STATE OF THE ART REVIEW

Management of colonic diverticulitis

Anne F Peery
University of North Carolina
School of Medicine, Chapel Hill,
NC 27599-7555, USA
Correspondence to:
Anne_Peery@med.unc.edu
Cite this as: BMJ 2021;372:n72
http://dx.doi.org/10.1136/bmj.n72
Series explanation: State of the
Art Reviews are commissioned
on the basis of their relevance
to academics and specialists
in the US and internationally.
For this reason they are written
predominantly by US authors.
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A BST RAC T
Left sided colonic diverticulitis is a common and costly gastrointestinal disease
in Western countries, characterized by acute onset of often severe abdominal
pain. Imaging is necessary to make an initial diagnosis and determine disease
severity. Colonoscopy should be done six to eight weeks after diagnosis to
rule out a missed colon malignancy. Antibiotic treatment is used selectively in
immunocompetent patients with mild acute uncomplicated diverticulitis. The
clinical course of diverticulitis commonly includes unpredictable recurrences and
chronic gastrointestinal symptoms, which are a detriment to quality of life. A better
understanding of prognosis has prompted a shift toward non-operative approaches.
The decision to undergo prophylactic colon resection should be individualized to
consider the severity of diverticulitis, the patient’s health and immune status, and
the patient’s preferences and values, as well as benefits and risks. Because only a
section of colon is removed, recurrent diverticulitis remains a risk. Acute diverticulitis
with an abscess is treated with antibiotics that cover Gram negative and anaerobic
bacteria, with or without percutaneous drainage. Acute diverticulitis with purulent
or feculent contamination of the peritoneal cavity is managed with surgery; primary
resection and anastomosis is the procedure of choice in stable patients.

Introduction publication of multiple observational studies and

Left sided colonic diverticulitis is a common (209
cases per 100 000 person years) gastrointestinal
disease in Western countries, characterized by acute
onset of abdominal pain, which is often severe.1
The clinical course of diverticulitis commonly
includes unpredictable recurrences and chronic
gastrointestinal symptoms.2 Diverticulitis can lead
to the development of a colonic stricture or fistula
and, when complicated by an abscess or perforation,
can be fatal. Among gastrointestinal diseases,
diverticulitis is a leading cause of ambulatory visits,
hospital admissions, and colon surgery, accounting
for substantial healthcare expenditures.3 4
Diverticulitis is a heterogeneous disease in
both presentation and prognosis (box 1). Acute
uncomplicated diverticulitis is the most common
presentation of the disease and is characterized by
acute onset of diverticular inflammation without
abscess or perforation. This inflammation often
includes surrounding tissues. Smoldering diverticulitis
is an uncommon presentation that persists for
weeks to months and should not be confused with
symptomatic uncomplicated diverticular disease.
Acute complicated diverticulitis is diverticular
inflammation combined with obstruction, abscess,
or perforation. Recurrent diverticulitis is diverticulitis
that resolves completely and then abruptly returns.
In the past decade, our understanding of
diverticulitis has expanded substantially with the
clinical trials. Historically, diverticulitis was thought
to be an aggressive disease, and the threshold
for surgical intervention was low. With a better
understanding of prognosis, a shift toward non-
operative approaches has occurred.
Diverticulitis is also now recognized as a chronic
disease for patients with recurrent episodes or
ongoing symptoms.8 Recent clinical trials have
questioned the longstanding practice of treating
uncomplicated diverticulitis with antibiotics.2 9
Although the contribution of a Western lifestyle to
risk of diverticulitis has been validated, emerging
evidence indicates a strong genetic component.10-12
This article reviews the literature responsible
for these important advances and provides a
comprehensive and evidence based summary of
the medical management of patients with acute
diverticulitis. Surgical management is beyond
the scope of this review. The review is written to
inform specialists, academic clinicians, and clinical
researchers. A summary of management is provided
in a box at the end.
Sources and selection criteria
With the assistance of a librarian, I searched PubMed,
Embase, and Cochrane databases from 2010 to
December 2019, using the terms “diverticulitis” and
“diverticular disease” and also identified references
from international, European, and American

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 STATE OF THE ART REVIEW
Box 1: Nomenclature
Diverticulosis
The presence of diverticula. Diverticula form when mucosa and submucosa herniate
through the muscularis propria layer of the colon wall
Acute uncomplicated diverticulitis
Diverticular inflammation of acute onset, with or without a phlegmon. This is also
called modified Hinchey Ia diverticulitis5
Acute complicated diverticulitis
Diverticular inflammation of acute onset with an abscess and/or perforation,
with or without peritonitis. The modified Hinchey classification is widely used in
clinical practice to distinguish the stages of diverticulitis complicated by abscess or
peritonitis5:
• Ib—paracolic or mesocolic abscess
• II—pelvic, distant intra-abdominal, or retroperitoneal abscess
• III—generalized purulent peritonitis
• IV—generalized fecal peritonitis
Acute diverticulitis with paracolic air or gas
Diverticulitis with just extraluminal air or gas is considered by some authors to be
uncomplicated diverticulitis,6 whereas others classify this as complicated diverticulitis
because of an increased risk of abscess formation7
Diverticular stenosis/stricture
A fibrotic narrowing in the colon that forms as a result of diverticulitis. This is
sometimes non-specifically called complicated diverticular disease
Diverticular fistula
An abnormal connection from the colon to another hollow organ or skin that forms as
a result of diverticulitis. This is also non-specifically called complicated diverticular
disease
Smoldering diverticulitis
Overt diverticular inflammation that persists for weeks to months. This includes
patients who improve somewhat or nearly completely and then relapse quickly after
stopping antibiotics
Recurrent diverticulitis
Diverticulitis that resolves completely and then abruptly returns
Diverticular disease
This is a non-specific term that some authors use to describe any pathology related
to a colonic diverticulum, including diverticular hemorrhage. Diverticulosis is also
sometimes included in this definition
Symptomatic uncomplicated diverticular disease
This is defined as chronic gastrointestinal symptoms attributed to colonic
diverticulosis in the absence of overt inflammation. This non-specific term should
not be used to describe patients with ongoing symptoms after an episode of acute
diverticulitis
guidelines on diverticulitis published during
this time period. We selected systematic reviews,
meta-analyses, randomized controlled trials, and
observational studies (excluding case reports and
small case series). We excluded articles that were not
peer reviewed and those not published in English.
Studies were prioritized by design, as noted above,
and by patient numbers, quality, and publication
date.
Overall quality of evidence
Randomized controlled trials and meta-analyses have
assessed treatment with antibiotics, mesalamine for
2
prevention of diverticulitis, and quality of life after
elective surgery and have compared colon resection
with a primary anastomosis with Hartmann’s
BMJ: first published as 10.1136/bmj.n72 on 24 March 2021. Downloaded from http://www.bmj.com/ on 28 June 2021 by guest. Protected by copyright.
procedure. This evidence is of higher quality than
that for prognosis, risk factors, and diagnosis, which
is informed by several large observational studies.
The overall quality of evidence is low, and an
urgent need for trials of diverticulitis treatment and
prevention remains.
Incidence and temporal trends
The incidence of colonic diverticulitis was 209 adults
per 100 000 person years in a US population based
study between 2000 and 2007 (fig 1).1 The incidence
of hospital admissions for diverticular disease was
49 adults per 100 000 person years in a population
based Swedish study between 2003 and 2010.13
Most admissions (99.1%) were for diverticulitis. The
incidence of perforated diverticulitis was 2.7 adults
per 100 000 person years in a UK population based
study between 1990 and 2005.14
The incidence of surgery for diverticular disease was
8 per 100 000 person years in the Swedish study.13 The
rates of elective surgery and urgent/emergent surgery
were 3 and 2 per 100 000 person years, respectively, in
a population based US study in 2006.15 Rates of both
elective and urgent/emergent surgery were highest
in the 65-79 year age group compared with all other
age groups.15 Fatality rates for diverticular disease
in a US registry of death certificates were 0.9 deaths
per 100  000 adults.3 Increasing age, comorbidity
burden, emergent admission, severe disease,
surgical intervention, and low volume hospitals
were all associated with increased odds of death in a
population based US study.16
In another US population based study of outpatient
and inpatient diverticulitis, disease incidence
increased by 50% in 2000-07 compared with 1990-
99.1 The trend was similar in men and women. The
increase over time was highest in adults aged 30-
39 and 40-49 years.1 The incidence of complicated
diverticulitis (10-14%) did not change over this time.
Hospital admissions for diverticulitis have increased
in other countries over approximately the same
time.17 18 Increased use of computed tomography,
which allows for a more definitive diagnosis, may
account for some of these trends.
Clinical course
Colonic diverticulosis
Colonic diverticula are acquired herniations in the
colon wall (box 1). The cause of colonic diverticulosis
is likely related to dysfunctional connective tissues
and not to a low fiber diet.19-22 In Western countries,
colonic diverticula are most common in the sigmoid
colon. In a US colonoscopy based study, 72% of
participants with diverticulosis had only sigmoid
diverticula.23 The average number of diverticula in
the sigmoid colon (mean 12) was twice that of other
colon locations (mean 5).
Colonic diverticula are highly prevalent in Western
countries. In a US colonoscopy based study of
doi: 10.1136/bmj.n72 | BMJ 2021;372:n72 | the bmj
 STATE OF THE ART REVIEW

