Clinical review

Management of diverticulitis
Simon E J Janes, Allan Meagher, Frank A Frizelle

The prevalence of perforated sigmoid diverticular

disease in developed countries has increased from
2.4/100 000 in 1986 to 3.8/100 000 in 2000.1 Diverticular disease is one of the five most costly gastrointestinal
disorders in the United States.2 Thirty years ago, the proportion of people who died from diverticular disease
was decreasing.3 During the past 20 years, however,
annual age standardised rates of admission and surgical
intervention have increased by 16% from 20.1/100 000
to 23.2/100 000, whereas inpatient and population
mortality remains unchanged.4
This increasing burden of disease means that clinicians in primary and secondary care will see increasing
numbers of patients with diverticular disease and its
complications. This review covers recent developments
in the management of diverticular disease, including
the current trend towards conservative rather than
operative management after recovery from the initial
episode.5

Sources and selection criteria

We searched Medline and the Cochrane Library to
locate English language articles on diverticular disease
and diverticulitis, from 1964 until April 2005. We
obtained further articles from the references cited in
the initial literature review. We prioritised evidence
from well designed randomised controlled trials, when
available.

Natural history of diverticular disease

The prevalence of diverticulosis (see box 1 for
definitions) increases uniformly with age, affecting
50% of people by the fifth decade and 67% by the
eighth decade,6 with similar frequency in men and
women.7 Approximately three quarters of patients with
anatomical diverticulosis remain asymptomatic
throughout their lifetime.6 Asymptomatic disease is
often an incidental finding during investigation of
colonic disorders; these patients need no specific treatment or follow-up. Of the remaining 25% of patients
who develop symptoms, approximately three quarters
develop diverticulitis (a third of whom have complications; box 1), and a quarter develop diverticular haemorrhage, which is massive in a third of cases.8

Pathophysiology
Although diverticular disease is common, the pathogenesis remains incompletely understood. EpidemioBMJ VOLUME 332

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Summary points
Diverticular disease is a common disorder, the
prevalence of which is increasing as the
proportion of elderly people increases
Dietary fibre may prevent development of
diverticular disease, but once symptoms develop
the benefit from fibre supplementation is unclear
The risk of perforation may be increased by use
of non-steroidal anti-inflammatory drugs
Recent advances in diagnosis and treatment have
enabled successful medical management of
patients who would previously have had surgery
Emergency surgery has evolved from a three
stage procedure to a two stage or one stage
procedure

Colorectal Unit,
Department of
Surgery,
Christchurch
Hospital,
PO Box 4345,
Christchurch,
New Zealand
Simon E J Janes
house surgeon
Frank A Frizelle
professor
Department of
Colorectal Surgery,
St Vincents
Hospital,
Darlinghurst, NSW,
2010, Australia
Allan Meagher
consultant colorectal
surgeon
Correspondence to:
F A Frizelle
frank.frizelle@
chmeds.ac.nz
BMJ 2006;332:2715

logical studies have shown an inverse relation between

the incidence of diverticular disease and fibre content
of the diet.9 Low dietary fibre decreases stool bulk and
prolongs transit time, causing increased intraluminal
pressure. High intraluminal pressure may cause
herniation of colonic mucosa through areas of
weakness, produced by penetration of vasa recta that
supply the submucosa and mucosa. As a result,
diverticula are typically found in parallel rows between
the taeniae coli (fig 1).6
Most studies indicate that patients with diverticula
have higher resting and postprandial colonic pressures
than controls.6 10 However, other studies have found
normal intraluminal pressures in patients with
symptomatic diverticular disease,11 suggesting an alternative pathogenesis. Muscle wall thickening and
contraction of the taeniae coli precedes diverticula formation and may be the primary pathogenic mechanism. Irreversible contraction occurs as a result of
increased elastin deposition,12 which together with age
related changes in collagen composition may weaken
the colonic wall, predisposing to diverticula formation.
The interrelation of high intraluminal pressures
and colonic wall weakness remains poorly understood.
The sigmoid colon is less compliant than the
ascending colon. This may predispose to the classic
type of diverticulosis seen in Western countries,
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Box 1: Terminology
Diverticulosisthe presence of diverticula that are
asymptomatic
Diverticular diseasediverticula associated with
symptoms
Diverticulitisevidence of diverticular inflammation
(fever, tachycardia) with or without localised symptoms
and signs
Complicated diverticulitisperforation*, abscess,
fistula, stricture/obstruction
*As diverticulitis by definition means at least a
microperforation in all cases,6 in this review
perforation means rupture of a peridiverticular abscess
into the peritoneal cavity, causing either purulent or
faecal peritonitis.

