Preoperative staging of perforated diverticulitis by computed tomography scanning.

BACKGROUND: Treatment of perforated diverticulitis depends on disease severity classified according to Hinchey's preoperative classification. This study assessed the accuracy of preoperative staging of perforated diverticulitis by computerized tomography (CT) scanning. METHODS: All patients who presented with perforated diverticulitis between 1999 and 2009 in two teaching hospitals of Rotterdam, the Netherlands, and in addition had a preoperative CT scan within 24 h before emergency surgery were included. Two radiologists reviewed all CT scans and were asked to classify the severity of the disease according to the Hinchey classification. The CT classification was compared to Hinchey's classification at surgery. RESULTS: Seventy-five patients were included, 48 of whom (64 %) were classified Hinchey 3 or 4 perforated diverticulitis during surgery. The positive predictive value of preoperative CT scanning for different stages of perforated diverticulitis ranged from 45 to 89 %, and accuracy was between 71 and 92 %. The combination of a large amount of free intra-abdominal air and fluid was strongly associated with Hinchey 3 or 4 and therefore represented a reliable indicator for required surgical treatment. CONCLUSIONS: The accuracy of predicting Hinchey's classification by preoperative CT scanning is not very high. Nonetheless, free intra-abdominal air in combination with diffuse fluid is a reliable indication for surgery as it is strongly associated with perforated diverticulitis with generalized peritonitis. In 42 % of cases, Hinchey 3 perforated diverticulitis is falsely classified as Hinchey 1 or 2 by CT scanning.

Spontaneous regression of clinical inguinal hernias in preterm female infants.

PURPOSE: This is a prospective study of 8 clinically apparent inguinal hernias in 7 preterm infant girls. METHODS: The diagnosis was made clinically and confirmed by ultrasonography, which also showed the contents of the hernia. RESULTS: One hernia contained an ovary, the other 7 intestinal loops. The hernias with only intestinal loops regressed spontaneously when the girls were between the ages of 2 and 6 months postpartum. This was confirmed by ultrasonography. At follow-up 2 to 6 years later there has been no recurrence. The hernia that contained the ovary did not regress, and hernia repair (confirming the presence of the ovary) was carried out uneventfully. CONCLUSIONS: The authors suggest that preterm infant girls with an inguinal hernia should have ultrasonography performed at presentation. Surgery probably will be required when the hernia contains structures such as an ovary. When the hernia contains only intestinal loops an expectant policy may be advisable. Larger studies are needed to validate these findings.

The role of computed tomography in the management of acute pancreatitis.

Sixty-three patients with the clinical diagnosis of acute pancreatitis were submitted to contrast enhanced CT examination. As compared to Ranson's objective clinical parameters, CT grading according to Hill et al. as modified by Balthazar et al. was found to reflect accurately the severity of acute pancreatitis. Evaluation of serial CT examination did not reveal any significant progression in classification during the course of acute pancreatitis. The presence of hypodense areas in the pancreas as a single parameter seems to have a distinct prognostic value. In only one out of five pancreatic abscesses was the presence of gas bubbles observed on CT. It is concluded that contrast enhanced CT has a definite place in the management of acute pancreatitis.