Impact of CT imaging on predicting the surgical management of acute diverticulitis

PURPOSE: The incidence of colonic diverticular disease is increasing, and several grading systems based on CT findings have been developed. The objective of this study was to define the impact of various CT findings of colonic diverticulitis and to demonstrate which factors affect the need for operative treatment. METHODS: Three hundred fifty-seven patients diagnosed with colonic diverticulitis from January 2010 to July 2016 were retrospectively evaluated. Patients were excluded if pure diverticulosis, diverticular bleeding, colon cancer, or relevant data deficiencies, and the remaining patients (n = 178) were reviewed. Patients were categorized into a successful nonoperation group and an operation group. The operation group was then matched 1:2 with the nonoperative group based on age, gender, American Society of Anesthesiologists physical status classification, and body mass index. RESULTS: After propensity score matching, there were no significant differences regarding patients' demographic characteristics between the 2 groups. Left location was more associated with need for operation than the right side (79.2% vs. 31.3%, P < 0.001). CT findings such as distant intraperitoneal air, pericolic air, and free fluid were significantly more apparent in the operation group. When these factors were evaluated in a multivariate analysis, distant intraperitoneal air showed statistical significance (P = 0.046) and pericolic air and left location a significant trend (P = 0.071 and P = 0.067, respectively). CONCLUSION: This study suggests that distant intraperitoneal air is the most important factor in the need for surgery in patients with colonic diverticulitis. Further study will be able to identify more detailed CT findings and verify their significance, and will be helpful in designing practical scoring and classification systems.

Nonsteroidal anti-inflammatory drugs induced diaphragm disease: a report of 3 cases and literature review

Multiple strictures of small bowel induced by nonsteroidal anti-inflammatory drugs (NSAIDs), were known as diaphragm disease. The purpose of these case reports is to present 3 cases of diaphragm disease of small bowel and summarize the clinical features of this disease entity. A 34-year-old man, a 63-year-old man, and a 66-year-old woman were admitted to Daegu Catholic University Medical Center because of recurrent intestinal obstructions. Two of these patients had taken heavy NSAIDs use. Capsule endoscopy was performed in all cases and the all capsules were retained by circumferential strictures of the ileum. Segmental resection of the strictures was performed in 2 patients and 1 underwent just enterotomy and capsule removal. In conclusion, clinicians should be aware that diaphragm disease might be a cause of small bowel obstruction especially in patients receiving long term NSAIDs therapy.

Unusual intestinal obstruction due to idiopathic sclerosing encapsulating peritonitis: a report of two cases and a review

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick fibrotic membrane encasing the small intestine like a cocoon. Accurate preoperative diagnosis is often difficult. We present 2 cases of SEP that were diagnosed preoperatively by contrast-enhanced computed tomography scan. A 38-year-old man and a 56-year-old woman were admitted to Daegu Catholic University Medical Center because of recurrent intestinal obstruction. We performed exploratory laparotomy with doubt of the preoperative diagnosis of SEP. We confirmed the diagnosis of SEP on laparotomy and performed adhesiolysis. Both patients recovered successfully and had no signs of recurrence. A better awareness of SEP and its radiological features should lead to more correct preoperative diagnosis and result in more appropriate management, including surgery.

Mullerian Adenosarcoma Arising From Rectal Endometriosis

A Mullerian adenosarcoma is an extremely rare tumor characterized by a stromal component of usually low-grade malignancy and by a benign glandular epithelial component. A Mullerian adenosarcoma occurs mainly in the uterus, but also in extrauterine locations. Extrauterine Mullerian adenosarcomas are thought to arise from endometriotic deposits. A 36-year-old female presented to Daegu Catholic University Medical Center with a symptom of loose stool for several months. The imaging studies revealed a rectal mass, so she underwent a laparoscopic low anterior resection. Although extemporary pathology revealed an inflammatory myofibroblastic tumor, the final histologic diagnosis was a Mullerian adenosarcoma arising from rectal endometriosis. To our knowledge, except a concomitant rectal villotubular adenoma, cases of Mullerian adenosarcomas arising the rectal wall are rare. An adenosarcoma arising from endometriosis should be considered in the differential diagnosis of a pelvic mass, even one appearing in rectal wall, because ectopic endometrial tissue exists everywhere.