowel habits and fever may also occur. Laboratory testing may demonstrate leukocytosis or an elevated C-reactive protein. Imaging options can include computed tomography (CT) of the abdomen and pelvis with intravenous contrast, magnetic resonance imaging (MRI), or ultrasound (US), though most classification systems for diverticulitis incorporate CT findings. While the majority of diverticulitis cases are uncomplicated, complications may affect up to 25% of patients. Treatment of complicated diverticulitis requires antibiotics and surgical consultation. Antibiotics are not required in select patients with uncomplicated diverticulitis. Appropriate patients for supportive care without antibiotics should be well-appearing, have pain adequately controlled, be able to tolerate oral intake, be able to follow up, have no complications, and have no immunocompromise or severe comorbidities. CONCLUSIONS: An understanding of literature updates can improve the ED care of patients with acute diverticulitis.

Preoperative CT diagnosis of perforated Meckel's diverticulitis in a young patient: a case report.

OBJECTIVES: Meckel's diverticulum (MD) is a common asymptomatic congenital intestinal anomaly. Clinical manifestations of MD can occur in about 4 % of cases by the presentation of its complications, generally intestinal occlusion, bleeding, and diverticular inflammation. MD's complications are challenging preoperative diagnoses, as manifest with clinical symptoms that overlap with those of other acute non-traumatic abdominal diseases. Thus, in the emergency setting, abdominal computed tomography (CT) represents an essential tool for the correct diagnosis of complicated MD. CASE PRESENTATION: We present a case of a preoperative CT diagnosis of perforated Meckel's diverticulitis in a young patient admitted to our Emergency Department complaining of acute abdominal pain. CONCLUSIONS: The case highlights the importance of evaluating Meckel's diverticulum complications among the differential diagnoses of acute non-traumatic abdominal pain and the high sensitivity of CT in assessing their presence in the proper clinical setting.

Primary Epiploic Appendagitis: A Mimicker of Abdominal Pain.

Epiploic appendagitis is a rare cause of acute lower abdominal pain. Epiploic appendices are fat-filled serosal outpouchings of the cecum and sigmoid colon. Primary epiploic appendagitis (PEA) is characterized by epiploic inflammation caused by torsion of the appendage leading to ischemia or thrombosis of the appendage draining vein. Secondary epiploic appendagitis occurs in association with other inflammatory conditions of the abdomen or pelvis, most commonly diverticulitis. PEA is an important clinical mimicker of more severe causes of acute abdominal pain, such as diverticulitis, appendicitis, or gynaecological causes. The ease of access to computed tomography (CT), the diagnostic test of choice, has resulted in increased recognition of PEA. The classic CT findings of PEA are an ovoid mass measuring between 1.5 and 3.5 cm surrounded by a hyperattenuating/hyperdense ring with a centrally located hyperdense area. It is important to diagnose PEA as it is self-limiting and the correct diagnosis can prevent unnecessary hospital admission, antibiotic use, or even surgical intervention. We present a case of a 65-year-old male with a history of diverticulitis, presenting with left lower quadrant abdominal pain who was diagnosed with PEA based on CT and successfully managed with conservative treatment.

Giant sigmoid diverticulum.

Unlike acute diverticulitis, giant diverticulum larger than 4 cm is a rare entity with few cases described in the literature. We present a case of a 66-year-old male patient diagnosed with colonic diverticulosis. He presented to the emergency department with symptoms of acute abdomen and was diagnosed by CT scan with a 13x14 cm giant diverticulum showing signs of complication. Given the findings, an urgent surgical intervention was decided, and diverticulectomy at the diverticular neck was performed using an endostapler. The etiology of giant diverticula is related to a mechanism of one-way valve at the diverticular neck. Diagnosis poses a challenge as the clinical presentation is nonspecific. The imaging modality of choice is CT scan, which reveals a large cystic image dependent on the sigmoid colon. Definitive treatment is surgical, either by resecting the affected segment including the lesion or by performing a simple diverticulectomy in uncomplicated cases.

