Limiting stochastic harm when monitoring diverticular flogosis for

Limiting stochastic harm when monitoring
diverticular flogosis for lower Hinchey classes.
Personal proposal for a selection
method Reliability Ultrasound Score (RUS)
Ann. Ital. Chir., 2014 85: 479-484
pii: S0003469X1402199X
Pierpaolo Caputo, Marco Rovagnati, Hamid Pakrawanan, Pier Luigi Carzaniga
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S.C di Chirurgia, Azienda Ospedaliera di Lecco, Ospedale “L. Mandic” di Merate (Lecce), Italy
Limiting stochastic harm when monitoring diverticular flogosis for lower Hinchey classes. Personal proposal for
a selection method Reliability Ultrasound Score (RUS)
BACKGROUND: An article in the BMJ issueof May 2012 (11) tackled the issue of safeguarding health by preventing diagnostic overtreatment. An observation of the diagnostic options in clinical routine enabled us to critically assess the appropriateness or notof the use of ionising radiation in monitoring acute diverticulitis by means of CT imaging. This disease, which has alwaysbeen frequent in elderly patients, has recently assumed a new role as an endemicdiseasein the
Caucasian populationaged 40 to 50 in the Western world (6).
MATERIAL AND METHOD: We considered 79 cases coming under observation in the Emergency Roomover a period of 115
months, selected from a pool of 136 according to Hinchey Score (Hs) 0-1a-1b- assigned on admission after an
Ultrasound(US) examination . The choice of the first diagnostic approach depended on the severity of the patient ‘s clinical condition, the degree of collaboration of the same and the discretion of the radiologist, although the concerted opinion was to prefer the US test given its clearly- established advantages of being convenient and harmless. During the
period of recovery we noted the tendency to subordinate the choice of instrument to the habit and discretion of the
attending practitioner. Our proposal was to introduce a standardised personal criterion which took into account the problem of stochastic harm from ionising radiation. The need of exposure or not to verify the clinical condition by means
of a CT as opposed to a US was thus deduced by means of an Reliability Ultrasound Score (RUS)
RESULTS: Using such score we were able to schedule in 14 out of the 37 cases in one branch of the study, an effective
diagnostic check-up programmein safety and with an overall saving of 32 % of the ionising radiation. During this study
wequantified a total amount of miniSivertnot dispensed, in 79 cases with Hs<2deserving of hospital admission.
CONCLUSION: This choice moves in the direction of safeguarding the patient fromdiagnostic overtreatment,with a potential increase in stochastic harm. The application of a reliability assessment filterof the US examination is currently in
the study phase as regards acute diverticular disease in classesHS=/>2°.
KEY
WORDS:
Colonic diverticula, Hinchey score, Ultrasound, Stochastic harm
Introduction
In 1973 the International Radioprotection Commission
specified that every diagnostic and therapeutic procedure
Pervenuto in Redazione Giugno 2013.Accettato per la pubblicazione
Ottobre 2013
Correspondence to: Pierpaolo Caputo, MD S.C di Chirurgia, Azienda
Ospedaliera di Lecco, Ospedale “L. Mandic” di Merate. (Le), Italy
(e-mail: [email protected])
should be justified as regards its ethics, cost and safety.
No activities entailing exposure to ionising radiation
should become part of clinical procedure unless the certain benefit to those subjects exposed could be demonstrated. In May 2012 Cartabellota quoted an article12 in
the BMJ, addressing the issue of safeguarding health including by means of preventing over diagnosis, suggesting that
the appropriacy of diagnostic procedures be carefully considered. In standard clinical practice, the request for diagnostic monitoring of patients suffering from acute diverticular disease is often left to personal discretion, the result