Only 1% of patients who presented with acute

,QFLGHQFHSHUSDWLHQW\HDUV  uncomplicated diverticulitis had an emergency
resection within six months.32

BMJ: first published as 10.1136/bmj.n72 on 24 March 2021. Downloaded from http://www.bmj.com/ on 28 June 2021 by guest. Protected by copyright.
Approximately 11-30% of patients presenting with

acute diverticulitis have diverticular inflammation
without an abscess but paracolic extraluminal air
 on a computed tomography scan.33 34 Whether this
presentation is more likely to progress to an abscess
or perforation is debated. In a systematic review
 of six studies with 195 diverticulitis patients with
      
paracolic extraluminal air, 6% of patients needed
$JHJURXSV\HDUV
Fig 1 | Incidence of colonic diverticulitis per 100 000 person years in US population
based study between 2000 and 2007. Orange bars are women and blue bars are men.
This included patients admitted to hospital and those treated as outpatients1
271 181 procedures, the prevalence of diverticulosis
increased with age in men and women of all races
and ethnicities, from 24% in ages 40-49 to 72%
in ages 80 years and older (fig 2).24 Diverticulosis
was less prevalent in women than in men of similar
age. Non-Hispanic black and Asian/Pacific Islander
individuals were less likely to have diverticulosis
compared with non-Hispanic whites. When
diverticulosis was present, Asian/Pacific Islanders
were more likely to have proximal only diverticulosis
whereas non-Hispanic black individuals were more
likely to have pan-colonic diverticulosis.
Although colonic diverticula are common, the risk
of progression to diverticulitis is low. In a retrospective
cohort study of patients with colonic diverticulosis,
the incidence of developing diverticulitis was
1-4% over seven years of follow-up (fig 2).25
With the exception of diverticular hemorrhage,
colonic diverticula are otherwise thought to be
asymptomatic. Among patients undergoing routine
screening colonoscopy, the presence of diverticulosis
was not associated with mucosal inflammation or
chronic gastrointestinal symptoms.30 31
First episode of diverticulitis
Most patients with diverticulitis have acute
uncomplicated diverticulitis (box 1) and are managed
in the outpatient setting. In a community based study
of incident diverticulitis, 88% of patients presented
with uncomplicated diverticulitis.1 In a trial of
patients with acute uncomplicated diverticulitis
confirmed by computed tomography, the median
time to recovery was 14 days.9 Unfortunately, acute
uncomplicated diverticulitis does not always resolve
within days. In the same trial, 6% of patients had
smoldering diverticulitis at six months.
A small proportion of patients with acute
uncomplicated diverticulitis will progress to
complicated diverticulitis (fig 2). The risk of
progression was 5% within three months in a
prospective study of 1087 patients with diverticulitis
confirmed by computed tomography.26 The
complications were colonic obstruction (2.1%),
perforation (1.2%), abscess (0.7%), and fistula
(0.8%). Most (76%) perforations and abscesses
occurred within 10 days of the initial presentation.
the bmj | BMJ 2021;372:n72 | doi: 10.1136/bmj.n72
emergency surgery.35 The timing of surgery was
not reported. In a small trial published after the
systematic review, 19% of diverticulitis patients with
only extraluminal air developed an abscess within
three days of diagnosis.7
Of course, some patients present initially with
diverticulitis and an abscess (Hinchey Ib or II)
(box 1). In a community based study of incident
diverticulitis that included outpatients and
inpatients with diverticulitis, only 12% of patients
presented with complicated diverticulitis.1 The
most common complication was abscess (69%). In
an observational cohort study of 10 342 patients
with an incident diverticular abscess (Hinchey
Ib or II), 32% of patients did not respond to non-
operative management (antibiotics with or without
percutaneous drainage) and needed surgery within
30 days (fig 2).28 Of those who did not have surgery
within 30 days, 24% had an elective colectomy
within six months of discharge. This surgery resulted
in a stoma in 10% of patients (5% ileostomy,
5% colostomy). Although these surgeries were
performed “electively,” some of these patients likely
had ongoing diverticulitis necessitating diversion. In
the cohort, 52% of patients were managed without
surgery.
Rarely, a patient will present with acute
diverticulitis and purulent or feculent contamination
of the peritoneal cavity (Hinchey III or IV diverticulitis)
(box 1). This is almost always managed with surgery.
In a retrospective cohort study, 14% of patients with
a first admission for diverticulitis underwent urgent/
emergent colon resection.36 On the basis of data
from a large national surgical quality improvement
program, the risk of 30 day morbidity with urgent
surgery was 55%.37 Mortality was 7%, and the
median length of hospital stay was nine to 10 days.
Recurrent episodes
The risk of recurrent diverticulitis depends on
multiple factors including severity of the initial
episode and number of previous episodes. After an
index episode of diverticulitis, the risk of a second
episode was 8% at one year, 17% at five years,
and 22% at 10 years.1 After a second episode of
diverticulitis, the risk of a third episode was 19%
at one year, 44% at five years, and 55% at 10 years.
After a third episode of diverticulitis, the risk of
a fourth episode was 24% at one year and 40% at
three years. These estimates include patients with
diverticulitis of any severity and accounted for
3
4
A B C

~70% by 5% within 48% surgery within

age 80 3 months 6 months
No diverticulosis Diverticulosis Hinchey IA Complicated Hinchey IB/II Status post
diverticulitis diverticulitis diverticulitis resection
STATE OF THE ART REVIEW

1-4% over 6% within 25-36% over

7 years 6 months 5 years
Diverticulosis Diverticulitis Hinchey IA Smoldering Hinchey IB/II Recurrent
diverticulitis diverticulitis diverticulitis admission
No surgery diverticulitis

45%
abdominal pain 15% within 5% over
at 1 year 24 months 5 years
Diverticulitis Ongoing Hinchey IA First recurrant Hinchey IB/II Diverticulitis
GI symptoms diverticulitis diverticulitis diverticulitis emergent surgery
No surgery or death

