ultrasound in diverticular disease...ultrasound in diverticular disease stefan schanz evang....
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Ultrasound in
Diverticular Disease
Stefan SchanzEvang. Krankenhaus Kalk, Köln
Is there a role of Ultrasound in diverticular disease ?
Acute left lower quadrant pain
Criteria for an ideal imaging technique:
broad availabilty
low cost
no side effects
easy and fast carrying-out
repeatable any time
Technique and wall structures
1 mucosa2 musc. mucosae3 submucosa4 muscularis propria5 serosa
layers of the bowel wall
}
thickened bowel wall inCrohn's colitis
Small bowel colonstomach
Requirements for gastrointestinal US
small-parts US probes (5-10 MHz)
colour (power-) doppler
experienced examiner
US in diverticlar disease
longitudinal view
US in diverticulosisHollerweger et al., Ultraschall in Med 2002
number of proofed diverticula n (pts.)sonography colonoscopy
1-5 14 1 (+4)
6-10 3 10
>10 11 17 (+1)
28 33
5 false neg. sensitivity 85%
Criteria for evaluation of diverticulitis
thickening of the bowel wall – "target sign"
hypertrophy of Lamina muscularis
diverticulum – "dome sign"
inflammatory pericolic fat – "pericolitis"
pericolic abcess
US in diverticulitis
US in diverticulitis
US in diverticulitis
97%97%63Soliman et al. 2004
98%94%203Ripollés et al. 2003
97%76%247Moll et al. 2002
100%91%51Alberti et al. 2002
100%91%23*Chou et al. 2001
99%77%102Hollerweger et al. 2001
91%95%22Pisanu et al. 2000
100%95%19Estaban Hernandez et al. 1998
93%84%74Zielke et al. 1997
97%99%74Schwerk et al. 1993
98%98%52Schwerk et al. 1992
100%100%18*Wada et al. 1990
-85%54Wilson & Toi 1990
80%85%123Verbank et al. 1989
98%96%23Federmann 1989
study n senitivity specificity
1148 91% 96%*right-sided diverticulitis
US vs. CT in acute diverticulitisFarag Soliman et al. 2004- prospective study, n = 63
- US & CT exam. within 24 h after admission- results:
11/012(1)12(1)no pathology (n=11)
3/03(0)3(1)gastroenteritis (n=3)
1/11(0)0(0)appendicitis (n=1)
2/23(1)2(0)gynecologic tumor (n=2)
3/32(0)3(0)carcinoma of sigmoid (n=3)
43/2842(0)43(0)diverticulitis (n=43)
follow up/histopathologyCTUSdiagnosis
sensitivity & specificity for CT and US: 97%
limitations of US
large and complex abcess
distal sigmoid involvement
overlap between colonic cancer
and other inflammatory diseases
peridiverticular abscess
perforated carcinoma of the sigmoid
Crohn‘s disease
acute colitis
Advantages of US in diverticular disease
wide availability
diagnostic method with sufficient sens.
low cost
no iodinated contrast material
no side effects (radiation)
examiner = attending physician
Clinical ultrasound
MD
Patient
US
Diagnosis
experience & skill
clinical knowledge(history, physical exam., Lab. values etc. )
plausibilitycontrol
?
Conclusions
US as initial imaging technique in abdominal/pelvic painand suspicion of diverticulitis is highly sensitive
Reserve CT:- in patients with doubtful results in US or- discrepancy between US and clinical evolution- in large abcesses
US as a follow-up imaging technique
"You cannot depend on your eyes
when imagination is out of focus"
Mark Twain
