Gastrointestinal Imaging Clinical Obser vations

Sheiman et al.
Chronic Diverticulitis

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Gastrointestinal Imaging
Clinical Observations

Chronic Diverticulitis:
Clinical, Radiographic,
and Pathologic Findings
Laura Sheiman1
Marc S. Levine1
Alicia A. Levin1
Jonathan Hogan2
Stephen E. Rubesin1
Emma E. Furth2
Igor Laufer 1
Sheiman L, Levine MS, Levin AA, et al.

OBJECTIVE. The purpose of our study is to present a series of 14 patients with chronic
diverticulitis on barium enema examinations and to correlate the radiographic findings with
the clinical and pathologic findings in these patients.
CONCLUSION. Chronic diverticulitis is a distinct pathologic entity characterized by
the frequent development of chronic obstructive symptoms and abdominal pain rather than
the classic clinical findings of acute sigmoid diverticulitis. Barium enema examinations
usually reveal a relatively long segment of circumferential narrowing in the sigmoid colon
with a spiculated contour and tapered margins, sometimes associated with retrograde
obstruction. Our experience suggests that chronic diverticulitis can often be diagnosed on the
basis of the characteristic clinical and radiographic findings in these patients.

Keywords: abdominal CT, barium enema, chronic

diverticulitis, gastrointestinal imaging
DOI:10.2214/AJR.07.3597
Received December 27, 2007; accepted after revision
February 29, 2008.
1
Department of Radiology, Hospital of the University of
Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
Address correspondence to M. S. Levine (marc.levine@
uphs.upenn.edu).
2

Department of Pathology, Hospital of the University of

Pennsylvania, Philadelphia, PA.
AJR 2008; 191:522528
0361803X/08/1912522
American Roentgen Ray Society

522

iverticular disease of the colon is

a common and potentially serious
condition; it has been estimated
that 1025% of people with co
lonic diverticulosis develop one or more
episodes of diverticulitis [1]. Most of these
patients have acute diverticulitis with a left
lower quadrant inflammatory mass second
ary to a perforated sigmoid diverticulum. Af
fected individuals present with a typical con
stellation of clinical findings, including acute
left lower quadrant pain, tenderness, fever,
and leukocytosis [2, 3]. Abdominal CT has
been shown to be the most sensitive imaging
technique for detecting sigmoid diverticulitis
because of its ability to show bowel-wall
thickening, pericolic inflammatory stranding,
and associated inflammatory collections or
abscesses in these patients [46].
In our practice, however, we have en
countered a subset of patients with a chronic
form of diverticulitis who presented with obstructive symptoms or abdominal pain of at
least 2 months duration, often in the absence
of abdominal tenderness, fever, or leukocytosis. At surgery, however, these patients had
pathologic findings of diverticulitis with
acute or chronic inflammatory changes and
associated fibrosis. Because of its differing
clinical presentation, chronic diverticulitis
poses a diagnostic challenge for clinicians
caring for these patients. Although CT is the
imaging technique of choice for the detec-

tion of acute diverticulitis [46], patients

with chronic diverticulitis may undergo a
barium enema examination as the initial diagnostic imaging test because of chronic obstructive symptoms or abdominal pain. To
our knowledge, this condition has not been
described previously in the radiologic literature. The purpose of our study therefore is to
present a series of patients with chronic diverticulitis on barium enema examinations
and to correlate the radiographic findings
with the clinical and pathologic findings in
these patients.
Materials and Methods
Patient Population
A computerized search of the radiology
database at our university hospital revealed 54
patients with a diagnosis of chronic diverticulitis
on barium enema examinations during an 8-year
period from April 1998 to June 2006. Twenty-four
(44%) of these 54 patients underwent surgery with
resection of the diseased colon, and pathologic
specimens confirmed the presence of diverticulitis
in 21 (one had colonic carcinoma, one had meta
static ovarian carcinoma, and one had radiation
colitis). Medical records were available for 19 of
these 21 patients. For the purposes of this study,
chronic diverticulitis was defined as surgically
proven diverticulitis in which clinical signs or
symptoms were present for 2 months or longer.
Eighteen (95%) of the 19 patients with available
medical records fulfilled this clinical criterion;

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Chronic Diverticulitis
four of the 18 patients were subsequently excluded
because barium enema images were not available
for review. The remaining 14 patients constituted
our study group.
Seven patients were men (50%) and seven were
women (50%). The mean age was 64 years (age
range, 3384 years). Medical records for these 14
patients were reviewed by one author to determine
the clinical presentation (including the nature and
duration of clinical signs and symptoms) and
treatment (Table 1).

