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Diverticulitis

Last updated: October 18, 2021

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Diverticulitis is a diverticular disease caused by inflammation of colonic diverticula and occurs as a complication of diverticulosis, more commonly in older adults. It may remain localized (mild uncomplicated diverticulitis) or progress, resulting in complications such as abscess or perforation (complicated diverticulitis). Diverticulitis typically manifests with fever and left lower quadrant abdominal pain as the sigmoid colon is most commonly involved. CT abdomen with IV contrast is the preferred diagnostic modality in suspected acute diverticulitis. Uncomplicated diverticulitis usually responds to conservative management with bowel rest and analgesics; oral broad-spectrum antibiotics are reserved for patients at high risk of complications. In complicated diverticulitis, management consists of parenteral antibiotics, treatment of any complications, and, in some cases, emergency colonic resection. Once the acute phase has resolved, a colonoscopy is often performed to rule out malignancy. Elective colectomy is recommended for all patients with complicated diverticulitis that is managed conservatively. The procedure is not routinely indicated for uncomplicated diverticulitis.

See also “Diverticulosis.”

Inflammation or infection of colonic diverticula (typically false diverticula caused by weakness in the intestinal wall) [1][2]

  • Incidence [3][4]
    • 188/100,000 person-years [4]
    • Increases with age
    • Occurs in ∼ 4–20% of individuals with diverticulosis
  • Disease burden [3]
    • Accounts for > 165,000 annual hospital admissions in the US.
    • Likelihood of requiring surgery: ∼ 15%
    • Mortality: ∼ 1%

Epidemiological data refers to the US, unless otherwise specified.

In elderly or immunocompromised patients, clinical symptoms may only be mild.

Recommendations in this section are consistent with the 2021 American Gastroenterological Association (AGA) guidelines on the medical management of diverticulitis and the 2018 joint European Association for Endoscopic Surgery (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) consensus statements on acute diverticulitis management. [5][8]

Approach [8][9][10]

  • Suspect acute diverticulitis in adult patients presenting with LLQ pain, fever, and leukocytosis.
  • The diagnosis is typically confirmed with imaging, preferably CT abdomen with IV contrast.
    • Consider obtaining imaging in patients with:
      • An unclear diagnosis
      • Immune deficiency
      • Poor response to treatment
      • Recurrent disease for which surgery is being considered
    • Can defer imaging in patients with a prior history of diverticulitis who have:
      • Symptoms similar to previous episodes
      • No signs of severe or complicated disease
  • Consider colonoscopy to screen for malignancy once the acute phase has resolved and the risk of perforation is reduced.

Women presenting with LLQ pain should receive a pelvic examination in order to assess for gynecologic etiologies. [10]

Laboratory studies [9][11][12]

Diverticulitis is highly likely in patients with LLQ pain and tenderness, no vomiting, and CRP > 50 mg/L. [5]

Imaging [9][12][13][14][15][16]

Avoid colonoscopy during the acute phase of diverticulitis because of the risk of perforation!

  • To choose the best treatment approach and determine the prognosis, identifying the stage of acute diverticulitis is recommended. [12]
  • The modified Hinchey classification is based on CT findings and is the most commonly used classification. [5]
Modified Hinchey classification of diverticulitis [15][16][19]

Stage

CT findings Interpretation
Inflammation 0
  • Clinically mild diverticulitis
Ia
Abscess Ib
  • Stage Ia findings
  • PLUS pericolic abscess
  • Diverticulitis with local abscess formation
II
  • Stage Ia findings
  • PLUS an abscess distant to the primary infection
  • Diverticulitis with distant abscess formation
Perforation III
IV

The differential diagnoses listed here are not exhaustive.

Recommendations in this section are consistent with the 2021 American Gastroenterological Association (AGA) guidelines on the medical management of diverticulitis and the 2018 joint European Association for Endoscopic Surgery (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) consensus statements on acute diverticulitis management. [5][8]

Approach [10][16][20]

Consider imaging, antibiotic therapy, and surgical consultation early for immunocompromised patients, as they are at high risk of developing severe or complicated disease. [8]

Uncomplicated diverticulitis [5][8][10][12][16]

Patients without severe symptoms or comorbidities can be managed in an outpatient setting if they have uncomplicated diverticulitis, oral intake is tolerated, and adequate follow-up can be ensured. [10]

Complicated diverticulitis [5][10][15][16][18][21]

Obtain an urgent surgical consult in patients with features of generalized peritonitis or sepsis.

Long-term management

Uncomplicated diverticulitis [5][8][9]

  • Clear liquid diet
  • Supportive care
  • Consider broad-spectrum oral antibiotics in patients at high risk for complications (not routinely indicated). [22]
  • Outpatient treatment with follow-up in 2–3 days or earlier if symptoms worsen
  • Consider referral for colonoscopy after the resolution of symptoms

Complicated diverticulitis [5][8][16][23]

Early [19]

Late [19]

We list the most important complications. The selection is not exhaustive.

One-Minute Telegram 21-2021-2/3: Amoxicillin-clavulanate: An alternative to fluoroquinolones in treating diverticulitis?

