Diverticulitis - ClinicalKey

6/8/23, 21:46 Diverticulitis - ClinicalKey
CLINICAL OVERVIEW
Diverticulitis
Elsevier Point of Care (see details)
Updated May 1, 2023. Copyright Elsevier BV. All rights reserved.
Synopsis
Urgent Action
Hospitalize all patients with signs and symptoms of systemic illness, peritonitis, or
complicated disease
Immediate surgical consultation is necessary for patients with peritonitis,

complicated disease, or vascular catastrophe
Patients with perforated diverticulitis and diffuse peritonitis should undergo
emergent surgical intervention 1
Key Points
Diverticulitis involves microperforation of a diverticulum, with ensuing localized
inflammation contained by pericolic fat and mesentery
Constipation and a Western diet of highly refined, low-fiber foods are thought to be major
contributing factors to diverticulosis
Diagnosis of acute diverticulitis can usually be made on the basis of history and physical
examination
Lower left quadrant tenderness may be present, but right-sided signs do not preclude
diagnosis; low-grade fever is common
CT of abdomen/pelvis is the imaging test of choice for confirming the diagnosis
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Conservative (nonsurgical) management of uncomplicated diverticulitis, with or without

oral antibiotic therapy, results in resolution in most patients
All patients with complicated diverticulitis require treatment with oral or IV antibiotics
Patients who have severe or complicated diverticulitis or whose condition does not respond
to medical therapy often require surgical intervention
Pitfalls
Fever is often absent in older adults; a rectal temperature may be required for detection of
fever in this population 2
Older adults and some patients taking corticosteroids may have unremarkable findings,
even in the presence of severe diverticulitis 2
Right-sided diverticulitis is often confused with appendicitis
Terminology
Clinical Clarification
Diverticulosis involves saclike outpouchings of mucosa and submucosa through the
muscular layer of the colon 3
Diverticulitis involves microperforation of a diverticulum, with ensuing localized

inflammation contained by pericolic fat and mesentery; most common complication of
diverticulosis 4
Classification
Modified Hinchey classification for acute diverticulitis 5
Stage 0: clinically mild diverticulitis
Stage Ia: confined pericolic inflammation and phlegmonous inflammation
Stage Ib: abscess formation (less than 5 cm) in or near area of primary inflammatory
process
Stage II: intra-abdominal abscess, pelvic or retroperitoneal abscess, and/or abscess distant
from primary inflammatory process
Stage III: generalized purulent peritonitis

Stage IV: fecal peritonitis
Alternative classification systems such as the CDD (Classification of Diverticular Disease) 6

and DICA (Diverticular Inflammation and Complication Assessment) 7 have been advocated
by some authors but as yet have not replaced modified Hinchey classification
Acute complicated diverticulitis 8
Diverticulitis associated with any of the following:
Uncontained perforation with a systemic inflammatory response
Fistula
Abscess
Stricture
Obstruction
Acute uncomplicated diverticulitis 8 9
Inflammation in a diverticula‐bearing bowel segment and the surrounding tissue that is

not associated with perforation, fistula, abscess, stricture, or obstruction
Chronic diverticulitis 9
Colonic wall thickening or chronic mucosal inflammation may develop if acute

diverticulitis does not resolve completely
May be uncomplicated or complicated (involving stenosis, which may lead to acute bowel
obstruction, or fistula formation)
Diagnosis
Clinical Presentation
History
Acute lower left quadrant abdominal pain (most commonly); right-sided pain can occur in
some cases
More generalized abdominal pain may occur with peritonitis
Constitutional symptoms
Fever
Chills
Other gastrointestinal symptoms
Nausea or vomiting
Abdominal mass
Constipation or diarrhea
Flatulence or bloating
Urinary symptoms (eg, dysuria, urgency, frequency) can occasionally occur