[Meckel's diverticulitis, an uncommon cause of acute abdomen]. / Diverticulitis de Meckel, una causa poco frecuente de abdomen agudo.

Meckel's diverticulum corresponds to the aberrant involution of the omphalo-mesenteric canal or vitelline duct, which is located at the level of the antimesenteric border of the terminal ileum. It is the most common structural anomaly of the gastrointestinal tract, it is almost always asymptomatic and its diagnosis is usually incidental, however the complication with diverticulitis is an unusual condition. We describe the case of a 65-year-oldman, who was admitted from another institution with a diagnosis of acute abdomen. On physical examination, he presented signs of peritoneal irritation with evidence of leukocytosis and neutrophilia in the admission blood count. Computerized tomography of the abdomen with intra venous contrast was performed, which was interpreted as complicated Meckel's diverticulitis, being corroborated during the surgical act and confirmed by pathological anatomy. Meckel's diverticulitis is a rare entity, however it is important to recognize it within the differential diagnoses of acute abdomen, which will allow prompt intervention and a favorable outcome.

El divertículo de Meckel (DM) corresponde a la involución aberrante del canal onfalo-mesentérico o conducto vitelino, el cual se ubica a nivel del borde antimesentérico del íleon terminal. Es la anomalía estructural más común del tracto gastrointestinal, casi siempre es asintomático y su diagnóstico por lo general es incidental, sin embargo, la complicación con diverticulitis es una condición poco usual. Describimos el caso de un hombre de 65 años, que ingresó referido de otra institución con diagnóstico de abdomen agudo, al examen físico presentó signos de irritación peritoneal con evidencia de leucocitosis y neutrofilia en hemograma de ingreso. Se realizó tomografía computarizada de abdomen con contraste endovenoso, la cual se interpretó como diverticulitis de Meckel complicada, siendo corroborado durante el acto quirúrgico y confirmado mediante anatomía patológica. La diverticulitis de Meckel es una entidad rara, sin embargo, es importante reconocerla dentro de los diagnósticos diferenciales de abdomen agudo, lo cual permitirá una pronta intervención y un favorable desenlace.

¿Cómo diagnosticamos la diverticulitis aguda? Resultados de una encuesta nacional sobre el papel de las técnicas de imagen / How do we diagnose acute diverticulitis? Results of a national survey about the role of imaging techniques

Introducción: La elección de las técnicas de imagen en el diagnóstico de la diverticulitis aguda (DA) es un motivo de controversia. Los objetivos del estudio fueron conocer las preferencias de los radiólogos y el grado de utilización de las distintas técnicas en su manejo radiológico. Métodos: Se difundió una encuesta por Internet a través de la Sociedad Española de Diagnóstico por Imagen del Abdomen (SEDIA) y Twitter, con preguntas sobre ámbito de trabajo, protocolización, preferencias personales y la realidad asistencial en el manejo radiológico de la DA. Resultados: Se obtuvieron 186 respuestas. El 72% de los radiólogos encuestados trabaja en servicios organizados por «órgano y sistema» (S-OS). Existe protocolo de manejo de DA en un el 48% de los servicios, siendo en el 47,5% la ecografía la técnica de inicio. El 73% de los encuestados cree que la ecografía debería ser la primera opción diagnóstica, pero en realidad esto solo se efectúa en un 24% de los servicios, realizándose tomografía computarizada en el 32,8%, con diferencias significativas en horario de guardia. La clasificación más utilizada es la de Hinchey (75%). El 96% de los encuestados desearía un consenso de especialidad para utilizar la misma clasificación. Existe mayor tasa de protocolización, utilización de clasificaciones y mayor creencia en la ecografía como técnica inicial en S-OS y en hospitales con más de 500 camas. Conclusiones: Hay una gran variabilidad en el manejo radiológico de la DA, con divergencias en los protocolos utilizados y entre las opiniones de los radiólogos y la práctica clínica real.(AU)