Examination Technique
All 14 patients underwent barium enema exam
inations (with spot images and overhead radio
graphs), including eight double-contrast barium
enemas (57%) and six single-contrast barium
enemas (43%). All studies were performed using
digital fluoroscopic equipment (Diagnost 76,
Philips Healthcare or Sireskop SD, Siemens Medi
cal Solutions). All of the studies were performed
by residents, fellows, or one of three attending
gastrointestinal radiologists, and all were inter
preted and reported by the attending radiologists.
In three patients who had repeat barium enemas,
the initial examination was analyzed for this
study. All patients received 1 mg of IV glucagon at
the outset of the procedure to decrease patient
discomfort and minimize colonic spasm.
Ten (71%) of the 14 patients also underwent
abdominal CT within 6 months of the barium
enema examinations. All 14 patients underwent

helical CT of the abdomen (HiSpeed Advantage

or HiSpeed CT/I, GE Healthcare) according to an
established protocol. All but one patient received
500 mL of oral contrast material (23% diatrizoate
meglumine and diatrizoate sodium solution
[Gastrografin, Bracco]) and 150 mL of IV contrast
material (diatrizoate meglumine [Hypaque,
Sanofi-Aventis] or iohexol [Omnipaque 300, GE
Healthcare]). CT images were routinely obtained
during the portal venous phase with the patient in
a supine position during suspended respiration.
Axial images were obtained at 5- or 7-mm slice
collimations (pitch, 1.3:1; 200220 mAs) and
reconstructed with a soft-tissue algorithm. The
CT examinations were performed before the
barium enema examinations in six patients (mean
interval, 1.4 months; range, 0.13.8 months) and
after the barium enema examinations in four
patients (mean interval, 1.6 months; range, 0.15.6
months). We included CT examinations performed
up to 6 months before or after the barium enema
examinations because of the chronic nature of the
disease and long duration of symptoms in these
patients. CT examinations were not included,
however, if surgery had been performed between
the two studies.

of experience) to determine the radiographic find

ings associated with chronic diverticulitis, includ
ing the appearance, length and width (magnifi
cation was accounted for on the radiographs by
using the approximate height of lumbar vertebral
bodies as a reference standard), and location of the
diseased segment.
The barium enema findings were reviewed to
determine the presence or absence of colonic
obstruction, focal extravasation into a pericolic
collection, or fistula formation. The presence and
location of underlying colonic diverticulosis were
also assessed. On review of the CT images, the
presence or absence of localized wall thickening
(> 5 mm) [5, 6], pericolic fat stranding, fistulas,
giant diverticula, small-bowel or colonic
obstruction, small-bowel dilatation, pneumo
peritoneum, and portomesenteric venous gas was
noted. There were no major discrepancies between
the original radiographic reports and the retro
spective review of the barium enema examina
tions or abdominal CT examinations.

Review of Pathologic Findings

Histologic sections from the resected surgical
specimens in these 14 patients were reviewed
retrospectively by two authors (both pathologists)
to characterize the pathologic findings of chronic
diverticulitis, including the presence of divertic
ular disease, inflammation, and fat stranding.
Inflammation was defined by the presence of acute
inflammatory cells (i.e., neutrophils) or chronic

Review of Images
All of the images from the 14 barium enema
examinations and 10 abdominal CT examinations
were reviewed by a consensus of two authors (both
gastrointestinal radiologists with 25 and 23 years

TABLE 1: Presenting Clinical Findings in 14 Patients with Chronic Diverticulitis

Symptom
Duration (mo)

Obstructive
Symptoms

Left Lower
Quadrant Pain

Tenderness

Fever

Leukocytosis

Gastrointestinal
Bleeding

Other

23

24

Draining fistula to skin

Weight loss

10

36

11

Weight loss

12

10

Stool from vagina

13

12

Patient No.

14
Totala

11b

10 (71)

9 (64)

2 (14)

2 (14)

1 (7)

3 (21)

Fecaluria
5 (36)

NotePlus sign indicates present, minus sign indicates absent.

aExcept where otherwise indicated, data in Total row are number of clinical findings with percentage in parentheses.
bMean symptom duration.

