Image Presentation

High-Resolution Sonographic
Spectrum of Diverticulosis,
Diverticulitis, and
Their Complications

S. Boopathy Vijayaraghavan, MD, DMRD

Objective. The purpose of this study was to evaluate the high-resolution sonographic features of
diverticulosis, diverticulitis, and their complications. Methods. During a period of about 4 years 8
months, there were 25 patients with sonographic features of diverticulosis, uncomplicated diverticuli-
tis, and complicated diverticulitis. The clinical symptoms, sonographic features, follow-up investiga-
tions, and management details were recorded. Results. The common symptoms were pain in the left
lower quadrant and fever. Sonographic features of uncomplicated diverticulitis were a varying appear-
ance of the diverticulum with pericolic inflammation. Colonic wall thickening was not a consistent
sign. Complications seen were pericolic, mesocolic, and intraperitoneal abscesses, colovesical fistulas,
colouterine fistulas, perforation, and small-bowel obstruction. Uninflamed diverticula were seen in all
patients with left-sided disease. They had 7 types of sonographic appearances. Conclusions.
Uncomplicated diverticulitis is seen as a diverticulum of variable echogenicity with pericolic inflamma-
tion. An inflamed diverticulum is not visualized in complicated diverticulitis. Visualization of uninflamed
diverticula helps reinforce the diagnosis of uncomplicated diverticulitis and predict the cause in com-
plicated diverticulitis. Key words: diverticulitis; diverticulosis; sonography.

D
Received July 2, 2005, from Sonoscan Ultrasonic Scan
Centre, Coimbatore, India. Revision requested
August 24, 2005. Revised manuscript accepted for
publication September 8, 2005.
Address correspondence to S. Boopathy
Vijayaraghavan, MD, DMRD, 16 B Venkatachalam
Rd, R. S. Puram, Coimbatore 641 002, India.
E-mail: sonoscan@vsnl.com or sboopathy@eth.net
Video online at www.jultrasoundmed.org.
iverticulosis of the colon is characterized by
numerous saccular outpouchings in the colon.
Most of them are actually acquired pseudodi-
verticula, consisting of herniations of the
mucosa and submucosa through the muscular coat of
the colon. Some of them are true diverticula containing
all layers of the bowel wall, and these are congenital. The
anatomic distribution of the diverticula also varies with
the geographic location. Left-sided colonic diverticula
are common in Western countries, less common in South
America, and rare in Africa and Asia.1 Right-sided diver-
ticulosis is much more common in Asia.2 It is uncommon
before the age of 40 years and increases in frequency with
age. Diverticulitis is inflammation of a diverticulum. It
can be uncomplicated, or it can result in complications
such as perforation. In this presentation, the high-resolu-
tion sonographic features of diverticulosis, diverticulitis,
and their various complications are illustrated.

© 2006 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 2006; 25:75–85 • 0278-4297/06/$3.50
High-Resolution Sonography of Diverticulosis and Diverticulitis