Rarely, there may be concurrent diverticular bleeding with blood in stool
Complicated diverticulitis presents with typical features of underlying pathology (eg,

abscess, fistula, obstruction, free perforation)
Physical examination
Lower left quadrant tenderness may be present, but right-sided signs do not preclude
diagnosis
Right-sided diverticulitis is often confused with appendicitis
Low-grade fever is common (may be absent in older adults [eg, those aged 65 years or older])
2
Signs of peritoneal inflammation (eg, muscle guarding, rebound tenderness) are absent with
uncomplicated diverticulitis
With peritonitis
Generalized tenderness with rebound and guarding on abdominal examination
Abdomen may be distended and tympanic to percussion
Bowel sounds may be diminished or absent
Older adults and some patients taking corticosteroids may have unremarkable findings,
even in the presence of severe diverticulitis 2
Causes and Risk Factors
Causes
Segmental spasm of muscular coat of bowel causes anatomic and physiologic changes in
colon, contributing to development of diverticula (diverticulosis); changes lead to mucosal
extrusion at colon’s weakest points, adjacent to penetrating nutrient artery
Constipation and a Western diet of highly refined, low-fiber foods are thought to be major
contributing factors to diverticulosis; however, recently the role of dietary fiber has been
questioned 4
Diverticulitis develops owing to initial microperforation of a diverticulum
Process begins with blockage of colonic opening of diverticulum or by direct contact with
food and fecal particles lodged in affected section of bowel
Increased intraluminal or direct local pressure results in erosion of diverticular wall,

leading to inflammatory changes, focal necrosis, and perforation; process is typically mild
and limited by local pericolic fat and mesentery
Risk factors and/or associations
Age
More common with increasing age; less common before age 40 years (less than 10% of cases)
4
Some studies have suggested an increasing frequency of diverticular disease in younger

patients 6
Sex
In patients older than 50 years, acute diverticulitis occurs more frequently in females 1
In patients younger than 50 years, acute diverticulitis occurs more commonly in males 1
Genetics
40% to 50% of the risk for diverticulitis is attributable to genetic predisposition 10 11
Ethnicity/race
Diverticulosis is less common in non-Hispanic Black people and Asian/Pacific Islanders

compared with non-Hispanic White people 12
Other risk factors/associations

Most common in industrialized Western societies 13
In Western countries, left-sided diverticulosis is most common; however, in Asian countries,

diverticulosis is predominantly right-sided 4
Lifestyle factors implicated in development of diverticulitis 14
Obesity 13
Decreased physical activity 4

Alcohol consumption 4
Smoking 13
Aspirin and other NSAIDs 13
Immunosuppression and chronic corticosteroid use 12
Diets high in red meat 13
Consumption of particulate foods, such as nuts, popcorn, corn, and sunflower seeds, does
not contribute to the development of diverticulitis and may even have a potential protective
impact 14
Diagnostic Procedures
Primary diagnostic tools

Diagnosis of acute diverticulitis can often be made on
the basis of history and physical examination,
although clinical diagnosis can be inaccurate 4
Laboratory tests may be of help when diagnosis is in

question Diverticulitis. - CT shows thickened
wall of the sigmoid colon (arrows)
WBC count, C-reactive protein, procalcitonin, and with stranding in the adjacent fat (*)
indicative of diverticulitis.
fecal calprotectin are potentially useful in predicting
severity of diverticulitis 8
Patients with tenderness in the left lower quadrant of

the abdomen, a C-reactive protein level greater than 50
mg/L, and no history of vomiting are highly likely to ha

diverticulitis (positive predictive value of 97%-100%) 15
CT of abdomen and pelvis is the imaging test of choice

8 15
A step-up approach with initial abdominal ultrasono

ultrasonography is inconclusive or negative has been
approach in cases of suspected acute diverticulitis 15
Selective imaging is recommended in patients with any
Pain localized to left lower quadrant

Absence of vomiting
C-reactive protein level greater than 50 mg/L
History of acute diverticulitis
Colonoscopy is not required to diagnose acute diverticu

an increased risk of perforation 6
Laboratory
Imaging
Differential Diagnosis
Most common
Inflammatory bowel disease (Related: Crohn Disease)
Inflammatory bowel disease includes Crohn disease and ulcerative colitis (Related:
Ulcerative Colitis)
Typically a chronic disorder marked by intermittent flares and relapses
Abdominal distention and tenderness
Bloody diarrhea, fever, and dehydration can be seen
Suspect Crohn disease with aphthous ulcers and perianal involvement
Differentiated by colonoscopy and biopsy confirming diagnosis
Pyelonephritis (Related: Urinary Tract Infection in Adults)
Infection, usually bacterial in origin, of upper urinary tract
Patient may present with flank pain and costovertebral angle tenderness
Dysuria and polyuria
Pyuria noted on urinalysis
Differentiated by history, physical examination, and urine culture to identify causative