of customary procedures or the presumption of a greater
guarantee of definition with the CT 7, 10 as opposed to
Ann. Ital. Chir., 85, 5, 2014
479
P. Caputo, et. al.
11.710°9/L (range: 5.4-19.3 10°9/L) with neutrophilia
in 72 cases with mean values of 74.9% (range 71.889.2%) PCR: 4.2mg/dl (range 1.3- 23.2 mg/dl). Bowel
movements were altered in 56 patients (73.6%) by an
average of 2.7 days (range: 0-9). 7 patients, with no
fever or neutrophilia were treated solely with Mesalazina
2400 mg divided into three doses over the 24 hour period, in the feverish cases it was deemed opportune to
also administer an associated antibiotic treatment with
Ceftriaxone 2 g./die and Metronidazolo 1500 mg/die
divided into 3 doses. All patients were intensively monitored for the first 72 hours following admission during
which time the hematochemical indexes of flogosis were
observed, showing a mean decrease in Leukocytes to values of a 8.84 10°9/L (range 6.2-10.8 10°9/L), neutrophilia with mean values of 68.7% (range 59.3-78%)
and CRP: 5.8mg/dl (range 3.4-29.2mg/dl). 5 patients,
4 Hs:0and 1 Hs:1a with rapid favourable clinical progress
required no further clinical control and were discharged
within the first 48 hours of observation. The remaining
74 patients, hospitalised in the surgery ward, were divided into 2 randomised groups of 37 patients each: group
A with 34 US and 3 US+CT was monitored according
to discretional, non—standardised criteria. Group B with
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the US, given the greater sensitivity and more specific
nature of the former as well as its non-dependence on
the skill of the operator. During our study we conducted
a critical re-examination of the cases of improper use of
ionising radiation when studying the progress of diverticular disease in precocious acute phase. We evaluated
the clinical use of a personal selection criterion to classify the reliability of the preliminary US test, called the
Reliability Ultra Sound score (RUS) applied to one of
the two branches of the study conversely to the control
group in which diagnosis during monitoring was left to
the clinician’s discretion. We proposed the routine clinical use of the RUS classification as a discriminating indicator of the reliability of the US diagnosis method, aimed
at limiting the use of more sophisticated diagnostic
instruments but with a significant margin of stochastic
harm.
Materials and Methods
Over a period of 15 months we considered 79 patients,
32 women and 47 men having a mean age of 62 (range
41-87) suffering from acute diverticular syndrome selected for admission and chosen from a total of 136 diagnosed on admission to the Emergency Room (ER) with
acute diverticulitis, on the basis of their categorisation
in a severity class defined according to the Hinchey Score
(Hs) < 2, inferred from a preliminary US examination.
The choice of class of patients was based on the experience of a recent study which we conducted on patients
suffering from diverticular disease in the acute stage,
showing that in the classes Hs: < 2, out of a total of
100 patients analysed, the need to shift treatment
towards invasive therapies at a later date never arose. The
patients considered were therefore respectively: 47 Hs0,
22 H1a, 10 H1b. with a BMI ranging from 19 to 34
(average 27, ±1 SD). Each patient was subjected to clinical assessment, pre-operative blood tests with particular
reference to flogosis indexes such as leukocyte formula
and Protein C Reactive and to instrumental diagnosis
with X-ray of the abdomen in orthostasis and/or tangential projection, standard Rx of the chest, US, and/or
CT scan. In 70 of these 79 cases (88.6%)the choice of
preliminary diagnostic imaging proved satisfactory with
the US alone, in 9 (11.3%) cases diagnostic completion
by means of a CT scan was required since these patients
presented a leukocyte value of >15000 10°9/L, PCR>
10 mg/dl, in 18 diffuse peritoneal sensitivity, a mean
underarm temperature of 38.7°C (range 38.4° 40.5°C),and poor ultrasound resolution, in 1 case the
patientdid not collaborate during the abdominal scanning manoeuvre with the US probe. Hs classification
was performed on the basis of the US/CT datum. Out
of all the patients 36 were feverish with a mean underarm temperature(TA) of 37.6°C. (range: 37.1°40.5°C.),the mean alteration in white blood cells was
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Ann. Ital. Chir., 85, 5, 2014
TABLE I
Enrollment criteria
Access from ER
Acute Diverticulitis diagnosis
Admission imaging diagnostic US and/or CT
Hinchey score =0-1a-1b
October 2011to December 2012
Reliability Ultrasound Score
criteria
favourable Not favourable
Operator Skill
+1
-1
Accurate ultrasound description
+1
-1
BMI< 30
+1
-1
Consistency of US and clinical examinatio +1
-1
abdominal meteorism
+1
-1
TABLE II - Excess intake of radiation in mSv for CT versus chest Xray examination
CT
Skull
Cervical Spine
Dorsal Spine
Lumbar Spine
Thorax
Abdomen
Pelvis
Efficace dosis in mSv
1,7
1,7
4,4
5,1
7,7
7,8
8,8
Limiting stochastic harm when monitoring diverticular flogosis for lower Hinchey classes.