Materials and Methods multiple diverticula were seen in thick-walled

segments of the colon in 2 (Figure 1). In the
Between May 2000 and December 2004, there remaining 9 patients, only 1 inflamed diverticu-
were 25 patients with sonographic features lum was seen. It was seen as a hypoechoic diver-
suggestive of diverticulosis, uncomplicated ticulum (Figure 2A), an echogenic diverticulum
diverticulitis, or complicated diverticulitis. The with a hypoechoic peripheral zone (Figure 2B),
clinical features of the patients were recorded. or an echogenic diverticulum with acoustic
Sonography was performed initially with an shadowing (fecalith) and a hypoechoic peripher-
HDI 3500 scanner and later with HDI 4000 and al zone (Figure 2C). Of these, 2 were diverticulitis
HDI 5000 Scanners (Philips Medical Systems, of the cecum (Figure 3), and the rest were left-
Bothell, WA), using convex 2- to 5-MHz, convex sided. A pericolic abscess with pericolic inflam-
4- to 7-MHz, and linear 5- to 12-MHz probes. mation was seen in 4 patients (Figure 4). One of
Sonography was performed with a graded com- them had an additional abscess in the thickened
pression technique.3 Final diagnosis was based and echogenic sigmoid mesocolon (Figure 5).
on a barium enema study (16 patients), com- Other complications of diverticulitis were seen in
puted tomographic scanning (2 patients), cys- 7 patients, the descriptions of which are given
toscopy (3 patients), laparotomy (8 patients), or below.
a combination thereof.
Case 1
Results A 46-year-old man had an acute abdomen. There
was pneumoperitoneum seen to the left of the
Of the 25 patients, 17 (68%) were male and 8 umbilicus with a hypoechoic tract extending
(32%) were female. The age of the patients from this region to a normal-appearing sigmoid
ranged from 31 to 95 years for left-sided disease colon (Figure 6). There were a few uninflamed
and 24 to 62 years for right-sided disease. Pain in diverticula in the proximal colon. Laparotomy
the left lower quadrant was the most common revealed diverticulitis of the sigmoid colon with
symptom (Table 1). Three patients were referred perforation, and resection of the sigmoid colon
for problems unrelated to diverticulosis. Two of was performed.
them were previously known to have diverticulo-
sis. One patient who had acute pancreatitis was Cases 2 and 3
found to have diverticulosis of the sigmoid colon Two men aged 53 and 59 years had pneumaturia.
on sonography. In 7 patients, the symptoms were One of them also had a history of recurrent uri-
related to the complications of diverticulitis. The nary tract infections. Sonography revealed air in
sonographic findings are summarized in Table 2. the urinary bladder (Figure 7) and a fistulous
Uncomplicated diverticulitis was seen in 11 tract between the urinary bladder and the sig-
patients. Pericolic inflammation was seen in all moid colon (Figure 8). A water enema showed a
of them. It was seen as echogenic fat with loss of
compressibility. Colonic wall thickening (>5 mm) Table 2. Sonographic Findings of Patients With
was seen in 7 of them. Among these 11 patients, Diverticulitis
Finding n
Table 1. Symptoms of Patients With Diverticulitis Uncomplicated diverticulitis 11
Symptom n Left colon 9
Cecum 2
Left-sided disease 20 Complicated diverticulitis 11
Pain in left lower quadrant 14 Pericolic and mesocolic abscess 4
Fever 4 Perforation 1
Acute abdomen 3 Colovesical fistula 2
Loose stools 2 Mass, colovesical fistula 1
Pneumaturia 2 Small-bowel obstruction 1
Urinary tract infection 1 Colouterine fistula 1
Foul-smelling vaginal discharge 1 Intraperitoneal abscess with 1
Right-sided disease 2 small-bowel obstruction
Pain in right lower quadrant 2 Uninflamed diverticula 20
Total 22 Total patients 22

76 J Ultrasound Med 2006; 25:75–85

 Vijayaraghavan

gush of fluid from the colon into the urinary
bladder (Figure 9 and Video 1). There were mul-
tiple uninflamed diverticula in the proximal sig-
moid colon. The diverticulosis was confirmed by
a barium enema study. The colovesical fistula
was seen on the barium enema study and cys-
toscopy. The patients underwent surgery, in
which resection of the fistula and sigmoid colon
was done.
Figure 2. Scans of the sigmoid colon (SI) showing uncomplicat-
ed diverticulitis with pericolic inflammation (arrowheads). The
diverticulum (arrows) appears hypoechoic (A), echogenic with a
hypoechoic peripheral zone (B), and echogenic with dense
shadowing (fecalith) and a hypoechoic peripheral zone (C).
A

Case 4
A 45-year old man had pain in the left lower
quadrant. Sonography revealed a hypoechoic
mass close to the dome of the urinary bladder
with inflamed fat around it (Figure 10). It mim-
icked a urachal mass, but there were uninflamed
diverticula of the sigmoid colon, indicating that
the mass could be due to an inflamed diverticu-
lum. The patient’s condition was managed con-
servatively. A rescan done 10 days later showed
marked resolution of the mass. There was air in
the urinary bladder. A water enema revealed a
B
colovesical fistula, which was confirmed by cys-
toscopy and a barium enema. It was later cor-
rected by surgery.

Case 5
A 75-year-old woman was referred for sonogra-
phy for pain in the abdomen and vomiting.
Sonography revealed small-bowel obstruction.
There was a tender mass of thick-walled small
bowel and thick-walled sigmoid colon (Figure

Figure 1. Oblique scan of the left iliac fossa showing the thick-
walled sigmoid colon with multiple echogenic diverticula
(arrows) and inflamed pericolic fat.