organisms
Colorectal cancer (Related: Colorectal Cancer)
Most common symptoms are rectal bleeding, abdominal pain, and change in bowel
habits
Abdominal examination may show a palpable mass, hepatomegaly, or distention due to

colonic obstruction or malignant ascites
A distal rectal lesion may be identified by digital rectal examination
Peritoneal implants in the cul-de-sac may be palpable with metastatic disease
Colonoscopy shows morphologic features suggesting malignant polyps (eg, irregular

contours; central depression; contact bleeding; shape deformity; flat sessile polyps or
raised pedunculated polyps; small, regularly spaced papules; abnormal vasculature or
surface pattern)
Differentiated by colonoscopy and biopsy confirming diagnosis
Ovarian cancer (Related: Ovarian Cancer)
May present with abdominal fullness and early satiety, pelvic and back pain, constipation,
or pelvic mass
Transvaginal ultrasonography may allow identification of abnormal masses
Differentiated by laparoscopy or laparotomy with histopathology, which provides

definitive diagnosis
Ischemic colitis
Inflammation of colon due to interruption of colonic blood supply
Associated with vascular or cardiovascular disease
Diarrhea with dark blood clots

Diffuse and poorly defined colonic tenderness with pain out of proportion to palpation
Fever and tachycardia, often in association with progressive hypotension and impending
sepsis
Differentiated by thumbprinting on barium enema
Pseudomembranous colitis
Characterized by diarrhea and bowel inflammation associated with antibiotic use (leading
to overgrowth of Clostridium difficile) (Related: Clostridioides difficile Infection)
History of antibiotic use
Abdominal tenderness, fever, and diarrhea
In symptomatic patients, perform stool testing for Clostridium difficile (only on diarrheal
samples)
Differentiated by history and stool testing positive for Clostridium difficile
Pelvic inflammatory disease (Related: Pelvic Inflammatory Disease)
Involves a range of inflammatory disorders of the upper genitourinary tract in females
Lower abdominal pain, vaginal discharge, and abnormal uterine bleeding
Dysuria and dyspareunia
Pain on manipulation of cervix

Adnexal tenderness or mass
Laparoscopy is gold standard for diagnosis; minimum criteria for diagnosis include tubal
wall edema, hyperemia of tubal surface, and exudate on tubal surfaces and fimbriae
Differentiated with laparoscopic confirmation of diagnosis
Endometriosis
Presence of functioning endometrial tissue outside the uterine cavity
Dysmenorrhea, dyspareunia, and infertility
Tender uterosacral ligaments
Cul-de-sac nodularity
Induration of rectovaginal septum

Obliteration of the cul-de-sac with fixed uterine retroversion can be seen in some
patients with extensive disease
Adnexal mass
Differentiated by laparoscopy showing endometrial tissue outside the uterine cavity
Appendicitis
Inflammation of the appendix; most common in younger patients
Often confused with right-sided diverticulitis
Gradual onset of dull periumbilical pain that localizes in right lower quadrant of
abdomen within 12 to 48 hours
Most sensitive symptoms are vomiting, fever (higher than 37.3 °C), and right lower
quadrant pain
Rebound tenderness with voluntary or involuntary guarding is usually present
Right lower quadrant pain on palpation of left lower quadrant (Rovsing sign) may be
noted
Psoas sign (pain aggravated by right thigh extension) may be noted
CT with contrast enhancement shows enlarged appendix (ie, appendix diameter more
than 6 mm in adults)
Differentiated by history, physical examination, and CT
Irritable bowel syndrome (Related: Irritable Bowel Syndrome)
Functional disorder involving abdominal pain and altered bowel habits without a specific
organic pathosis
Commonly involves nonspecific abdominal tenderness, often in lower left quadrant
Physical examination findings are normal
Loose stools, often in the morning and after meals, alternating with constipation
Differentiated by clinical history
Treatment
Goals
Control symptoms
Manage related complications
Disposition
Admission criteria
Admit patients with signs and symptoms of systemic illness, peritonitis, or complicated
disease
Admission is also recommended for patients who require parenteral narcotic analgesia, who
are unable to tolerate oral hydration, or whose outpatient therapy has failed
Criteria for ICU admission

