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Colonic diverticulosis and diverticular disease:

Epidemiology, risk factors, and pathogenesis
Author: John H Pemberton, MD
Section Editor: Lawrence S Friedman, MD
Deputy Editor: Shilpa Grover, MD, MPH, AGAF

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2022. | This topic last updated: Apr 30, 2021.

INTRODUCTION

Diverticular disease of the colon is an important cause of hospital admissions and a

significant contributor to healthcare costs in Western and industrialized societies
[1,2].

This topic will review the epidemiology, risk factors, and the pathogenesis of
diverticulosis and diverticular disease. The clinical manifestations, diagnosis, and
treatment of diverticulitis, diverticular bleeding, and segmental colitis associated
with diverticula (diverticular colitis) are discussed in detail, separately. (See "Clinical
manifestations and diagnosis of acute colonic diverticulitis in adults" and "Acute
colonic diverticulitis: Medical management" and "Colonic diverticular bleeding".)

DEFINITIONS

● A diverticulum is a sac-like protrusion of the colonic wall.

● Diverticulosis is defined by the presence of diverticula. Diverticulosis may be

asymptomatic or symptomatic.
 ● Diverticular disease is defined as clinically significant and symptomatic
diverticulosis due to diverticular bleeding, diverticulitis, segmental colitis
associated with diverticula, or symptomatic uncomplicated diverticular
disease.

• Diverticular bleeding is characterized by painless hematochezia due to

segmental weakness of the vasa recta associated with a diverticulum. (See
"Colonic diverticular bleeding".)

• Diverticulitis is defined as inflammation of a diverticulum. Diverticulitis may

be acute or chronic, uncomplicated or complicated by a diverticular
abscess, fistula, bowel obstruction, or free perforation. (See "Clinical
manifestations and diagnosis of acute colonic diverticulitis in adults" and
"Acute colonic diverticulitis: Medical management".)

• Segmental colitis associated with diverticula or diverticular colitis is

characterized by inflammation in the interdiverticular mucosa without
involvement of the diverticular orifices. (See "Segmental colitis associated
with diverticulosis".)

• Symptomatic uncomplicated diverticular disease is characterized by

persistent abdominal pain attributed to diverticula in the absence of
macroscopically overt colitis or diverticulitis. This has also been described
as smouldering diverticulitis, especially when wall thickening is present in
the absence of inflammatory changes on computed tomography.

EPIDEMIOLOGY

● Diverticulosis – The prevalence of diverticulosis is age-dependent, increasing

from less than 20 percent at age 40 to 60 percent by age 60 [3,4]. The
distribution of diverticulosis within the colon varies by geography:

• Western and industrialized nations have prevalence rates of 5 to 45 percent,

depending upon the method of diagnosis and age of the population [5,6].
Approximately 95 percent of patients with diverticula have sigmoid
diverticula ( image 1) [7]. Diverticula are limited to the sigmoid colon in
 65 percent of patients; in 24 percent of patients diverticula predominantly
involve the sigmoid, but are also present in other parts of the colon
( image 2); in 7 percent of patients diverticula are equally distributed
throughout the colon; and in 4 percent diverticula are limited to a segment
proximal to the sigmoid colon. The distribution of diverticula may also vary
by race. In one prospective study of 624 individuals undergoing screening
colonoscopy in the United States, 260 (42 percent) had colonic diverticulosis
[8]. While most diverticula in both Black patients and White patients were
located in the sigmoid colon, the distribution of the diverticula in the
ascending colon or hepatic flexure was higher in Black patients as
compared with White patients (20 versus 8 percent).

• In Asia, the prevalence of diverticulosis is between 13 and 25 percent, and

diverticulosis is predominantly right-sided [9-13].

• The prevalence of diverticulosis has increased both in the Western

hemisphere and in countries that have adopted a more Western lifestyle. As
an example, Japan has experienced an increase in the prevalence of right-
sided diverticulosis similar to the increase in left-sided diverticula in
westernized countries [14,15].

● Diverticular bleeding – Among patients with diverticulosis, bleeding occurs in

approximately 5 to 15 percent and is massive in a third of those patients [16].
The right colon is the source of colonic diverticular bleeding in 50 to 90 percent
of patients [17-20]. A possible explanation for this is that right-sided diverticula
have wider necks and domes, exposing a greater length of vasa recta to injury.
Another contributing factor may be the thinner wall of the right colon [16].

