Suspected left sided diverticulitisBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f928 (Published 27 February 2013) Cite this as: BMJ 2013;346:f928
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I found this article by N De Korte el al extremely useful. Junior doctors deal commonly with surgical admission cases like diverticulitis and requesting the appropriate scans can sometimes be a challenge.
This article states that ultrasonography ideally should be first line for imaging uncomplicated diverticulitis. However, it does have its limitation in obese patients and highly dependant on operator's experience.
Perhaps setting a guideline which help doctors to choose the appropriate scans can be helpful. The guideline ideally should state the suitability of each scan to each pathology after taking into account the signs, symptoms and body weight of the patient. This would be beneficial to junior doctors who still lack clinical experience, and to radiologists who do not have to spend time cancelling inappropriate scans.
Competing interests: No competing interests
This piece provides some reassurance to clinicians like us who like to know that we do not stand alone at the bed side merely resigned to speculating.
The usual clinical scenario in acute diverticular inflammations is pain and tenderness in the proximity of the inflamed segments; in bad cases, the local signs may mass up into the clinical picture of localised peritonitis with localised rebound and guarding with or without known history of a chronic diverticular disease in an individual whose abdomen away from the involved segment is generally normal, soft, non tender and at times not even distended.
The presence of systemic features of fever and 'extracolonic' symptoms of vomiting and malaise may be present depending on the degree of the inflammatory process going on and presence or otherwise of comorbidities that may increase the total burden of abdominal inflammation; eg coexisting biliary or gastic lesions.
In straight cases of local peritonitis unconfounded by extra-alimentary features, the tendency is to go ahead anyway and institute the standard protocols of gut rest, parenteral fluids and anti infective agents and where suitable and wise, pain control.
This approach tends to lead to resolution even before confirmation of the trigger pathology (diverticulitis) is achieved; and so a more elective imaging schedule is possible.
I find it relevant to make this point because there are still parts of the world where access to some of these necessary ancillary investigations is either not available in the admitting hospital or even in the admitting town and yet it is imperative that management must not be delayed for this reason or else a localised peritonitis can conflagrate as we stand waiting by the bed side into diffuse or generalised peritonitis with a wider pattern of morbidity and increased mortality rate.
In some settings, patients may need to travel to another centre (in or out of town) to access scans (any type) but only after the acute phlegmonous phase is reasonably controlled.
If a pro-active containment is done of this category of patient, the subsequent investigations can be done on outpatient basis, done with better design and by the best skills available in the circumstance.
Therefore a sequential pattern of management though may not be the best, can nevertheless find good and reliable use where synchronous protocols are impossible.
A small but useful advantage of sequential protocol over the synchronous (simultaneous treatment and investigations) is the relative lack of pain post resolution and therefore less discomfort on ultrasonography with chances of better resolutions and sensitivity.
With an uncompromised sonographic assessment, and therefore more reliable result, the subset that needs to proceed to face radiation from a CT scan is remarkably less.
And so will be the eventual cost.
Where sequential approach is used however, lingering diagnostic uncertainties as to the trigger pathology makes it mandatory to secure urgent appointments for confirmation of diagnosis to minimise delays in case the underlying or a coexisting problem is malignancy.
Among the cases presenting with acute diverticulitis particularly of the left side, a significant fraction comes with prior history and a previously confirmed diverticular disease and so heightens the index of suspicion in any current presentation.
That said, little must be assumed since a history is not a necessary guarantee that the present presentation must be from same trigger as the previous ones.
The ability of the ct scan to pick up many more anatomic lesions than can sonography is worth noting where there are no constraints of availablity, skill or cost.
Competing interests: No competing interests