Patients with severe diverticular bleeding who are hemodynamically unstable
Patients with sepsis or septic shock
Patients undergoing surgical treatment may require ICU admission
Recommendations for specialist referral

Obtain immediate surgical consultation for patients with peritonitis, complicated disease,
or vascular catastrophe
Refer to a gastroenterologist for uncomplicated diverticulitis or noncatastrophic diverticular

bleeding
Treatment Options
Patients with uncomplicated diverticulitis can usually be managed conservatively as
outpatients, with or without oral antibiotic therapy 5
Recent evidence has suggested an uncertain benefit of antibiotics for acute uncomplicated
diverticulitis, and as a result, many professional organizations no longer recommend
routine use 19 20 21
American Society of Colon and Rectal Surgeons and the American College of Physicians
have stated that selected, otherwise healthy patients with early-stage uncomplicated
diverticulitis can be treated without antibiotics 8 18
Most of these patients can be managed as outpatients with medical supervision 18
Antibiotic therapy is appropriate for patients with significant comorbidities, signs of

systemic infection, or immunosuppression and those beyond early-stage disease 8
Guidelines from the European Society of Coloproctology and the World Society of
Emergency Surgery recommend against routine antibiotic therapy for immunocompetent
patients with acute uncomplicated diverticulitis and no signs of systemic inflammation 9 15
17
Reserve antibiotic treatment for immunocompromised patients and patients with sepsis
Guidelines from the American Gastroenterological Association recommend that antibiotics

can be used selectively rather than routinely in immunocompetent patients with mild,
uncomplicated diverticulitis 11
Antibiotic treatment is advisable for patients who have comorbidities, refractory

symptoms or vomiting, or a C-reactive protein greater than 140 mg/L or baseline WBC
count greater than 15 × 109 cells/L, and for those who are frail
Also recommended in cases of uncomplicated diverticulitis associated with a fluid

collection or long segment of inflammation on CT scan
Outpatient treatment of mild uncomplicated diverticulitis typically consists of either an oral

fluoroquinolone or trimethoprim-sulfamethoxazole plus metronidazole, or oral
amoxicillin-clavulanate monotherapy (preferred owing to potential adverse effects with
fluoroquinolones) 11 22
Duration of antibiotic treatment, when given, is typically 3 to 7 days but can be longer
depending on patient's health status, severity of illness, and CT findings 11 23
Treat all patients with complicated diverticulitis with oral or IV antibiotics, depending on
severity 9 11 24
Oral first-, second-, and third-generation cephalosporins in combination with

metronidazole are potential options, because they have reasonable activity against non–
extended-spectrum β-lactamase–producing strains of Escherichia coli 25
Hospitalization and treatment with IV antibiotics are indicated for patients with
perforation, large abscesses, sepsis, or bowel obstruction, serious comorbidities, or an
inability to tolerate oral liquid 24
Effective antibiotic regimens should cover typical enteric gram-negative organisms along
with anaerobic flora, 1 especially if there is a concurrent abscess
For patients with moderate disease, options include combination therapy with either a
fluoroquinolone, cefotaxime, or ceftriaxone plus metronidazole or monotherapy with
ertapenem, or moxifloxacin 24 25
In severely ill patients, options include meropenem monotherapy, imipenem-cilastatin,

piperacillin-tazobactam, or doripenem monotherapy, or combination therapy with either
cefepime, ceftazidime, or a fluoroquinolone plus metronidazole 24 25
Duration of antibiotic treatment, when given, is typically 4 to 7 days, providing source

control is achieved; can be longer depending on patient's health status, severity of illness,
and CT findings 24
Antibiotic treatment alone is recommended for abscesses smaller than 3 cm (the American
Society of Colon and Rectal Surgeons and the European Society of Coloproctology) 9 8 or for
those smaller than 4 to 5 cm (the World Society of Emergency Surgery) 1 17
Percutaneous drainage is indicated in addition to antibiotic therapy for patients with larger
abscesses
If percutaneous drainage of the abscess is not feasible or unavailable, antibiotics can be

