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For further information, see CMDT Part 15-36: Diverticular Disease of the Colon

Key Features

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

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


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



  • 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 ...

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