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Chronic Diverticulitis: Clinical, Radiographic, and Pathologic Findings

Laura Sheiman1, Marc S. Levine1, Alicia A. Levin1, Jonathan Hogan2, Stephen E. Rubesin1, Emma E. Furth2 and Igor Laufer1

1 Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
2 Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, PA.


Figure 1
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  		Fig. 1 —74-year-old woman with chronic diverticulitis who presented with 12-month history of constipation and left lower quadrant pain. Left posterior oblique spot image from double-contrast barium enema examination shows 4-cm-long segment of narrowing in sigmoid colon with distorted, spiculated folds and relatively tapered margins (arrows). Also note multiple sigmoid diverticula.

 

Figure 2
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  		Fig. 2A —49-year-old man with chronic diverticulitis who presented with 5-month history of left lower quadrant pain but no fever, leukocytosis, or abdominal tenderness or rebound. Left posterior oblique spot image from double-contrast barium enema examination shows 5-cm-long segment of narrowing in sigmoid colon with markedly tethered, spiculated folds and tapered margins (arrows). Also note diverticula in distal descending colon.

 

Figure 3
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  		Fig. 2B —49-year-old man with chronic diverticulitis who presented with 5-month history of left lower quadrant pain but no fever, leukocytosis, or abdominal tenderness or rebound. Axial image from oral and IV contrast-enhanced abdominal CT obtained 3 months earlier shows long segment of colonic wall thickening (white arrows) with pericolic inflammatory stranding (arrowhead) and fluid in sigmoid mesentery (black arrow). Also note multiple gas-filled diverticula in sigmoid colon.

 

Figure 4
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  		Fig. 3A —56-year-old man with chronic diverticulitis who presented with 3-month history of pencil-thin stool and rectal bleeding. Left posterior oblique spot image from double-contrast barium enema examination shows 3-cm-long segment of narrowing in sigmoid colon with preserved but distorted mucosal folds and relatively abrupt margins (arrows).

 

Figure 5
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  		Fig. 3B —56-year-old man with chronic diverticulitis who presented with 3-month history of pencil-thin stool and rectal bleeding. Axial image from oral and IV contrast-enhanced abdominal CT obtained 5 days before A shows long segment of colonic wall thickening (arrows) with minimal pericolic inflammatory change and multiple gas-filled diverticula in sigmoid colon.

 

Figure 6
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  		Fig. 4 —85-year-old woman with chronic diverticulitis and colonic obstruction who presented with 3-month history of pencil-thin stool and bloating. Left posterior oblique spot image from double-contrast barium enema examination shows segment of marked narrowing in sigmoid colon causing complete retrograde obstruction with no colonic filling more proximally. Note tapered distal margin (arrow) and distorted folds within narrowed segment. Nevertheless, differentiation from malignant tumor is more difficult because of incomplete filling of diseased segment without visualization of proximal margin.

 

Figure 7
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  		Fig. 5 —84-year-old woman with chronic diverticulitis and sigmoidovaginal fistula who presented with 10-month history of constipation and stool draining from vagina. Left lateral spot image from single-contrast barium enema examination shows 6-cm-long segment of narrowing with distorted mucosal folds and tapered margins (white arrows) in sigmoid colon. Also note focal extravasation of barium into fistulous track (small black arrows) that communicates inferiorly with vagina (large black arrows).

 

Figure 8
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  		Fig. 6 —64-year-old man with chronic diverticulitis who presented with 24-month history of nausea, bloating, and left lower quadrant abdominal pain. Frontal spot image from single-contrast barium enema examination shows 6-cm-long segment of narrowing in distal descending and proximal sigmoid colon with markedly distorted, spiculated folds and tapered margins (large white arrows). Note associated colocolic fistula (small white arrows) extending from one end of narrowed segment to other. Second shorter segment of narrowing with tethered folds but more abrupt margins (black arrows) is seen more distally in sigmoid colon.

 

Figure 9
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  		Fig. 7A —77-year-old woman with chronic diverticulitis who presented with 8-month history of left lower quadrant pain but no fever, leukocytosis, or abdominal tenderness or rebound. Frontal spot image from single-contrast barium enema examination shows 3-cm area of extrinsic mass effect and tethering (arrows) on lateral border of junction of sigmoid and descending colon, causing eccentric narrowing of bowel. Also note multiple diverticula in adjacent colon.

 

Figure 10
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  		Fig. 7B —77-year-old woman with chronic diverticulitis who presented with 8-month history of left lower quadrant pain but no fever, leukocytosis, or abdominal tenderness or rebound. Axial image from unenhanced (because of clinical suspicion of urinary tract calculus) abdominal CT obtained 4 months after A shows inflammatory collection (white arrow) abutting distal colon (black arrow). Also note gas-filled colonic diverticula. Acute diverticulitis is more likely to be associated with pericolic inflammatory collections, whereas chronic diverticulitis is more likely to be associated with relatively long segments of circumferential luminal narrowing on barium enema and CT.

 

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