Case 15 - Diverticulitis

This patient also has diverticulitis.  There are actually two foci of disease, one in the descending colon and the second in the sigmoid colon.  Look at each.  In the descending colon there is a focal area of thickened bowel (compare to the thin wall of the cecum), surrounding mesenteric stranding, thickening of the adjacent peritoneum, and an adjacent diverticula.  The same findings are present in the proximal sigmoid colon:  thickened wall, mesenteric stranding, peritoneal thickening, and a diverticula.

The differential diagnosis of an asymmetrically thickened focal segment of large bowel includes diverticulitis, neoplasm, Crohns disease, ischemia, and infectious colitis, with the latter three being less likely.  If the area of thickening is several centimeters long or if there is a mass-like phlegmon, it is impossible to exclude underlying malignancy.  Many colonic neoplasms will cause small micro-perforations and generate surrounding inflammation and present with symptoms suggesting diverticulitis.  The inflammation will improve with antibiotics but the mass-like appearance of the bowel will not.  Since older people get both diverticulosis and colon cancer, the presence of multiple diverticula does not exclude carcinoma.  We routinely recommend followup with either CT or direct visualization to ensure resolution after antibiotics.

Ischemia has varied appearances, but solitary short segments of ischemic large bowel are rare.  Likewise, inflammatory bowel disease will usually involve longer and multiple segments.  Crohns also usually presents in a younger age group, involves the terminal ileum, and the patient will probably carry that diagnosis into the exam.  We will discuss these entities later.

Notice the well displayed ileocecal valve.  Find the appendix.  It is air filled.  Where there is no air it is collapsed and measures less than 6 mm..  There is no surrounding stranding.  It is normal.

Did you notice the missing left rectus muscle and the right breast reconstruction (using the left rectus muscle)?

 

Take home point