Diverticulitis 2019

Gastrointestinal Tract and Abdomen Surgery
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Diagnosis and Management of Acute Diverticulitis — 1
Gastrointestinal Tract and Abdomen
Diagnosis and Management of Acute Diverticulitis

Tiffany K Weidner, MD, John T Kidwell, MD, David A Etzioni, MD, MSHS, FACS, FASCRS
Overview
Colonic diverticular disease refers to the presence of diverticula—small outpouchings of colon
mucosa and submucosa— that occur at sites of vascular penetration within the colon wall. These
outpouchings occur between the mesenteric tenia and the two nonmesenteric teniae. The presence
of these outpouchings is termed diverticulosis. A majority of these diverticula are pseudodiverticula,
as they do not involve all layers of the bowel wall (missing the muscular layer) [see Figure 1]. A
minority are true diverticula, which are located predominantly in the right colon.1
Copyright © 2019 Decker Intellectual Properties 2019 Mar. 20

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Figure 1
Anatomic findings of a segment of colon containing pseudodiverticula. Diverticula are located at sites
where blood vessels enter the colonic wall.
The prevalence of diverticular disease increases with age, with diverticula being present in 40 to
80% of patients older than 80 years in the United States.2Although a majority of patients are
asymptomatic, diverticular disease can become symptomatic with the development of either
inflammation or bleeding associated with diverticula. There are two leading theories regarding the
process by which a diverticulum can become inflamed (diverticulitis). In the first theory, the

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diverticulum becomes obstructed by feces or hardened mucus which can lead to a localized
perforation. The second is that diverticulitis is a primary inflammatory process.3-5
The risk of diverticulitis in patients with known diverticulosis has been shown to be between 4.3%
(mean follow up of 11 years after diagnosis of diverticulosis) and 7% (mean follow up of 14.1
years).6,7Diverticulitis is the cause of an estimated 300,000 admissions per year and more than $2
billion of annual health care expenditure in the United States.8,9Rates of hospitalization for acute
diverticulitis had been increasing over the past several decades, most prominently in patients under
65 years, until they appear to have peaked in 2008 and have since plateaued or possibly started to
decline.2-10 Women have higher rates of diverticulitis than men.10The sigmoid colon is the site of
approximately 72 to 90% of diverticulitis in the United States, followed by descending colon, right
colon, and transverse colon.2,11 In Asian populations, the right colon is the most common site of
disease.12
Risk Factors for Diverticular Disease

A wide range of factors is associated with elevated risk for developing diverticular disease [see
Table 1]. Constipation and a low fiber diet have generally been thought to be causative, but several
studies in the past 5 years have failed to confirm this association.13, 14

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A high-fiber diet may protect against complications of diverticular disease, and a daily high fiber
diet is recommended in patients with a history of acute diverticulitis by the American
Gastroenterological Association (AGA).15, 16 Despite popular belief, foods such as corn, nuts, and
popcorn have not been found to increase the risk of diverticulitis or diverticular bleeding and may
actually have a protective effect against diverticulitis.17Calcium channel blockers and statins have
some protective effect against diverticular disease.18 Smoking, alcohol, aspirin and NSAIDs, opioids,
corticosteroids, obesity, decreased physical activity, summer season in the United States, low vitamin
D levels, and western-style diet (specifically red and processed meats, refined grains, sweets, French
fries, high-fat dairy products) have all been shown to be associated with diverticular disease and its
complications.18–23 Table 2 shows a list of the most recent guidelines regarding diverticular disease

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[see Table 2a & Table 2b].

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For patients with known diverticular disease, the ability of diet and lifestyle modifications to
diminish the occurrence of diverticulitis is limited. The AGA has proposed several sensible
recommendations for patient with a history of acute diverticulitis, including increased fiber intake and
vigorous physical activity.
Pharmacologic agents including mesalamine, rifaximin, and probiotics have some role in the
prevention of recurrent attacks of acute diverticulitis; however, the evidence is not strong enough to
recommend their use at this time.24 The colon microbiome may also be involved in diverticular
disease, and there is an evolving body of research investigating the relationships between intestinal
bacteria and diverticular disease.22, 25, 26