Fig 2 | Clinical course of colonic diverticulosis and diverticulitis. Panel A: prevalence of colonic diverticulosis increases with age. By the age of 80, ~70% of Western adults have colonic
diverticulosis.24 Among adults with colonic diverticulosis, the risk of developing diverticulitis is low (1-4% over 7 years).25 Ongoing symptoms after an episode of diverticulitis are common. At
1 year follow-up, 25% of patients reported mild abdominal pain, 20% reported moderate to severe abdominal pain, and 33% reported altered bowel habits.3 Panel B: a small proportion (5%
within 3 months) of patients with acute uncomplicated diverticulitis (Hinchey Ia) progress to complicated diverticulitis.26 Most (76%) perforations and abscesses occur within 10 days of the
initial presentation.26 Acute uncomplicated diverticulitis does not always resolve within days; 6% of patients have smoldering diverticulitis.9 After an index episode of acute uncomplicated
diverticulitis (Hinchey Ia), the risk of a second episode is 15% over 24 months.27 Panel C: among patients with a diverticular abscess (Hinchey Ib/II diverticulitis), 48% have urgent or elective
surgery within 6 months.28 Among patients with Hinchey Ib/II diverticulitis managed successfully without surgery, the risk of recurrence requiring admission is 25-36% over 5 years of follow-
up.28 29 Of patients with Hinchey Ib/II diverticulitis initially managed successfully without surgery, 5% will go on to have emergency surgery or to die from diverticulitis over 5 years of follow-up.
Interval elective resection does not decrease this risk.29 GI=gastrointestinal

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recurrence of diverticulitis in the outpatient and
inpatient settings. In a trial of patients with acute
uncomplicated diverticulitis confirmed by computed
tomography, only 3% had recurrent diverticulitis, of
whom 1% underwent emergent sigmoid resection
within six months.9 In the same trial, 15% of patients
had recurrent diverticulitis within 24 months.27
Recurrent diverticulitis is more common
after an episode of complicated diverticulitis
managed without surgery than after an episode of
uncomplicated diverticulitis. After successful non-
operative treatment of complicated diverticulitis, the
risk of recurrence requiring admission was 36% over
4.5 years of follow-up (fig 2).29 In another cohort, the
five year risk of diverticulitis recurrence requiring
admission was 25%. Recurrence of complicated
diverticulitis was low at 14%, and the risk of urgent
colectomy was 8%.28 The risks associated with
complicated diverticulitis were highest in the first year
after the initial diagnosis and decreased over time.28
These estimates did not include recurrent disease
managed in the ambulatory setting. In a randomized
trial of elective resection versus observation in
diverticulitis with extraluminal air or abscess initially
managed conservatively, observation was associated
with a low risk of recurrence.7 Within three years of
follow-up, 8% in the surgery group had a recurrence
compared with 32% in the observation group. All
recurrences were managed without surgery.
Recurrent diverticulitis is not associated with an
increased risk of complicated diverticulitis. Multiple
studies have shown that the risk of complicated
diverticulitis is greatest with the patient’s first
episode.1 In a UK population based retrospective
cohort study, patients with two or more episodes
of diverticulitis had a reduced risk of developing
diverticulitis with perforation or abscess compared
with those with no history of diverticulitis (odds
ratio 0.78, 95% confidence interval 0.62 to 0.98).38
No association was seen with development of a
diverticular stricture. Recurrent diverticulitis was
associated with an increased but still very low risk
of fistulizing disease (odds ratio 1.43, 1.00 to 2.04).
Risk factors for diverticulitis
Age
In a US population based study, incidence of
diverticulitis increased with age and was most
common in adults over the age of 60 (fig 1).1
Historically, diverticulitis in young adults (age <40-50
years) was thought to be a more severe disease with
a more aggressive prognosis. However, a systematic
review and meta-analysis of 21 studies with 7477
patients found that young age was not associated
with higher risk of complicated diverticulitis at
presentation (pooled risk ratio 1.19, 95% confidence
interval 0.94 to 1.50).39 In 10 studies with 4115
patients, young age was not associated with need
for emergency surgery (pooled risk ratio 0.93,
0.70 to 1.24).39 Young age was not a risk factor for
recurrence (pooled risk ratio 1.19, 0.94 to 1.50) in
four studies with robust reporting of follow-up.39
the bmj | BMJ 2021;372:n72 | doi: 10.1136/bmj.n72
STATE OF THE ART REVIEW
Although substantial heterogeneity was present in
these studies, this work suggests that diverticulitis is
not a more aggressive disease in young adults.
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Sex
Across several studies, diverticulitis was more
common among men than women at younger ages
(<60 years) (fig 1).1 13 17 At older ages (>60 years),
diverticulitis was more common among women
than men. Use of hormone replacement therapy
for menopause increased the risk of incident
diverticulitis among postmenopausal women
compared with those who never used such therapy
(current use: hazard ratio 1.28, 95% confidence
interval 1.18 to 1.39; past use: 1.35, 1.25 to 1.45).40
Genes
Genes contribute 40-50% of diverticulitis risk.41 42
In a population based study, siblings of cases had
an increased risk of diverticular disease compared
with the general population (relative risk 2.92, 95%
confidence interval 2.50 to 3.39).41 The association
was stronger for siblings of young cases (<40 years:
relative risk 7.02, 4.82 to 10.23; 40-44 years: 4.35,
3.17 to 5.98; 45-49 years: 3.06, 2.33 to 4.03) than
for siblings of older cases (≥50 years: 1.76, 1.33 to
2.33), suggesting a greater role for genetic factors in
young onset disease.41
Obesity
Obesity increases risk of diverticulitis. In a
prospective cohort study, men with an obese body
mass index (>30) had a greater risk of diverticulitis
than lean men (body mass index <21) (relative risk
1.78, 1.08 to 2.94).43 Estimates of central obesity
were also associated with diverticulitis risk (relative
risk 1.50, 1.13 to 2.00, for highest fifth versus lowest
fifth of waist to hip ratio, adjusted for body mass
index).43 In a different prospective cohort study,
obesity was associated with risk of diverticulitis in
women (hazard ratio 1.42, 1.08 to 1.85 for body
mass index >35 v <22.5), and this risk increased with
severity of obesity.44
Diet and lifestyle
High quality diet, physical activity, and not smoking
