Right-Sided Colonic Diverticulitis: Clinical Features, Sonographic Appearances, and Management

Abstract

Purpose: This study aims to evaluate patients with right-sided colonic diverticulitis detected at ultrasonography (US).

Methods: We retrospectively analyzed 14 patients. Demographic data, clinical features, and US images were documented.

Results: In the 14 patients, clinical manifestations included right lower abdominal tenderness (93%), leukocytosis (57.1%), and fever (28.6%). Diverticulitis occurred in cecum and ascending colon with a similar frequency (35.7%). US features included diverticular wall thickening (50%), surrounding echogenic fat (50%), intradiverticular echogenic material (50%), adjacent lymph node enlargement (21.4%), intradiverticularor peridiverticular fluid collection (28.6%), and color flow signals on or surrounding the diverticula (14.3%). Two (14.2%) patients suffered from recurrence. Two (14.3%) patients had abscess formation, and one (7.1%) patient had diverticulum perforation. Most (85.7%) patients received conservative treatment only. One (7.1%) patient received computed tomography-guided drainage due to diverticulum perforation and pocket of abscess formation. One patient underwent surgery due to recurrent diverticulitis-related fistula.

Conclusion: Common US features of diverticulitis include diverticular wall thickening, surrounding echogenic fat, and intradiverticular echogenic material. Proper recognizing of these features helps in differentiating diverticulitis from appendicitis and may obviate an unnecessary emergent surgery.

Keywords: complication; computed tomography; recurrent right-sided diverticulitis; ultrasonography.

Figure 1

A 63-year-old male patient suffered from right lower abdominal pain for 1 day. (A) Ultrasonography of the right lower abdomen. Longitudinal scan shows a thick-walled diverticulum (arrow) with adjacent echogenic fat (arrowhead); (B) contrastenhanced computed tomography with coronal reconstruction shows a diverticulum on the ascending colon associated with thick wall and pericolic fat stranding (arrow).

Figure 2

A 53-year-old male patient presented with right lower abdominal pain for 1 day. (A) Ultrasonography shows a protruding out-pouch (arrows) from colonic wall (short arrows), representing a colonic diverticulum. The diverticular wall and the adjacent colonic wall are thickened. The lumen contains an echogenic structure causing acoustic shadows, which is consistent with stone formation (arrowhead); (B) noncontrast computed tomography demonstrates a diverticulum with a hyperdense stone in the lumen (arrowhead), colon wall thickening, and pericolic fat stranding.

Figure 3

A 81-year-old female patient suffered from right lower abdominal pain for 5 days. (A) Sagittal scan; (B) transverse scan. Both the images show a focal hypoechoic area with blood flow and containing an intradiverticular stone; (C) and (D) contrastenhanced computed tomography reveals cecal wall thickening and fat stranding (arrow). The appendix was relatively spared (arrowhead).

Figure 4

A 65-year-old male patient suffered from right lower abdominal pain for 3 days. (A) Sagittal scan; (B) transverse scan. Both demonstrate cecal wall thickening (short arrows), blood flow on the diverticular wall, and some echogenic material in thediverticulum (arrow), suggesting gas-forming abscess in the lumen; (C) contrast-enhanced computed tomography shows marked thickening of the wall and fat stranding along with some gas bubble (arrow), indicating diverticulitis with abscess formation.

Figure 5

A 35-year-old female patient had right lower quadrant abdominal pain for 1 day. (A) Transverse scan demonstrates a hypoechoic nodule (arrow) in the pericolic region, suggesting an enlarged lymph node; (B) contrast-enhanced computed tomography scan shows several pericolic lymph nodes (arrows). In addition, colonic wall thickening and fat stranding are also noted, suggesting the diagnosis of diverticulitis.

Figure 6

A 34-year-old female patient presented with right lower abdominal pain and a tender palpable mass for several days. (A) and (B) Ultrasonography shows an ill-defined localized fluid accumulation (arrow) in the right lower abdomen, connecting between a focal protruding (short arrow) and a fluid space inside the right psoas muscle (arrowhead). The small focal protruding is continuous to the cecal wall, representing an inflamed and perforated cecal diverticulum; (C) contrast-enhanced computed tomography reveals an ill-defined mass with rim enhancement, which is compatible with diverticulitis rupture and abscess formation. A fistula (arrow) between the ascending colon and right psoas muscle (arrowhead) is also demonstrated; (D) computed tomographyguided aspiration of the abscess was performed (black arrow). The patient was discharged 7 days later. No surgical intervention was done. C = cecum.