Results
It may be inferred from our casuistics and an analysis
of the literature how the problem of acute relapses of
colic diverticulitis cannot be addressed without a preliminary Hs classification. Depending on such classification the domiciliary treatment for classesHs:0 and Hs:1a1b,even with abscess of less than 3 cm. 9 has already
been described. In our personal experience such procedure entailed single-medication, domiciliary treatment
with Metronidazolo (1500 mg/day) associated with a liquid diet for 48 hours, a clinical check-up 72 hours later and radiological check-up after one month in the
absence of complications.
The use of the RUS filter in clinical practice proved to
be a useful instrument for choosing the diagnostic
approach, showing that the Hs classes of the 14 patients
recruited for US control on the basis of a score of >4in
the preliminary US examination did not undergo variations in class from the original classes. Clinical routine
and diagnostics further confirmed the choice of conservative treatment.
The exclusion of use of ionising radiation while ensuring the safe diagnosis of the patient has been shown to
be possible, as proven by the comparison of the results
of the 2 branches of the study. While aware of the limitation posed by casuistics involving a small number, we
can assert that in the control group A, the individual
decision of the clinician without the application of the
filter RUS led to the arguable use (US: 2 versus 14) in
at least 12 cases of CT scans, compared to group B,
The overall risk of significant stochastic harm is certainly
higher thanin the second group. The level of mSv dispensed, definable as inappropriate, considering that the
mean radiation used for an abdominal CT scan in a
patient with a BMI index of 19-25is 7.8 mSv, was
93.6mSv.
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36 US and1 US+CT scan was monitored applying a personal assessment filter to the US preliminary investigation, called the Reliability Ultrasound Score (RUS), interpreting the numerical result of this test with an indicative value of the need or not to proceed with further
investigation by means of diagnosis with the more sophisticated CT scan. This screening test is based on 5 parameters, each with a value of 1 and algebraic sum of
which between positives(favourable) and negatives (nonfavourable express a numerical value. These parameters
are described below :1)the skill of the radiologist (S),both
in terms of general experience and specifically in reading the ultrasound images of the intestinal ansae, 2)the
presence of abdominal meteorism (M)such as to prejudice the readability of the abdominal content, 3)a BMI
value of > 30, (B) 4) an accurate ultrasound description
of the lesion(A) in terms of characteristics and extension
and 5)the consistency of the objective clinical examination(E)and the ultrasound radiographic report. The algebraic sum of the values of the 5 parameters, was interpreted in two ways: “favourable” or positive (+1) and
“not favourable” or negative (-1), (Fig. 1). In cases with
a value of RUS< 4, it was deemed appropriate to resort
to further control by means of a CT scan, in cases with
a RUS value of =/> 4-5, the control by means of US
was considered exhaustive. In group A, 35 patients
(94.5%) were controlled by means of a CT scan and
only 2(5.4%) by means of US; in group B, after application of the filter RUS, 14 (37.8%) patients were controlled again with US, the remaining 23 (62.1%) with
CT scan, having scored RUS<4. No patients were selected as requiring a shift in therapy towards surgery, hence
no patient ended the period of hospitalisation with a
non-conservative approach. The decision to confirm US
monitoring for group B was applied in the absence of
clinical deterioration. Average hospitalisation times were
8.34 days (range 2-15). The overall greater number of
mini Sivert administered to the control group A compared to the patients in group B, was 93.6 mSv, equal
to 4680 standard X-rays (0.02 mSv each) of the thorax
and with an overall increase in stochastic harm of 38.4
years of exposure to natural radiation.
TABLE III - Related stochastic harm
Examination
Additional risk
of fetal tumor,
per exam
chest X-ray
1/1000.000
Rx skull
1/300.000
Rx hip
1/67.000
Rx abdomen
1/30.000
Rx Lumbar Spine 1/15.000
CT skull
1/10.000
CT chest
1/.2.500
Period of exposure to
natural radiation that involves
risk by the same amount
3 days
11 days
7weeks
4 months
7 months
1years
3,6 year
Discussion
Pursuant to the Decree Law 230, 1995 1,3 it is the
responsibility of the radiologist to make sure that a register is kept of the ionising radiation administered, with
the patient’s details and a description of the procedure
performed. In Italy, of the total number of radiations
performed in ER, 10%are CT scans 10,with an undoubted advantage in terms of accurate diagnosis, especially
when using the latest generation multilayer models but
with an inevitable exposure to radiation, certainly superfluous inthe presence of negative tests. The induced
effects after iatrogenic exposure are generally of a stochastic nature (erythema, skin ulcers, cancer, leukaemia,
hereditary effects). These effects are of a probabilistic
nature and in fact no threshold value has been demonstrated below which they do not occur and symptoms