● Diverticulitis – Approximately 4 to 15 percent of patients with diverticulosis

develop diverticulitis [7,21-23]. The incidence of diverticulitis increases with
age. The mean age at admission for acute diverticulitis is 63 years [24]. While
the incidence of acute diverticulitis is lower in younger individuals,
approximately 16 percent of admissions for acute diverticulitis are in patients
under 45 years of age [25]. In contrast to Asia, diverticular disease is
predominantly left-sided in western countries, with right-sided diverticulitis
being present in only 1.5 percent of cases [26].
 The incidence of diverticulitis is increasing. A nationwide inpatient study of
hospitalizations in the United States showed an increase in admissions for
acute diverticulitis by 26 percent from 1998 to 2005 [24]. The largest increase
was in patients aged 18 to 44 years (82 percent). Elective operations for
diverticulitis also increased by 29 percent with the largest increase in patients
aged 18 to 44 years (73 percent).

Although a male preponderance was noted in early series, subsequent studies

have suggested either equal distribution or a female preponderance [7]. Under
age 50 years, diverticulitis is more common in men; there is a slight female
preponderance between the ages of 50 and 70, and a marked female
preponderance over age 70 [27-30].

The prevalence of segmental colitis associated with diverticulosis (diverticular colitis)

and symptomatic uncomplicated diverticular disease (SUDD) are unknown.

RISK FACTORS

Several lifestyle factors have been associated with diverticular disease. A prospective
cohort study evaluated the association between lifestyle factors and the risk of
diverticulitis in over 51,000 men aged 40 to 75 years [31]. There were 907 incident
cases of diverticulitis over 757,791 person-years of follow-up. High dietary intake of
red meat, low dietary fiber, lack of vigorous physical activity, high BMI (≥25 kg/m2),
and smoking (≥40 pack-years) were all independently associated with an increased
risk of diverticulitis. There was an incremental reduction in the risk of diverticulitis
with an increase in the number of low-risk lifestyle factors (low red meat intake, high
dietary fiber, normal BMI, vigorous physical activity, and never-smoker). Adherence
to a low-risk lifestyle was associated with a 50 percent (95% CI 20-71) lower risk of
diverticulitis.

Diet

Low fiber, high fat, and red meat — Low dietary fiber and high intake of fat or
red meat are associated with an increased risk of symptomatic diverticular disease.
Dietary fiber and a vegetarian diet may reduce the incidence of symptomatic
diverticular disease by decreasing intestinal inflammation and altering the intestinal
microbiota [4,32,33]. In a cohort study that included over 47,000 men, after
adjustment for age, energy-adjusted total fat intake, and physical activity, total
dietary fiber intake was noted to be inversely associated with the risk of
symptomatic diverticular disease (RR 0.58 highest quintile versus lowest quintile for
fiber intake) [32]. The risk of diverticular disease was significantly increased with
diets that were low in fiber and were high in total fat or red meat as compared with
diets that were low in both fiber and total fat or red meat (RR 2.35 and 3.32,
respectively) [32]. (See 'Definitions' above.)

However, the role of fiber in the development of diverticulosis is unclear. Several

early studies suggested that low dietary fiber predisposes to the development of
diverticular disease, but other studies have been conflicting [3,32,34-42]. Fiber also
does not reduce symptoms in patients with symptomatic uncomplicated diverticular
disease [40,41,43,44].

Seeds and nuts — Nut, corn, and popcorn consumption are not associated with an
increase in risk of diverticulosis, diverticulitis or diverticular bleeding. In a large
observational study that included 47,228 men between the ages of 40 and 75 years,
there was an inverse association between the amount of nut and popcorn
consumption and the risk of diverticulitis (HR nuts 0.8, 95% CI 0.63-1.01; HR popcorn
0.72, 95% CI 0.56-0.92) [45]. In addition, no association was found between
consumption of corn and diverticulitis or between nut, popcorn, or corn
consumption and diverticular bleeding or uncomplicated diverticulosis. (See "Acute
colonic diverticulitis: Medical management", section on 'Recurrent diverticulitis'.)