are associated with a reduced risk of diverticulitis in
prospective cohort studies. Consuming a diet high
in fruits, vegetables, whole grains, poultry, and fish
was associated with reduced risk of diverticulitis in a
highest versus lowest fifth comparison (hazard ratio
0.74, 0.60 to 0.91).45 Compared with meat eaters,
a vegetarian diet was associated with reduced risk
of hospital admission or death due to diverticular
disease (relative risk 0.69, 0.55 to 0.86).46 Higher
consumption of red meat was associated with an
increased risk (relative risk 1.58, 1.19 to 2.11,
comparing the lowest with the highest fifth).47
Vigorous physical activity was associated with a
reduced risk of diverticulitis in a highest versus
lowest fifth comparison (relative risk 0.66, 0.51 to
0.86).48 In a prospective cohort study, a healthy
5
STATE OF THE ART REVIEW
lifestyle (defined as <51 g daily red meat, >23 g daily
dietary fiber, 2 hours’ exercise weekly, normal body
mass index, never smoker) was associated with a
substantially reduced risk of diverticulitis (relative
risk 0.27, 0.15 to 0.48).49
Non-steroidal anti-inflammatory drugs
Common over-the-counter medications are
associated with increased risk of diverticulitis. In a
prospective cohort study, regular use (at least twice
a week) of aspirin (hazard ratio 1.25, 1.05 to 1.47)
or non-steroidal anti-inflammatory drugs (1.72,
1.40 to 2.11) was associated with increased risk of
diverticulitis.50 A meta-analysis of eight studies found
that use of non-steroidal anti-inflammatory drugs
was associated with increased risk of complicated
diverticulitis (odds ratio 2.49, 1.98 to 3.14).51
Immunosuppression
Patients who are immunosuppressed have an
increased risk of acute diverticulitis, complicated
diverticulitis, and mortality from diverticulitis
compared with patients who are immunocompetent.
In a meta-analysis of 25 studies, patients with
a solid organ transplant and/or taking chronic
corticosteroids had an increased risk of incident
diverticulitis compared with the general population.52
A different meta-analysis of five studies reported that
corticosteroid use was associated with increased
odds of diverticulitis with perforation (odds ratio 9.1,
3.5 to 23.6) compared with no use.51 In a population
based study, corticosteroid use was associated with
increased mortality risk in patients with complicated
diverticulitis compared with no corticosteroid use
(hazard ratio for chronic use at one year 1.74, 1.42
to 2.14).53
Pathophysiology
The pathophysiology of diverticulitis is unknown.
Longstanding hypotheses suggest that diverticulitis
is a consequence of inspissated stool, bacterial
translocation, local ischemia, and/or diverticular
microperforation.54 Although the mechanism of this
disease remains to be determined, provocative but
limited evidence suggests that colonic dysmotility,
dysfunctional connective tissue, gut dysbiosis, and
chronic inflammation play a role.21 55-63 Evidence is
also emerging for at least 35 novel risk loci and gene
variants associated with altered smooth muscle or
nerve functions, connective tissue function, and
possibly epithelial or immune function.10-12 In these
genome-wide association studies in diverticular
disease, no overlap was seen with susceptibility
loci for inflammatory bowel disease.64 The recent
evidence on the pathophysiology of diverticulitis and
the plausibility of the suggested gene variants has
been reviewed previously.21
Clinical presentation and diagnosis
Diverticulitis most commonly presents with acute
onset of left lower quadrant abdominal pain, fever,
and leukocytosis. Complicated diverticulitis can
6
present with diffuse abdominal pain. Non-specific
inflammatory markers are often elevated; an initial
C reactive protein concentration above 170 mg/L can
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predict complicated diverticulitis,65 66 although a
low C reactive protein does not rule out complicated
diverticulitis.67 68
Because the diagnostic accuracy of history,
physical examination, and laboratory values
alone for diverticulitis is poor,69 most guidelines
recommend doing a computed tomography scan in
a patient with suspected diverticulitis, both to make
an accurate diagnosis and to determine disease
severity. A meta-analysis determined the diagnostic
test accuracy of computed tomography (eight
studies) and transabdominal ultrasonography (six
studies) for patients with suspected diverticulitis.70
The sensitivity of computed tomography was 94%
(95% confidence interval 87% to 97%), and the
specificity was 99% (90% to 100%). The sensitivity
of ultrasonography was 92% (80% to 97%), and
the specificity was 90% (82% to 95%). Computed
tomography scanning was also more likely than
transabdominal ultrasonography to identify
alternative diagnoses. A computed tomography scan
performs better in obese patients and is better able
to assess the distal sigmoid colon, which is difficult
to visualize with transabdominal ultrasonography.71
In Western countries, diverticulitis is most common
in the sigmoid colon. Ultrasonography has the
advantage of being radiation sparing, but an accurate
interpretation is operator dependent.
Considerable disagreement exists about whether a
patient should have a colonoscopy after an episode of
diverticulitis to rule out a missed colon malignancy.
Some authors consider the risk of a missed
malignancy to be unacceptably high, whereas others
consider the risk to be low.72 73 In a meta-analysis
of 31 studies that included 50 445 patients, 1.3%
(95% confidence interval 0.1% to 2.0%) of patients
with uncomplicated diverticulitis and 7.9% (2.5%
to 18.3%) of patients with complicated diverticulitis
were found to have colorectal cancer on follow-up
colonoscopy (fig 3).74 The prevalence of advanced
adenomas was 4.4%, and the prevalence of
adenomas was 14%.74 In a nationwide case-control
study, the odds of receiving a diagnosis of colon
cancer was 31 (95% confidence interval 19 to 52)
within six months of an admission for diverticular
disease.75 The increased risk was present only in the
first six months, which is further evidence that colon
cancer can be misdiagnosed as diverticulitis.
Given these clear risks, colonoscopy should be
performed six to eight weeks after an acute episode
of complicated diverticulitis or after a first episode of
uncomplicated diverticulitis.72 76-79 If a high quality
colonoscopy was performed in the previous year and
no alarm symptoms are present, the examination
does not need to be repeated. Patients with recurrent
uncomplicated diverticulitis and no alarm symptoms
should follow routine colorectal cancer screening
and surveillance intervals. It is important to be
aware that patients with post-colonoscopy colorectal
doi: 10.1136/bmj.n72 | BMJ 2021;372:n72 | the bmj