may appear even many years after exposure. The stanAnn. Ital. Chir., 85, 5, 2014
481
P. Caputo, et. al.
presence of gas or conspicuous adipose tissue, its nonoperator-dependent status and the panoramic nature of
the image. On the basis of our experience, where for
classes Hs0,Hs1a,Hs1b, requiring admission in the
absence of a clinical deterioration we in no case needed to shift treatment towards an invasive approach, imaging control using the CT method proves entirely arguable
and becomes superfluous when the preliminary US image
has proven entirely effective for a credible description of
the radiological picture. The advantage is given by the
saving of administering a mean 7.8 mSv/ patient, if normal-type (BMI 18-25)and of the social costs of the examination. The saving in administering ionising radiation
requires the acquisition of several parameters, some of
which related to the patient’s constitution and in part
to the experience of the radiologist. In our experience
we have verified the importance of the radiologist’s skill
in interpreting the image of the intestinal wall, in often
difficult conditions, especially in the diagnostic reading
at the entrance, with paresis phenomena and intestinal
meteorism. Monitoring by imaging should be constantly associated with bio humoral and objective monitoring, without ruling out a more sophisticated control by
means of CT 7,8, in case of need. It may be useful to
adopt the following guidelines before prescribing a radiological examination, especially where a high radiation
impact is involved:
- the real utility of the exam for the patient;
- whether the required information can be inferred from
tests already performed;
- consideration of the risks/efficacy: can the same data
be acquired using alternative methods which do not
entail a radiation risk;
- assessing whether such request for control has considered the evolution of the disease compatibly with the
progression/resolution times to prevent requests for diagnosis in excess of those strictly necessary.
From the data in our possession we can say that we have
made a further instrument available,by use of the filter
RUS , for working efficiently and with a saving in the
administration of ionising radiation, with reference to
acute relapses of diverticular disease. We are currently in
the study phase of applying said filter to other diagnostic-clinical spheres.
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dard goal today is to limit exposure to essential cases, and
reduce the ionising radiation needed for a precise and
detailed diagnosis, to a minimum. The Euratom
97/43directive 4, has expressly made the practitioner prescribing the radiological procedure liable according to the
principle of justification expressed in Legislative Decree 187
30/05/2000 1,4, known as the patient radioprotection
decree. It is believed that there is a probability of 5in
100,000that a person exposed to a dose of 1 mini Sivert
will contract during their lifetime, a stochastich arm
tumour which goes to add to the overall probability of
contracting a tumour within one’s lifetime of 25-30. Added
to these figures is the one in 100, 000 probability of hereditary stochastic harmper miniSivert of exposure.
Table II highlights the corresponding amount of ionising radiation compared to the minimal amount of a
chest X-ray in which a dose of 0.02 miniSivert is sufficient. Radiation of pregnant women further predicts both
stochastic risks to the foetus and deterministic in relation to the stage of gestation. Table III compares the
additional risk of tumours occurring per single radiological examination compared to the same risk occurring
in a period of exposure to natural radiation. These values are subject to variation in relation to the age and
body mass of the patient. The relation between the level of oxygenation and susceptibility to ionising radiation
has been demonstrated by studies related to the induced
release of free radicals of the tissues, which facilitate the
absorption of radiation. It is known that the formation
of free radicals depends on the amount of oxygen present in the tissues, it thus follows that the most radiosensitive organs are those most oxygenated. The response
to ionising radiation thus varies depending on the type
of cell and the evolutionary stage of such cell, younger
cells having a greater oxygen consumption. The most
sensitive tissues are haematopoietic (bone marrow), gastro-intestinal, germinal and broncho-pulmonary. This
would suggest that the absorption capacity of an older
patient is less than that of a younger patient, the average age of the patients we examined was 62. We verified, in accordance with the literature 9, the importance
of the HS classification already upon admission to the
ER 12; in class H<2 patients requiring hospitalisation,
with RUS≥4 on the admission US, we can confirm the
unnecessary nature of a CT control scan, preferring the
motivated choice of US diagnosis versus CT. Validated
by the use of the filter RUS an approach may be formulated of necessary and not overestimated imaging to
control the evolution of the clinical picture and, when
there is evidence, update the admission HS. As regards
acute diverticular disease, it is known from the figures
in literature that the advantages of the US are a greater
spatial resolution of the intestinal ansae compared to the
CT scan as well as the advantage of real time images
with data on the elasticity of the wall after compression,
and of motility. The classic prerogatives for CT are its
speed of execution, resolution of the images even in the
482
Ann. Ital. Chir., 85, 5, 2014
Conclusions
Current legislation deriving from the Patient
Radioprotection decree, the question of appropriacy of
health expenditure and compliance with professional
ethics testify to the need for a reasoned and motivated
choice of the clinical and diagnostic procedure adopted
for the patient. In assessing complex diverticular disease,
we believe that the preliminary requirement is for classification according to the Hinchey Score. We have considered, for the moment in classes Hs<2a, the appro-
Limiting stochastic harm when monitoring diverticular flogosis for lower Hinchey classes.