AJR:191, August 2008

523

Sheiman et al.
Institutional Review Board Approval
Our institutional review board approved all
aspects of this retrospective study and did not
require informed consent from any patients whose
radiographic images or medical records were in

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inflammatory cells (i.e., lymphocytes) in the

bowel wall or adjacent pericolic fat or within
pericolic collections. Fat stranding was defined as
fibrosis in the pericolic fat on representative
pathologic specimens.

Fig. 174-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 doublecontrast 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.

cluded in our study. This investigation also was

HIPAA-compliant.

Results
Clinical Findings
The mean duration of symptoms in our
population was 11 months (range, 236
months). Ten (71%) of the 14 patients presented with one or more clinical signs of obstruction, including constipation in five patients
(36%), decreased stool caliber in three (21%),
bloating in three (21%), and nausea and vomiting in three (21%). Six patients (43%) had
obstructive symptoms and left lower quadrant
abdominal pain. Signs of gastrointestinal
bleeding included melena in one patient
(7%), rectal bleeding in one (7%), and melena and rectal bleeding in one (7%). No patients had abdominal rebound or guarding.
Twelve patients (86%) had prior episodes
of diverticulitis (mean number of episodes,
1.7; range, 14), and six (43%) had received
antibiotics before surgery without clinical
improvement. The indications for surgery
(sigmoid resection) in these 14 patients included colonic luminal narrowing or obstruc
tion (or both) on barium enema examina
tions in seven patients (50%) (six of whom
also had intractable obstructive symptoms
and one of whom also had an obstructing
stricture at colonoscopy); symptomatic, intractable fistulas in three (21%); recurrent
diverticulitis in two (14%); failed medical
treatment for diverticulitis in one (7%); and a

Fig. 249-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.
A, 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.
B, 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.

524

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Chronic Diverticulitis
Fig. 356-year-old man with chronic diverticulitis who presented with 3-month
history of pencil-thin stool and rectal bleeding.
A, 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).
B, 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.

A
giant sigmoid diverticulum in one (7%). Only
one (7%) of the 14 patients (described previously) underwent preoperative colonoscopy.
Radiographic Findings
Barium enema examinationsBarium
enema examinations revealed sigmoid diver
ticulosis in 13 (93%) of the 14 patients; diver
ticula were present in the descending colon in
six patients (43%), the transverse colon in
three (21%), and the ascending colon in two
(14%). The sigmoid colon alone was involved
in eight patients (57%), both the sigmoid and
descending colon in five (36%), and the
descending colon alone in one (7%).
All 14 patients had findings of sigmoid
diverticulitis on barium enema examinations.
There was circumferential narrowing of the
sigmoid colon in thirteen patients (93%)
(Figs. 16). The mean length of the narrowed
segment was 4.8 cm (range, 26 cm) and the
mean width (at its narrowest point) was 0.6
cm (range, 0.11.7 cm). The segment of
narrowing in all 14 patients had a tethered or
spiculated contour with distorted but
preserved mucosal folds (Figs. 16).
Of the 13 patients with circumferential
narrowing, the proximal margins of the narrowed segment were tapered in 10 patients,
abrupt in two, and difficult to characterize in
one, and the distal margins were tapered in
10 patients, abrupt in two, and overhanging
in one. The narrowed segment caused retro-

AJR:191, August 2008

grade obstruction of the sigmoid colon in

three patients (23%), which was complete in
two (14%) and partial in one (7%). Differentiation from malignant tumor was more difficult in the patients with complete obstruction because of incomplete filling of the
diseased segment, with inadequate visualization of the proximal margin (Fig. 4).
The remaining patient had findings of sigmoid diverticulitis with asymmetric mass effect, spiculation and tethering of the contour,
and distorted mucosal folds but no evidence of
circumferential colonic narrowing (Fig. 7A).
Four patients (29%) had focal extravasation of barium from the sigmoid colon, with
a discrete extraluminal pericolic collection
in two patients, an extraluminal track in one,
and both a collection and a track in one. Two
patients (14%) had fistulas involving the sigmoid colon, including a colovaginal fistula in
the patient passing stool from her vagina
(Fig. 5) and a colocolic fistula in the patient
with a draining cutaneous fistula (Fig. 6).
Neither a colocutaneous fistula in this patient
nor a colovesical fistula in the patient with
fecaluria and pneumaturia were visualized
on the barium enema examination. One patient had a giant (5 cm in diameter) diverticulum in the sigmoid colon.
Abdominal CTAbdominal CT revealed
findings of sigmoid diverticulitis in nine
(90%) of the 10 patients who underwent CT.
The mean length of involved colon was 8.9