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GLYHUWLFXOLWLVš
Fig 3 | Risk of colon malignancy in patients with initial diagnosis of colonic
diverticulitis. Among patients with acute uncomplicated diverticulitis, 1.3% will be
found to have colon cancer on follow-up colonoscopy. Among patients with complicated
diverticulitis, 7.9% will be found to have colon cancer on follow-up colonoscopy74
cancer are two to four times more likely to have
a history of diverticular disease than those with
detected colorectal cancer.80 81 This risk may be
because patients with diverticular disease sometimes
have distorted colonic architecture, making it easier
to miss lesions or for lesions to be incompletely
resected.
Treatment
Treatment of diverticulitis depends on multiple
factors including disease severity, symptom burden,
and a patient’s general health and comorbidities.
Although patients with acute complicated
diverticulitis are managed in hospital, most
patients with acute uncomplicated diverticulitis are
successfully treated in the outpatient setting. In a
systematic review of 19 studies, outpatient treatment
of acute uncomplicated diverticulitis was associated
with only 7% risk of readmission, usually for
symptom control.82 Emergency surgery was very rare
(0.2%). Guidelines suggest that immunocompetent
patients with acute uncomplicated diverticulitis can
be managed in the outpatient setting if they have
no significant comorbid diseases and a manageable
symptom burden, can maintain oral intake, and have
ready access to medical care and social support.83 84
Despite limited evidence, bowel rest (consuming
only liquids and avoiding all solid foods) is commonly
recommended in the acute phase of diverticulitis.
This recommendation is based on the small risk
of progression to obstruction or perforation. This
recommendation is reasonable in the acute setting
of the hospital when surgery may be necessary, but
preliminary work suggests that bowel rest may not be
necessary for all patients with acute uncomplicated
diverticulitis. In a small prospective cohort study, 86
patients with acute uncomplicated diverticulitis were
allowed to consume an unrestricted diet.85 In six
months of follow-up, 8% developed a serious adverse
event defined as need for surgery, readmission
due to pain, or recurrence. Although there was no
control group, the risk of need for surgery (3%) was
similar to what has been reported in other natural
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STATE OF THE ART REVIEW
history studies. Anecdotally, patients have reported
successfully managing mild recurrences of acute
uncomplicated diverticulitis by adhering to a liquid
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only diet for a few days.
Hinchey Ia diverticulitis
Guidelines recommend that antibiotic treatment
can be used selectively, rather than routinely,
in immunocompetent patients with acute
uncomplicated diverticulitis (Hinchey Ia) (table
1).6 72 76 83 86-88 Two randomized controlled trials
and seven observational studies have shown no
benefit of antibiotic treatment in patients with acute
uncomplicated diverticulitis.2 32 89-95 In a meta-
analysis of nine studies that included 2505 patients
with acute uncomplicated diverticulitis treated with
or without antibiotics, no significant difference was
seen in the risk of complications, readmission, need
for surgery or percutaneous drainage, or recurrence.96
Importantly, these studies excluded patients who
were immunocompromised, patients with imaging
concerning for complicated diverticulitis, and
patients with any signs or symptoms of sepsis/
systemic inflammatory response syndrome.
A minority of patients with uncomplicated
diverticulitis will deteriorate and progress to
complicated diverticulitis. Patients at risk for
progression should be treated with a course of
antibiotics that cover Gram negative and anaerobic
bacteria. The risk of progressing from uncomplicated
to complicated diverticulitis was 5% within three
months in a prospective study of 1087 patients with
disease confirmed by computed tomography.26 Risk
factors for progression to any complication were
American Society of Anesthesiologists score III or IV
(odds ratio 4.43, 1.57 to 12.48), longer duration of
symptoms (more than five days) before presentation
(3.25, 1.72 to 6.13), baseline presence of vomiting
(3.94, 1.96 to 7.92), and baseline C reactive protein
above 140 mg/L (2.86, 1.51 to 5.43). Risk factors for
progression to abscess/perforation were vomiting
(odds ratio 3.53, 1.36 to 9.15), baseline C reactive
protein above 140 mg/L (3.24, 1.36 to 7.91), and
baseline white blood cell count above 15×109
cells/L (3.66, 1.50 to 8.94). The presence of a fluid
collection or longer segment of inflammation on a
baseline computed tomography scan was associated
with increased risk of developing complicated
diverticulitis.97 Although paracolic extraluminal air
was not associated with progression in this study,97
extraluminal air was associated with abscess
development in another study.7
Hinchey Ib/II diverticulitis
Smaller (<3 cm) paracolic abscesses are treated with
antibiotics that cover Gram negative and anaerobic
bacteria. No strong evidence is available to guide a
particular antibiotic regimen, route, or duration.
Antibiotic regimens for diverticulitis are numerous
and have been summarized elsewhere.98 Larger
abscesses (≥3 cm) are treated with percutaneous
drainage and antibiotics. The evidence for
7
8
Table 1 | Recommendations from major published guidelines on diverticulitis
Guideline Imaging to make diagnosis
Germany, DGVS/ Imaging should be
DGAV, 201576 performed; first US followed
by CT in uncertain situations
or complicated disease
Italy, SICCR, CT is first line examination
201577 in patients presenting
with symptoms suggesting
diverticulitis
US, AGA, 201572 78 No recommendation
International, EAES Recommend selective
and SAGES, 201886 imaging in patients with left
lower quadrant abdominal
pain, absence of vomiting,
CRP >50 mg/L, and/or
history of diverticulitis.
Modality of choice is CT;
alternatively, US at centers
with expertise
International, Imaging is recommended
WSES, 202083 to make diagnosis. CT is
first choice. US in initial
evaluation if performed by
expert operator. Step-up
approach with CT after
inconclusive or negative US
may be safe
US, ASCRS, 20206 CT is most appropriate
initial imaging modality in
assessment of suspected
diverticulitis
European, ESCP, Imaging is needed to
202084 confirm diagnosis if
no previous diagnostic
information. CT is
recommended as first line
investigation in suspected
diverticulitis
AGA=American Gastroenterological Association; ASCRS=American Society of Colon and Rectal Surgeons; 5-ASA=5-aminosalicylic acid; CRP=C reactive protein; CT=computed tomography; DGAV=German Society of General and Visceral Surgery;
DGVS=German Society of Digestive and Metabolic Diseases; EAES=European Association for Endoscopic Surgery; ESCP=European Society of Coloproctology; MRI=magnetic resonance imaging; NSS=Netherlands Society of Surgery; QoL=quality of life;
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SAGES=Society of American Gastrointestinal Endoscopic Surgeons; SICCR=Italian Society of Colorectal Surgery; US=ultrasound; WSES=World Society of Emergency Surgery.
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Colonoscopy to rule out malignancy
Colonoscopy after conservative
treatment of diverticulitis is
recommended
Colonic investigation is needed
Colonoscopy should be performed if
high quality examination has not been used selectively, rather use of mesalamine;
recently done
Recommend against routine colonic
evaluation after successfully treated
uncomplicated acute diverticulitis,
unless high risk features are present
In CT proven uncomplicated
diverticulitis treated non-operatively, prescribe antibiotic
routine colonic evaluation is not
recommended. In diverticular
abscesses treated non-operatively,
early colonic evaluation (4-6 weeks) is
suggested
After acute complicated diverticulitis,
colon should be endoscopically
evaluated if colonoscopy has not been
done recently
Endoscopic follow-up remains
controversial and may not be necessary
for patients with symptom-free
recovery after single episode of CT
verified uncomplicated diverticulitis.
All other patients treated without
resection for acute diverticulitis should
be followed up with examination of
colon at least 6 weeks after episode, if
not done within previous 3 years
Antibiotics for
uncomplicated
diverticulitis in
immunocompetent Medical therapy for
patients prevention
Antibiotic therapy is No recommendation
not necessary
Use on case by case Fiber plus rifaximin
basis is more effective
than fiber alone
in preventing
diverticulitis, with low
therapeutic advantage
Antibiotics should be Recommend against
than routinely suggest against the
use of rifaximin or
probiotics
Trial of non-antibiotic Use of mesalamine
therapy can be does not prevent
considered with recurrent diverticulitis
appropriate follow-up or improve chronic
gastrointestinal
symptoms; role of
rifaximin, probiotics,
and fiber is less well
defined
Recommend not to No recommendation
therapy
Selected patients Mesalamine, rifaximin,
with uncomplicated and probiotics not
diverticulitis can recommended
be treated without to reduce risk of
antibiotics recurrence but may be
effective in reducing
chronic symptoms
Patients with acute Neither mesalamine,
uncomplicated rifaximin nor probiotics
diverticulitis do not can be recommended
need antibiotics to prevent recurrent
routinely. Antibiotic diverticulitis or
treatment should persistent complaints
be reserved for after episode of acute
immunocompromised diverticulitis
patients and patients
with sepsis
Prophylactic resection for
recurrent uncomplicated
diverticulitis in
immunocompetent patients
Surgery should be performed
after individual case evaluation
Decision to perform elective
resection after one or more
episodes of diverticulitis should
be taken on case by case basis
Decision to perform elective
prophylactic colon resection
should be individualized
Recommend elective resection
in patients with symptomatic
diverticular disease that is
negatively affecting quality of life
Suggest evaluating patient
related factors and not number
of previous episodes in planning
elective sigmoid resection
Decision to recommend elective
sigmoid colectomy after
recovery from uncomplicated
acute diverticulitis should be
individualized
Goal of elective surgery after one
or more episodes of diverticulitis
is to improve QoL. Indication
should be individualized
and based on frequency of
recurrences, duration and severity
of symptoms after attacks, and
comorbidity of patient. Elective
surgery to prevent complicated
disease is not justified
Prophylactic resection for
complicated diverticulitis
successfully managed
non-operatively in
immunocompetent
patients
Surgery in inflammation-
free interval is
recommended
No recommendation
No recommendation
Recommend surgery Recommend early
should not be routinely elective resectional
offered solely to avoid surgery
future episodes after single
episode of successfully
treated Hinchey I/II acute
diverticulitis
No recommendation
After successful non-
operative treatment of
diverticular abscess,
elective resection should
typically be considered
Decision to operate
on patients after
conservatively managed
episode of acute
complicated diverticulitis
should follow same
principles as for patients
with uncomplicated
diverticulitis; resection is
not recommended routinely
Prophylactic surgery in
immunocompromised
patients
No recommendation
No firm conclusions can
be drawn
No recommendation
STATE OF THE ART REVIEW
After episode of
diverticulitis treated
conservatively,
suggest planning
elective sigmoid
resection in patients
at high risk, such as
immunocompromised
patients
Decision to offer sigmoid
colectomy after recovery
from uncomplicated
acute diverticulitis in
immunosuppressed
patients should be
individualized
Decision for elective
resection after acute
episode of diverticulitis
in immunocompromised
patients should follow
same principles as
in other patients; not
recommended routinely