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Diverticulitis
The clinical manifestation of diverticulitis varies widely in terms of acuity, severity, and character. In
this section, we discuss complicated versus uncomplicated diverticulitis, diagnosis, medical and
surgical treatment, and special situations.
COMPLICATED VERSUS UNCOMPLICATED DIVERTICULITIS
Traditionally, cases of diverticulitis are categorized as being complicated or uncomplicated, based

on certain pathophysiologic findings. In the recent past, patients with complicated diverticulitis
necessarily received a recommendation for surgery, either in the acute or elective context. Based on
current evidence, this distinction has questionable importance, as many patients with complicated
diverticulitis do not require surgery.
Complicated Diverticulitis
A complicated episode of diverticulitis involves extensive phlegmon, abscess, fistula, obstruction,

or free perforation [see Figure 2]. Of all cases of diverticulitis, 9 to 10% of patients present with
complicated diverticulitis as their first episode.11, 27, 28 When complicated diverticulitis does occur, it is
most commonly during an initial episode, with subsequent episodes much more likely to be
uncomplicated.11

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Figure 2
Major complications of diverticular disease of the sigmoid colon. Figure courtesy of Alice Y Chen
A pericolic abscess occurs in approximately 16% of patients hospitalized with diverticulitis and may
be categorized according to the Hinchey classification of diverticular perforations with stage I referring
to a localized pericolic abscess and stage II referring to a larger mesenteric abscess spreading
toward the pelvis [see Figure 3 ].11, 18, 29

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Figure 3
The Hinchey classification divides diverticular perforations into four stages. Mortality increases
significantly in stages III and IV.Figure courtesy of Alice Y Chen
Colonic fistulas occur in 4 to 20% of patients with diverticulitis and are responsible for up to 16% of
surgeries performed for diverticular disease.30–32 Colovesical fistulas are the most common,
accounting for 65% of all diverticular fistulas.33 Colovaginal fistulas account for approximately 25% of
all diverticular fistulas and are usually seen in women who have undergone a hysterectomy as the
uterus provides protection against formation of a fistula to the vagina.33, 34 Other less common

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fistulas include colocolonic, coloenteric, colouterine, or colocutaneous fistulas.
Partial or complete colonic obstructions with acute diverticulitis are not uncommon and result from
colon wall edema and/or fibrotic stricture. Mild obstructions are more common and usually resolve
with antibiotics and bowel rest, whereas high-grade obstructions, which are rare in the acute setting,
usually portend the need for urgent surgery. Chronic partial or complete obstruction can be due to
stricture formation that can result usually after multiple diverticulitis episodes. These strictures are
most commonly found in the sigmoid colon, and patients complain of constipation and narrowed
stools. Inflammatory changes can also cause a secondary small bowel obstruction as a result of
tethering between small bowel and a diverticular phlegmon or abscess.
A rare but dangerous complication of acute diverticulitis, occurring in 1 to 2% of cases, is free

perforation.18 This can result from either an abscess that perforates into the peritoneum causing
purulent peritonitis (Hinchey stage III) or free rupture of a diverticulum resulting in feculent peritonitis
(Hinchey stage IV). The distinction between these two clinical situations is not of great importance, as
urgent operative care is required for both.
Uncomplicated Diverticulitis
Uncomplicated acute diverticulitis refers to inflammation of an area of colon without extensive

phlegmon or other complications (eg, fistula, abscess, or stenosis). Distinguishing between
uncomplicated and complicated diverticulitis is not of great importance, as this distinction does not
drive treatment. Colonic fistulas and obstructions are generally an indication for surgery in a fit
patient. Abscesses that respond well to nonsurgical therapy generally do not mandate an operation
nor does perforation that is not clinically severe. Clinical decision-making in these cases should be
individualized.

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DIAGNOSIS AND TRIAGE OF DIVERTICULITIS
History and Physical Examination
In uncomplicated diverticulitis, classic symptoms are left lower quadrant abdominal pain, low-grade
fever, and irregular bowel habits. Urinary symptoms may occur if the affected colon is adjacent to the
bladder. Constipation or diarrhea can be seen as well as nausea, vomiting, and rectal
urgency.18 Physical examination reveals localized left lower quadrant abdominal tenderness with
variable degrees of guarding and rebound tenderness. A mass may be palpable. The stool may
contain traces of blood, but gross bleeding is unusual in the setting of active diverticulitis. Unusual
presentations of diverticulitis are included in Table 3 [see Table 3].