considered the primary treatment unless emergency surgery is required 15
Nonoperative management of acute diverticulitis with abscess (IV antibiotics, NPO,

percutaneous drainage) has a failure rate of 21.8% 26
Consider elective colectomy after successful treatment of diverticular abscess, particularly if

abscess was larger, located pelvically, or required percutaneous drainage, because recurrence
is common
For treatment of segmental colitis associated with diverticular disease, consider a combination
of ciprofloxacin and metronidazole with mesalamine 10
Treatment course is prolonged
In severe cases, systemic corticosteroids may be required
Emergent or elective surgical intervention may be required
Patients with severe or complicated diverticulitis who are acutely ill, appear toxic, or whose
condition does not respond to medical therapy often require urgent surgical intervention 8
Patients with perforated diverticulitis and diffuse peritonitis should undergo emergent
surgical intervention 1
Open surgical approach is recommended for generalized peritonitis with septic shock 27
Laparoscopic approach may be an alternative for hemodynamically stable patients 27 28

29
Surgical approach depends on patient's health status and severity of disease. May include
the following: 27 30
Primary resection and anastomosis (with or without a diverting stoma) in clinically

stable patients with no comorbidities 15
Hartmann procedure in patients who are critically ill or have multiple major
comorbidities 15
Laparoscopic peritoneal lavage and drainage in patients with purulent peritonitis only
(not for patients with fecal peritonitis and controversial)
Nonrestorative resection of the affected segment of the colon 15
Damage control strategy may be useful in patients who are extremely ill with
abdominal sepsis. Consists of initial surgery to remove source of sepsis, with
subsequent anatomical restoration of the gastrointestinal tract after a period of
recovery 15
Elective colectomy is generally recommended for all patients who have recovered from
complicated diverticulitis; however, some experts now suggest a more conservative and
individualized approach that may be reasonable 8 11
For patients with uncomplicated diverticulitis, individualize decisions about elective

segmental colectomy based on patient and presentation; not recommended based on
number of recurrences alone 11 31
Not generally recommended before a third episode of uncomplicated diverticulitis 12
Recommended for patients who are immunosuppressed and at risk of serious

complications or death from recurrent attacks of diverticulitis 8
Drug therapy
Penicillins
Piperacillin-tazobactam
May be used for empiric therapy in adults and children, but reserve for higher-risk
patients because of its broader-spectrum antimicrobial activity 25
Piperacillin Sodium, Tazobactam Sodium Solution for injection; Adults: 3.375 g (3 g

piperacillin and 0.375 g tazobactam) IV every 4 to 6 hours or 4.5 g (4 g piperacillin and
0.5 g tazobactam) IV every 6 hours for 3 to 7 days.
Amoxicillin-clavulanate 32
For mild cases and patients tolerating oral intake and as step-down to complete
therapy
Amoxicillin Trihydrate, Clavulanate Potassium Oral tablet; Adults: 875 mg amoxicillin

with 125 mg clavulanate PO every 12 hours or 500 mg amoxicillin with 125 mg
clavulanate PO every 8 hours for a total treatment duration of 3 to 7 days.
Trimethoprim-sulfamethoxazole 32
For mild cases and patients tolerating oral intake
Sulfamethoxazole, Trimethoprim Oral tablet; Adults: 160 mg trimethoprim/800 mg

sulfamethoxazole PO twice daily with metronidazole.
Cephalosporins
All may be used in combination with metronidazole for initial empiric therapy for lower-
risk patients 25
Cefotaxime
Cefotaxime Sodium Solution for injection; Adults: 1 to 2 g IV every 6 to 8 hours for 3 to