B
cm (range, 415 cm). Localized wall thickening (mean thickness, 12.5 mm; range,
819 mm) and pericolic fat stranding were
present in all nine of these patients (Figs. 2B
and 3B). Inflammatory collections were
identified in three patients (30%) (Fig. 7B)
and fistulas in three (30%), including one colocolic fistula and two colovesical fistulas.
One of the colovesical fistulas was seen in
the patient with fecaluria and pneumaturia.
The other two fistulas suggested on CT were
found in patients without barium enema or
clinical findings of fistulas. One patient was
found to have a 7 5 cm giant sigmoid diverticulum. None of the CT scans revealed
small-bowel dilatation or obstruction, pneumoperitoneum, or portomesenteric venous
gas, and none of the three patients with colonic obstruction findings on barium enema
examinations were found to have definite colonic obstruction on CT.
Pathologic Findings
Histologic sections of the resected specimens revealed chronic inflammatory cells in
the pericolic fat (n = 4), bowel wall (n= 1), or
both (n= 8) in 13 patients (93%); acute inflammatory cells in the pericolic fat (n= 7),
bowel wall (n= 3), or both (n= 1) in 11 patients (79%); and fibrosis of the pericolic fat
(i.e., fat stranding) in 13 patients (93%). The
one patient without chronic inflammatory
cells had fibrosis of the pericolic fat.

525

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Sheiman et al.

Fig. 485-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.

Finally, one patient with acute and chronic

inflammation of the sigmoid colon had an
associated diverticular abscess. Thus, all 14
patients had pathologic findings of chronic
diverticulitis with chronic inflammatory
cells or fibrosis of the pericolic fat, and 11
(79%) of these 14 patients also had acute
inflammatory changes in the sigmoid colon.
Discussion
Diverticulosis is a common condition, affecting nearly 50% of adults over 50 years
old in Western countries [7]. Affected individuals may develop acute diverticulitis,
usually resulting from a perforated sigmoid
diverticulum with a pericolic inflammatory
collection or abscess. The clinical and radiographic findings of acute diverticulitis have
been well documented [26]. To our knowledge, however, the findings of chronic diverticulitis have not been addressed previously
in the radiologic literature.
As the name implies, chronic diverticulitis
is a variant of diverticulitis in which symp
toms can persist for 6 months to 1 year or
longer [8]. In our study, the mean duration of
symptoms at the time of presentation was 11

526

Fig. 584-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).

months, and one patient had symptoms for as

long as 3 years. In contrast, patients with
acute diverticulitis have a mean duration of
symptoms of only 214 days [912]. Chronic
diverticulitis therefore is characterized by a
far more indolent course and longer duration
of clinical signs and symptoms than the acute
form of this disease.
Chronic diverticulitis can also be distinguished from acute diverticulitis by the nature
of the presenting signs and symptoms. Whereas patients with acute diverticulitis usually
have a combination of left lower quadrant
pain, tenderness, leukocytosis, and fever [2,
3], only nine (57%) of our 14 patients with
chronic diverticulitis had left lower quadrant
abdominal pain (the mean duration of pain
was 11 months), and these patients rarely if
ever had abdominal tenderness, rebound,
guarding, fever, or leukocytosis. Instead, 10
(71%) of our 14 patients with chronic diverticulitis had one or more signs or symptoms
of colonic obstruction, including constipation,
decreased stool caliber, nausea and vomiting,
and bloating. This compares with a prevalence
of obstructive symptoms of only 6.5% in a
recent series of surgical patients with acute

sigmoid diverticulitis [13]. Patients with

chronic diverticulitis therefore are much
more likely to have obstructive symptoms
than those with acute diverticulitis.
Because of chronic obstructive symptoms
and abdominal pain in our patients with
chronic diverticulitis, they were more likely
to undergo barium enema examinations than
those with acute diverticulitis in whom abdominal CT is almost always performed as
the initial diagnostic imaging test. In our
study, barium enema examinations were performed before or instead of CT in eight
(57%) of 14 patients with chronic diverticulitis. In 13 patients (94%), the barium enema
findings revealed a relatively long segment of
circumferential narrowing in the sigmoid colon with a spiculated contour and generally
tapered margins, sometimes associated with
retrograde obstruction (Figs. 16). In contrast,
acute diverticulitis is more likely to be characterized on barium enema examinations by
asymmetric mass effect and tethering of the
sigmoid colon due to an inflammatory collection abutting the bowel without circumferential luminal narrowing. Chronic diverticulitis
therefore produces characteristic findings on