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Symptoms of complicated disease depend on the complication that is present. Symptoms of an

abscess are difficult to distinguish from standard acute diverticulitis. A colovesical fistula can present
with pneumaturia, abdominal pain, fecaluria, recurrent urinary tract infections, hematuria, and urinary
frequency.33, 35 Common presentation of a colovaginal fistula is passage of gas or stool through the
vagina or presence of persistent foul smelling discharge.36Speculum examination may reveal a site of
granulation tissue and drainage at the apex of the vaginal cuff.36 Patients with free perforation
classically start with left lower quadrant pain and progress to general peritonitis. A small percentage
of patients may have a diverticulum rupture with only air escaping and only have localized symptoms.
Differential Diagnosis
Differential diagnosis for diverticulitis includes gynecologic and urinary disorders, perforated colon
carcinoma, ulcerative colitis, Crohn disease, irritable bowel syndrome, ischemic colitis, and epiploic
appendagitis or appendicitis. Chronic diarrhea, multiple areas of colon involvement, perianal disease,
perineal or cutaneous fistulas, or extraintestinal manifestations are suggestive of Crohn disease.37
Laboratory Studies
Patients with acute diverticulitis may present with a mild leukocytosis, but a normal white blood cell
count is also common.38 In patients with free perforation or peritonitis, serum amylase and lipase may
be mildly elevated.39 A sterile pyuria can result from inflammation adjacent to the bladder or ureter.40
Radiologic Studies
CT is the current standard of care for diagnosis and triage of suspected diverticulitis. IV contrast
increases the value of the study and is routinely used. Oral and/or rectal contrast can help visualize
diverticula or diagnose a fistulous connection or perforation but can add to delays in obtaining
imaging in acute situations.41 The most frequent CT findings of acute diverticulitis are bowel wall
thickening, pericolonic inflammation, and diverticula [see Figure 4].42

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Figure 4
CT scan showing thickening of the sigmoid colon (arrows) caused by acute diverticulitis.
Complications of diverticulitis are also routinely evaluated with CT. Air in a bladder that has not
been recently instrumented or bladder wall thickening with an adjacent segment of diseased colon are
signs of a colovesical fistula [see Figure 5a & Figure 5b].42

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Figure 5a
CT scan in a patient with a developing colovesical fistula showing thickened bladder wall (arrow)
adjacent to segment of acute diverticulitis in the sigmoid colon

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Figure 5b
CT scan showing air in the bladder (arrow) as a result of colovesical fistula.
Colovaginal fistulas, however, may be better evaluated with a contrast enema or combination
vaginoscopy and colonoscopy due to poor visualization of the vagina on CT.36, 43 If the sigmoid colon
freely moves out of the pelvis on contrast enema in steep Trendelenburg position, the diagnosis of
colovaginal fistula can be safely ruled out.36Another important benefit of CT is the ability to detect
diverticular-associated abscesses as well as guide interventions such as percutaneous abscess
drainage.
Distinguishing colon carcinoma from diverticular disease on CT can prove difficult [see Figure 6a
and Figure 6b] and has been advocated as a justification for colonoscopy in the interval after an
episode of diverticulitis.42

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Figure 6a
CT scan showing inflammation with sigmoid wall thickening and diverticulosis that was mistaken for
acute diverticulitis in a patient who was later found to have sigmoid adenocarcinoma on follow up
colonoscopy (arrow)

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Figure 6b
CT scan showing similar inflammation and wall thickening confirmed to be acute diverticulitis after
resolution with antibiotics and normal follow up colonoscopy (arrow).
Findings that imply diverticulitis include greater than 10 cm segment of colonic involvement,
pericolonic inflammation, extraluminal air, mesenteric vascular engorgement, or fluid at the root of the
sigmoid mesentery; enlargement of pericolic lymph nodes is more commonly seen with
malignancy.42Albeit a rare occurrence, perforated sigmoid cancer can produce similar findings to
diverticular disease. MRI may have higher sensitivity and specificity than CT for differentiating

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between diverticulitis and sigmoid cancer, with the advantage of no ionizing radiation.44
Endoscopy
Due to the difficulty of distinguishing diverticulitis from malignancy on CT, both the AGA and the
American Society of Colon and Rectal Surgeons (ASCRS) guidelines recommend a colonoscopy 6 to
8 weeks after an episode of diverticulitis if the patient has not had a recent complete colonoscopy
[see Figure 7].16, 45