7 days.
Ceftriaxone
Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV/IM every 12 to 24 hours

for 3 to 7 days.
Quinolones
Ciprofloxacin
May be used in combination with metronidazole for initial empiric therapy for lower-
risk patients with serious β-lactam allergies 25
IV dosing
Ciprofloxacin Solution for injection; Adults: 400 mg IV every 8 to 12 hours for 3 to 7

days.
Oral dosing
Ciprofloxacin Hydrochloride Oral tablet; Adults: 500 mg PO every 12 hours for 3 to 7

days.
Moxifloxacin
May be used for initial empiric therapy for lower-risk patients with serious β-lactam
allergies 25
IV dosing
Moxifloxacin Hydrochloride Solution for injection; Adults: 400 mg IV every 24

hours for 3 to 7 days.
Oral dosing
Moxifloxacin Hydrochloride Oral tablet; Adults: 400 mg PO every 24 hours for 3 to 7
days.
Carbapenems
Ertapenem
May be used as monotherapy for initial empiric therapy for lower-risk patients 25
Ertapenem Solution for injection; Adults: 1 g IV once daily for 3 to 7 days.
Imipenem-cilastatin
Imipenem, Cilastatin Sodium Solution for injection; Adults: 500 mg IV every 6 hours
or 1 g IV every 8 hours for fully susceptible organisms and 1 g IV every 6 hours for
organisms with intermediate susceptibility. Treat for 3 to 7 days.
Aztreonam
For empiric treatment of infections in which enteric gram-negative bacteria may play a
role
Aztreonam plus metronidazole plus vancomycin can be used as an option for higher-risk
patients with a severe reaction to β-lactam agents 25
Aztreonam Solution for injection; Adults: 1 to 2 g IV every 6 to 8 hours for 3 to 7 days.

Metronidazole
Active against anaerobic flora of gastrointestinal tract
Provides effective treatment when used in conjunction with an agent active against gram-
negative enteric bacteria
IV dosing
Metronidazole Solution for injection; Adults: 500 mg IV every 6 to 12 hours or 1.5 g IV

every 24 hours for 3 to 7 days.
Oral dosing
Guidelines suggest as part of combination step-down oral therapy with a second- or

third-generation cephalosporin or a fluoroquinolone
Metronidazole Oral tablet; Adults: 500 mg PO every 6 hours for 3 to 7 days.
Vancomycin
Aztreonam plus metronidazole plus vancomycin can be used as an option for higher-risk
patients with a severe reaction to β-lactam agents 25
Vancomycin Hydrochloride Solution for injection; Adults: 20 to 35 mg/kg/dose (Max:

3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12 hours;
adjust dose based on target PK/PD parameter. Consider loading dose in critically ill
patients. Treat for 3 to 7 days.
Vancomycin Hydrochloride Solution for injection; Obese Adults: 20 to 25 mg/kg/dose

(Max: 3,000 mg/dose) IV loading dose, followed by 15 to 20 mg/kg/dose IV every 8 to 12
hours (Usual Max: 4,500 mg/day); adjust dose based on target PK/PD parameter. Consider
loading dose in critically ill patients. Treat for 3 to 7 days.
Mesalamine
May be used for segmental colitis associated with diverticular disease, in combination
with ciprofloxacin and metronidazole
Mesalamine Oral capsule, extended-release; Adults: 800 to 3,000 mg/day PO as a single

dose or in divided doses.
Nondrug and supportive care

Diet
No evidence to support dietary restrictions in uncomplicated diverticulitis; unrestricted diet
as tolerated may be preferable 9
Clear liquid diet for 2 to 3 days is reasonable for patient comfort during the acute phase;
advanced to low-fiber diet as tolerated 11 24
Patients with severe complicated diverticulitis should have no oral intake until condition
has stabilized 24
Maintenance of hydration 5
Particularly in patients with dehydration, peritonitis, complicated disease, or significant

bleeding
Pain relief 24
Acetaminophen and antispasmodics are first line analgesics
Avoid NSAIDs in patients with acute diverticulitis, because they are associated with risk of
diverticulitis and complicated diverticulitis 33
Avoid opioid narcotics, if possible, because they are associated with increased risk of
perforated diverticulitis
Procedures
CT-guided percutaneous drainage
General explanation
CT-guided needle aspiration of abscesses, followed by Gram stain and culture of aspirate
Indication
Drainage of diverticulitis complicated by abscess formation
Consider for peridiverticular abscess larger than 3 to 5 cm in diameter (threshold varies by

organization), those that do not resolve with antibiotics, or when in the presence of patient
deterioration 1 8 9 17
Contraindications
Bleeding disorders; limited data regarding safety
Complications
Iatrogenic injury to adjacent organs
Extending infected material into noninfected tissue
Inadequate removal of infected material
Interpretation of results
Modify antibiotic regimen as needed based on culture results
Laparoscopic surgery
General explanation
Laparoscopic colonic resection and primary reanastomosis
Benefits of laparoscopy include decreased pain, decreased wound infection rate, 34