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Chronic Diverticulitis
Fig. 664-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.

barium enema examinations that can usually

be differentiated from those of acute diverticulitis in the proper clinical setting.
The circumferential luminal narrowing in
chronic diverticulitis is presumably caused
by chronic inflammation or fibrosis of the colonic wall and surrounding pericolic fat, as
was observed on the resected pathologic
specimens in all 14 patients (100%) in our
study. In pathology texts, chronic diverticulitis is characterized by longitudinal spread of
the inflammatory process in the colonic wall,
progressively ensheathed by inflammatory
and fibrous tissue [14, 15]. These pathologic
features most likely account for the greater
length of the narrowed segment and the
higher frequency of circumferential narrowing in chronic diverticulitis than in acute diverticulitis. Nevertheless, 11 patients (79%)
also had acute inflammatory cells in the sigmoid colon and one (7%) had a diverticular
abscess. It therefore is uncertain how often
chronic diverticulitis results from recurrent
episodes of acute diverticulitis superimposed
on low-grade, smoldering disease. Whatever
the explanation, the high prevalence of obstructive symptoms in patients with chronic
diverticulitis can be attributed to the high
frequency of circumferential narrowing of
the sigmoid colon in these individuals.
The major consideration in the differential
diagnosis of chronic diverticulitis with narrowing and spiculation of the sigmoid colon
on barium enema examinations is metastatic

AJR:191, August 2008

disease, resulting from intraperitoneal seeding or direct extension of a contiguous pelvic

malignancy. However, patients with metastatic tumor often have known primary malignancies, more rapid progression of symptoms, and associated weight loss, whereas our
patients with chronic diverticulitis usually
had chronic obstructive symptoms without
associated weight loss or known malignant
tumors. Endometriosis may occasionally be
manifested on barium enema examinations by
circumferential narrowing and spiculation of
the sigmoid colon, but this condition usually
occurs in young women with cyclic abdominal symptoms rather than older patients.
Primary colonic carcinoma is also a frequent cause of sigmoid narrowing in older
patients, but mucosal folds are usually obliterated within the narrowed segment, which has
abrupt, shelflike borders. Although colonic
carcinoma can usually be differentiated from
diverticulitis on the basis of the radiographic
findings, tumors that spread submucosally or
perforate with associated pericolic inflammation can sometimes mimic the appearance of
diverticulitis. It can also be more difficult to
distinguish malignant tumor from diverticulitis in patients with relatively high-grade obstruction that prevents adequate visualization
of the narrowed segment, precluding analysis
of its radiographic features. In most cases,
however, the diagnosis of chronic diverticulitis can be suggested on the basis of the clinical
and radiographic findings in these patients.

CT revealed findings of sigmoid diverticulitis with localized wall thickening and pericolic fat stranding in nine (90%) of 10 patients in whom CT was performed (Figs. 2B
and 3B). CT also revealed inflammatory
collections in three patients (Fig. 7B) and
fistulas in three, but no patients had definite
evidence of obstruction on CT. Unlike the
findings on barium enema examinations, the
CT findings in patients with chronic diverticulitis therefore were similar to those in
patients with acute diverticulitis [5, 6].
Because of the circumferential luminal
narrowing that was observed in most of our
patients with chronic diverticulitis, surgical
resection of the sigmoid colon was required
for relief of obstructive symptoms. In contrast, stricture formation and obstruction
have necessitated surgical intervention in
only 612% of patients treated for acute diverticulitis [16, 17]. Our experience therefore
suggests that patients with chronic diverticulitis are more likely to require surgical resection of the diseased sigmoid colon than those
with the acute form of this disease.
Most patients with acute diverticulitis are
treated medically. Thus, endoscopy and biopsy are required to rule out colonic carcinoma whenever the radiographic findings are
equivocal for diverticulitis versus tumor. In
contrast, patients with chronic diverticulitis
are more likely to undergo surgery because
of varying degrees of colonic obstruction.
Endoscopic visualization and biopsy of the
diseased segment become less important in
this group because histologic examination of
the resected specimen will enable a definitive pathologic diagnosis to be made in almost all cases. In our study, only one (7%) of
14 patients with chronic diverticulitis underwent preoperative colonoscopy.
Our investigation has the limitations of a
retrospective study, including selection bias
and interpretation bias. Our requirement of
pathologic confirmation of diverticulitis on
surgical specimens created a particular selection bias because patients with circum
ferential luminal narrowing presumably
were more likely to undergo surgery than
those with asymmetric disease and no luminal narrowing. Nevertheless, this was a descriptive study of the clinical and radio
graphic findings in chronic diverticulitis and
not an analysis of radiographic accuracy in
detecting this condition.
In conclusion, we have reported a small
subset of patients with diverticulitis who developed chronic disease with fibrosis and