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Figure 7
Colonoscopic view of several sigmoid diverticula reveals no evidence of active diverticulitis (eg,
edema or narrowing).
The authors’ practice is to repeat colonoscopy if the affected portion of colon has not been
visualized in the past 3 years. Recommended timing is 6 to 8 weeks after resolution of the acute
process, although this is controversial. Benefits of early colonoscopy in patients who are admitted to
the hospital (after the resolution of symptoms) include the potential to avoid another visit for
colonoscopy, as well as expedited discovery of carcinoma.46 Early colonoscopy has risks, however,
including increased patient discomfort, difficulty with completing the procedure, and increased risk of
perforation during the acute process.46, 47
Further controversy exists regarding the necessity of colonoscopy after an episode of acute
diverticulitis. Brar and colleagues performed a retrospective review of 249 patients who underwent
endoscopy within 1 year of admission for diverticulitis and found the incidence of clinically significant
neoplasia to be equal to the general population in patients with uncomplicated diverticulitis but did find
a significantly higher risk in patients with complicated diverticulitis.48 Suhardja and colleagues also
concluded that routine colonoscopy may not be necessary after uncomplicated diverticulitis but is
indicated after complicated diverticulitis due to the significantly higher risk of neoplasia compared with
uncomplicated disease.49 Other studies have reported similar findings.50, 51

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TREATMENT OF DIVERTICULITIS
Treatment of Acute Uncomplicated Diverticulitis
Historically, the mainstays of the treatment of uncomplicated acute diverticulitis are bowel rest and
antibiotics. Recent evidence, however, has challenged this traditional approach. A large randomized
clinical trial in the Netherlands by Daniels and colleagues compared treatment of uncomplicated acute
diverticulitis with antibiotics versus observation alone and found the only significant difference in
outcomes between the groups to be a shorter length of stay in the observation group (2 versus 3
days).5 A retrospective review in Norway found only a 4% failure rate during follow up of 12 months
with observation alone in patients with uncomplicated acute diverticulitis.52 Many nationally and
internationally recognized societies recommend considering observation without antibiotics in
uncomplicated cases if the patient is immunocompetent and without signs of severe infection or
significant medical comorbidities.16, 53–58 The ASCRS and the European Association for Endoscopic
Surgery remain more traditional in their treatment guidelines and still recommend antibiotics in all
patients until more evidence exists.45, 59
Bowel rest as an outpatient typically consists of a liquid or low residue (low fiber) diet until
symptoms have resolved, at which point a high fiber diet is resumed. A recent prospective study
reported an unrestricted diet during treatment in the outpatient setting for uncomplicated diverticulitis
is safe.60Antibiotics, if prescribed, should cover gram-negative and anaerobic bacteria.18 Commonly
used regimens include amoxicillin-clavulanic acid or ciprofloxacin plus metronidazole for 7 to 10
days.5, 61 Outpatient management is successful in up to 93 to 95% of patients with uncomplicated
disease.61, 62
Reasons for hospitalization include severe systemic symptoms, complicated disease (although
small abscesses may be managed as an outpatient in a clinically stable patient), inability to tolerate
oral hydration, or presence of significant comorbidities.45 Inpatients are typically treated with nothing
by mouth or a clear liquid diet and IV antibiotics. A surgical consultation is recommended if admitted
by a nonsurgical team.18 With resolution of pain and return of bowel function, diet is advanced to a
low residue diet and antibiotics are transitioned to oral. A high-fiber diet is typically resumed as an
outpatient after complete resolution of symptoms.

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Treatment of Acute Complicated Diverticulitis
Extensive phlegmon or small abscesses up to 3 to 4 cm typically respond to antibiotics and bowel

rest. Larger abscesses are also treated with antibiotics and bowel rest with the addition of
percutaneous drainage if amenable [see Figure 8]. This approach allows 70 to 85% of patients with
abscesses to avoid an urgent operation [see Figure 9a and Figure 9b].45, 63
Figure 8
Algorithm outlining treatment of acute diverticulitis with abscess.

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Figure 9a
CT scan showing a pericolic abscess (arrow) caused by a contained perforation arising from sigmoid
diverticulitis

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Figure 9b
A pigtail catheter (arrow) has been placed into the abscess cavity by the interventional radiologist.
Treatment for fistulas secondary to diverticular disease is elective surgical resection. Patients may
be managed conservatively if preferred by the patient or if the patient is unfit for surgery.35 In such
situations, an informed consent discussion should mention that these fistulas do not spontaneously
resolve. Urosepsis can be avoided either with low-dose maintenance antibiotics or antibiotics as
treatment for emerging symptoms.35

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Acute diverticulitis can cause small or large bowel obstruction, either from scarring/stenosis or
tethering between bowel and phlegmon/abscess. As with any bowel obstruction, a nasogastric tube is
an option to minimize distention and the risk of aspiration. In most cases, ileus-related symptoms
resolve with antibiotic treatment. Large bowel obstruction, however, can lead to considerable
morbidity and may necessitate acute or subacute surgical intervention. The obstruction is often
partial, allowing preparation of the bowel in many cases if desired. High-grade obstruction mandates
expeditious surgery to avoid cecal necrosis and perforation [see Figure 10a and Figure 10b].
Figure 10a