characterised by increased intraluminal pressures,

infectious complications, and perforation. In contrast,
right sided diverticula predominate in Asian countries,
typically with normal intraluminal pressures and a tendency to bleeding rather than perforation,13 presumably owing to underlying connective tissue abnormality. Other mechanisms may account for these diverse
geographic phenotypes; a recent theory proposes that
hypersensitivity of colonic smooth muscle to anticholinesterases causes dysmotility in diverticular
disease, which may promote diverticula formation.14
Once diverticula have formed, stool may become
inspissated within the neck. In a process similar to
appendicitis, the obstructing faecalith promotes secretion of mucus and bacterial overgrowth, which distends
and erodes the thin walled diverticulum. Localised
ischaemia develops, enabling translocation of mucosal
bacteria and eventual perforation.15 Hinchey et al
developed a useful system to classify the inflammation
following diverticular perforation (box 2).16 Most
perforations are small and contained within pericolic
fat, causing a small pericolic abscess (stage one
disease). Larger abscesses (stage two) may rupture into
the peritoneal cavity (stage three). Progression to gross
faecal peritonitis (stage four) is determined by whether
the faecalith continues to obstruct the diverticulum.

Symptomatic disease
Patients often develop colicky abdominal pain,
bloating, or flatulence, which is exacerbated by eating
and relieved by passage of flatus or stool. Although

these symptoms are largely due to colonic wall tension

and raised intraluminal pressure, a recent randomised
controlled study found that intravenous hyoscine
butylbromide (an antispasmodic agent) was no better
than placebo at relieving distension.17 Bleeding from
the rectum or a positive faecal occult blood test
warrants careful exclusion of other colonic pathology.
Examination may reveal tenderness in the left lower
quadrant without guarding or systemic signs of inflammation.
Considerable overlap exists between symptoms of
diverticular disease and irritable bowel syndrome. As
both diagnoses are relatively common, some people
may have symptoms attributable to both conditions.
However, the temporal relation between these distinct
entities remains controversial. Although irritable
bowel-like symptoms may follow an episode of
diverticulitis,18 evidence of the reverse is lacking, as the
natural history of irritable bowel syndrome seems to be
independent of the presence or absence of symptomatic diverticular disease.19

Treatment of uncomplicated disease

Large prospective studies have identified a preventive
effect of both dietary fibre and physical exercise in the
development of diverticular disease.20 Once symptoms
have developed, however, evidence of a benefit from
fibre is less convincing: of two small randomised
controlled trials comparing fibre and placebo, one
found no difference in symptoms and the other
reported improved symptoms but no change in bowel
dysfunction after three months follow-up.21 22 Another
randomised controlled trial found that adding
rifaximin, a rifamycin antibiotic, to fibre supplementation decreased symptoms after 12 months of
treatment23; 10% of participants were unable to
complete the trial, however, and analysis was not by
intention to treat. Although some people may benefit
from supplementary fibre, more evidence is needed
from studies with longer follow-up before fibre supplementation can be widely recommended.
Mesalazine has been shown to significantly reduce
symptomatic recurrence at four years compared with
placebo,24 but abdominal pain was more common with
mesalazine. A more recent randomised controlled trial
suggests that mesalazine may be superior to rifaximin
in overall control of symptoms.25 A large case-control
study found that use of calcium channel blockers,
which decrease intracolonic pressure, was associated
with a reduction in diverticular perforation.26 Long
term use of opioids (which increase intracolonic
pressure) seems to increase the risk of diverticular perforation.27 Whether these associations are causal
remains unclear, so insufficient evidence exists to make
recommendations on use of calcium channel blockers

Box 2: Hinchey classification of peritoneal

contamination in diverticulitis

Fig 1 Pathology specimen showing two parallel rows of diverticula

between the taeniae coli

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Stage 1. Pericolic or mesenteric abscess

Stage 2. Walled-off or pelvic abscess
Stage 3. Generalised purulent peritonitis
Stage 4. Generalised faecal peritonitis

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Box 3: Indications for surgery

Fig 2 Computed tomogram of a large sigmoid diverticular abscess,

with thickening of the bowel wall and inflammation of the
surrounding fat

or opioid analgesics in patients with diverticular

disease.
Use of non-steroidal anti-inflammatory drugs
remains the most consistently identified risk factor for
diverticular perforation but accounts for only a fifth of
all cases of perforation.28 The hypothesised mechanism
is due to the adverse affect of prostaglandin inhibition
on mucosal blood flow. When considering nonsteroidal anti-inflammatory drugs for patients with
diverticular disease, the risk of perforation should be
balanced against the therapeutic benefit.