Physical inactivity — Vigorous physical activity appears to reduce the risk of

diverticulitis and diverticular bleeding. In a prospective study of approximately
48,000 men aged 40 to 75 who were free of known colonic disease at baseline, the
risk of developing symptomatic diverticular disease was inversely related to overall
physical activity (RR 0.63 for highest versus lowest extremes) after adjustment for
age and dietary fat and fiber [46]. Most of the decrease in risk with exercise was
associated with vigorous activity such as jogging and running. Men in the lowest
quintile for both dietary fiber and physical activity had an increased risk of
symptomatic diverticular disease as compared with men in the highest quintile for
both (RR 2.56, 95% CI 1.36-4.82).
Obesity — Obesity has been associated with an increase in risk of both diverticulitis
and diverticular bleeding. In a large, prospective cohort study of 47,228 male health
professionals, there were 801 incident cases of diverticulitis and 383 cases of
diverticular bleeding during 18 years of follow-up [47]. The risk of diverticulitis and
diverticular bleeding was significantly higher in those with the highest quintile of
waist circumference as compared with the lowest (RR diverticulitis 1.56, 95% CI 1.18-
2.07; RR diverticular bleeding 1.96, 95% CI 1.30-2.97).

Other — Current smokers appear to be at increased risk for perforated diverticulitis

and a diverticular abscess as compared with nonsmokers (OR 1.89, 95% CI 1.15-3.10)
[48]. Caffeine and alcohol are not associated with an increased risk for symptomatic
diverticular disease [49].

Several medications are associated with an increased risk of diverticulitis and

diverticular bleeding including nonsteroidal antiinflammatory drugs, steroids, and
opiates [50-53]. In contrast, statins may be associated with a decreased risk of
diverticular perforation (OR 0.44, 95% CI 0.20-0.95). In addition, higher levels of
vitamin D have been associated with a reduced risk of hospitalization for
diverticulitis [54]. In a study that included 9226 patients with uncomplicated
diverticulosis and 922 patients with diverticulitis requiring hospitalization, patients
with uncomplicated diverticulosis had significantly higher prediagnostic serum
levels of 25-hydroxyvitamin D (25(OH)D) levels as compared with patients with
diverticulitis requiring hospitalization (29.1 versus 25.3 ng/mL). The risk of
hospitalization for diverticulitis decreased with increasing vitamin D levels (adjusted
RR highest versus lowest quintile of 25(OH)D 0.49, 95% CI 0.38-0.62).

Patients with Ehler-Danlos, Marfan's, and Williams-Beuren syndromes, HIV infection

and those undergoing chemotherapy are also at increased risk for developing acute
diverticulitis [30,55-58].

PATHOGENESIS

Diverticulosis — Diverticula develop at well-defined points of weakness, which

correspond to where the vasa recta penetrate the circular muscle layer of the colon
( figure 1) [18]. A typical colonic diverticulum is a "false" or pulsion diverticulum, in
which mucosa and submucosa herniate through the muscle layer, covered only by
serosa ( picture 1).

Abnormal colonic motility is an important predisposing factor in the development

diverticula. Patients with diverticulosis have exaggerated segmentation contractions
in which segmental muscular contractions separate the lumen into chambers
( image 3). It is hypothesized that the increase in intraluminal pressure
predisposes to herniation of mucosa and submucosa. The neural basis for the
abnormal motility observed in patients with diverticulosis remains unclear, although
one report found that a central event appeared to be upregulation of smooth
muscle M3 receptors [59,60].

The development of diverticula specifically in the sigmoid colon can be explained by

Laplace’s law according to which pressure (P) is proportional to wall tension (T) and
inversely proportional to bowel radius (R), where k is a conversion factor (P = kT ÷ R).
Since the sigmoid colon is the segment of the colon with the smallest diameter, it is
the site of the highest pressure during segmentation of the colon [61]. Additional
structural changes may also decrease resistance of the wall to intraluminal pressure.
As an example, most patients with sigmoid diverticula exhibit thickening of the
circular muscle layer, shortening of the taeniae, and luminal narrowing. There is no
hypertrophy or hyperplasia of the bowel wall, but increased elastin deposition is
found in the taeniae [62]. There are also structural changes in collagen that are
similar to, but greater in magnitude than those that occur because of aging [63].
Structural changes in the wall may also be responsible for the appearance of
diverticula at an early age in connective tissue disorders such as Ehlers-Danlos and
Marfan's syndromes and in autosomal dominant polycystic kidney disease [64]. (See
"Clinical manifestations and diagnosis of Ehlers-Danlos syndromes" and "Genetics,
clinical features, and diagnosis of Marfan syndrome and related disorders" and
"Autosomal dominant polycystic kidney disease (ADPKD): Extrarenal
manifestations".)

