CT in the diagnosis and management of acute diverticulitis - Forum

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Schom

CT in the diagnosis and management of acute diverticulitis - Ärzteforum

Post#1 »

The discussion over the past several weeks about diverticulitis has prompted me to do some more reading. The literature raises more questions than it answers about the diagnosis and treatment of diverticulitis. My conclusion, however, is that imaging (CT, Ultrasound, BE -- CT is the best) does have an important role.

I have read the article from the recent NEJM. My understanding of the review is that there is good support of using CT in the diagnosis and management of acute diverticulitis. I don't think that anyone on this forum is suggesting that CT be used for every case of acute diverticulitis -- most often this diagnosis can be made on clinical grounds. Treatment can be based on this, and this is supported in the article: "In patients for whom the diagnosis of diverticulitis can be made with confidence by clinical examination, it is reasonable to begin empirical treatment immediately." Nobody is going to dispute this. However, at least at my institution, this is not the patient with whom the surgeon is involved. Straightforward, uncomplicated 'ticitis is treated as an outpatient by primary care doctors. Surgeons become involved in severe cases, requiring hospitalization. It is in these patients that the risk of complications is high and our threshold to image the area should be low. Again, from the article "CT is the safest and most cost effective diagnostic method, with additional potential for use in the treatment of abscesses"...."If the pain has not resolved in two to three days, if fever and leukocytosis do not resolve, or if serial physical examinations reveal peritoneal signs, further imaging studies are appropriate." THESE are the patients with whom surgeons are concerned.

Incidentally, this is exacly the position published in Diseases of Colon and Rectum. Entitled "Practice Parameters for Sigmoid Diverticulitis -- Supporting Documentation", the American Society of Colon and Rectal Surgeons also support liberal used of imaging studies. Again, if the diagnosis is clear, then nothing further is needed - "If the clinical picture is clear, it has been suggested that no other tests are needed to make the diagnosis, and the diagnosis is made of the basis of clinical criteria." Again, I submit that these are not the majority of cases that I see. "In cases where the diagnosis of diverticulitis is in question, other tests may be performed..."

I think that my practice of liberal use of CT in suspected complicated diverticulitis is well supported in the literature.


John Dissector

Re: CT in the diagnosis and management of acute diverticulitis - Ärzteforum

Post#2 »

I totally agree with everything you said--your position is my position. However, I responded to a post that IN FACT said he used CT on every case up front "to establish the diagnosis", and THAT response was what all the argument was about--a bunch of people on this list are doing just that, against all current standards as indicated by this NEJM review and against your understanding as well. So you are wrong when you said that nobody would argue with empirically beginning treatment in the typical case with presentation of LLQ peritonitis--in fact, a sizable number on this list DID argue with that, much to my surprise and chagrin, because I have no idea where they get that stance from--it's not from any evidence I'm aware of.

Also, you say surgeons tend only to see the complicated cases--however, we admit all cases involving acute abdominal pain, and I would feel uncomfortable having those not accustomed to dealing with acute abdominal conditions do so--so no, in fact, we and many others see mostly the uncomplicated cases--perhaps allowing nonsurgeons to care for these patients to the point you describe is why you are seeing complicated cases?

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