Diverticular Disease

General Principles


  • Diverticula consist of outpouchings in the bowel, most commonly in the colon, but can also be seen elsewhere in the gut.
  • Diverticular bleeding can occur from an artery at the mouth of the diverticulum.
  • Diverticulitis results from microperforation of a diverticulum and resultant extracolonic or intramural inflammation.


Clinical Presentation

  • Diverticulosis is usually asymptomatic. Although diverticulosis may be found in patients being investigated for symptoms of abdominal pain and altered bowel habits, a causal link is difficult to establish.
  • Typical symptoms of diverticulitis include left lower quadrant abdominal pain, fevers and chills, and alteration of bowel habits. Localized left lower quadrant abdominal tenderness may be elicited on physical examination.

Diagnostic Testing


Diverticulitis may be associated with an elevated white blood cell count with a left shift.


  • Diverticula are frequently seen on screening colonoscopy.
  • Imaging studies, most commonly CT scans, can be useful in the diagnosis of diverticulitis.
  • Colonoscopy is contraindicated for 4–6 weeks after an episode of acute diverticulitis, but it should be performed after that interval to exclude a perforated neoplasm or IBD if a patient has not had a recent high-quality colonoscopy.1


  • Increased dietary fiber is generally recommended in patients with diverticulosis, although no conclusive data exist to support its benefit.
  • A low-residue diet is recommended for mild diverticulitis, although no evidence exists to support this practice.1
  • There is no evidence that patients with diverticulosis should avoid nuts or seeds.


  • Oral antibiotics (e.g., ciprofloxacin, 500 mg PO bid, and metronidazole, 500 mg PO tid, for 10–14 days) may suffice for mild diverticulitis; spontaneous resolution has also been described in mild cases.1
  • Hospital admission, bowel rest, IV fluids, and broad-spectrum IV antimicrobial agents are typically required in moderate to severe cases.

Surgical Management

  • Surgical consultation should be obtained for perforation, abscess, fistula, or failure to improve with antibiotics.
  • Abscesses may require percutaneous drainage in addition to antibiotics.
  • Elective surgical resection is not recommended following acute uncomplicated diverticulitis, but may be necessary in recurrent diverticulitis; surgical decisions need to be individualized.1


  • Perforation: Although microperforation is part of the pathogenesis of diverticulitis, frank perforation with peritonitis requires surgical consultation.
  • Abscess: Large (>4 cm) abscesses may require percutaneous drainage. Small abscesses may resolve with antibiotics.
  • Fistula: Inflammation from diverticulitis may lead to fistulization into adjacent organs, such as the bladder, vagina, or adjacent bowel. This typically requires surgery.
  • Segmental colitis associated with diverticulosis (SCAD) is a rare entity where mucosal inflammation is seen in the sigmoid colon adjacent to diverticula, which is important to consider before diagnosing IBD in an elderly patient with diverticulosis.


  1. Peery AF, Shaukat A, Strate LL. AGA clinical practice update on medical management of colonic diverticulitis: expert review. Gastroenterology. 2021;160:906-911.e1.  [PMID:33279517]


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