S2k-Leitlinie Divertikelkrankheit/Divertikulitis

Statement of the Section Internal Medicine of the DEGUM – Ultrasound Obtains Pole Position for Clinical Imaging in Acute Diverticulitis

“…The German guideline 2014 [1] unanimously came to a new classification (CDD, classification of diverticular disease), …”

“…Accordingly, initially only one diverticulum is concerned. Inflammation leads to increased pressure followed by microperforation evoking a peridiverticular mesenteric inflammatory reaction which may progress to a pericolic and mural phlegmonous infiltration which secondarily may involve further diverticula and / or cause fistulisation, sealed perforation, abscess, free perforation, peritonitis, or a stenosing inflammatory sigmoidal tumor [1,23]. The peridiverticular reaction is a macroscopically visible fibrofatty hyperperfused mass, which is an important element for diagnosis both at US (including CEUS, qFig.…”

“…inflammation and imaging), rather representing irritable bowel syndrome in carriers of diverticulosis. Accordingly, US may visualize diverticulosis and accentuated colonic wall but does not reflect any correlate of inflammation in these patients [1]. The term segmental colitis associated with diverticula (SCAD) refers to an unspecific segmental inflammation between sigmoidal diverticula.…”

“…Also apostrophized as ´left sided appendicitis´, the triad (i) spontaneous pain in the left lower quadrant, exaggerated by movements, (ii) an inflammatory reaction (CRP, WBC, temperature) and (iii) local guarding upon palpation, is unspecific, time-dependent, and variable, and thus may raise the suspicion of diverticulitis but neither satisfies contemporary diagnostic needs nor excludes most differential diagnoses [4,29]. The German Guideline [1] fosters the development that this diagnostic gap can definitely be closed by qualified ultrasonography. Because in Germany legal radiation protection applies according § 23(1) RöV from 2011, radiology is only allowed, "if a justifying indication applies.…”

“…This classification addresses and stratifies different types of diverticulitis but also comprises asymptomatic diverticulosis, symptomatic diverticular disease (SUDD; largely resembling irritable bowel syndrome), and diverticular bleeding (qTable 1) [1]. Among the diagnostic keynotes, the guideline stresses (1) the necessity to expand physical examination and laboratory analyses (CRP, WBC, urine analysis) by an imaging method (US or CT) for a safe diagnosis of diverticulitis, and (2) the obligation to classify diverticular disease.…”