percutaneous drainage is limited. If this fails, surgery
is necessary. In a retrospective cohort study of 447
patients with diverticulitis with abscess formation
(Hinchey Ib and II) managed non-operatively with
antibiotics with or without percutaneous drainage,
9% needed emergency surgery within 30 days of
presentation.99 During this time, 5.6% developed a
complication (defined as obstruction, perforation,
or fistula), 21% had clinical deterioration/
disease progression, and 14% had “persistent”
diverticulitis.99 A cut-off size of 5 cm predicted need
for emergency surgery within 30 days of presentation.
Percutaneous drainage did not reduce the risk of
treatment failure or emergency surgery.
Hinchey III/IV diverticulitis
Acute diverticulitis with purulent or feculent
contamination of the peritoneal cavity is almost
always managed with surgery and antibiotics.
Although a Hartmann’s procedure (resection of
sigmoid colon with formation of end colostomy)
is most often used, robust evidence from four
randomized clinical trials shows that colon resection
with a primary anastomosis (with or without
diverting ileostomy) is associated with better
outcomes.100-103 In a meta-analysis of the four trials
comparing primary anastomosis with Hartmann’s
procedures, patients who had a primary anastomosis
were more likely to not have a stoma at 12 months
after surgery (risk ratio 1.34, 1.16 to 1.54) compared
with those who had a Hartmann’s procedure.104  105
Less than a third of patients undergo colostomy
reversal within one year of a Hartmann’s procedure,
and having a colostomy is a substantial detriment
to quality of life.106 Take down surgery to reverse
the stoma after primary anastomosis with ileostomy
had a reduced risk (risk ratio 0.23, 0.07 to 0.70) of
a major postoperative complication compared with
take down surgery for a Hartmann’s procedure. No
difference was found between the groups in major
postoperative complications (risk ratio 0.88, 0.59
to 1.32) or postoperative mortality (0.84, 0.34 to
2.08). In a decision analysis considering surgical
risk and quality of life, colon resection with a
primary anastomosis provided greater quality
adjusted life years for patients with Hinchey III
diverticulitis compared with Hartmann’s procedure
or laparoscopic lavage.107 In stable patients with
Hinchey III and IV diverticulitis, primary resection
and anastomosis is the procedure of choice.
Smoldering diverticulitis
A typical course of diverticulitis resolves within a
few weeks, but chronic or smoldering diverticulitis,
defined as diverticulitis that persists for weeks to
months, has been reported. This includes patients
who improve somewhat or almost completely and
then relapse quickly after stopping antibiotics. This
is in contrast to recurrent diverticulitis, in which
patients tend to have a clear interval free from
symptoms and inflammation. A small prospective
study of patients who had elective segmental
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STATE OF THE ART REVIEW
colectomy found that 41% of patients with “resolved”
acute uncomplicated diverticulitis had a macroscopic
or microscopic diverticular abscess on histology.108
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In a small trial of elective surgery for patients with
recurrent diverticulitis and/or ongoing complaints,
51% had diverticular inflammation and 9% had
an abscess or covered perforation on histology.109
This work suggests that ongoing inflammation
can be missed on imaging and that smoldering
diverticulitis may be more common than previously
recognized. No evidence is available to guide the
management of smoldering diverticulitis. In clinical
practice, patients with smoldering diverticulitis are
treated with a course of antibiotics that cover Gram
negative and anaerobic bacteria. A prolonged course
of antibiotics is often necessary, and segmental
resection is sometimes needed for persistent disease.
Ongoing symptoms after an episode of acute
diverticulitis
Ongoing gastrointestinal symptoms are common
after recovery from the acute phase of diverticulitis.
In a nested case-control study with 2204 patients,
patients with diverticulitis were 4.7 (95% confidence
interval 1.6 to 14.0) times more likely to receive a
diagnosis of incident irritable bowel syndrome over
nine years of follow-up compared with controls.110 In
another study, at one year follow-up after a diagnosis
of acute uncomplicated diverticulitis confirmed by
computed tomography, 25% of patients reported
mild abdominal pain, 20% reported moderate to
severe abdominal pain, and 33% reported altered
bowel habits (fig 2).2 Compared with the general
population, the prevalence of chronic gastrointestinal
symptoms in patients who have recovered from
diverticulitis is significantly higher than expected.111
Ongoing symptoms after an episode of diverticulitis
should not be termed symptomatic uncomplicated
diverticular disease; this is a non-specific term.
The differential diagnosis for chronic
gastrointestinal symptoms after an episode
of diverticulitis is broad. Repeat imaging and
colonoscopy are often necessary to rule out
ongoing inflammation or a misdiagnosis. Delayed
complications such as a diverticular stricture or
fistulizing disease should be considered. Ongoing
symptoms in the setting of otherwise normal
laboratory values, imaging, and colonoscopy are a
detriment to patients’ quality of life. Unfortunately,
ongoing symptoms do not always improve with
surgery. After colectomy, chronic gastrointestinal
symptoms persisted in 22-25% of patients.87 112
Preliminary evidence suggests that patients with a
history of diverticulitis have visceral hypersensitivity
in association with low grade mucosal inflammation
and alterations in neuropeptide receptor
expression.113 Another preliminary study of patients
with a history of diverticulitis found evidence of
damage to the enteric nervous system with reactive
remodeling of enteric ganglia, nerves, and interstitial
cells of Cajal.114 In the setting of an otherwise normal
work-up including imaging and colonoscopy, these
9
STATE OF THE ART REVIEW
patients often benefit from a management strategy
specific to visceral hypersensitivity, similar to that
for post-infectious irritable bowel syndrome, with a
low to modest dose of a tricyclic antidepressant.115
Counseling patients after recovery from acute
diverticulitis
After recovery from an acute episode of diverticulitis,
patients are at risk for recurrent episodes. Recurrent
diverticulitis affects a person’s physical, social, and
psychological health. In a qualitative research study,
patients with a history of diverticulitis reported
disease associated anxiety, embarrassment, isolation,
and lack of control. They also described avoiding
social engagements, missing work, and restricting
their diet.116 As misinformation about diverticulitis
is common, all patients should be counseled on the
prognosis, risk factors, and prevention strategies for
diverticulitis to ensure that they are well informed.79
Diet and lifestyle
Compelling evidence shows that high quality
diet, physical activity, not smoking, and a normal
body mass index are associated with a reduced
risk of incident diverticulitis. Multiple guidelines
recommend encouraging patients with a history
of diverticulitis to maintain or adopt a healthy diet
and lifestyle. However, patients with a history of
diverticulitis do not need to avoid nut, corn, and
popcorn consumption.117 In a prospective cohort
study, regular consumption (at least twice a week)
of nuts (hazard ratio 0.80, 0.63 to 1.01) or popcorn
(0.72, 0.56 to 0.92) was associated with a reduced
risk of diverticulitis compared with infrequent
consumption (less than once a month).117
Non-steroidal anti-inflammatory drugs
Regular use (at least twice a week) of aspirin or
non-steroidal anti-inflammatory drugs is associated
with increased risk of diverticulitis. Guidelines
recommend that non-steroidal anti-inflammatory
drugs should be avoided in patients with a history of
diverticulitis.72 Patients with recurrent diverticulitis
who take aspirin for primary prevention of
cardiovascular disease can consider avoiding this
drug after weighing the potential risks and benefits
with their primary care provider.
Medical treatment
No medical therapies are available to prevent recurrent
episodes of diverticulitis. 5-aminosalicylic acid (5-ASA)
is an anti-inflammatory drug used for the treatment of
ulcerative colitis. A meta-analysis of seven randomized
controlled trials with 1805 participants found no
evidence of an effect when comparing 5-ASA versus
control for prevention of recurrent diverticulitis (31%
v 30%; risk ratio 0.69, 0.43 to 1.09).118 No evidence
supports the use of any probiotic or cyclic rifaximin to
prevent diverticulitis.78 119 Guidelines generally agree
that treatment with 5-ASA, rifaximin, or probiotics
to reduce the risk of recurrent diverticulitis is not
recommended (table 1).6 72 86
10
Prophylactic surgery
Prophylactic segmental colon resection reduces the
risk of recurrent diverticulitis. Resection is often
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used to treat a persistent abscess, stricture, or fistula.
Treatment should not be confused with resection for
prevention of recurrence. The three indications for
prophylactic surgery are reviewed in box 2.
Immunocompetent patient with recurrent
uncomplicated diverticulitis
Historically, the goal of elective surgery in this
population was to prevent emergency surgery.
This is no longer the goal. The risk of emergency
surgery is highest with the initial presentation of
diverticulitis.121 Guidelines recommend that the
decision to have elective, prophylactic resection be
individualized to consider severity of disease, general
health status, and patient’s preferences and values,
as well as benefits and risks (table 1).6 72 76 83 86-88
Benefits—A segmental colectomy reduces the risk
of recurrent diverticulitis. Because only a section
of colon is removed with this surgery, elective
resection for diverticulitis is not a cure, and recurrent
diverticulitis remains a risk. Using claims based
data in a commercially insured population, the rate
of recurrent diverticulitis at five year follow-up was
found to be 61% in patients managed conservatively
compared with 15% in patients who had elective
surgery.121 Although evidence is limited, elective
surgery may benefit quality of life and chronic
gastrointestinal symptoms compared with non-
operative management. In a systematic review and
meta-analysis of 21 low quality studies that included
1858 patients, those who had surgery had higher
quality of life scores and a lower proportion had
gastrointestinal symptoms compared with those who
did not have surgery.120 The first randomized controlled
trial comparing elective surgery with conservative
management for patients with recurrent or persistent
complaints after an episode of left sided diverticulitis
(DIRECT trial) was published in 2017.122 The trial
randomized 109 generally healthy patients with a
history of Hinchey I or II diverticulitis. At six month
follow-up, the gastrointestinal quality of life index
score was significantly higher in patients randomized
to surgery (mean score 114) than in those managed
without surgery (mean score 100; mean difference
14, 95% confidence interval 7 to 21). A difference of
10 or more is considered clinically important. Among
patients randomized to non-operative management,
46% ultimately had surgery. At five year follow-up
in an intention to treat analysis, general quality
of life, mental and physical health, and pain also
significantly improved. The gastrointestinal quality
of life index score also remained higher in patients
randomized to surgery (mean score 118) compared
with those managed without surgery (mean score
109; mean difference 10, 2 to 18).109 Importantly, in
two other studies, chronic gastrointestinal symptoms
persisted in 22-25% of patients after colectomy.87 112
Risks—Although surgery will reduce the risk
of recurrence and potentially improve chronic
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 STATE OF THE ART REVIEW