Introduction: The choice of imaging techniques in the diagnosis of acute diverticulitis is controversial. This study aimed to determine radiologists’ preferences for different imaging techniques in the management of acute diverticulitis and the extent to which they use the different radiologic techniques for this purpose. Methods: An online survey was disseminated through the Spanish Society of Abdominal Imaging (Sociedad Española de Diagnóstico por Imagen del Abdomen (SEDIA)) and Twitter. The survey included questions about respondents’ working environments, protocolization, personal preferences, and actual practice in the radiological management of acute diverticulitis. Results: A total of 186 responses were obtained, 72% from radiologists working in departments organized by organ/systems. Protocols for managing acute diverticulitis were in force in 48% of departments. Ultrasonography was the initial imaging technique in 47.5%, and 73% of the respondents considered that ultrasonography should be the first-choice technique; however, in practice, ultrasonography was the initial imaging technique in only 24% of departments. Computed tomography was the first imaging technique in 32.8% of departments, and its use was significantly more common outside normal working hours. The most frequently employed classification was the Hinchey classification (75%). Nearly all (96%) respondents expressed a desire for a consensus within the specialty about using the same classification. Hospitals with>500 beds and those organized by organ/systems had higher rates of protocolization, use of classifications, and belief that ultrasonography is the best first-line imaging technique. Conclusions: The radiologic management of acute diverticulitis varies widely, with differences in the protocols used, radiologists’ opinions, and actual clinical practice.(AU)

How do we diagnose acute diverticulitis? Results of a national survey about the role of imaging techniques.

INTRODUCTION: The choice of imaging techniques in the diagnosis of acute diverticulitis is controversial. This study aimed to determine radiologists' preferences for different imaging techniques in the management of acute diverticulitis and the extent to which they use the different radiologic techniques for this purpose. METHODS: An online survey was disseminated through the Spanish Society of Abdominal Imaging (Sociedad Española de Diagnóstico por Imagen del Abdomen (SEDIA)) and Twitter. The survey included questions about respondents' working environments, protocolization, personal preferences, and actual practice in the radiological management of acute diverticulitis. RESULTS: A total of 186 responses were obtained, 72% from radiologists working in departments organized by organ/systems. Protocols for managing acute diverticulitis were in force in 48% of departments. Ultrasonography was the initial imaging technique in 47.5%, and 73% of the respondents considered that ultrasonography should be the first-choice technique; however, in practice, ultrasonography was the initial imaging technique in only 24% of departments. Computed tomography was the first imaging technique in 32.8% of departments, and its use was significantly more common outside normal working hours. The most frequently employed classification was the Hinchey classification (75%). Nearly all (96%) respondents expressed a desire for a consensus within the specialty about using the same classification. Hospitals with >500 beds and those organized by organ/systems had higher rates of protocolization, use of classifications, and belief that ultrasonography is the best first-line imaging technique. CONCLUSIONS: The radiologic management of acute diverticulitis varies widely, with differences in the protocols used, radiologists' opinions, and actual clinical practice.

Enhancing Disease Classification in Abdominal CT Scans through RGB Superposition Methods and 2D Convolutional Neural Networks: A Study of Appendicitis and Diverticulitis.

The primary symptom of both appendicitis and diverticulitis is a pain in the right lower abdomen; it is almost impossible to diagnose these conditions through symptoms alone. However, there will be misdiagnoses happening when using abdominal computed tomography (CT) scans. Most previous studies have used a 3D convolutional neural network (CNN) suitable for processing sequences of images. However, 3D CNN models can be difficult to implement in typical computing systems because they require large amounts of data, GPU memory, and extensive training times. We propose a deep learning method, utilizing red, green, and blue (RGB) channel superposition images reconstructed from three slices of sequence images. Using the RGB superposition image as the input image of the model, the average accuracy was shown as 90.98% in EfficietNetB0, 91.27% in EfficietNetB2, and 91.98% in EfficietNetB4. The AUC score using the RGB superposition image was higher than the original image of the single channel for EfficientNetB4 (0.967 vs. 0.959, p = 0.0087). The comparison in performance between the model architectures using the RGB superposition method showed the highest learning performance in the EfficientNetB4 model among all indicators; accuracy was 91.98% and recall was 95.35%. EfficientNetB4 using the RGB superposition method had a 0.011 (p value = 0.0001) AUC score higher than EfficientNetB0 using the same method. The superposition of sequential slice images in CT scans was used to enhance the distinction in features like shape, size of the target, and spatial information used to classify disease. The proposed method has fewer constraints than the 3D CNN method and is suitable for an environment using 2D CNN; thus, we can achieve performance improvement with limited resources.

