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Anatomically, a diverticulum is an outpouching of the intestinal wall, lined with the intestinal mucosa on the inside and covered in the peritoneum on the external surface. The pathogenesis is unclear and multifactorial, with marked geographical differences and a higher incidence in western countries. Although diverticular disease of the intestine is very common, with the prevalence increasing with age (less than 10% in patients under 40 years of age and about 70% in those over 80), the condition is mostly asymptomatic and often undiagnosed[1]. The first clinical manifestation is usually caused by complications of the condition, and includes detection of fecal occult blood, hemochezia or, more rarely, melena, abdominal pain and/or sideropenic anemia[2]. Diverticulitis may result in life-threatening conditions such as intestinal perforation, peritonitis, abscesses, strictures, adhesions and ileus[3].

The gold standard in diagnosis of intestinal diverticulosis is computed tomography (CT) with luminal radiocontrast, including multislice enteroclysis and colonography[4]. Data post-processing allows for two-dimensional (2D) and three-dimensional (3D) image reconstruction, with the possibility of a so-called ‘virtual’ colonoscopy with detailed visualization of intestinal pathologies[5]. Direct colonoscopy and capsule endoscopy (with a miniature wireless camera) are additional diagnostic modalities[6]. Ultrasonography is limited in resolution and specificity, and thus it is not a typical diagnostic approach in the detection of diverticula. Despite this, sonography remains the imaging method of choice in cases of acute abdomen, in which pronounced diverticular complications such as diverticulitis and the surrounding inflammatory reactions may be detected[7]. Here we report an incidental finding of simple intestinal diverticulosis without inflammation or other complications, detected during gynecological examination using 3D/four-dimensional (4D) transvaginal ultrasound.

A 58-year-old woman, with a suspected endometrial polyp, underwent gel sonohysterography using a transvaginal probe (GE E8 Expert; GE Medical Systems, Waukesha, WI, USA). On 2D imaging, hyperechogenic foci were detected behind the uterus in the rectosigmoid colon (Figures 1a and b). 4D mode imaging revealed that the foci were not displaced by intestinal peristalsis, thus rendering unlikely the possibility that they represented stool lumps (default settings, threshold 28, quality high 1, B-mode angle 96°, volume angle 60°, mix 50% surface smooth/50% light, speckle reduction imaging 3). After setting the green line of the region of interest above and below the foci (Figure 1c), crater-like hollow structures were discovered extending behind the intestinal lumen. Subsequent 3D examination suggested the presence of two liquid-filled intestinal diverticula (Figure 1e) containing intraluminal echogenic lumps (‘lump-and-hollow’ appearance; Figure 1d). The presence of a pair of sigmoidal diverticula was confirmed by endoscopy (Figure 1f).

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Figure 1. Sigmoidal diverticula discovered by transvaginal virtual colonoscopy using three-dimensional (3D) ultrasound. (a) Transvaginal two-dimensional (2D) ultrasound image showing the uterus with a polyp (). Behind the uterus, two prominent hyperechogenic foci can be seen in the rectosigmoid colon (arrows). (b) Additional 2D view showing positions of the uterine cervix () and one of the discovered retrouterine echogenic foci (arrow). (c) Multiplanar mode with 3D surface rendering of the rectosigmoid colon. The render view direction was up–down. The green line in Plane A (upper left) intersects with the two echogenic foci (arrowheads). (d) Longitudinal view demonstrating that the intestinal diverticulum contains liquid in its straightened lumen (dashed line), with a small lump of echogenic material (). (e) Sonographic transvaginal virtual colonoscopy: 3D surface rendering of the rectosigmoid colon clearly showing liquid-filled orifices of two intestinal diverticula (arrows). (f) Sigmoidoscopy revealed a pair of diverticula (arrows), corresponding precisely with the double-hollow and double-lump sonographic findings in Figures 1a, c and e. Prominent ridge-like haustration () was caused by instrumental gas inflation during endoscopic examination; such an artifact could not be seen in corresponding sonograms obtained under physiological conditions (Figures 1c and e).

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To the best of our knowledge, there is no similar record in the medical literature showing that intestinal diverticulosis can be diagnosed by 3D ultrasound. Our findings open new possibilities for using the described sonographic settings to examine canalicular and cystic abdominal defects in a non-invasive, quick and comfortable manner.

  • R. Dankovcik†‡, V. Vargova§, K. Balasicova†, P. Contos¶, S. Tkacova†, S. Muranska‡

  • and M. Dudas*‡‡

  • 2nd Department of Obstetrics and Gynecology, P. J. Safarik University and L. Pasteur University Hospital, Kosice, Slovak Republic;

  • Center for Prenatal Diagnosis, s.r.o., Kosice, Slovak Republic;

  • §3rd Department of Internal Medicine, P. J. Safarik University and L. Pasteur University Hospital, Kosice, Slovak Republic;

  • Surgery Unit, Railway Hospital, Kosice, Slovak Republic; and

  • ‡‡Fetal Medicine Program, Institute of Biology and Ecology, P. J. Safarik University, Kosice, Slovakia

References

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