Box 2: Indications for prophylactic resection

Prophylactic resection for diverticulitis requires shared decision making between patient and physicians. This discussion should include disease

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severity, general health status, and the patient’s preferences and values, as well as benefits and risks. The three indications for prophylactic
resection are as follows.
1) Immunocompetent patient with recurrent uncomplicated diverticulitis
• Resection should not be considered before the third episode of uncomplicated diverticulitis, as the risks of resection are too high120
• Surgical resection should not be considered to prevent urgent surgery or colostomy, as those risks are very low1
• After a third episode of uncomplicated diverticulitis, patients should understand that they have two options: they can have surgery to prevent more
episodes or they can continue to manage recurrent episodes without surgery6 83 84 86
• The risk of recurrent diverticulitis at five year follow-up is 61% in patients managed without surgery compared with 15% in patients who have an
elective resection121
• An important factor in deciding whether to have prophylactic surgery for diverticulitis is how much recurrent episodes bother the patient.
Diverticulitis episodes are unpredictable, and the effect of this uncertainty on day-to-day life is important to consider. Some evidence suggests that
surgery improves quality of life122
• Chronic gastrointestinal symptoms may or may not improve with surgery. After colectomy, chronic gastrointestinal symptoms persisted in 22-25%
of patients80 108
• The most common surgery is a segmental resection of the colon with primary anastomosis. In some cases, a temporary diverting stoma (ileostomy)
is necessary to protect the colorectal anastomosis while it heals. A second operation is performed weeks later to take down or remove the stoma
• The major risks of surgery include infection, need for repeat operation, development of scar tissue in the abdomen, abdominal wall hernia, and
rarely death.123 These risks are higher in older adults and those patients who are frail or have comorbidities
2) Immunocompetent patient with complicated diverticulitis successfully managed non-operatively
• Some guidelines recommend prophylactic resection with the singular goal of preventing a complicated recurrence, whereas others recommend
individualized decision making6 83 84 86
• The risk of recurrent diverticulitis at three year follow-up is 32% in patients with complicated diverticulitis managed without surgery compared with
8% in those who have an elective resection7
• Of patients with Hinchey Ib/II diverticulitis initially managed successfully without surgery, 5% will go on to have emergency surgery or to die from
diverticulitis over five years of follow-up. Interval prophylactic resection does not decrease this risk29
• The most common surgery is a segmental resection of the colon with primary anastomosis. In some cases, a temporary diverting stoma (ileostomy)
is necessary to protect the colorectal anastomosis while it heals. A second operation is performed weeks later to take down or remove the stoma
• The major risks of surgery include infection, need for repeat operation, development of scar tissue in the abdomen, abdominal wall hernia, and
rarely death. These risks are higher in older adults and those patients who are frail or have comorbidities
3) Immunocompromised patient with diverticulitis successfully managed non-operatively
• Some guidelines recommend prophylactic resection with the singular goal of preventing a complicated recurrence, whereas other guidelines
recommend individualized decision making6 83 84 86
• Patients who are immunosuppressed have an increased risk of death from diverticulitis compared with patients who are immunocompetent.53
Evidence by immunosuppression type is limited
• Evidence on prognosis after successful non-operative management of diverticulitis in patients who are immunocompromised is limited. Therefore,
the benefits of prophylactic resection in this population are uncertain
• The major risks of surgery include infection, need for repeat operation, development of scar tissue in the abdomen, abdominal wall hernia, and
rarely death. The risks of surgery are higher in patients who are immunocompromised than in immunocompetent patients

gastrointestinal symptoms, this comes at the cost
of risk of surgical complications. The risks of
elective surgery are well described. Using data from
a national surgical quality improvement program,
2.4% of patients who had an elective surgery for
recurrent uncomplicated diverticulitis experienced
an anastomotic leak, 16.5% had a surgical site
infection, 2.5% had an unplanned return to the
operating room, and 0.2% died within 30 days.123
Timing—When to offer a patient with recurrent
diverticulitis an elective surgery is unknown. In a
decision analysis comparing colonic resection with
conservative management for patients with recurrent
diverticulitis, elective surgery after two episodes
of diverticulitis was associated with the highest
chance of stoma formation and lowest quality
adjusted survival.120 This was primarily driven by the
mortality risk related to surgery. Elective surgery and
conservative management were comparable after the
third episode of diverticulitis. These results suggest
that prophylactic surgery should not be considered
until after a third episode of uncomplicated
diverticulitis.
Immunocompetent patient with complicated
diverticulitis successfully managed non-operatively
Patients with a history of complicated diverticulitis
successfully managed without surgery are at
increased risk of recurrence and complicated
recurrence. Some guidelines recommend resection
after recovery from complicated diverticulitis to
prevent a complicated recurrence and possible
urgent surgery, whereas more recent guidelines have
recommended a more individualized approach (table
1).6 83 84 86 In a population based study of patients
with complicated diverticulitis successfully managed
non-operatively, 5% went on to have emergency
surgery or to die from diverticulitis over 4.5 years