Comparison between single and serial computed tomography images in classification of acute appendicitis, acute right-sided diverticulitis, and normal appendix using EfficientNet.

This study aimed to develop a convolutional neural network (CNN) using the EfficientNet algorithm for the automated classification of acute appendicitis, acute diverticulitis, and normal appendix and to evaluate its diagnostic performance. We retrospectively enrolled 715 patients who underwent contrast-enhanced abdominopelvic computed tomography (CT). Of these, 246 patients had acute appendicitis, 254 had acute diverticulitis, and 215 had normal appendix. Training, validation, and test data were obtained from 4,078 CT images (1,959 acute appendicitis, 823 acute diverticulitis, and 1,296 normal appendix cases) using both single and serial (RGB [red, green, blue]) image methods. We augmented the training dataset to avoid training disturbances caused by unbalanced CT datasets. For classification of the normal appendix, the RGB serial image method showed a slightly higher sensitivity (89.66 vs. 87.89%; p = 0.244), accuracy (93.62% vs. 92.35%), and specificity (95.47% vs. 94.43%) than did the single image method. For the classification of acute diverticulitis, the RGB serial image method also yielded a slightly higher sensitivity (83.35 vs. 80.44%; p = 0.019), accuracy (93.48% vs. 92.15%), and specificity (96.04% vs. 95.12%) than the single image method. Moreover, the mean areas under the receiver operating characteristic curve (AUCs) were significantly higher for acute appendicitis (0.951 vs. 0.937; p < 0.0001), acute diverticulitis (0.972 vs. 0.963; p = 0.0025), and normal appendix (0.979 vs. 0.972; p = 0.0101) with the RGB serial image method than those obtained by the single method for each condition. Thus, acute appendicitis, acute diverticulitis, and normal appendix could be accurately distinguished on CT images by our model, particularly when using the RGB serial image method.

Colonic Diverticulitis Location Affects the Diagnostic Accuracy of Point-of-Care Ultrasound: A Multicenter, 10-Year Study.

OBJECTIVE: Point-of-care ultrasound (PoCUS) has high sensitivity and specificity in diagnosing uncomplicated colonic diverticulitis in Western patients. Evidence regarding the accuracy of PoCUS in Asian patients in which diverticulitis frequently occurs in the right-side colon is lacking. This multicenter, 10-y study was aimed at evaluating the diagnostic accuracy of PoCUS in various locations of uncomplicated diverticulitis among Asians. METHODS: A convenience sample of patients with suspected colonic diverticulitis who had undergone computed tomography (CT) were eligible. Patients undergoing PoCUS before CT were included. The primary outcome was the diagnostic accuracy of PoCUS in the various locations, compared with the final diagnosis made by the expert physicians. The sensitivity, specificity, positive predictive value and negative predictive value were computed. The logistic regression model was used to investigate the possible factors related to the accuracy of PoCUS. RESULTS: A total of 326 patients were included. The overall accuracy of PoCUS was 92% (95% confidence interval [CI]: 89.1%-95.0%) and was lower in the cecum (84.3%, 95% CI: 77.8%-90.8%), compared with other locations (p < 0.0001). Nine of 10 false positives had the final diagnosis of appendicitis: 5 had an outpouching structure whose origin in the cecum could not be traced and 4 had elongated "diverticula." Moreover, body mass index was negatively associated with the accuracy of PoCUS in cecal diverticulitis (odds ratio: 0.79, 95% CI: 0.64-0.97) after adjusting for other covariates. CONCLUSION: Point-of-care ultrasound exhibits high diagnostic accuracy in diagnosing uncomplicated diverticulitis in the Asian population. However, the accuracy varies according to location, and was relatively low in the cecum.