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CT scan showing marked thickening of the sigmoid wall (arrows) in a patient with diverticular disease
who presented with large bowel obstruction
Figure 10b
Adjacent plane of same patient showing cecal dilation to 10 cm (double arrow) secondary to acute
diverticulitis causing large bowel obstruction
If significant fecal loading is present, this can be managed by performing Hartmann procedure or
on-table lavage followed by primary anastomosis.64 A survey of GI surgeons in the United States

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indicated that 50% would opt for a one-stage procedure in low-risk patients with obstruction, whereas
94% would opt for a staged procedure in high-risk patients.65
Small bowel obstruction or ileus may also complicate a clinical picture of diverticulitis. Mechanical
small bowel obstruction may occur as a consequence of adherence of the small bowel to a focus of
diverticulitis, especially in the presence of a large pericolic abscess.66 Typical symptoms include
periumbilical, crampy abdominal pain and vomiting, but these characteristic manifestations may be
obscured in part by pain attributed to diverticulitis. CT imaging often helps the surgeon differentiate
between primary and secondary small bowel obstruction, but ultimately exploratory surgery may be
required for both diagnosis and treatment.
Free perforation with peritonitis happens in 1 to 2% of all cases of diverticulitis and is an indication
for emergent surgery. Perforation with limited pneumoperitoneum and no peritonitis in stable
immunocompetent patients can sometimes be successfully managed with close observation,
antibiotics, and bowel rest.67
Summary
This chapter highlights the key pieces of diagnosis and basic management of acute diverticulitis for
the surgical reader. Distinguishing diverticulitis from cancer or other diseases and choosing the most
appropriate treatment based on the patient’s clinical condition and imaging findings are the key steps
to correctly managing a patient with acute diverticulitis.
Financial Disclosures: Tiffany K Weidner, MD, John T Kidwell, MD, and David A Etzioni, MD, have
no relevant financial relationships to disclose.
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DOI 10.2310/7800.2391
Acknowledgement
The authors and editors gratefully acknowledge the contributions of the previous authors, John P.
Welch, MD, FACS and Jeffrey L. Cohen, MD, FACS, to the development and writing of this review.

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Gastrointestinal Tract and Abdomen Surgery

Gastrointestinal Tract and Abdomen

Diagnosis and Management of Acute Diverticulitis

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Risk Factors for Diverticular Disease

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[see Table 2a & Table 2b].

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COMPLICATED VERSUS UNCOMPLICATED DIVERTICULITIS

Traditionally, cases of diverticulitis are categorized as being complicated or uncomplicated, based

A complicated episode of diverticulitis involves extensive phlegmon, abscess, fistula, obstruction,

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fistulas include colocolonic, coloenteric, colouterine, or colocutaneous fistulas.

A rare but dangerous complication of acute diverticulitis, occurring in 1 to 2% of cases, is free

Uncomplicated acute diverticulitis refers to inflammation of an area of colon without extensive

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DIAGNOSIS AND TRIAGE OF DIVERTICULITIS

History and Physical Examination

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Symptoms of complicated disease depend on the complication that is present. Symptoms of an

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CT scan showing air in the bladder (arrow) as a result of colovesical fistula.

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Treatment of Acute Uncomplicated Diverticulitis

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Treatment of Acute Complicated Diverticulitis

Extensive phlegmon or small abscesses up to 3 to 4 cm typically respond to antibiotics and bowel

Algorithm outlining treatment of acute diverticulitis with abscess.

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2. Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004;363:631–9.

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uncomplicated acute diverticulitis. Br J Surg 2017;104:52–61.

Gastroenterol Hepatol 2013;11:1609–13.

Gastroenterol Hepatol 2016;14:980–985.e1.

International Symposium on Diverticular Disease. J Clin Gastroenterol 2016;50(Suppl 1):S101–7.

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prospective cohort study. Gastroenterology 2017;152:1023–30.e2.

Aliment Pharmacol Ther 2015;42:664–84.

Colorectal Dis 2017;32:1375–83.

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Gastrointest Liver Dis 2014;23:379–86.

Colorectal Dis 2016;18:483–7.

resonance imaging: preliminary experiences. Acta Radiol 2013;54:237–41.

Colorectal Dis 2016;18:1101–7.