Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-36: Diverticular Disease of the Colon + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Laboratory Tests ++ Leukocytosis, mild to moderate Stool occult blood test positive, but hematochezia is rare +++ Imaging Studies ++ Indications for CT scan of the abdomen Suspected diverticulitis, especially in patients with fever, leukocytosis, and signs of sepsis or peritonitis Evidence of complicated disease in immunocompromised patients Presentation of mild symptoms for first time to look for evidence of diverticulitis (colonic diverticula, wall thickening, pericolic fat infiltration) and to exclude other causes of abdominal pain Patients who respond to acute medical management should undergo complete colonic evaluation with colonoscopy or radiologic imaging CT colonography) 4–8 weeks after resolution of clinical symptoms to exclude colorectal cancer (which may mimic diverticulitis) Endoscopy and colonography are contraindicated during the initial stages of an acute attack because of the risk of free perforation +++ 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 Download Section PDF Listen +++ +++ Medications ++ Most patients with uncomplicated disease can be managed with conservative measures Mild diverticulitis (mild symptoms and no peritoneal signs) Clear liquid diet for 2–3 days 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 Following recovery from complicated diverticulitis, a subsequent elective one-stage surgical resection is generally recommended to reduce recurrent episodes of complicated disease +++ Therapeutic Procedures ++ Percutaneous catheter drainage of localized abdominal abscess, with subsequent single-stage elective surgical resection of diseased segment of colon + Outcome Download Section PDF Listen +++ +++ Complications ++ Phlegmon Abscess Perforation Peritonitis Sepsis Chronic inflammation or an untreated abscess may lead to Smoldering disease (ongoing pain, leukocytosis) Fistula formation that may involve the bladder, ureter, vagina, uterus, bowel, and abdominal wall Stricturing of the colon with partial or complete obstruction +++ Prognosis ++ Diverticulitis recurs in 15–20% 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 +++ 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 Download Section PDF Listen +++ + +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] + +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] + +Strassle PD et al. Rates of elective colectomy for diverticulitis continued to increase after 2006 guideline change. Gastroenterology. 2019 Dec;157(6):1679–81. [PubMed: 31499038] + +Van Dijk ST et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Long-term effects of omitting antibiotics in uncomplicated acute diverticulitis. Am J Gastroenterol. 2018 Jul;113(7):1045–52. [PubMed: 29700480] + +Zoog E et al. An update on the current management of perforated diverticulitis. Am Surg. 2017 Dec 1;83(12):1321–8. [PubMed: 29336748]