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  1. Francis NK, Sylla P, Abou-Khalil M, et al. EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice. Surg Endosc. 2019; 33 (9): p.2726-2741. doi: 10.1007/s00464-019-06882-z . | Open in Read by QxMD
  2. Cao Y, Strate LL, Keeley BR, et al. Meat intake and risk of diverticulitis among men. Gut. 2017; 67 (3): p.466-472. doi: 10.1136/gutjnl-2016-313082 . | Open in Read by QxMD
  3. Strate LL, Keeley BR, Cao Y, Wu K, Giovannucci EL, Chan AT. Western Dietary Pattern Increases, and Prudent Dietary Pattern Decreases, Risk of Incident Diverticulitis in a Prospective Cohort Study. Gastroenterology. 2017; 152 (5): p.1023-1030.e2. doi: 10.1053/j.gastro.2016.12.038 . | Open in Read by QxMD
  4. Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021; 160 (3): p.906-911.e1. doi: 10.1053/j.gastro.2020.09.059 . | Open in Read by QxMD
  5. Wilkins T, Embry K, George R. Diagnosis and Management of Acute Diverticulitis. American Family Physician. 2013; 87 (9): p.612-620.
  6. Swanson SM, Strate LL. Acute Colonic Diverticulitis. Ann Intern Med. 2018; 168 (9): p.ITC65. doi: 10.7326/aitc201805010 . | Open in Read by QxMD
  7. Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019; 156 (5): p.1282-1298.e1. doi: 10.1053/j.gastro.2018.12.033 . | Open in Read by QxMD
  8. Feingold D, Steele SR, Lee S, et al. Practice Parameters for the Treatment of Sigmoid Diverticulitis. Diseases of the Colon & Rectum. 2014; 57 (3): p.284-294. doi: 10.1097/dcr.0000000000000075 . | Open in Read by QxMD
  9. American College of Radiology (ACR) Appropriateness Criteria® - Left Lower Quadrant Pain. https://acsearch.acr.org/docs/69356/Narrative/. Updated: January 1, 2018. Accessed: August 28, 2019.
  10. DeStigter K, Keating D. Imaging Update: Acute Colonic Diverticulitis. Clinics in Colon and Rectal Surgery. 2009; 22 (03): p.147-155. doi: 10.1055/s-0029-1236158 . | Open in Read by QxMD
  11. Andeweg CS, Mulder IM, Felt-Bersma RJF, et al. Guidelines of Diagnostics and Treatment of Acute Left-Sided Colonic Diverticulitis. Dig Surg. 2013; 30 (4-6): p.278-292. doi: 10.1159/000354035 . | Open in Read by QxMD
  12. Tochigi T, Kosugi C, Shuto K, Mori M, Hirano A, Koda K. Management of complicated diverticulitis of the colon.. Annals of gastroenterological surgery. 2018; 2 (1): p.22-27. doi: 10.1002/ags3.12035 . | Open in Read by QxMD
  13. Abu-Zidan FM, Cevik AA. Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced. World Journal of Emergency Surgery. 2018; 13 (1). doi: 10.1186/s13017-018-0209-y . | Open in Read by QxMD
  14. Stollman N, Smalley W, Hirano I, et al. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015; 149 (7): p.1944-1949. doi: 10.1053/j.gastro.2015.10.003 . | Open in Read by QxMD
  15. Salzman H, Lillie D. Diverticular disease: diagnosis and treatment.. Am Fam Physician. 2005; 72 (7): p.1229-34.
  16. Peery AF, Stollman N. Antibiotics for Acute Uncomplicated Diverticulitis: Time for a Paradigm Change?. Gastroenterology. 2015; 149 (7): p.1650-1. doi: 10.1053/j.gastro.2015.10.022 . | Open in Read by QxMD
  17. Rezapour M, Stollman N. Antibiotics in Uncomplicated Acute Diverticulitis: To Give or Not to Give?. Inflammatory Intestinal Diseases. 2018; 3 (2): p.75-79. doi: 10.1159/000489631 . | Open in Read by QxMD
  18. Siewert B, Tye G, Kruskal J, Sosna J, Opelka F. Impact of CT-Guided Drainage in the Treatment of Diverticular Abscesses: Size Matters. American Journal of Roentgenology. 2006; 186 (3): p.680-686. doi: 10.2214/ajr.04.1708 . | Open in Read by QxMD
  19. Onur MR, Akpinar E, Karaosmanoglu AD, Isayev C, Karcaaltincaba M. Diverticulitis: a comprehensive review with usual and unusual complications. Insights into Imaging. 2016; 8 (1): p.19-27. doi: 10.1007/s13244-016-0532-3 . | Open in Read by QxMD
  20. Wilkins T, Baird C, Pearson AN, Schade RR. Diverticular bleeding.. Am Fam Physician. 2009; 80 (9): p.977-83.
  21. Pemberton JH. Acute diverticulitis complicated by fistula formation. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-diverticulitis-complicated-by-fistula-formation.Last updated: September 23, 2015. Accessed: December 13, 2016.
  22. Bharucha AE, Parthasarathy G, Ditah I, et al. Temporal Trends in the Incidence and Natural History of Diverticulitis: A Population-Based Study. Am J Gastroenterol. 2015; 110 (11): p.1589-1596. doi: 10.1038/ajg.2015.302 . | Open in Read by QxMD
  23. Meyer J, Buchs NC, Ris F. Risk of colorectal cancer in patients with diverticular disease.. World Journal of Clinical Oncology. 2018; 9 (6): p.119-122. doi: 10.5306/wjco.v9.i6.119 . | Open in Read by QxMD
  24. Etzioni DA, Mack TM, Beart RW, Kaiser AM. Diverticulitis in the United States: 1998–2005. Ann Surg. 2009; 249 (2): p.210-217. doi: 10.1097/sla.0b013e3181952888 . | Open in Read by QxMD
  25. Barroso AO, Quigley EM. Diverticula and Diverticulitis: Time for a Reappraisal.. Gastroenterology & hepatology. 2015; 11 (10): p.680-8.
  26. Heise CP. Epidemiology and Pathogenesis of Diverticular Disease. J Gastrointest Surg. 2008; 12 (8): p.1309-1311. doi: 10.1007/s11605-008-0492-0 . | Open in Read by QxMD