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STATE OF THE ART REVIEW
of follow-up. Importantly, interval elective resection
did not decrease this risk (odds ratio 0.98, 0.81 to
1.19).29 Given these findings, prophylactic surgery
should not be automatically recommended to this
population with the goal of preventing emergency
surgery or death from diverticulitis. In a randomized
trial of elective resection versus observation in
diverticulitis with extraluminal air or abscess initially
managed conservatively, observation was associated
with a low risk of recurrence.7 Within three years of
follow-up, 8% in the surgery group had a recurrence
compared with 32% in the observation group. All
recurrences were managed without surgery.
Immunocompromised patient with diverticulitis
successfully managed non-operatively
Some guidelines recommend that
immunocompromised patients with a history of
diverticulitis successfully managed non-operatively
should consider prophylactic colon resection, whereas
others recommend individualized decision making
(table 1).6 83 84 86 The goal of surgery in this population
is to prevent complicated recurrence. Patients
who are immunosuppressed have an increased
risk of complicated diverticulitis and an increased
risk of death from perforated diverticulitis.51 53
Unfortunately, evidence on prognosis after successful
non-operative management of diverticulitis in
patients who are immunocompromised is limited.
The risk likely differs by type of immunosuppressant
drug and condition, but most evidence is for
patients receiving corticosteroids. In the setting of
an elective segmental resection for diverticulitis,
patients who are immunosuppressed have an
increased risk of postoperative morbidity (odds ratio
1.5, 1.17 to 1.83) compared with patients who are
immunocompetent.124
Emerging therapies
Multiple studies of diverticulitis are under way. A trial
is comparing the risk of readmission in patients with
mild diverticulitis treated with antibiotics versus
no antibiotics (clinicaltrials.gov NCT02785549).
Another trial is evaluating the safety and efficacy
of rifaximin versus placebo for the prevention of
recurrent diverticulitis (NCT03469050). A prospective
study is assessing whether biomarkers can predict
recurrent diverticulitis and ongoing symptoms
(NCT04407793). Investigators are determining the
role of genes in diverticulosis (NIH R01DK094738)
and diverticulitis (NIH K08DK124687). A prospective
cohort study is examining the role of diet, lifestyle,
and the gut microbiome/metabolome in incident and
recurrent diverticulitis (NIH R01DK101495). A trial
in patients with a history of diverticulitis is comparing
the effect of placebo or prebiotic on gut microbiota
composition and function, gastrointestinal transit
and permeability, and symptoms (NCT03742076).
The DEBUT study is determining how doctors and
patients make the decision to offer or have elective
surgery for diverticulitis (NCT02776787). The
COSMID trial is a pragmatic, patient level randomized
12
superiority trial of elective colectomy versus best
medical management for patients with quality of life
limiting diverticular disease (NCT04095663). The
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FRESCO trial aims to understand the effect of elective
surgery on bowel function and quality of life in
patients with recurrent uncomplicated diverticulitis
(NCT03994978). The estimated dates of completion
for these studies are within the next five years.
Guidelines
Multiple national and international guidelines
on the management of diverticulitis have been
published and are referenced throughout this
review (table 1). Most guideline developers
performed a systematic review of the literature and
assessed the quality of evidence by using Grade of
Recommendation, Assessment, Development, and
Evaluation (GRADE) methodology.6 72 78 83 86 88 The
German and European Society of Coloproctology
guidelines were consensus based.76 84 The
guidelines all generally recommend that a
diagnosis should be confirmed with imaging, that
immunocompetent patients should be managed
without antibiotics, and that the decision
to recommend prophylactic colectomy in an
immunocompetent patient after uncomplicated
diverticulitis should be individualized. Some of the
guidelines recommend that immunocompromised
patients may benefit from early resection, whereas
the two most recent guidelines recommend a
more individualized approach. The guidelines do
not agree on whether a colonoscopy should be
performed after non-operative management of
diverticulitis to rule out malignancy.
Conclusion
Colonic left sided diverticulitis is a common and
costly gastrointestinal disease in Western countries.
No definitive cure or identified means of prevention
exists. Patients with diverticulitis have a painful
and unpredictable disease that forces many to
consider whether they may need major surgery.
Until recently, we blamed this disease on dietary
indiscretion and told our patients that the natural
history was catastrophic. Thankfully, we now
appreciate that multiple factors contribute to risk of
diverticulitis and that the prognosis is not usually
so dire.
Although management of diverticulitis is
increasingly evidenced based, an urgent need
to study this complex disease remains. The
pathogenesis of diverticulitis is poorly understood
and is more complicated than stool abrading the wall
of a diverticulum. The prognosis for diverticulitis
needs to be better defined, particularly in patients
who are immunosuppressed and in those with a
history of complicated diverticulitis managed non-
operatively. Inadequate evidence exists to guide
physicians and their patients through the decision
to consider prophylactic surgery. The genetics of this
disease need to be studied with a granular approach
specific to each manifestation.
doi: 10.1136/bmj.n72 | BMJ 2021;372:n72 | the bmj

These gaps in our understanding are fundamental
barriers to better treatment and prevention. The
incidence of diverticulitis will likely continue to
rise with increasing obesity and aging Western
populations. Although recent research gives us
more to offer patients with diverticulitis, the field
of diverticulitis is several decades behind those of
most common gastrointestinal diseases. Hopefully,
ongoing studies and increased research funding can
answer the many questions that remain.
SUMMARY OF MANAGEMENT OF DIVERTICULITIS
Diagnosis
• In patients presenting with suspected acute diverticulitis, an abdominal computed
tomography scan should be performed to confirm the diagnosis, to determine the
severity of disease, and to rule out an alternative diagnosis. This is most important
for the first presentation and less important for a stereotypical mild recurrence6 83 84
• A step-up approach with computed tomography performed after an inconclusive
or negative ultrasound scan may be considered in centers with expertise in
ultrasonography; computed tomography performs better in obese patients and is
better able to assess the distal sigmoid colon, which is difficult to visualize with
transabdominal ultrasonography83
• Colonoscopy should be performed six to eight weeks after a diagnosis of
complicated diverticulitis or first episode of uncomplicated diverticulitis; in the
absence of alarm symptoms, a colonoscopy does not need to be repeated if a
high quality examination has been performed in the previous year. Patients with
recurrent uncomplicated diverticulitis and no alarm symptoms should follow routine
colorectal cancer screening and surveillance intervals6 72 83 84
• Ongoing gastrointestinal symptoms are common after recovery from the acute phase
of diverticulitis, and alternative diagnoses should be considered. The differential
diagnosis for chronic gastrointestinal symptoms is broad. Repeat imaging and
colonoscopy is often necessary to rule out a misdiagnosis or ongoing inflammation
Treatment
• Antibiotic treatment is not necessary in healthy, immunocompetent patients who
present with mild acute uncomplicated diverticulitis.6 83 84 86 Patients with acute
uncomplicated diverticulitis who have comorbidities or are frail, who present with
refractory symptoms or vomiting, or who have a C reactive protein concentration
above 140 mg/L or baseline white blood cell count above 15×109 cells/L are at
higher risk for developing a complication, and treatment with antibiotics should be
considered.
• Patients who are immunosuppressed have an increased risk of mortality from
diverticulitis and should always be treated with antibiotics6 83 84 86
• Small (<3 cm) paracolic abscesses can be treated with antibiotics. Larger abscesses
are treated with percutaneous drainage and antibiotics. If this fails, surgery is
necessary
• In stable patients with Hinchey III and IV diverticulitis, primary resection and
anastomosis is the procedure of choice104 105
Prevention
• Patients with a history of diverticulitis should understand that a high quality diet,
physical activity, not smoking, and a normal body mass index are associated with a
reduced risk of diverticulitis72 78
• Patients with a history of diverticulitis should avoid regular use of non-steroidal anti-
inflammatory drugs72 78
• Patients with a history of diverticulitis do not need to avoid nut, corn, and popcorn
consumption72 78
• 5-aminosalicylic acid, probiotics, and rifaximin should not be used to prevent
recurrent diverticulitis72 78 84
• The decision to undergo prophylactic colon resection should be individualized
to consider severity of diverticulitis, general health and immune status, patient’s
preferences and values, and benefits and risks (box 2)6 83 84 86
the bmj | BMJ 2021;372:n72 | doi: 10.1136/bmj.n72
STATE OF THE ART REVIEW
RESEARCH QUESTIONS
• What is the pathophysiology of diverticulitis? What
BMJ: first published as 10.1136/bmj.n72 on 24 March 2021. Downloaded from http://www.bmj.com/ on 28 June 2021 by guest. Protected by copyright.
factors are associated with recurrent diverticulitis
and complicated recurrence?
• How can we effectively treat uncomplicated
diverticulitis? Does percutaneous drainage improve
outcomes in patients with an abscess? How can we
prevent recurrent diverticulitis without surgery?
• Which patient populations benefit from an elective
segmental resection?
• Why do patients with quiescent diverticulitis have
ongoing gastrointestinal symptoms? How can these
symptoms be effectively managed?
PATIENT INVOLVEMENT
Three patients with diverticulitis reviewed the
manuscript and provided constructive feedback on
treatment and prevention.
I thank Sarah Towner Wright, School of Medicine Librarian, University
of North Carolina at Chapel Hill for assisting with the literature search.
Contributors: AP reviewed the literature and wrote this review. She is
the guarantor.
Funding: This research was supported in part by a grant from the
National Institutes of Health K23DK113225 and NIH R01DK094738.
Competing interests: I have read and understood the BMJ policy on
declaration of interests and declare the following interests: None
Provenance and peer review: Commissioned; externally peer
reviewed.
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