decreased blood loss, and shorter length of hospital stay, 34 although intraoperative
procedure time is longer; long-term benefits are unclear 5
Indication
Recurrent uncomplicated diverticulitis that is well localized and significantly resolved from
the acute state
Laparoscopic approach is recommended in elective surgery for diverticular disease, when

feasible 1
Contraindications
Coagulopathy
Fulminant colitis
Critical colonic distention
Complications
Anastomotic leakage
Ileus
Laparotomy with sigmoid resection 31
General explanation
Resection of the diseased colon is accompanied by creation of an end colostomy and a rectal
stump; Hartmann procedure is commonly used
Indication
Complicated diverticulitis or multiple episodes of uncomplicated diverticulitis
Failed percutaneous drainage of clinically relevant abscesses, enterocutaneous fistulas, and

bowel obstruction
Exploratory laparotomy is considered to be the final therapeutic modality
Contraindications
Contraindications to primary anastomosis are fecal or purulent peritonitis, severe comorbid
conditions (including uncorrected bleeding dyscrasia), poor nutrition, and
immunosuppression
Complications
Ileus
Comorbidities
Immunocompromised status
Transplant recipients and patients with chronic diseases affecting the immune system are
at increased risk of more aggressive and complicated diverticulitis 5
Those with impaired inflammatory response may have only extraluminal gas on CT
without other typical radiographic findings of diverticulitis
Monitoring
Follow up 4 to 6 weeks after resolution of symptoms of an episode of diverticulitis or after
surgical treatment
Arrange follow-up colonoscopy to exclude occult malignancy unless patient has had one
within past year 11 35 36
Colonoscopy is recommended after any episode of acute complicated diverticulitis 8 11
Prevalence of colorectal cancer is 7.9% to 10.8% in patients diagnosed with

complicated diverticulitis 14
Also obtain in patients who report ongoing symptoms (bleeding, changed bowel habits,
ongoing pain) after an episode of uncomplicated acute diverticulitis 9
May not be necessary for patients with symptom‐free recovery after a single episode of
CT-verified uncomplicated diverticulitis when patient has no signs of colorectal cancer,
such as anemia, hematochezia, or change in bowel habit, and where the symptoms of
diverticulitis are resolving at 4-week follow-up 9 14 37
Arrange colonoscopy at least 6 to 8 weeks after an episode of acute complicated

diverticulitis has resolved or symptoms have fully resolved (whichever is longer) 8 9 11
Complications and Prognosis
Complications
Diverticular bleeding
Intestinal abscess
Intestinal fistula
Colovesical fistula (most common)
External large bowel fistula
Enterocolic fistula
Intestinal obstruction/stricture 4
Peritonitis 5
Sepsis 5
Septic shock
Segmental colitis
Pyogenic liver abscesses
Prognosis
Outpatient management is successful in 94% to 97% of patients 4
Approximately 15% to 20% of patients with diverticulitis develop complications 4
Approximately 15% to 30% of patients who are hospitalized for acute diverticulitis require
surgical intervention 4
Risk of recurrent symptoms after acute diverticulitis ranges from 7% to 45%; half of
recurrences occur within 1 year 12
Risk for recurrent disease increases with each subsequent episode of acute diverticulitis
Recurrence of diverticulitis is more likely after an episode of complicated diverticulitis

managed without surgery than after an episode of uncomplicated diverticulitis
Screening and Prevention
Prevention
After an episode of diverticulitis, advise patients on the following secondary prevention
measures:
High-fiber diet 38 5
Adequate exercise 5 appropriate to age
Smoking cessation and limited intake of alcohol and red meat (Related: Tobacco Use
Disorder and Smoking Cessation) 5
Weight loss if overweight 8

