eMedicine Specialties > Emergency Medicine > Gastrointestinal

Diverticular Disease: Differential Diagnoses & Workup

Author: Bennett Goss, MD, MPH, Chief Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Coauthor(s): Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Aug 17, 2009

Differential Diagnoses

Abdominal Hernias
Irritable Bowel Syndrome
Abdominal Trauma, Blunt
Lower Gastrointestinal Bleeding
Acalculous Cholecystitis
Lower Gastrointestinal Bleeding, Surgical Treatment
Adnexal Tumors
Lymphogranuloma Venereum
Appendicitis
Mesenteric Artery Ischemia
Cholangitis
Ovarian Cysts
Cholecystitis
Ovarian Torsion
Cholelithiasis
Pancreatitis, Acute
Chronic Mesenteric Ischemia
Pelvic Inflammatory Disease
Colon Cancer, Adenocarcinoma
Perforated Peptic Ulcer
Crohn Disease
Peritonitis and Abdominal Sepsis
Duodenal Ulcers
Proctitis and Anusitis
Ectopic Pregnancy
Syphilis
Endometriosis
Tuberculosis
Endometritis
Ulcerative Colitis
Gastric Ulcers
Urinary Tract Infection, Females
Gastritis, Acute
Urinary Tract Infection, Males
Hemorrhoids
Volvulus, Sigmoid and Cecal
Inflammatory Bowel Disease
Intestinal Perforation

Other Problems to Be Considered

Actinomycosis
Amebiasis
Angiodysplasias
Carcinoma of the colon (particularly distal colon)
Collagen diseases
Fecal impaction
Foreign body granuloma
Gonococcal and nongonococcal proctitis
Infectious colitis 
Irritable bowel syndrome
Ischemic colitis
Meckel diverticulitis
Colorectal cancer
Cystitis
Pancreatic disease
Pseudomembranous colitis
Renal disease
Small bowel obstruction
Postirradiation proctosigmoiditis

Workup

Laboratory Studies

  • Complete blood count: CBC identifies leukocytosis and/or a left shift in acute diverticulitis; however, 60% of patients may have a normal white blood cell count, particularly elderly and immunocompromised patients. Manage GI bleeding by establishing hematocrit.
  • Type and cross-match blood; also obtain coagulation and bleeding time profiles in patients with lower GI bleeding or frank peritonitis.
  • Urinalysis/urine culture: This identifies urinary tract infections and hematuria. It indicates existence of colovesicular fistulas or if diverticular disease is the etiology.
  • Serum electrolytes: In the absence of a prerenal picture, an elevated BUN/creatinine ratio indicates the presence of blood in the GI tract.
  • Lipase/amylase and liver function tests: These may help establish other etiologies or features in the presentation of abdominal pain. This is particularly important when patients present atypically (eg, steroid therapy, elderly patients, those with diabetes) or relatively late in the course of an inflammatory process with generalized tenderness or frank peritonitis.
  • Perform blood cultures if acute diverticulitis is suspected prior to infusion of empiric antibiotic therapy.

Imaging Studies

  • Plain radiographs: An acute abdominal series, with flat and upright abdominal imaging, identifies signs of intestinal irritation (ileus) and two thirds of visceral perforations (free air). Radiographs can identify volvulus, bowel obstruction, renal stones, and occasionally suggest the existence of intra-abdominal masses. Chest radiographs can identify free air to rule out perforation.


"Thumbprinting" (seen in left mid quadrant) on a...

"Thumbprinting" (seen in left mid quadrant) on a plain abdominal radiograph (close-up image).

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"Thumbprinting" (seen in left mid quadrant) on a...

"Thumbprinting" (seen in left mid quadrant) on a plain abdominal radiograph (close-up image).



Thickening of the bowel wall in the descending co...

Thickening of the bowel wall in the descending colon due to bowel edema can be seen in the left lower quadrant on this plain abdominal radiograph. Note the narrowed colonic lumen. Note the CT scan images in this article are from the same 62-year-old patient with diverticulitis.

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Thickening of the bowel wall in the descending co...

Thickening of the bowel wall in the descending colon due to bowel edema can be seen in the left lower quadrant on this plain abdominal radiograph. Note the narrowed colonic lumen. Note the CT scan images in this article are from the same 62-year-old patient with diverticulitis.