Diverticulitis
Evidence of systemic inflammation (fever, neutrophilia,
tachycardia) differentiates diverticulitis from simple
diverticular disease. A tender inflammatory mass is
occasionally palpable, and an associated change in
bowel habit may occur. Initial outpatient treatment
should include a clear liquid diet and broad spectrum
oral antibiotics with activity against anaerobes and
Gram negative rods.1 Symptomatic improvement
should be seen within two or three days. The need for
admission in uncomplicated cases is determined by
response to treatment, ability to tolerate oral intake,
and comorbid disease. Conservative treatment of acute
uncomplicated diverticulitis results in resolution of
symptoms in 70-100% of patients.5 Admitted patients
should improve after two to four days of bowel rest and
intravenous antibiotics; failure of conservative measures warrants further investigation.

Purulent or faecal peritonitis

Uncontrolled sepsis
Fistula (fig 3)
Obstruction (fig 4)
Inability to exclude carcinoma

are limited because the disease process is predominantly extraluminal. Computed tomography is a safer,
more cost effective alternative,6 7 with therapeutic
potential for drainage of percutaneous abscesses.
Tomographic evidence of diverticulitis includes
inflammation of pericolic fat, clonic wall thickening, or
peridiverticular abscess (fig 2). Abscesses less than 5 cm
in diameter tend to regress after antibiotic treatment,30
and abscesses under 2 cm can be successfully managed
on an outpatient basis with oral antibiotics,31 the cost of
which is 80% lower than inpatient treatment.
Computed tomography guided percutaneous drainage gives rapid control of sepsis and prompt relief of
symptoms for Hinchey stage 1-2 lesions, after which
patients may remain asymptomatic.31
After recovery from the initial episode, the risk of
recurrent symptoms varies from 7% to 45%,5 reflecting
a broad spectrum of disease severity and diagnostic
criteria in various studies. Most complications occur
during the first admission,32 after which the disease
seems to run a benign course, with a greater risk of
dying from unrelated diseases than from complications related to diverticulitis.29

Emergency surgery
Box 3 summarises indications for surgery. Purulent or
faecal peritonitis was traditionally managed by three
stage procedures. The first operation controlled sepsis
by drainage and transverse colostomy formation. After
an unspecified time, the disease segment was excised.
Eventual colostomy closure and restoration of bowel
continuity completed the third stage. A critical
literature review published in 1984 found that the
operative mortality with a three stage procedure
approached 25%.33 Subsequently, a two stage procedure involving formation of an end colostomy with
oversewing of the rectal stump (Hartmann procedure)

Complicated diverticulitis
The natural history of complicated diverticular disease
remains poorly understood, probably because consultant surgeons see only two or three cases a year, and
almost a third of patients die from unrelated causes
during follow-up.29 Advances in antimicrobial chemotherapy may have contributed to more successful
medical management; recent reports have shown
recurrence rates of 2% per patient year of follow-up.29

Diagnostic imaging
In acute diverticulitis, the colonic mucosa is grossly and
microscopically normal, despite substantial inflammation of the pericolic fat. Consequently, contrast enemas
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Fig 3 This elderly man with diverticular disease developed a urinary

tract infection and pneumaturia. Double contrast barium enema
showed a colovesical fistula. Diverticular disease is the most
common cause of this type of fistula

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Fig 4 Double contrast barium enema showing a suspicious stricture

(arrow) and multiple diverticula. Pathology confirmed that the
stricture was non-malignant

became preferable, and operative mortality was almost

halved. A recent multicentre randomised controlled
trial found that a one stage procedure (primary
anastomosis) significantly reduced rates of postoperative peritonitis and emergency reoperation compared
with a two stage procedure,34 without adversely
affecting operative mortality. Use of a one stage procedure has been limited by concerns about anastomosis
failure due to peritoneal contamination, gut oedema or
inflammation, and unprepared bowel. Relatively
recently introduced techniques, such as preoperative
computed tomography guided drainage of abscesses
followed by staged laparotomy and on-table colonic
lavage in patients with obstructive diverticular disease
may decrease anastomotic failure and facilitate one
stage procedures.35

Elective resection to prevent

complications of diverticular disease
During the past 20 years, postoperative mortality after
emergency procedures has remained unchanged at
12-36%,5 despite advances in surgical techniques, antibiotic treatment, and intensive care. Elective sigmoid
resection after two episodes of uncomplicated diverticulitis has been recommended to prevent complications and reduce emergency procedures.6 7 These
recommendations were based on historic data of low
validity, which suggested that recurrent attacks are less
likely to respond to medical treatment and have a
higher mortality rate.
Recent evidence indicates that prophylactic resection would have little impact in preventing subsequent
complications,5 as most patients who need urgent surgery have no history of diverticular disease. A large
cross sectional population based study estimated the
incidence of perforated diverticulitis at 4 cases per
100 000 population per year, with less than a quarter
of patients having a history of diverticular disease.36
Other studies show that only 3-33% of patients who
need emergency surgery for perforation have documented diverticular disease,37 38 indicating that for most
people who develop complications a complication is
the first manifestation of disease.
Recommending elective resection needs a careful
risk-benefit assessment, in which the morbidity,
mortality, and costs of all subsequent attacks (including
emergency surgery) are weighed against the morbidity,
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mortality, and costs when patients have elective