J Ultrasound Med 2006; 25:75–85 77

High-Resolution Sonography of Diverticulosis and Diverticulitis
Figure 3. Scan of the right iliac fossa showing uncomplicated
diverticulitis of the cecum. The arrow points to an echogenic
diverticulum with inflamed fat around it (arrowheads). CAE indi-
cates cecum.
11A). There were multiple inflamed diverticula in
this segment of the sigmoid colon (Figure 11B)
and uninflamed diverticula in the proximal
colon. The patient’s condition was managed con-
servatively. Later, diverticulosis was confirmed
by a barium enema study, and resection of the
sigmoid colon was done.
Case 6
A 70-year-old postmenopausal woman had a
foul-smelling vaginal discharge. Sonography
Figure 4. Scans of the left iliac fossa showing a pericolic abscess (A) with surrounding inflamed fat. The abscess is filled with fluid in
A and fluid and air in B. BL indicates urinary bladder; and SI, sigmoid colon.
A B
78
showed air in the uterine cavity (Figure 12A).
There was an air-filled tract extending from the
uterine cavity into a thick-walled sigmoid colon
(Figure 12B). There were multiple uninflamed
diverticula in the proximal sigmoid colon.
Laparotomy revealed a mass involving the sig-
moid colon and the fundus of the uterus with
diverticulosis of the sigmoid colon, which was
removed. Histopathologic examination con-
firmed diverticulitis of the sigmoid colon with a
colouterine fistula.
Case 7
A 59-year-old man had acute pain in the
abdomen and vomiting. Sonography revealed
small-bowel obstruction due to an intraperi-
toneal abscess containing some air (Figure 13).
The abscess was located in the left lumbar
region, medial to the descending colon. There
were multiple diverticula in the distal descending
colon and the sigmoid colon. Laparotomy
revealed small-bowel obstruction due to an
intraperitoneal pericolic abscess caused by com-
plicated diverticulitis of the descending colon.
There was diverticulosis of the descending and
sigmoid colon. Resection of the diseased seg-
ment of the colon was done.
Uninflamed diverticula were seen in the colon
away from the diseased segment in all the
patients with left-sided disease. They were seen
in 9 patients with uncomplicated diverticulitis of
the left colon, 4 with a pericolic abscess, and 7
with complicated diverticulitis. They were also
J Ultrasound Med 2006; 25:75–85