RISULTATI: In base a questo score è stato possibile pianificare, in 14 casi sui 37 di uno dei due bracci di studio, un iter diagnostico di controllo efficace, in sicurezza e con un risparmio del 32% globale di quota di radiazioni ionizzanti. Nel corso di questo lavoro, abbiamo
quantificato la quota complessiva di miniSivert non erogata, su 79 casi con Hs< 2 meritevoli di ricovero ospedaliero.
CONCLUSIONI: L’attenzione di questo studio è stata sulla
salvaguardia del paziente dall’eccesso diagnostico, con un
incremento potenziale del rischio stocastico. L’utilizzo del
filtro dato dallo Score di Attendibilità Ultrasonografica
(RUS), è attualmente nella fase di studio riguardo le classi HS ≥ 2° della malattia diverticolare acuta.
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priacy of using the assessment filter RUS of the abdominal US exam upon admission, the preliminary exam
widely used in ERs, which enabled us to give a reliability index of such exam. In the cases of RUS≥4, a
control of the abdominal radiological picture using the
US method once again may be requested. In cases with
RUS< 4it is advisable to subject the patient to control
using a CT scan. The randomised study was performed
on two branches studying 37 patients each and a comparison of the data showed that in the study group B,
with the application of the score RUS a presumable saving of 12 CT scans out of 37 patients (32.4%)was
achieved compared to the control group A. The greater
overall assumption of ionising radiation in mSv by group
A compared to group B was 85.8 mSv. This choice moves
in the direction of safeguarding the patient from diagnostic overtreatment, with a potential increase in stochastic harm. The application of a reliability assessment filter
of the US examination is currently in the study phase as
regards acute diverticular disease in classes HS ≥ 2°.
Riassunto
BACKGROUND: Un articolo del BMJ del maggio 2012 (11)
tratta il problema della salvaguardia della salute attraverso la prevenzione dall’ overtreatment diagnostico.
L’osservazione delle scelte diagnostiche nella routine clinica, ci ha consentito di valutare criticamente
l’opportunità o meno dell’uso delle radiazioni ionizzanti
da Tomografia assiale computerizzata (CT) nel monitoraggio per immagini della diverticolite acuta. Questa
patologia, risulta essere, da sempre frequente nel paziente anziano e, recentemente, una nuova patologia a carattere endemico anche nella etnia caucasica della 4°-5°
decade nel mondo occidentale 6.
MATERIALI E METODI: Abbiamo considerato 79 casi giunti alla osservazione dell’ Dipartimento d’Emergenza in
15 mesi, selezionati da un pool di 136 in base all’
Hinchey Score (Hs) 0-1a-1b attribuito all’ingresso con
esame Ultrasonografico (US). La scelta del primo approccio diagnostico strumentale è dipesa dalla gravità della
clinica del paziente, dalla sua collaborazione e dalla
discrezionalità del radiologo, pur mantenendo un’ opzione preferenziale e condivisa per l’esame US in virtù dei
noti vantaggi di praticità e innocuità. Durante il ricovero, per quanto riguarda il monitoraggio per immagini
della lesione, abbiamo verificato la tendenza ad orientare la scelta strumentale in base alla discrezionalità ed abitudine dei curanti. La nostra proposta è stata
l’introduzione di un criterio personale standardizzato che
tenesse conto del problema del rischio stocastico da radiazioni ionizzanti. La necessità dell’ esposizione o meno, a
verifica del quadro clinico con Tomografia Assiale
Computerizzata (CT) versus US, è stata, quindi, dedotta dall’uso di uno score di attendibilità delle esame US
preliminare (Reliability US Score: RUS).
References
1. D.Lgs 187/700: Attuazione direttiva 97/43 EURATOM in materia di protezione sanitaria delle persone contro i pericoli delle radiazioni ionizzanti connesse a esposizioni mediche. www.arpal.gov.it.
