Diagnostic Imaging Pathways - Iliac Fossa Pain (Acute Left)
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This pathway provides guidance on the imaging of adult patients with left iliac fossa pain, with emphasis on investigations for suspected diverticulitis and its complications.
Date reviewed: October 2018
Date of next review: October 2021
Published: April 2019
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1a |  |
Diverticulitis Image 1a (Computed Tomography): Inflammatory changes are seen around the sigmoid colon without abscess formation (arrow). |
| 1b |  |
Image 1b (Computed Tomography): Sigmoid diverticulitis complicated by an abscess (arrow). |
| 2a |  |
Diverticular Disease
Image 2a: Sigmoid colectomy showing multiple diverticular outpouchings through the bowel wall. Note the attenuated muscularis propria (black arrows) compared to the normal muscle layer (blue arrow). |
| 2b |  |
Image 2b (H&E, x2.5): Histological section showing an uninflamed diverticulum extending through the muscularis propria of the large bowel wall. |
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Teaching Points
Teaching Points
- In suspected acute colonic diverticulitis, imaging is generally required to confirm the diagnosis and to evaluate for complications that may require surgical intervention. Contrast-enhanced CT is the imaging modality of choice
- CT can also demonstrate alternative diagnoses
- In young female patients, gynaecological causes are more common and should be investigated first with US
- Diverticular abscesses diagnosed on CT scan may be treated initially by CT guided percutaneous drainage or surgery
- Colon thickening on CT may represent inflammatory or neoplastic changes, so in some cases of diverticulitis, delayed colonoscopy (or CT colonography) may be warranted to rule out malignancy
us
Transabdominal/Transvaginal Ultrasound
- Transabdominal US is the first imaging modality of choice for evaluation of acute pelvic pain in young females in the reproductive age group 1-5
- Provides information regarding the uterus, adnexa and ovaries as well as non-gynaecological causes of pain in young women with left lower quadrant/pelvic pain 4,5
- Transvaginal ultrasound where available and appropriate can provide more detailed examination for gynaecological disease 1,5
- Advantages
- Rapid
- Inexpensive
- No ionising radiation and requires no patient preparation or contrast material administration
- Limitations 6
- Interloop abscesses and abscesses filled with gas may not be well visualised or may mimic loops of bowel
- Limited value in diagnosing bowel-related pathology
- If there is suspicion of acute diverticulitis or diverticular abscess on US, CT may be indicated for further delineation
ct
Computed Tomography (CT)
- Imaging modality of choice for evaluation of suspected acute diverticulitis 7-13
- Can also demonstrate alternative diagnoses, e.g. renal or vascular disease, epiploic appendagitis, etc.
- Clinical assessment alone is not precise enough to diagnose diverticulitis and imaging is generally recommended to confirm the diagnosis and to evaluate for complications 12,14-16
- Contrast-enhanced CT is the most accurate diagnostic test for diverticulitis, with 95% sensitivity and 96% specificity 17
- CT can be used to grade the severity of diverticulitis 18 and is also a good predictor of the need for surgical management or percutaneous drainage of abscess 19
- However, a negative CT scan does not completely excluded diverticulitis
- In patients with suspected acute diverticulitis, an accurate diagnosis (including detection of alterative diagnoses) was made in 68% of patients with CT compared to 48% with ultrasound 17
- CT criteria of diverticulitis include 10
- Presence of diverticula with pericolic infiltration of fatty tissue
- Thickening of colonic wall
- Abscess formation
- Colonic cancer may uncommonly present as localised abscess and mimic diverticular disease on CT. There is ongoing discussion whether patients with uncomplicated diverticulitis should be routinely followed up with colonoscopy as a number of studies have demonstrated that the risk of cancer is low 20-22
- Advantages
- Unlimited field of view
- High clinical utility
- Short examination time
- Limitations
- Exposure to ionising radiation and contrast
radiography
Plain Radiography
- An erect chest radiograph (CXR) is a quick and inexpensive investigation with low radiation that can demonstrate pneumoperitoneum, which may suggest complicated diverticulitis in the context of left iliac fossa pain
- Erect CXR is generally preferred to supine abdominal radiographs (AXR). A retrospective study of 250 surgically confirmed cases of hollow organ perforation found the sensitivity of erect CXR to be 85.1% compared to 80.4% for supine AXR and 98.0% for left decubitus AXR for the detection of pneumoperitoneum, though neither difference reached statistical significance. 23 Lack of free air on plain radiography does not rule out perforation 24