Figure 5. Oblique scan of the left iliac fossa showing an abscess
(arrowhead) in the thick and echogenic sigmoid mesocolon
(arrows) away from the sigmoid colon (SI).
seen in 3 patients with diverticulosis who had
sonography for unrelated clinical conditions.
The number of such diverticula varied from 1 to
5 in each patient. They showed 7 types of appear-
ance on sonography (Table 3). The first 3 types
were seen as outpouchings from the colon
because of a visible hypoechoic wall of the diver-
ticulum with varying appearance of the center,
when compared with the normal contour of the
colon (Figure 14A). The appearance of the center
of the diverticulum was (1) hypoechoic when
there was no air in it (Figure 14B), (2) echogenic
when there was a varying amount of air (Figure
14, C and D), and (3) echogenic with a dense
shadow because of fecalith (Figure 14E). The
next 3 types of appearance were seen as (4) oval
or round echogenic masses (Figure 15A), (5)
Figure 6. Longitudinal scan in the left lower abdomen showing
free peritoneal air (arrows) with a hypoechoic tract (arrowhead)
up to a normal-looking sigmoid colon (SI).
J Ultrasound Med 2006; 25:75–85
Vijayaraghavan
echogenic masses with a dense shadow due to
fecalith (Figure 15B), and (6) an echogenic line
(Figure 15C) outside the contour of the colon.
The wall of the diverticulum was not visible in
these 3 types. The seventh type of appearance
was an intramural echogenic line contiguous
with the echogenic lumen of the colon (Figure
16). More than 1 type of appearance was seen in
the same patient. The numbers of patients in
whom the various types of appearance were
seen were as follows: type 1 in 3 patients, type 2
in 12, type 3 in 7, type 4 in 18, type 5 in 4, type 6
in 3, and type 7 in 3 (Table 3).
Discussion
Diverticulitis of the colon results from inflamma-
tion of a colonic diverticulum. The initial event is
a microperforation of the wall of the diverticu-
lum, which results in peridiverticulitis or phleg-
mon and is referred to as uncomplicated
diverticulitis. Complicated diverticulitis ensues if
continuation of the inflammatory and septic
process is associated with an abscess, obstruc-
tion, free perforation, or a fistula. The most com-
mon symptoms include left lower quadrant
abdominal pain (93%–100%), fever (57%–100%),
and leukocytosis (69%–83%).1 If there has been
progression of the disease process, the patient
may report symptoms of complicated divertic-
ulitis such as recurrent urinary tract infections,
pneumaturia that results from a colovesical fis-
tula, or a feculent vaginal discharge from a
colouterine fistula. The patient with free perfora-
Figure 7. Longitudinal scan of the urinary bladder (BL) showing
air (arrow) in it.
79
High-Resolution Sonography of Diverticulosis and Diverticulitis
Figure 8. Oblique scan through the urinary bladder and left iliac
fossa showing an air-filled tract (arrow) extending from the sig-
moid colon (SI) into the lumen of the urinary bladder (BL).
tion and peritonitis has acute peritoneal signs
and abdominal wall rigidity consistent with a
perforated viscus. Diverticula develop in rows
between the mesenteric and the 2 lateral taeniae.
They may be intraperitoneal or extraperitoneal
in location. The complications of diverticulitis
depend on the location of the diverticulum and
its neighboring organs. Extraperitoneal divertic-
ulitis can develop into a pericolic abscess.
Intraperitoneal diverticulitis can result in perfo-
ration into the peritoneal cavity, an intraperi-
toneal abscess, or fistula formation with the
urinary bladder, the small bowel, or, rarely, the
uterus. Sonography and computed tomography
are the imaging methods of choice for the diag-
nosis of acute colonic diverticulitis, with similar
Figure 9. Image after a water enema showing the echogenic
gush of fluid (arrow) from the colon into the urinary bladder (BL).
80
performance of 94%.4–7 Because sonography is
operator dependent, proper technique and
direct physician involvement in the examination
may be crucial for making an accurate diagnosis.
The sonographic examination using graded
compression is well tolerated by patients and
should be used to localize the painful area. The
same technique is used to study the colon, prox-
imal or distal to the diseased segment, to look for
the uninflamed diverticula.
Colonic mural thickening, pericolic inflamma-
tion, and, at times, the visualization of diver-
ticula are the most common criteria used for
the sonographic diagnosis of diverticulitis.8–12
Hollerweger et al7 assessed the value of visualiza-
tion of an inflamed diverticulum as a sign of
diverticulitis. Even though they considered seg-
mental bowel wall thickening (≥5 mm), pericolic
inflammation (altered echogenicity of pericolic
fat and loss of compressibility), inflamed diver-
ticula, and evidence of complicated disease (per-
forations, abscesses, and fistulas) as indications
of diverticulitis, nonvisualization of inflamed
diverticula or complications was taken as a neg-
ative finding for diverticulitis. They described 4
types of sonographic appearance of an inflamed
diverticulum. They were hypoechoic, predomi-
nantly echogenic, an echogenic center with a
surrounding hypoechoic rim, and an echogenic
mass with acoustic shadowing and, usually, a
peripherally hypoechoic rim. They were able to
diagnose 94% of cases of diverticulitis using
these criteria. An inflamed diverticulum as a
sonographic sign of diverticulitis had overall sen-
Figure 10. Longitudinal scan of the urinary bladder showing a
hypoechoic mass (M) close to the dome of the urinary bladder
(BL) with inflamed fat around it.
J Ultrasound Med 2006; 25:75–85
 Vijayaraghavan

A B
Figure 11. A, Scan of the left lower quadrant showing a large mass of thick-walled small bowel (SB) and the sigmoid colon (SI) with
inflamed fat around it. B, Scan slightly below the section in A showing a thick-walled sigmoid colon (SI) with inflamed thick-walled
diverticula (arrows).

sitivity of 77%. Applying this sign only to patients
with uncomplicated diverticulitis, sensitivity
improved from 77% to 96%. This result was due
to the fact that, in the cases of complicated diver-
ticulitis, the diverticula are involved in the
inflammatory process and are dissolved by
phlegmonous inflammation and gangrene.
Hence they are not seen. In the series presented
here, 1 of the patterns of an inflamed diverticu-
lum described by Hollerweger et al,7 along with
pericolic inflammation, was seen in all 11
patients with uncomplicated diverticulitis.
Colonic wall thickening was seen in only 7 of
these 11 patients, but uninflamed diverticula
were seen away from the involved segment of the
colon in all patients, reinforcing the diagnosis of
diverticulitis.
In patients with complicated diverticulitis, the
symptoms and clinical features were not related
to diverticulitis and were those of the complica-
tions.13 In the series presented here, there were
11 cases of complicated diverticulitis: 4 pericolic
abscesses, 1 perforation, 3 colovesical fistulas, 1
colouterine fistula, 1 intraperitoneal abscess
with small-bowel obstruction, and 1 small bowel
obstruction. In all these patients, uninflamed

Figure 12. A, Longitudinal scan of the pelvis in a postmenopausal woman showing air in the uterine cavity and a thick-walled sig-
moid colon. BL indicates urinary bladder; SI, sigmoid colon; and UT, uterus. B, Oblique scan of the pelvis and left iliac fossa showing
an air-filled tract (arrow) extending from the uterine cavity into the adjacent thick-walled sigmoid colon.

