Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Print Section ++ For further information, see CMDT Part 15-36: Diverticular Disease of the Colon + Key Features Print Section ++ ++ Essentials of Diagnosis ++ Acute abdominal pain and fever Left lower abdominal tenderness and mass Leukocytosis ++ General Considerations ++ Defined as macroscopic inflammation of a diverticulum that may reflect a spectrum from inflammation alone, to microperforation with localized paracolic inflammation, to macroperforation with either abscess or generalized peritonitis Diverticulosis Present in 25% of adults over age 40 Increases with age Most cases are asymptomatic Diverticulitis occurs in 10–20% of patients with diverticulosis + Clinical Findings Print Section ++ ++ Symptoms and Signs ++ Abdominal pain, mild to moderate, aching, usually in the left lower quadrant Constipation or loose stools Nausea and vomiting Low-grade fever Left lower quadrant tenderness Palpable left lower quadrant mass Generalized abdominal pain and peritoneal signs in patients with free perforation ++ Differential Diagnosis ++ Perforated colorectal cancer Infectious colitis, eg, Campylobacter, Clostridioides difficile Inflammatory bowel disease Ischemic colitis Appendicitis Gynecologic Pelvic inflammatory disease Tubo-ovarian abscess Ovarian cyst or torsion Ectopic pregnancy Mittelschmerz Endometriosis Urinary calculus Gastroenteritis + Diagnosis Print Section ++ ++ Laboratory Tests ++ Leukocytosis, mild to moderate Stool occult blood test positive, but hematochezia is rare ++ Imaging Studies ++ Endoscopy and colonography are contraindicated during the initial stages of an acute attack because of the risk of free perforation Perform radiologic imaging (CT colonography or barium enema) only after resolution of clinical symptoms to document extent of diverticulosis or presence of fistula CT scan of the abdomen indicated To confirm diagnosis In patients who do not improve rapidly after 2–4 days of empiric therapy In severe disease to diagnose abscess Presence of colonic diverticula and wall thickening, pericolic fat infiltration, abscess formation, or extraluminal air or contrast suggests diagnosis ++ Diagnostic Procedures ++ Colonoscopy Recommended in patients over age 50 who have not undergone appropriate screening Should be considered in other high-risk patients, especially those with suspicious radiologic imaging, diverticulitis with complications or protracted symptoms, or family history of colorectal cancer Contraindicated during acute attack Perform only after resolution of clinical symptoms to document extent of diverticulitis and to exclude other clinical disorders + Treatment Print Section ++ ++ Medications ++ Most patients can be managed with conservative measures Mild diverticulitis (mild symptoms and no peritoneal signs) Clear liquid diet Broad-spectrum oral antibiotics with anaerobic activity, such as amoxicillin and clavulanate potassium, 875 mg/125 mg twice daily orally; or metronidazole, 500 mg three times daily orally; plus either ciprofloxacin, 500 mg twice daily orally, or trimethoprim-sulfamethoxazole, 160/800 mg twice daily orally, for 7–10 days Severe diverticulitis (high fevers, leukocytosis, or peritoneal signs) Nothing by mouth Intravenous fluids Nasogastric tube suction if ileus is present Intravenous antibiotics targeting both anaerobic and aerobic (gram-negative) bacteria, such as either single-agent therapy with a second-generation cephalosporin (eg, cefoxitin), or piperacillin-tazobactam, or ticarcillin clavulanate; or combination therapy (eg, metronidazole or clindamycin plus an aminoglycoside or third-generation cephalosporin [eg, ceftazidime, cefotaxime]) for 7–10 days ++ Surgery ++ Indications for surgery Generalized peritonitis Large undrainable abscesses Clinical deterioration despite medical management and percutaneous drainage Surgery in two stages for abscesses for which catheter drainage is not possible or helpful Diseased colon is resected, temporary colostomy of proximal colon is created, and distal colonic stump is either closed (forming a Hartmann pouch) or exteriorized as a mucous fistula Weeks later, colon is reconnected electively ++ Therapeutic Procedures ++ Percutaneous catheter drainage of localized abdominal abscess, with subsequent single-stage elective surgical resection of diseased segment of colon + Outcome Print Section ++ ++ Complications ++ Fistula formation may involve the bladder, ureter, vagina, uterus, bowel, and abdominal wall Stricturing of the colon with partial or complete obstruction ++ Prognosis ++ Diverticulitis recurs in 15–30% of patients treated with medical management over 10–20 years; however, < 5% have more than two recurrences Recurrent mild attacks may warrant elective surgical resection in selected patients ++ Prevention ++ High-fiber diet ++ When to Refer ++ Failure to improve within 72 hours of medical management Presence of significant peridiverticular abscesses (4 cm or larger) requiring possible percutaneous or surgical drainage Generalized peritonitis or sepsis Recurrent attacks Chronic complications including colonic strictures or fistulas ++ When to Admit ++ Severe pain or inability to tolerate oral intake Signs of sepsis or peritonitis CT scan showing signs of complicated disease (abscess, perforation, obstruction) Failure to improve with outpatient management Immunocompromised or frail, elderly patient + References Print Section ++ + +Ahmed AM et al. Surgical treatment of diverticulitis and its complications: a systematic review and meta-analysis of randomized control trials. Surgeon. 2018 Dec;16(6):372–83. [PubMed: 30033140] + +Deery SE et al. Management of diverticulitis in 2017. J Gastrointest Surg. 2017 Oct;21(10):1732–41. [PubMed: 28547631] + +Feuerstein JD et al. Diverticulosis and diverticulitis. Mayo Clin Proc. 2016 Aug;91(8):1094–104. [PubMed: 27156370] + +Gachabayov M et al. Laparoscopic approaches to complicated diverticulitis. Langenbecks Arch Surg. 2018 Feb;403(1):11–22. [PubMed: 28875302] + +Huston JM et al. Antibiotics versus no antibiotics for the treatment of acute uncomplicated diverticulitis: review of the evidence and future directions. Surg Infect (Larchmt). 2018 Oct;19(7):648–54. [PubMed: 30204549] + +Knott L et al. Medical management of diverticular disease. Clin Colon Rectal Surg. 2018 Jul;31(4):214–6. [PubMed: 29942209] + +Meara MP et al. Emergency presentations of diverticulitis. Surg Clin North Am. 2018 Oct;98(5):1025–46. [PubMed: 30243445] + +Shaban F et al. Perforated diverticulitis: to anastomose or not to anastomose? A systematic review and meta-analysis. Int J Surg. 2018 Oct;58:11–21. [PubMed: 30165109] + +Zoog E et al. An update on the current management of perforated diverticulitis. Am Surg. 2017 Dec 1;83(12):1321–8. [PubMed: 29336748]