Faced with an acute episode of sigmoid diverticulitis of moderate severity, we consider some differential diagnosis.
The functional or irritable colon, associated with fever from another source, represents the main differential diagnosis. The painful history of long evolution, the more diffuse abdominal pain and no signs of peritoneal reaction to palpation abdominal argue in favor of this diagnosis. Otherwise the problem is more complex because colopexia functional and often are associated diverticulosis and diverticulitis can make a one colopexia functional. For the diagnosis of diverticulitis, the enema with water soluble iodinated derivatives review represents the best that can be done urgently. Deformation of the diverticular sacs which become sharp is characteristic of the diverticulitis, but the image analysis is difficult when there are coprolites intra diverticular addition, the diverticulitis is often accompanied by a thickening of the colic wall that creates an outline of stenosis or a small abscess pericallosa, giving an image of extrinsic compression of the colon.
A pyelonephritis can simulate an episode of diverticulitis pain when seated in the left iliac fossa to the lumbar region. The presence of a pyuria in cyto bacteriologic examination of urine, the ultrasound findings of excretory urography or even a CT scan, confirmed this diagnosis. However, voiding discomfort and pyuria may be present in an episode of diverticulitis.
The salpingitis in women can cause pain in hypogastria and left iliac fossa, but this is usually a young woman with a history of genital infection, vaginal and touch points to the dual diagnosis of symptoms, especially if we rely on the ultrasound findings.
Faced with an acute episode of sigmoid diverticulitis with abscess perisigmoid more severe, the differential diagnoses are different. Sigmoid cancer is the primary, and can manifest as muscle pain and fever when the tumor is complicated with a peritumoral abscess. The diagnosis is easy when the opaque enema shows ulceration or filling defect of the tumor. However, the signs of cancer are not always easy to recognize with a water-soluble iodinated contrast enema, and certain cancers can provide an image infiltrative stenosis of more regular and elongated it might seem a diverticulitis. When there is a complete stenosis is impossible to reach a conclusion. Just had a colonoscopy when the last episode of acute infectious sometimes allow the differential diagnosis, but the stenosis may be impassable, and some patients had come to operate if a true diagnosis, even using it in the preoperative exploration neither can establish a diagnosis only after excision of the pathologic examination.
Ischemic colitis is rare. May be responsible for a pain in the left iliac fossa in a patient with vascular background. Pain is usually most intense, followed by rectal bleeding. In the opaque enema, images can be confused with the perisigmoiditis, usually reaching to diagnosis after colonoscopy and biopsy after the acute phase.
Crohn's disease may be complicated by an abscess or narrowing pericallosa. But these complications are rarely reveal the disease and the clinical history is often more chronic.
Other differential diagnoses are rare, as some appendiceal abscess or pelvic mesocolics some pyosalpinx, ovarian tumors, lymphomas, or even the sigmoid or pelvic carcinomatosis endometriosis may lead to an extrinsic stenosis of the sigmoid.
Faced with a Sigmoid-vesical fistula sigmoid diverticulitis is the most frequent cause, but sigmoid cancer is the first differential diagnosis. The fistulous tract is often wider, more easily opacification. Suspected cancer in the water-soluble contrast enema confirmed by biopsy or cystoscopy colonoscopic. The other conditions likely to fistulizes a sigmoid bladder, such as Crohn's disease or colitis secondary to actinic radiation of pelvic cancer, are rare. Faced with a rare or ileal fistula colo-vaginal must be removed the same causes.
In the cecum and right colon, acute appendicitis and appendiceal abscess are the most frequent causes of infectious complications, so that diverticulitis is never the first suspected diagnosis. Right colon cancer is rarely complicated by an abscess pericallosa. Solitary ulcer of the right colon can be accompanied by an inflammatory tumor at that level. Crohn's disease, tuberculosis, yersiniosis, the ameboma and actinomycosis are rare diagnoses that could be brought to a radiological abnormal. Some diverticulitis of the hepatic angle of the colon could simulate cholecystitis, easily identified by ultrasound.
In the descending colon diverticular complications could be confused with a renal lesion infected with colon cancer complicated by an abscess or even with an ischemic colitis. The opaque enema with water-soluble iodinated derivatives is still the best test to link infectious complication of the colon and to try to clarify the cause, supplemented later by a colonoscopy.
In the case of generalized peritonitis, the cause is more difficult to recognize, but the treatment is always surgical whether appendiceal peritonitis by perforation of a sigmoid cancer, other drilling colic, peritonitis of genital origin or perforation ulcerosa, error diagnosis is less important.
If rectal bleeding abundant may endanger the life of the patient, colic diverticulosis is the most frequent cause, but there are many differential diagnoses, should establish an order of the scans available.
Bleeding high in relation to a peptic duodenal ulcer can trigger a massive bleeding from the anus red blood without hematemesis associated. A gastroduodenoscopy should be done before thinking about colonoscopy or arteriography.
Hemorrhoids or ulcers thermometer probe rectal bleeding or enemas can trigger abundant. We need to think about them and always start by exploring an anoscopy.
Angiodysplasia appear to be the most frequent cause of lower gastrointestinal bleeding, but should take into account that is associated with diverticulosis by almost 50%. They are less abundant and more recurrent and is often older patients. Colonoscopy is usually not diagnostic because the bleeding can not find the level of the mucosa in which seated vascular abnormalities, only selective mesenteric arteriography to discover an image associated with a vascular blurred more thickened and tortuous arteriole and an early and persistent opacification the dilated draining vein of the moment, angiodysplasia, or extravasation of contrast on the light in case of colic diverticular origin. Arteriography but may not show anything or multiple lesions in the colon or small intestine without being able to locate the site of bleeding.
An ulcerated Meckel diverticulum may bleed profusely. Youth can make the patient think about it, and arteriography emergency can make the diagnosis.
Colorectal tumors (polyps or cancer) rarely come to produce abundant bleeding, and can be easily recognized by colonoscopy.
The hemorrhagic rectocolitis can bleed profusely bleeding but this is rarely indicative of the disease.
Other causes are rare and occur in a particular context it is necessary to search for questioning: ischemic colitis, colitis or rectitys radiation, segmental colitis by nonsteroidal anti-inflammatory, solitary rectal ulcer, varices of the small intestine or colon by portal hypertension, rupture of an aortic or iliac aneurysm in the gut, the breakdown of an aorta-iliac prosthesis in the duodenum.
In a publication on current diagnosis and treatment of patients with lower gastrointestinal bleeding in which 100 consecutive patients were evaluated, the panendoscopic was revealed that the cause of higher origin in 11%, it was assumed that it was located in the small bowel 9% and the cause was not found in 6%. During the emergency colonoscopy was a definite colonic lesions in 74% of patients. Angiomatosis was found in 30% or 41% of all points of bleeding.