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
Diseases		Location of abdominal pain	Bowel habits	Rebound tenderness	Guarding	Genitourinary signs	Lab findings	Imaging	Other Features
GI diseases	Diverticulitis	Left lower quadrant (LLQ)	Constipation or Diarrhea	-	+	+	Leukocytosis	CT scan show evidence of inflammation
	Appendicitis	LLQ / RRQ	Constipation	+	+	-	Leukocytosis	Ultrasound shows evidence of inflammation	Nausea and vomiting, decreased appetite
	Inflammatory bowel disease	LLQ	Bloody diarrhea	-	-	-	Leukocytosis		Colonoscopy and tissue sampling are recommended for differentiating between Crohn's disease and ulcerative colitis
	Colon carcinoma	LLQ	Constipation	-	-	-	Serum carcino-embryogenic antigen Low serum vitamin B12 Hypercalcemia	CT scan, X-ray and MRI show metastasis
	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	-	+	-	Supra-pubic tenderness	Pyuria Presence of nitrites and leukocyte estrase	X-ray is done to rule out the suspicion of emphysematous cystitis CT scan shows gas in the bladder in cases of emphysematous cystitis
	Prostatitis	LLQ Groin pain	-	-	-	Tender and enlarged	Serum PSA elevated Leukocytosis Elevated CRP	CT scan shows edema and enlarged prostate Abscess may be observed
	Pelvic inflammatory disease	Bilateral	-	-	-	Purulent vaginal discharge	Nucleic acid amplification tests is the best laboratory test for PID	Transvaginal utrasonography
Gynecological diseases	Endometritis	LLQ	-	+	-	+	No specific tests	Ultrasound is helpful to rule out other differential diagnosis such as pelvic abscess, thrombosis and masses	Vaginal discharge Vaginal bleeding
Gynecological diseases	Salpingitis	LLQ/ RLQ		+/-	+/-		Leukocytosis	Pelvic ultrasound	Vaginal discharge

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
Classification of acute abdomen based on etiology		Presentation	Fever	Rigors and Chills	Abdominal Pain	Jaundice	Hypotension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging	Comments
Common causes of Peritonitis		Spontaneous bacterial peritonitis	+		Diffuse	−	−	−	−	Hypoactive	Ascitic fluid shows polymorphonuclear cells (PMN) >250 cells/mm³ Culture: Positive for single organism	Ultrasound for evaluation of liver cirrhosis	-
		Perforated gastric and duodenal ulcer	+		Diffuse	−	+	+	+	N	Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl	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	Hyperbilirubinemia Leukocytosis	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
	Ischemic causes	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
	Hemorrhagic causes	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 ROME III/IV criteria Pharmacologic studies based criteria	-	High dietary fiber Osmotic laxatives Antispasmodicdrugs

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	Bloody diarrhea Left lower quadrant abdominal pain Abdominal tenderness on physical examination Low grade fever	Leukocytosis Elevated serum amylase and lipase Sterile pyuria on urinalysis	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	Diarrhea mixed with blood and mucus, of gradual onset. Signs of weight loss Rectal urgency Tenesmus Blood is often noticed on underwear Different degrees of abdominal pain	Anemia Thrombocytosis A high platelet count Elevated ESR (>30mm/hr) Low albumin	Endoscopy	Induction of remission with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease.
Amoebiasis	Abdominal cramps Diarrhea Passage of 3 - 8 semiformed stools per day Passage of soft stools with mucus and occasional blood Fatigue Intestinal gas (excessive flatus) Rectal pain while having a bowel movement (tenesmus) Unintentional weight loss	Cysts shed with the stool	Detects amoeba DNA in feces	Amebic dysentery Metronidazole 500-750mg three times a day for 5-10 days Tinidazole 2g once a day for 3 days is an alternative to metronidazole Luminal amebicides for E. histolytica in the colon: Paromomycin 500mg three times a day for 10 days Diloxanide furoate 500mg three times a day for 10 days Iodoquinol 650mg three times a day for 20 days For amebic liver abscess: Metronidazole 400mg three times a day for 10 days Tinidazole 2g once a day for 6 days is an alternative to metronidazole Diloxanide furoate 500mg three times a day for 10 days must always be given afterwards.

References

↑ 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.
↑ Hardin, M. Acute Appendicitis: Review and Update. Am Fam Physician".1999, Nov 1;60(7):2027-2034
↑ Hanauer SB (1996). "Inflammatory bowel disease". N Engl J Med. 334 (13): 841–8. doi:10.1056/NEJM199603283341307. PMID 8596552.
↑ Cystitis-acute. MedlinePlus.https://www.nlm.nih.gov/medlineplus/ency/article/000526.htm Accessed on February 9, 2016
↑ Prostatitis - bacterial. NLM Medline Plus 2016. https://www.nlm.nih.gov/medlineplus/ency/article/000519.htm. Accessed on March 2, 2016
↑ Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.
↑ Konvolinka CW (1994). "Acute diverticulitis under age forty". Am J Surg. 167 (6): 562–5. PMID 8209928.
↑ 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.
↑ 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.
↑ ^10.0 ^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.
↑ 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.
↑ 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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[pmid17573742-1] 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

[pmid8596552-3] Hanauer SB (1996). "Inflammatory bowel disease". N Engl J Med. 334 (13): 841–8. doi:10.1056/NEJM199603283341307. PMID 8596552.

[hhh-4] Cystitis-acute. MedlinePlus.https://www.nlm.nih.gov/medlineplus/ency/article/000526.htm Accessed on February 9, 2016

[nlm-5] Prostatitis - bacterial. NLM Medline Plus 2016. https://www.nlm.nih.gov/medlineplus/ency/article/000519.htm. Accessed on March 2, 2016

[pmid27107781-6] Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.

[pmid8209928-7] Konvolinka CW (1994). "Acute diverticulitis under age forty". Am J Surg. 167 (6): 562–5. PMID 8209928.

[pmid16151544-8] 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.

[pmid16698746-9] 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.

[pmid12700377-10] 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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