- Lateral decubitus AXR should be considered to evaluate for perforation if erect CXR is not possible
- Alternatively, CT is more sensitive and is generally still indicated to evaluate the cause and location of the pathology, which may also be required for surgical planning
usdivertic
Ultrasound in Diverticulitis
- There is evidence that suggests graded-compression ultrasound (US) has a comparable sensitivity to CT for diagnosing acute diverticulitis, although the specificity of US is slightly lower
- It has been suggested that a strategy where CT follows a preliminary negative or inconclusive US might reduce CT exams by 50%. 14,26 This strategy is supported by a number of international guidelines 8,9,12
- However, other authors have suggested that patients who are critically ill with acute abdominal pain and signs of sepsis, possibly due to complicated diverticulitis, should proceed directly to CT without further delay 17
- Characteristic findings in acute diverticulitis include: 4,6
- Hypoechoic bowel wall thickening
- Presence of diverticula or abscesses
- Hyperechogenicity surrounding the bowel wall, implying active inflammation
- Advantages
- No exposure to ionising radiation or iodinated contrast
- Can be used to guide procedures e.g. percutaneous drainage of collection
- Disadvantages 27
- Skilled operator required
- Examination can be limited in obese patients
- Difficult to detect free air in deeply located abscesses
divertic
Management of Acute Diverticulitis
- The management of diverticulitis remains a challenge to the surgical community and there are still several areas of controversy 13
- Uncomplicated diverticulitis may be managed conservatively and many guidelines endorse outpatient treatment where possible, 13 although clinicians are discordant on this practice 11
- Major guidelines continue to endorse the routine use of antibiotics in uncomplicated diverticulitis, 8,28,29 however randomised control trials have showed no benefit from antibiotics 30,31
- Small abscesses <5cm may be managed conservatively although other cut-offs exist in the literature 13,18
- Larger abscesses require drainage and percutaneous drainage is favoured when feasible due to lower morbidity and mortality compared to emergency surgery 18,32
- Surgical intervention is indicated in purulent or fecal peritonitis (Hinchey III or IV); the recommendations for surgical approach vary 13,32
- Interval colonoscopy following acute diverticulitis is widely recommended. 32 However this practice has been questioned with observational studies reporting the rates of colorectal cancer in following uncomplicated diverticulitis to be similar to routinely screened populations. 33 There is still an increased risk following complicated diverticulitis. Given the associated risks and cost of colonoscopy, follow-up colonoscopy may only be warranted following complicated diverticulitis 33
- CT colonography may be an option if colonoscopy is incomplete or unfeasible, 34 however it is not generally recommended for colonic surveillance and colorectal cancer screening 35
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Bhosale PR, Javitt MC, Atri M, Harris RD, Kang SK, Meyer BJ, et al. ACR Appropriateness criteria(R) acute pelvic pain in the reproductive age group. Ultrasound quarterly. 2016;32(2):108-15. (Guideline). View the reference
- Bhavsar AK, Gelner EJ, Shorma T. Common Questions About the Evaluation of Acute Pelvic Pain. Am Fam Physician. 2016;93(1):41-8. (Review article). View the reference
- Katz DS, Khalid M, Coronel EE, Mazzie JP. Computed tomography imaging of the acute pelvis in females. Can Assoc Radiol J. 2013;64(2):108-18. (Review article). View the reference
- Ackerman SJ, Irshad A, Anis M. Ultrasound for pelvic pain II: nongynecologic causes. Obstet Gynecol Clin North Am. 2011;38(1):69-83, viii. (Review article). View the reference
- Amirbekian S, Hooley RJ. Ultrasound evaluation of pelvic pain. Radiol Clin North Am. 2014;52(6):1215-35. (Review article). View the reference
- O'Malley ME, Wilson SR. Ultrasonography and computed tomography of appendicitis and diverticulitis. Semin Roentgenol. 2001;36(2):138-47. (Review article). View the reference
- American College of Radiology. ACR appropriateness criteria. Left lower quadrant pain - suspected diverticulitis. 2014. (Guideline). View the reference
- Sartelli M, Catena F, Ansaloni L, Coccolini F, Griffiths EA, Abu-Zidan FM, et al. WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting. World J Emerg Surg. 2016;11(1):37. (Guideline). View the reference
- Binda GA, Cuomo R, Laghi A, Nascimbeni R, Serventi A, Bellini D, et al. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Techniques in coloproctology. 2015;19(10):615-26. (Guidelines). View the reference
- Andeweg CS, Mulder IM, Felt-Bersma RJ, Verbon A, van der Wilt GJ, van Goor H, et al. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg. 2013;30(4-6):278-92.
