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II./3.3.: Computed tomography – CT
The technique of computed tomography (CT) differs based on the given localisation and clinical question. If contast administration is necessary, the lumen of the aboral part of the gastrointestinal tract can be filled by contrast material rectally but not orally which necessitates a long time while the contrast material arrives to the colon. Fistula duct can be filled by a similar way, however, to carry out from the contralateral side (e.g. from the direction of urinary bladder or vagina), or by placing a probe towards the free or blind termination from retrograd direction is also possible. However, ascertainment of the inflammatory tissue contrast enhancement caused by diverticulitis or abscess can be flustered by lumen filling with positive contrast agent.
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Lineal, at least 4-5 mm thickening and contrast enhancement of the adipose tissue of the mesenterium of descendent colon/sigmoid colon may indicate inchoate/mild diverticulitis. Usually the inner and outside layer of the wall thickening enhances, not the middle one. In more severe case, extraluminal gas and fluid collections, absence of hypodensity of the adipose tissue, its contrast enhancement, fistula ducts, true abscesses can be observed along with the bowel lumen stenosis. Fistula ducts, abscess formation may occur even intramurally, whose signs include a hypodense center, peripheral enhancement and gas content. Indirect sign of the presence of diverticulitis is the increased vascularization of the mesocolon, pericolic and mesenterial dilation of the vessels.
Hinchey classification (1978), and its modified versions are used to classify the severity of the perforation complications of diverticulitis. Principally, stage rating helps the surgeon in decision making process. In general, laparoscopic peritoneal lavage is sufficient up to grade III., laparotomy, frequently associated with stoma formation is the most common surgical approach over this stage. Radiologist has a serious accountability in this diagnostic process, however, please note that differentiation of certain fluid collections is not possible with apparent surety.
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- Hinchey stage I. – localised (paracolic) abscess. Stage I. had been uniform in the original staging system. Afterwards this stage was divided to phase a. and b. according to the localisation of the inflammation. Stage I.a.: phlegmone, an inflammatory process infiltrating the soft tissues. Stage I.b.: abscess, which can be pericolic or mesenteric, and develops by the inflammation's progression via its demarcation.
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- Hinchey stage II. – pelvic abscess.
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- Hinchey stage III. – purulent peritonitis (surgeon finds pus in the peritoneal cavity)].
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- Hinchey stage IV. – faeculent peritonitis, if the faeces gets out into the peritoneal cavity via the perforation aperture. Very severe, often lethal.
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