527

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Sheiman et al.

Fig. 777-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.
A, 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.
B, 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.

scarring, often leading to the development of

luminal narrowing in the sigmoid colon.
Most of these patients presented with chronic
obstructive symptoms and abdominal pain
rather than the classic clinical findings of
acute sigmoid diverticulitis. In almost all
cases, barium enema examinations revealed
a relatively long segment of circumferential
narrowing in the sigmoid colon with a spiculated contour and tapered margins, sometimes associated with retrograde obstruction.
Our experience suggests that chronic diverticulitis can often be diagnosed on the basis
of the characteristic clinical and radiographic findings in these patients.
References
1. Parks TG. Natural history of diverticular disease
of the colon. Clin Gastroenterol 1975; 4:5369
2. Parks TG. Reappraisal of clinical features of diverticular disease of the colon. BMJ 1969; 4:
642645
3. Wong WD, Wexner SD, Lowry A, et al. Practice
parameters for the treatment of sigmoid diverticulitis: supporting documentation. Dis Colon Rectum 2000; 43:290297
4. Hulnick DH, Megibow AJ, Balthazar EJ, Naidich

528

DP, Bosniak MA. Computed tomography in the

evaluation of diverticulitis. Radiology 1984; 152:
491495
5. Cho KC, Morehouse HT, Alterman DD, Thornhill
BA. Sigmoid diverticulitis: diagnostic role of
CTcomparison with barium enema studies. Radiology 1990; 176:111115
6. Rao PM, Rhea JT, Novelline RA, et al. Helical CT
with only colonic contrast material for diagnosing
diverticulitis: prospective evaluation of 150 patients. AJR 1998; 170:14451449
7. Hughes LE. Postmortem survey of diverticular
disease of the colon. Part I. Diverticulosis and diverticulitis. Gut 1969; 10:336344
8. Schlachta CM, Mamazza J, Poulin EC. Laparoscopic sigmoid resection for acute and chronic
diverticulitis: an outcomes comparison with laparoscopic resection for nondiverticular disease.
Surg Endosc 1999; 13:649653
9. Elliott TB, Yego S, Irvin TT. Five-year audit of
the acute complications of diverticular disease.
Br J Surg 1997; 84:535539
10. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of disease and outcome in complicated diverticular disease. Am J Surg 2003;
186:696701
11. Laurell H, Hansson LE, Gunnarsson U. Acute

diverticulitis: clinical presentation and differential diagnostics. Colorect Dis 2007; 9:496501
12. Spiller R. How inflammation changes neuromuscular function and its relevance to symptoms in
diverticular disease. J Clin Gastroenterol 2006;
40[suppl 3]:S117S120
13. McConnell EJ, Tessier DJ, Wolff BG. Populationbased incidence of complicated diverticular disease of the sigmoid colon based on gender and
age. Dis Colon Rectum 2003; 46:11101114
14. Morson BC, Dawson IMP. Muscular disorders.
In: Morson BC, Dawson IMP, eds. Gastrointestinal pathology, 2nd ed. Oxford, UK: Blackwell
Scientific Publications, 1979:581593
15. Whitehead R, du Boulay CEH. Diverticular disease of the colon and solitary rectal ulcer syndrome. In: Whitehead R, ed. Gastrointestinal
and oesophageal pathology, 2nd ed. Edinburgh,
UK: Churchill Livingstone, 1995:431437
16. Killingback M, Barron PE, Dent OF. Elective
surgery for diverticular disease: an audit of surgical pathology and treatment. ANZ J Surg 2004;
74: 530536
17. Salem TA, Molloy RG, ODwyer PJ. Prospective
study on the management of patients with complicated diverticular disease. Colorect Dis 2006;
8:173176

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