  • CT scan: This is the test of choice for acute diverticulitis. Look for diverticula, localized colonic wall thickening (>5 mm), abscesses, fistulas, and pericolic fat inflammation, and exclude other pathologies, such as a tubo-ovarian abscess or aortic or other vascular blood leakage. Administering rectal contrast with no intravenous contrast has been shown in one study to be equally as sensitive as CT scans where oral contrast was administered; however, the test of choice is a CT scan that includes intravenous and oral contrast. Ten percent of CT scans are unable to determine between diverticular disease and carcinoma. Other findings include the following:
    • Thickened fascia, 78.9%
    • Colonic diverticula, 84%
    • Soft tissue masses representing phlegmon, pericolic fluid collections, representing abscesses, 35%
    • Muscular hypertrophy, 26.3%
    • Arrowhead sign (focal thickening of colonic wall with an arrowhead-shaped lumen pointing to inflamed diverticula), 23.7%


Thickening of the bowel wall in the descending co...

Thickening of the bowel wall in the descending colon due to bowel edema can be seen in the left lower quadrant on this CT scan. Note the narrowed colonic lumen (contrast in the lumen is white). Note the hypodense (dark) spot in the bottom right of the edematous colonic wall; this spot is an abscess that is forming within the bowel wall in a 62-year-old patient with diverticulitis.

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Thickening of the bowel wall in the descending co...

Thickening of the bowel wall in the descending colon due to bowel edema can be seen in the left lower quadrant on this CT scan. Note the narrowed colonic lumen (contrast in the lumen is white). Note the hypodense (dark) spot in the bottom right of the edematous colonic wall; this spot is an abscess that is forming within the bowel wall in a 62-year-old patient with diverticulitis.



Sigmoid diverticulitis in a 50-year-old man with ...

Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness.

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Sigmoid diverticulitis in a 50-year-old man with ...

Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness.



Sigmoid diverticulitis in a 50-year-old man with ...

Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness. Media files 9-12 are sections from the same patient.

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Sigmoid diverticulitis in a 50-year-old man with ...

Sigmoid diverticulitis in a 50-year-old man with history of diverticulosis and left lower abdominal pain and tenderness. Media files 9-12 are sections from the same patient.

  • Double-contrast enema: This is useful in the diagnosis of diverticulosis yet contraindicated in acute diverticulitis because of the fear of perforation, leak of barium and intestinal content, and subsequent severe peritonitis.
  • Water-soluble contrast enema: Water-soluble contrast is safe in intraluminal imaging and useful in the workup of patients with suspected diverticular disease. However, a prospective study in 2000 has shown CT scanning to have a 97% sensitivity rate as compared to 92% sensitivity rate for water-soluble contrast enema. CT scanning was also superior in detecting abscesses.
  • Ultrasonography: Ultrasonography is a noninvasive test used by a number of investigators and has been reported to have a specificity as high as 99.8%.3 When using high-resolution graded compression ultrasonography, a sensitivity of 85-98% has been reported and a specificity of 80-98%. Findings when used at the point of maximal tenderness can reveal bowel wall thickening of 4-5 mm, target appearance, and abscess formation.
  • Magnetic resonance imaging (MRI): MRI was evaluated in one study and found that it accurately identified diverticulitis in 10 out of 11 patients.4 Larger studies are needed to further evaluate the modality of MRI in aiding in diagnosis of diverticulitis.

Procedures

  • Endoscopy: Endoscopy is useful in diagnosing diverticular disease and in establishing the source of lower GI bleeding. Endoscopy is avoided in acute diverticulitis because of the fear of perforation and peritonitis. A nasogastric tube is usually inserted first to exclude most upper GI causes of rectal bleeding. A 2000 study found that aggressive urgent colonoscopy performed by a dedicated endoscopy team with experience in interventional procedures uses colonoscopy as both a diagnostic measure and a therapeutic measure.5
  • Technetium-99m-blood cell scan: Technetium-99m labeled RBC scan has a sensitivity of 97%, specificity of 85%, and a positive predictive value of 94% to identify active bleeding at a rate of 0.1 mL/min.6  It does, however, have a poor ability to localize the source of bleeding. Follow with a selective mesenteric arteriogram to identify the source.

More on Diverticular Disease

Overview: Diverticular Disease
Differential Diagnoses & Workup: Diverticular Disease
Treatment & Medication: Diverticular Disease
Follow-up: Diverticular Disease
Multimedia: Diverticular Disease
References
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Further Reading

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Keywords

diverticular disease, diverticulitis, acute diverticulitis, diverticulosis, lower gastrointestinal bleeding, lower GI bleeding, Meckel iliac diverticulum, congenital diverticula, peridiverticular inflammation, tenesmus, recurrent urinary tract infections, colovesicular fistulas, pneumaturia, feculent vaginal discharge, low-fiber diet, high fat diets, beefdiets, colonic segmentation, defects in colonic wall strength

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Contributor Information and Disclosures

Author

Bennett Goss, MD, MPH, Chief Resident Physician, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Bennett Goss, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Gino A Farina, MD, Program Director, Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine
Gino A Farina, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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