A B

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High-Resolution Sonography of Diverticulosis and Diverticulitis
Figure 13. Transverse scan of the left middle quadrant showing
an intraperitoneal abscess (arrow) with some air (arrowhead)
medial to the descending colon (C).
diverticula were seen away from the diseased
segment.
The visualization of uninflamed diverticula is
useful for reinforcing the diagnosis of uncom-
plicated diverticulitis. In complicated divertic-
ulitis, the visualization of an uninflamed
diverticulum is a clue for the cause of the com-
plication, and in this series, this finding helped
in predicting diverticulitis as the cause in 7
cases of complicated diverticulitis, which were
confirmed by surgery. To my knowledge, the
article by Hollerweger et al7 is the only study of
uninflamed diverticula. They studied the unin-
flamed diverticula in control subjects and
described the appearance of all the uninflamed
diverticula as rounded or oval echogenic out-
Table 3. Sonographic Appearance of Uninflamed
Diverticula
Appearance n
With visible wall
Outpouching with hypoechoic center 3 of uncomplicated diverticulitis is very char-
Outpouching with echogenic center 12
due to air
Outpouching with a densely shadowing 7 echogenicity with pericolic inflammation.
fecalith
Without visible wall
Oval or round echogenic mass outside 18
the colon
Echogenic mass with dense shadow 4
(fecalith) outside the colon
Echogenic line outside the colon 3 force the diagnosis of uncomplicated divertic-
Other
Intramural echogenic line 3 in complicated diverticulitis.
82
pouchings of the colonic wall, with or without
a thin peripheral hypoechoic rim of less than 1
mm. The pericolic inflammation was absent. In
the series presented here, uninflamed divertic-
ula were seen in all the patients with uncom-
plicated and complicated diverticulitis of the
left colon and in 3 control subjects, 2 known
and 1 unknown to have diverticulosis. The
uninflamed diverticula had 7 types of sono-
graphic appearances: 3 types were seen as well-
defined outpouchings with a visible wall and a
varying appearance of the center. The center
appeared hypoechoic without air or echogenic
and filled with varying amounts of air or a
densely shadowing fecalith. They were also
seen as oval or round echogenic masses and a
densely shadowing echogenic mass without a
visible wall outside the contour of the colon.
Some of them were seen just as echogenic lines
in the pericolic space, representing the air in
the diverticula, in which the wall of diverticu-
lum was invisible. Rarely, they were seen as
intramural echogenic lines, contiguous with
the echogenic lumen. Diverticula with differ-
ent appearances may be seen in the same
patient. The association of diverticulosis and
ulcerative colitis can mimic diverticulitis. In
ulcerative colitis, the inflammation is over a
longer segment of the colon, and the pericolic
inflammation surrounds the colon, whereas it
is focal in diverticulitis. Crohn disease and con-
tained perforated colonic cancer are 2 other
conditions that mimic diverticulosis with peri-
colic inflammation, fistulas, and abscess for-
mation. In both these conditions, an inflamed
diverticulum is not shown. Furthermore, unin-
flamed diverticula away from the diseased seg-
ment are also absent in these diseases. A
barium enema or colonoscopy is necessary,
after resolution of the acute phase of the dis-
ease, to rule out these diseases.
In conclusion, the sonographic appearance
acteristic. It shows a diverticulum of variable
Colonic wall thickening is not a consistent sign.
An inflamed diverticulum is not visualized in
complicated diverticulitis because it is dissolved
in the process. Visualization of uninflamed
diverticula away from the segment helps rein-
ulitis and predict the cause of the complication
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 Vijayaraghavan

A B

C D

Figure 14. Images of the left lower quadrant showing a normal

colon with pericolic fat (A) and uninflamed diverticula (arrows)
seen as outpouchings with a visible hypoechoic wall and hypoe-
choic center (B), an echogenic center with a bubble of air (C),
an echogenic center with more air (D), and an echogenic cen-
ter with dense shadowing due to fecalith (E).

J Ultrasound Med 2006; 25:75–85 83

High-Resolution Sonography of Diverticulosis and Diverticulitis
A
B 155:283–287.
C 7.
Figure 15. Images of the left lower quadrant showing divertic-
ula (arrows) appearing as an oval echogenic mass (A), an
echogenic mass with a dense shadow (fecalith) (B), and an
echogenic line (C) outside the contour of the colon. All of them
are devoid of a visible wall.
84
Figure 16. Image showing the diverticulum appearing as an
intramural echogenic line (arrow) contiguous with the
echogenic lumen.
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