- Siddiqui J, Zahid A, Hong J, Young CJ. Colorectal surgeon consensus with diverticulitis clinical practice guidelines. World Journal of Gastrointestinal Surgery. 2017;9(11):224-32. View the reference
- Vennix S, Morton DG, Hahnloser D, Lange JF, Bemelman WA. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis. 2014;16(11):866-78. View the reference
- Galetin T, Galetin A, Vestweber KH, Rink AD. Systematic review and comparison of national and international guidelines on diverticular disease. Int J Colorectal Dis. 2018;33(3):261-72.(Review article) View the reference
- Lameris W, van Randen A, van Gulik TM, Busch OR, Winkelhagen J, Bossuyt PM, et al. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum. 2010;53(6):896-904. (Level II-III evidence). View the reference
- Toorenvliet BR, Bakker RF, Breslau PJ, Merkus JW, Hamming JF. Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making. Colorectal Dis. 2010;12(3):179-86. (Level II-III evidence). View the reference
- Andeweg CS, Knobben L, Hendriks JC, Bleichrodt RP, van Goor H. How to diagnose acute left-sided colonic diverticulitis: proposal for a clinical scoring system. nn Surg. 2011;253(5):940-6. (Level II-III evidence). View the reference
- Andeweg CS, Wegdam JA, Groenewoud J, van der Wilt GJ, van Goor H, Bleichrodt RP. Toward an evidence-based step-up approach in diagnosing diverticulitis. Scand J Gastroenterol. 2014;49(7):775-84. (Level I evidence). View the reference
- Barat M, Dohan A, Pautrat K, Boudiaf M, Dautry R, Guerrache Y, et al. Acute colonic diverticulitis: an update on clinical classification and management with MDCT correlation. Abdominal radiology (New York). 2016;41(9):1842-50. (Review article). View the reference
- Shin S, Kim D, Kang UR, Yang C-S. Impact of CT imaging on predicting the surgical management of acute diverticulitis. Annals of Surgical Treatment and Research. 2018;94(6):322-9. (Level II-III evidence). View the reference
- Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-72. (Level I evidence). View the reference
- Andrade P, Ribeiro A, Ramalho R, Lopes S, Macedo G. Routine colonoscopy after acute uncomplicated diverticulitis - challenging a putative indication. Dig Surg. 2017;34(3):197-202. (Level II-III evidence). View the reference
- Daniels L, Unlu C, de Wijkerslooth TR, Stockmann HB, Kuipers EJ, Boermeester MA, et al. Yield of colonoscopy after recent CT-proven uncomplicated acute diverticulitis: a comparative cohort study. Surg Endosc. 2015;29(9):2605-13. (Level III evidence). View the reference
- Campbell JP, Gunn AA. Plain abdominal radiographs and acute abdominal pain. Br J Surg. 1988;75(6):554-6. (Level III evidence). View the reference
- Li Y, Song J, Lin N, Zhao C. Computed tomography scan is superior to x-ray plain film in the diagnosis of gastrointestinal tract perforation. Am J Emerg Med. 2015;33(3):480.e3-5. (Review article). View the reference
- Min JH, Kim HC, Kim SW, Yang DM, Rhee SJ, Oh J, et al. The value of initial sonography compared to supplementary CT for diagnosing right-sided colonic diverticulitis. Japanese journal of radiology. 2017;35(7):358-65. (Level II-III evidence). View the reference
- Laméris W, van Randen A, van Es HW, van Heesewijk JPM, van Ramshorst B, Bouma WH, et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ. 2009;338 (Level II-III evidence). View the reference
- Puylaert JB. Ultrasound of colon diverticulitis. Dig Dis. 2012;30(1):56-9. (Level III-IV evidence). View the reference
- Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57(3):284-94. (Guideline) View the reference
- Stollman N, Smalley W, Hirano I. American Gastroenterological Association institute guideline on the management of acute diverticulitis. Gastroenterology. 2015;149(7):1944-9. (Guideline) View the reference
- Chabok A, Pahlman L, Hjern F, Haapaniemi S, Smedh K. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99(4):532-9. (Level II evidence) View the reference
- Shabanzadeh DM, Wille-Jorgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:Cd009092. (Level I evidence) View the reference
- Nally DM, Kavanagh DO. Current controversies in the management of diverticulitis: a review. Dig Surg. 2018. (Review article) View the reference
- Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-72. (Level I evidence) View the reference
- Chabok A, Smedh K, Nilsson S, Stenson M, Pahlman L. CT-colonography in the follow-up of acute diverticulitis: patient acceptance and diagnostic accuracy. Scand J Gastroenterol. 2013;48(8):979-86. (Level II-III evidence) View the reference
- Laghi A. CT Colonography: an update on current and future indications. Expert review of gastroenterology & hepatology. 2016;10(7):785-94. (Review article) View the reference
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