2. ICPR 34/82: La protezione del paziente in Radiologia Diagnostica
(www.radiologiacremona.it.fisicamagri_inappropriatezza.pdf).
3. SIRM: La diagnostica per immagini; linee guida nazionali di riferimento. www.sirm.org. 18 february 2013.
4. Attuazione della direttiva 8096/29/EURATOM in materia di
protezione sanitaria della popolazione e dei lavoratori contri i rischi
derivanti dalle radiazioni ionizzanti. Decreto legislativo 26 maggio
2000, n 241- supplemento ordinario della Gazzetta Ufficiale n.203
del 31 agosto 2000.
5. Vasilleva MA: Ultrasoundstudy in colonicdiverticularmicroperforation. Vestn Rentgenol Radiol, 2011; 5: 24-7.
6. Zinzindohouè F, Samama G: Colonic diverticulosis: Which
patients need surgery? Rev Prat, 2009; 59(1): 19-9.
7. Puylaert JB: Ultrasound of colon diverticulitis. Dig Dis, 2012;
30 (1): 56-9.
8. Humes DJ: Diagnosis and managing acute diverticulitis.
Practitioner, 2012; 256 (1753): 21-3, 2-3.
9. MartínGil J, Serralta De Colsa D, García Marín A, Vaquero
Rodríguez A, ReyValcárcel C, PérezDíaz MD, SanzSánchez M,
Turégano Fuentes F: Safety and efficiency of ambulatory treatment of
acute diverticulitis. 2009; 32(2):83-7.
10. Anderson JC, Bundgaard L, Elbrond H, Laurberg S, Walker
LR, Storving J: Danish national guidelines for treatment of diverticular disease. Dan Med J, 2012; 59(5): C4453 Tonelli F, Di
Carlo V, Liscia G, Serventi A: Diverticular disease of colon:
Diagnosis and treatment. Consensus Conference, 5th Narional
Congress of the Italian Society of Academic Surgeons, Ann Ital
Chir, 2009; 80(2): 3.
11. Cartabellotta A: Overdiagnosis: La faccia oscura del progresso tecnologico? Evidence, 2012; 4(2):e 18.
12. Caputo P, Rovagnati M, Carzaniga PL: Is it possible to contain
the use of CT scans during clinical practice in relation to acute diverticular disease relapses without jeopardising the prospects of recovery?
Our preliminary experience. WSES Act. Bergamo; 2013.
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Commento e Commentary
PROF ANGELO FILIPPINI
Ordinario di Chirurgia Generale
“Sapienza” Università di Roma
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Lo studio è stato ben condotto. La diverticolite del colon è una patologia molto frequente nel mondo occidentale ed è caratterizzato da un’alta percentuale di complicante (10-25%)
Nel lavoro di Alberti 1, lo studio ecografico dell’intestino mostrò una buona accuratezza diagnostica, ma una sensibilità
del 66% nello studio dello spessore parietale colico e della flogosi diverticolare, con una percentuale di falsi negativi non
trascurabile (9.8%), tutti riconducibili allo stadio I di I Hinchey. L’ecografia, infatti, è un esame operatore dipendente e,
in accordo con la letteratura internazionale, il più accurato metodo di stadiazione della diverticolite rimane la TC con
mezzo di contrasto 2.
* * *
The study has been well carried out. Diverticulitis of the colon is a very frequent pathology in the western world and is
characterized by an high percentage of dangerous complications (10-25%).
In the study or Alberti et al. 1, ultrasonography showed a diagnostic accuracy, but a 66% sensitivity in the assessment of
wall thickness and in detecting the presence or diverticula; false-negative (9.8%) were all recorded in Hinchey stage I.
Infact, the ultrasonography is an operator-dependent test.
However, according to the Literature, the most accurate method or staging diverticular disease remains the CT scan 2.
References
1. Alberti A, Dattola P, Parisi A, Maccarone P, Rasile M: Role of ultrasonographic imaging in the surgical management of acute
diverticulitis of the colon. Chir Ital, 2002; 1-eb54( I ):71-5.
2. Pappalardo G, Frattaroli FM, Coiro S, Spolentini D, Nunziale A, Favella I., Vestri AR, Gualdi GF, Casciani E, Mobarhan
S: Effectiveness of clinical guidelines in time management of acute sigmoid diverticulitis. Results of a prospective diagnostic and therapeutic clinical trial. Ann Ital Chir, 2013; 84:171-77.
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