Avoid regular use of NSAIDs (except aspirin for secondary prevention of cardiovascular
disease) 11 33
Evidence does not support the dietary exclusion of whole pieces of fiber (eg, nuts, corn,
seeds) 11 13
Consider elective prophylactic surgical resection to prevent recurrences after acute

diverticulitis in patients with uncomplicated diverticulitis that is persistent or recurs
frequently or in patients with complicated diverticulitis 35 39
Consider on a case-by-case basis, taking into account the severity of diverticulitis,

patient's health status and preferences, and benefits and risks of surgery
Some experts suggest prophylactic segmental resection of the colon to prevent recurrence
after an episode of complicated diverticulitis 12
Prophylactic surgery may be considered after a third episode of uncomplicated

diverticulitis to prevent further recurrences 12
Rifaximin has been advocated as a possible option for secondary prevention of recurrent
acute diverticulitis; not routinely recommended 40
Mesalamine is not recommended to prevent recurrent diverticulitis 35
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6/8/23, 21:46 Diverticulitis - ClinicalKey

Immediate surgical consultation is necessary for patients with peritonitis,

CT of abdomen/pelvis is the imaging test of choice for confirming the diagnosis

Conservative (nonsurgical) management of uncomplicated diverticulitis, with or without

Right-sided diverticulitis is often confused with appendicitis

Diverticulitis involves microperforation of a diverticulum, with ensuing localized

Stage 0: clinically mild diverticulitis

Stage Ia: confined pericolic inflammation and phlegmonous inflammation

Stage III: generalized purulent peritonitis

Stage IV: fecal peritonitis

Alternative classification systems such as the CDD (Classification of Diverticular Disease) 6

Acute complicated diverticulitis 8

Diverticulitis associated with any of the following:

Uncontained perforation with a systemic inflammatory response

Acute uncomplicated diverticulitis 8 9

Inflammation in a diverticula‐bearing bowel segment and the surrounding tissue that is

Colonic wall thickening or chronic mucosal inflammation may develop if acute

More generalized abdominal pain may occur with peritonitis

Other gastrointestinal symptoms

Urinary symptoms (eg, dysuria, urgency, frequency) can occasionally occur

Complicated diverticulitis presents with typical features of underlying pathology (eg,

Right-sided diverticulitis is often confused with appendicitis

Generalized tenderness with rebound and guarding on abdominal examination

Abdomen may be distended and tympanic to percussion

Bowel sounds may be diminished or absent

Causes and Risk Factors

Diverticulitis develops owing to initial microperforation of a diverticulum

Increased intraluminal or direct local pressure results in erosion of diverticular wall,

Risk factors and/or associations

Some studies have suggested an increasing frequency of diverticular disease in younger

Diverticulosis is less common in non-Hispanic Black people and Asian/Pacific Islanders

Other risk factors/associations

In Western countries, left-sided diverticulosis is most common; however, in Asian countries,

Lifestyle factors implicated in development of diverticulitis 14

Decreased physical activity 4

Aspirin and other NSAIDs 13

Immunosuppression and chronic corticosteroid use 12

Diets high in red meat 13

Primary diagnostic tools

Laboratory tests may be of help when diagnosis is in

Patients with tenderness in the left lower quadrant of

mg/L, and no history of vomiting are highly likely to ha

CT of abdomen and pelvis is the imaging test of choice

A step-up approach with initial abdominal ultrasono

Selective imaging is recommended in patients with any

Pain localized to left lower quadrant

C-reactive protein level greater than 50 mg/L

History of acute diverticulitis

Colonoscopy is not required to diagnose acute diverticu

Typically a chronic disorder marked by intermittent flares and relapses

Abdominal distention and tenderness

Bloody diarrhea, fever, and dehydration can be seen

Suspect Crohn disease with aphthous ulcers and perianal involvement

Differentiated by colonoscopy and biopsy confirming diagnosis

Pyelonephritis (Related: Urinary Tract Infection in Adults)

Infection, usually bacterial in origin, of upper urinary tract

Dysuria and polyuria

Pyuria noted on urinalysis

Differentiated by history, physical examination, and urine culture to identify causative

Colorectal cancer (Related: Colorectal Cancer)

Abdominal examination may show a palpable mass, hepatomegaly, or distention due to

A distal rectal lesion may be identified by digital rectal examination

Peritoneal implants in the cul-de-sac may be palpable with metastatic disease

Colonoscopy shows morphologic features suggesting malignant polyps (eg, irregular