Diverticulitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2],Seyedmahdi Pahlavani, M.D. [3], Omodamola Aje B.Sc, M.D. [4], Ahmed Elsaiey, MBBCH [5]

Overview

Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever like appendicitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis. Diverticulitis must be also differentiated from diseases causing peritonitis.

Differentiating Diverticulitis from other Diseases

Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever. Diverticulitis must be also differentiated from diseases causing peritonitis.

Differentiating diverticulitis from diseases causing lower abdominal pain and fever

Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever like appendicitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis.[1][2][3][4][5][6]

Diseases Symptoms Signs Diagnosis Other Features
Location of abdominal pain Bowel habits Rebound tenderness Guarding Genitourinary signs Lab findings Imaging
GI diseases Diverticulitis Left lower quadrant (LLQ) Constipation

or

Diarrhea

- + +
Appendicitis LLQ / RRQ Constipation + + -
Inflammatory bowel disease LLQ Bloody diarrhea - - -
Colon carcinoma LLQ Constipation - - -
Strangulated hernia LLQ - - - -
  • No specific tests
  • CT scan used to detect the hernia and to show if it is single or multiple
Gentiourinary diseases Cystitis LLQ - + -
Prostatitis LLQ

Groin pain

- - -
Pelvic inflammatory disease Bilateral - - -
Gynecological diseases Endometritis LLQ - + - +
  • No specific tests
Salpingitis LLQ/ RLQ +/- +/-
  • Pelvic ultrasound

Differentiating diverticulitis from diseases causing peritonitis

The following table differentiates diverticulitis from other diseases causing peritonitis:

Classification of acute abdomen based

on etiology

Presentation Clinical findings Diagnosis Comments
Fever Rigors and Chills Abdominal Pain Jaundice Hypotension Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Common causes of

Peritonitis

Spontaneous bacterial peritonitis + Diffuse Hypoactive
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis -
Perforated gastric and duodenal ulcer + Diffuse + + + N Air under diaphragm in upright chest x- ray (CXR) Upper GI endoscopy for diagnosis
Acute suppurative cholangitis + + RUQ + + + + ±
Acute cholangitis + RUQ + N Abnormal LFT Ultrasound shows biliary dilatation Biliary drainage (ERCP) + intravenous (IV) antibiotics
Acute cholecystitis + RUQ + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric ± N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Acute appendicitis + RLQ + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + LLQ ± + Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation
Hollow Viscous Obstruction Small intestine obstruction Diffuse + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Gall stone disease/Cholelithiasis ±
Volvulus - Diffuse - + - Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Biliary colic - RUQ + - - N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Renal colic - Flank pain - - - N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical - - - Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis ± Diffuse - + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm - Diffuse - - - N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage - Diffuse - - - N Anemia CT scan History of trauma
Gynaecological Causes Fallopian tube Acute salpingitis + LLQ/ RLQ ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Ovarian cyst complications and endometrial disease Torsion of the cyst - RLQ / LLQ - ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Endometriosis - RLQ/LLQ - +/- +/- N Normal Laproscopy Menstrual-associated symptoms, pelvic

symptoms

Cyst rupture - RLQ / LLQ - +/- +/- N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy - RLQ / LLQ - - - N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding
Functional Irritable bowel syndrome - Diffuse - - - - N

Clinical diagnosis

-

Differentiating diverticulitis from diseases causing chronic diarrhea

The following diseases must be differentiated from diverticulitis presenting with chronic diarrhea.[7][8][9][10][10]

Cause History Laboratory findings Diagnosis Treatment
Diverticulitis Abdominal CT scan with oral and intravenous (IV) contrast

Bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy that covers anaerobic bacteria and gram-negative rods

  • A 7-10 day course of oral, broad-spectrum antibiotic therapy is the first line of therapy for acute uncomplicated diverticulitis.[11]
  • Hospital admission is indicated for elderly patients and patients with multiple comorbidities, compromised immune systems, inability to tolerate oral hydration, or failure to improve despite appropriate antibiotic therapy.
  • Hospitalized patients often require bowel rest, nasogastric tube placement, and parenteral antibiotics.[12]
  • Outpatients should be advised to follow a liquid diet for 2-3 days, after which a regular diet may be resumed slowly.
Ulcerative colitis Endoscopy
Amoebiasis Cysts shed with the stool Detects amoeba DNA in feces Amebic dysentery

Luminal amebicides for E. histolytica in the colon:

For amebic liver abscess:

References

  1. Laurell H, Hansson LE, Gunnarsson U (2007). "Acute diverticulitis--clinical presentation and differential diagnostics". Colorectal Dis. 9 (6): 496–501, discussion 501-2. doi:10.1111/j.1463-1318.2006.01162.x. PMID 17573742.
  2. Hardin, M. Acute Appendicitis: Review and Update. Am Fam Physician".1999, Nov 1;60(7):2027-2034
  3. Hanauer SB (1996). "Inflammatory bowel disease". N Engl J Med. 334 (13): 841–8. doi:10.1056/NEJM199603283341307. PMID 8596552.
  4. Cystitis-acute. MedlinePlus.https://www.nlm.nih.gov/medlineplus/ency/article/000526.htm Accessed on February 9, 2016
  5. Prostatitis - bacterial. NLM Medline Plus 2016. https://www.nlm.nih.gov/medlineplus/ency/article/000519.htm. Accessed on March 2, 2016
  6. Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.
  7. Konvolinka CW (1994). "Acute diverticulitis under age forty". Am J Surg. 167 (6): 562–5. PMID 8209928.
  8. Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR; et al. (2005). "Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology". Can J Gastroenterol. 19 Suppl A: 5A–36A. PMID 16151544.
  9. Satsangi J, Silverberg MS, Vermeire S, Colombel JF (2006). "The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications". Gut. 55 (6): 749–53. doi:10.1136/gut.2005.082909. PMC 1856208. PMID 16698746.
  10. 10.0 10.1 Haque R, Huston CD, Hughes M, Houpt E, Petri WA (2003). "Amebiasis". N Engl J Med. 348 (16): 1565–73. doi:10.1056/NEJMra022710. PMID 12700377.
  11. Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.
  12. Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.

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