Diverticular bleeding — As a diverticulum herniates, the penetrating vessel

responsible for the wall weakness at that point becomes draped over the dome of
the diverticulum, separated from the bowel lumen only by mucosa ( picture 2)
[18]. Over time, the vasa recta is exposed to injury along its luminal aspect, leading
to eccentric intimal thickening and thinning of the media. These changes may result
in segmental weakness of the artery, predisposing to rupture into the lumen.
Diverticular bleeding typically occurs in the absence of diverticulitis [18]. (See
"Colonic diverticular bleeding", section on 'Clinical manifestations'.)

Diverticulitis — The underlying cause of diverticulitis is micro- or macroscopic

perforation of a diverticulum. It was previously believed that obstruction of
diverticula (eg, by fecaliths) increased diverticular pressure and caused perforation.
However, such obstruction is now thought to be rare ( picture 3 and picture 1)
[36]. The primary process is thought to be erosion of the diverticular wall by
increased intraluminal pressure or inspissated food particles. Inflammation and
focal necrosis ensue, resulting in perforation. (See "Clinical manifestations and
diagnosis of acute colonic diverticulitis in adults" and "Acute colonic diverticulitis:
Medical management".)

The inflammation is frequently mild, and a small perforation is walled off by

pericolic fat and mesentery. This may lead to a localized abscess or, if adjacent
organs are involved, a fistula or obstruction. Poor containment of the inflamed
diverticulum or abscess results in free perforation and peritonitis.

Segmental colitis associated with diverticula — The pathogenesis of segmental

colitis associated with diverticula (SCAD) or diverticular colitis is incompletely
understood. The cause may be multifactorial, related to mucosal prolapse, fecal
stasis, or localized ischemia [65]. Other theories suggest that alterations in the gut
microbiota and chronic inflammation result in SCAD. (See "Segmental colitis
associated with diverticulosis".)

Symptomatic uncomplicated diverticular disease — Altered colonic motility may

be one of the underlying causes of abdominal pain and constipation in patients with
symptomatic uncomplicated diverticular disease (SUDD). In one study, patients with
SUDD displayed an increase in duration of rhythmic, low-frequency contractile
activity particularly in segments of the colon with diverticula [66]. In another study,
patients with diverticulosis were demonstrated to have a significantly reduced
density of interstitial cells of Cajal as compared with controls, suggesting that
abnormal colonic motility may be the underlying basis of symptoms in patients with
SUDD [67].
It has also been hypothesized that visceral hypersensitivity plays an important role
in the pathogenesis of SUDD. A study compared colonic visceral pain perception in
response to luminal distention in patients with SUDD, asymptomatic diverticulosis,
and healthy controls. In this study, patients with SUDD but not asymptomatic
diverticulosis and healthy controls demonstrated a heightened pain perception both
in the sigmoid colon with diverticula and in the unaffected rectum. The mechanism
of hypersensitivity in patients with SUDD may relate to increased neuropeptides and
alterations in enteric innervation following an episode of diverticulitis [68].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links:
Colonic diverticular disease".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical
jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

● Basics topics (see "Patient education: Diverticulitis (The Basics)")

● Beyond the Basics topics (see "Patient education: Diverticular disease (Beyond
 the Basics)")

SUMMARY

● A diverticulum is a sac-like protrusion of the colonic wall. Diverticulosis merely

describes the presence of diverticula. These may not be symptomatic or
complicated. Diverticular disease is defined as clinically significant and
symptomatic diverticulosis. Diverticular symptoms may be due to diverticular
bleeding, symptomatic uncomplicated diverticular disease, diverticulitis, or
segmental colitis associated with diverticulosis. (See 'Definitions' above.)

● The prevalence of diverticulosis increases with age from less than 20 percent at
age 40 to 60 percent by age 60. In the Western hemisphere, diverticulosis is
predominantly left-sided, with prevalence rates of 5 to 45 percent. In contrast,
in Asia, the prevalence of diverticulosis is lower and diverticulosis is
predominantly right-sided. Among patients with diverticulosis, bleeding occurs
in approximately 5 to 15 percent, with the right colon being the source of
colonic diverticular bleeding in 50 to 90 percent of patients. Approximately 5 to
15 percent of patients with diverticulosis develop diverticulitis. (See
'Epidemiology' above.)

● Dietary fiber is associated with a decreased risk of symptomatic diverticular

disease. A diet high in total fat and red meat is associated with an increased
risk of symptomatic diverticular disease. There is no association between nut,
corn, and popcorn consumption and the risk of diverticulosis and diverticular
bleeding.