resection. A cost effectiveness study found that expectant management rather than elective resection was
associated with fewer deaths and 2% fewer colostomies
and saved up to $5249 per patient, with most benefit
seen in younger patients.39 After elective resection,
approximately a quarter of patients have persisting
symptoms (probably reflecting coexisting irritable
bowel syndrome),7 and up to 10% develop recurrent
diverticulitis, of which 0-3.1% need re-resection.4043
Mortality increases with advancing age from zero to
15%, and around half of patients who have a
Hartmann procedure never regain intestinal continuity. Patients should be fully informed about the risks
and benefits associated with either conservative
management or elective resection when treatment
options are being discussed.

Diverticulitis in special circumstances

Symptoms and signs may develop late, and conservative treatment is more likely to fail, in immunocompromised patients, so early surgical intervention may be
needed. Approximately 10% of people with diverticular disease are under 40 years of age. Historically, the
disease was thought to be more aggressive in younger
people, with a male predominance, and resection after
one episode of diverticulitis was recommended. Recent
prospective data cast doubt on these recommendations.5 The diagnosis is often not considered in
younger women, who have a wide range of differential
diagnoses. In both sexes, higher rates of emergency
surgery are attributable to high rates of misdiagnoses.
The risk of complications attributable to young age at
diagnosis may simply reflect prolonged exposure to
diverticular disease, rather than pathological mechanisms.

Ongoing research
Alternatives in diverticulitis management trial
prospectively evaluating one stage procedures for
surgical management of acute complicated
diverticulitis. depts.washington.edu/sorce/
projects.html (accessed 4 Sept 2005)
Sigmoid diverticular disease: the surgical
epidemiologyan ongoing large scale study from the
Mayo Clinic, USA. www.mayoclinic.org/diverticulitis/
research.html (accessed 4 Sept 2005)
Clinical research questions that remain unanswered
Why diverticula are so common in the colon in
Western societies
Whether changes in lifestyle, especially diet, by
young people would prevent development of
diverticula in later life
Why some people get symptoms from diverticular
disease, but most do not
Why some people have an associated abnormality of
muscle in the colon
What leads to infection or other complication of a
diverticulum
How treatment of symptoms or complications can
be improved
Questions from the CORE homepage:
www.digestivedisorders.org.uk/Default.aspx?docname =
doc_diverticular&sec = Section12 (accessed 4 Sept 2005)

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Additional educational resources

Resources for doctors
Simpson J, Spiller R. Colonic diverticular disease. Clin
Evid 2004;12:599-609 (www.clinicalevidence.org/
ceweb/conditions/dsd/0405/0405.jsp)up to date
evidence based information on treatment and
interventions for diverticular disease
Janes S, Meagher A, Frizelle FA. Elective surgery after
acute diverticulitis. Br J Surg 2005;92:133-42a
comprehensive review of the evidence supporting
elective resection
Cleveland clinic website (www.clevelandclinicmeded.com/
diseasemanagement/gastro/colonic/colonic.htm)online
educational resource for clinicians
Resources for patients
National Digestive Diseases Information Clearinghouse
(digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/)
information on what diverticular disease is (with
pictures) and what causes it, the symptoms, and the
complications, as well as medical and surgical
treatment options
ASCRS (www.fascrs.org/displaycommon.cfm?an = 1&
subarticlenbr = 10)similar information to the above
site, but more concise

Conclusions
Dietary fibre supplementation, though often recommended for patients with symptomatic diverticular disease, is probably more useful as a preventive rather
than a therapeutic intervention. Although nonsteroidal anti-inflammatory drugs seem to increase the
risk of perforation, further studies are needed to determine the effects of calcium channel blockers and
opiates on perforation. Most complications of diverticulitis are associated with the initial attack, after which
the disease seems to run a benign course, with more
deaths caused by unrelated diseases than by complications of acute diverticulitis. Little evidence exists that
elective surgery after two attacks of diverticulitis
prevents future complications. Surgery for diverticular
disease has a high complication rate, and the outcomes
after surgery are often unpredictable. The recent trend
towards a one stage procedure may reduce overall
mortality for acute resections.
Contributors: SEJJ had the idea for the article and wrote the first
draft. AM and FAF critically reviewed and corrected the draft
version and provided additional references. FAF is the
guarantor.
Competing interests: None declared.
1
2
3
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5
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(Accepted 5 January 2006)

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