Endoscopic findings after CT proven acute diverticulitis: a systematic review and meta-analysis.

BACKGROUND: Traditionally, international guidelines recommend patients with acute diverticulitis should be followed up with a colonoscopy 6-8 weeks after discharge. However, the need for an interval colonoscopy has been increasingly challenged in the setting of computed tomography (CT). Previous meta-analyses have included studies which combined suspected rather than imaging confirmed diverticulitis and often without correlation with endoscopic findings. This meta-analysis aims to investigate endoscopic findings of patients with CT confirmed diverticulitis. METHODS: An electronic search of Medline, PubMed, Cochrane Library, Embase, CINAHL, Web of Science, Scopus, Clinicaltrials.gov and WHO ICTRP was performed up to October 18, 2021. Studies which reported CT confirmed acute diverticulitis in adults and who underwent endoscopic follow-up with either a colonoscopy or flexible sigmoidoscopy were included. Studies were excluded if diverticulitis was diagnosed by clinical grounds alone, ultrasound, barium enema, or other non-CT forms of imaging. RESULTS: A total of 68 studies with 13 905 patients were included. Median age was 58 years and male to female ratio was 0.84. Cancer was detected in 2.0% and advanced adenoma in 3.8%. Complicated diverticulitis had 9.2 higher odds of cancer compared to uncomplicated diverticulitis (95% CI 4.42-19.08, P < 0.001). Adenomas were detected in 17%. Of those diagnosed with colorectal cancer, 85% were concordant with the site of the diverticulitis on CT while 15% were incidental findings. CONCLUSION: Routine colonoscopic follow up should be recommended in medically fit patients who have CT proven acute diverticulitis due to the higher than population prevalence of colorectal cancer and advanced adenomas.

Accuracy of "TICS" ultrasound protocol in detecting simple and complicated diverticulitis: A prospective cohort study.

BACKGROUND: Point-of-care ultrasound (US) has been suggested as the primary imaging in evaluating patients with suspected diverticulitis. Discrimination between simple and complicated diverticulitis may help to expedite emergent surgical consults and determine the risk of complications. This study aimed to: (1) determine the accuracy of an US protocol (TICS) for diagnosing diverticulitis in the emergency department (ED) setting and (2) assess the ability of TICS to distinguish between simple and complicated diverticulitis. METHODS: Patients with clinically suspected diverticulitis who underwent a diagnostic computed tomography (CT) scan were identified prospectively in the ED. Emergency US faculty and fellows blinded to the CT results performed and interpreted US scans. The presence of simple or complicated diverticulitis was recorded after each US evaluation. The diagnostic ability of the US was compared to CT as the criterion standard. Modified Hinchey classification was used to distinguish between simple and complicated diverticulitis. RESULTS: A total of 149 patients (55% female, mean ± SD age 58 ± 16 years) were enrolled and included in the final analyses. Diverticulitis was the final diagnosis in 75 of 149 patients (50.3%), of whom 53 had simple diverticulitis and 22 had perforated diverticulitis (29.4%). TICS protocol's test characteristics for simple diverticulitis include a sensitivity of 95% (95% confidence interval [CI] 87%-99%), specificity of 76% (95% CI 65%-86%), positive predictive value of 80% (95% CI 71%-88%), and negative predictive value of 93% (95% CI 84%-98%). TICS protocol correctly identified 12 of 22 patients with complicated diverticulitis (sensitivity 55% [95% CI 32%-76%]) and specificity was 96% (95% CI 91%-99%). Eight of 10 missed diagnoses of complicated diverticulitis were identified as simple diverticulitis, and two were recorded as negative. CONCLUSIONS: In ED patients with suspected diverticulitis, US demonstrated high accuracy in ruling out or diagnosing diverticulitis, but its reliability in differentiating complicated from simple diverticulitis is unsatisfactory.