Vigorous physical activity appears to reduce the risk of diverticulitis and

diverticular bleeding. Obesity and several medications (eg, nonsteroidal anti-
inflammatory drugs, steroids, and opiates) are associated with an increased
risk of diverticulitis and diverticular bleeding. Statins may be associated with a
decreased risk of diverticular perforation. (See 'Risk factors' above.)

● Diverticula occur at points of weakness in the bowel wall where blood vessels
penetrate ( figure 1). The development of diverticula is probably
multifactorial, involving both increases in intraluminal pressure caused by
 abnormalities in motility and histologic abnormalities in the bowel wall, which
decrease tensile strength. (See 'Diverticulosis' above.)

● Segmental weakness of the artery in the diverticular wall predisposes to

rupture into the lumen, resulting in a diverticular bleed ( picture 2). In
contrast, the underlying cause of diverticulitis is micro- or macroscopic
perforation of the diverticulum itself. The inflammation is frequently mild, and
a small perforation is walled off by pericolic fat and mesentery. This may lead
to a localized abscess or, if adjacent organs are involved, a fistula or
obstruction. Poor containment of the inflamed diverticulum or abscess results
in free perforation and peritonitis. (See 'Diverticular bleeding' above and
'Diverticulitis' above.)

● Alterations in the gut microbiome, chronic inflammation, and visceral

hypersensitivity have been implicated in the pathogenesis of segmental colitis
associated with diverticula and symptomatic uncomplicated diverticular
disease. (See 'Segmental colitis associated with diverticula' above and
'Symptomatic uncomplicated diverticular disease' above.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Tonia Young-Fadok, MD, who

contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Terms of Use.

Topic 1379 Version 28.0

GRAPHICS

Diverticulosis of sigmoid colon with CT and VC

A CT scan through the pelvis (A) shows multiple air-filled diverticula (arrows) of the
sigmoid colon. Image B is a virtual colonoscopy of the sigmoid colon showing the necks
of sigmoid colon diverticula (arrows) from a luminal perspective.

CT: computed tomography; VC: virtual colonoscopy.

Graphic 91161 Version 2.0

Diverticulosis of colon on BE and CT colonography

A single contrast barium enema (A) shows diverticulosis of the ascending colon
(arrowheads) and descending colon (double arrow). Source images for a virtual
colonoscopy reconstructed in the coronal plane show diverticula in the ascending colon
(arrowhead) and extensive diverticulosis of the descending colon (double arrow).

BE: barium enema; CT: computed tomography.

Graphic 91200 Version 2.0

Location of colonic diverticula within the bowel
wall

Diverticula develop at four well-defined points around the

circumference of the colon, the sites at which the vasa recta
penetrate the circular muscle layer. These vessels enter the wall on
each side of the mesenteric taenia and on the mesenteric border of
the two antimesenteric taeniae. The insets represent the
development of a diverticulum at one such point of weakness.

Reproduced from: Pemberton JH, Armstrong DN, Dietzen CD. In: Textbook of
Gastroenterology, 2nd ed, Yamada T (Ed), 1995. By permission of Mayo Foundation
1997.

Graphic 62942 Version 4.0

Fecolith in diverticulum

Low power view shows a fecolith within a colonic diverticulum.

Courtesy of Robert Odze, MD.

Graphic 69797 Version 1.0

Diverticulosis muscle thickening and narrowing on BE and CT
colonography

A single contrast barium enema (A) shows diverticulosis (arrowhead) with circular muscle
thickening and luminal narrowing of the distal descending colon (double arrow). Source
images for a CT virtual colonoscopy reconstructed in the coronal plane show extensive
diverticulosis of the descending colon (arrow) with circular muscle thickening and luminal
narrowing (arrowhead).

BE: barium enema; CT: computed tomography.

Graphic 91201 Version 2.0

Blood vessel within a colonic diverticulum

Endoscopy showing a blood vessel within a diverticulum. The blood

vessel is separated from the bowel lumen only by mucosa. Over time,
the vessel wall is exposed to injury along its luminal aspect, possibly
leading to segmental weakness which predisposes to rupture into the
lumen.

Courtesy of James B McGee, MD.

Graphic 52254 Version 3.0

Normal sigmoid colon

Endoscopic appearance of the normal sigmoid colonic mucosa.

The fine vasculature is easily visible, and the surface is shiny and
smooth. The folds are of normal thickness.

Courtesy of James B McGee, MD.

Graphic 55563 Version 1.0
Diverticulum with nonobstructing fecolith

A nonobstructing fecolith is seen within a large diverticulum.

Graphic 80763 Version 2.0