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Diverticular disease: Diagnosis and treatment

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Diverticular Disease:
Diagnosis and Treatment
Holly Salzman, M.D., and Dustin Lillie, M.D.
University of California, San Diego, School of Medicine, San Diego, California

Diverticular disease refers to symptomatic and asymptomatic disease with an underlying pathology of colonic diverticula.
Predisposing factors for the formation of diverticula include a low-fiber diet and physical inactivity. Approximately 85
percent of patients with diverticula are believed to remain asymptomatic. Symptomatic disease without inflammation is
a diagnosis of exclusion requiring colonoscopy because imaging studies
cannot discern the significance of diverticula. Fiber supplementation
may prevent progression to symptomatic disease or improve symptoms
in patients without inflammation. Computed tomography is recom-
mended for diagnosis when inflammation is present. Antibiotic therapy
aimed at anaerobes and gram-negative rods is first-line treatment for
diverticulitis. Whether treatment is administered on an inpatient or out-
patient basis is determined by the clinical status of the patient and his or
her ability to tolerate oral intake. Surgical consultation is indicated for

ILLUSTRATION BY CYNTHIA TURNER

disease that does not respond to medical management or for repeated
attacks that may be less likely to respond to medical therapy and have
a higher mortality rate. Prompt surgical consultation also should be
obtained when there is evidence of abscess formation, fistula formation,
obstruction, or free perforation. (Am Fam Physician 2005;72:1229-34,
1241-2. Copyright © 2005 American Academy of Family Physicians.)

D
Patient information: iverticular disease includes a spec- tions of colon structure, intestinal motility,


A handout on diverticular trum of conditions sharing the diet, and genetic features.4
disease, written by the
authors of this article, is underlying pathology of acquired The true prevalence of diverticula is
provided on page 1241. diverticula of the colon. Because unknown, but in one large observational
diverticular disease occurs almost exclusively study5 of 9,086 consecutive patients under-
in developed countries, it has been dubbed a going colonoscopy for all indications, the
“disease of Western Civilization.”1 overall prevalence of diverticulosis was
Acquired diverticula form through the rel- 27 percent and increased with patient age.
ative weakness in the muscle wall of the colon Studies performed in the 1970s suggest that
at the site where arteries (the vasa recta) pene- the prevalence of diverticula may be as high
trate the muscularis layer to reach the mucosa as 60 percent in patients older than 80 years,
and submucosa. Diverticula generally are with no clear gender predilection. Of patients
multiple. Each diverticulum is typically 5 to with diverticula, 80 to 85 percent are believed
10 mm in diameter, but at times they can to remain asymptomatic. Three fourths of the
exceed 20 mm. The most common site is the remaining 15 to 20 percent of patients have
sigmoid colon, although diverticula can occur symptomatic diverticular disease with col-
throughout the large bowel, with right-sided icky abdominal pain but no inflammation.
disease being more common in Asians and in The remaining one fourth (or approximately
patients younger than 60 years.2,3 Vegetarians 5 percent of all patients with diverticula)
and others who consume large amounts of develop diverticulitis, and a small number
dietary fiber have a lower incidence of diver- will develop complications of diverticulitis
ticula. Although the pathogenic mechanisms such as abscess formation, fistulas, obstruc-
of diverticular disease are poorly understood, tion, or hemorrhage.6 Table 1 compares the
they are clearly related to complex interac- various diverticular syndromes.

October 1, 2005 ◆ Volume 72, Number 7 www.aafp.org/afp American Family Physician  1229
Diverticular Disease
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Patients with asymptomatic diverticulosis should eat a high-fiber diet to prevent symptomatic C 6
diverticular disease.
All patients with symptomatic diverticular disease should undergo colonoscopy to exclude C 6
underlying neoplasm.
Patients with suspected diverticulitis should undergo computed tomography with intravenous C 13, 17
and oral contrast rather than other diagnostic modalities such as endoscopy or contrast
radiography.
To provide adequate coverage of gram-negative rods and anaerobic bacteria, patients with acute C 6
diverticulitis treated as outpatients should receive metronidazole (Flagyl) combined with a
quinolone or with trimethoprim-sulfamethoxazole (Bactrim, Septra) or amoxicillin-clavulanate
(Augmentin).
Patients hospitalized with acute diverticulitis should receive metronidazole or clindamycin (Cleocin) C 6
combined with an aminoglycoside, a monobactam, or a third-generation cephalosporin.

A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1154 or
http://www.aafp.org/afpsort.xml.

Diverticulosis diverticular disease and smoking, caffeine, or alcohol

Diverticulosis is an anatomic diagnosis that describes intake, although lack of physical activity appears to play
the presence of one or more diverticula. Uncomplicated, at least an indirect role. In a large prospective study11 of
asymptomatic diverticulosis typically is diagnosed inci- 43,881 U.S. male health care professionals, an inverse
dentally and does not require further work-up. Con- relationship was noted between the consumption of
sensus guidelines6 recommend a high-fiber diet in these insoluble dietary fiber and the development of symptom-
patients to prevent symptomatic diverticular disease, atic diverticular disease.
although there are no randomized controlled trials to
diagnosis
support or refute this strategy.
The diagnosis of symptomatic diverticular disease is one
Symptomatic Diverticular Disease of exclusion in patients with diverticula (Table 2). Tradi-
Symptomatic diverticular disease, also known as symp- tionally, diverticula are identified by barium enema, and
tomatic diverticulosis, is characterized by nonspecific additional investigations are performed as indicated to
attacks of abdominal pain without evidence of an inflam- rule out other potential causes of symptoms in individual
matory process. This pain typically is colicky in nature, patients. Although computed tomography (CT) has been
but can be steady, and often is relieved by passing flatus used commonly in the investigation of diverticular dis-
or having a bowel movement. Patients often note that ease, the morphology of diverticular segments makes the
attacks are precipitated by eating. Bloating and changes diagnosis of underlying cancer difficult even with ideal
in bowel habits also can occur, and constipation is more technique.12 Consensus expert opinion recommends
common than diarrhea. Fullness or tenderness in the left colonoscopy in all patients who present with symptom-
lower quadrant, or occasionally a tender palpable loop of atic diverticular disease to exclude underlying neoplastic
sigmoid colon, often is appreciated on physical examina- disease.6 CT colonography is a promising modality that
tion. These nonspecific symptoms overlap considerably may supplant colonoscopy once further data demon-
with those of irritable bowel syndrome; disorders of strating its effectiveness are available.
inhibitory control of neuromuscular function may play a
management
role in the development of both diseases.7
Several uncontrolled studies11 suggest that fiber supple-
pathogenesis mentation benefits patients with symptomatic diver-
For unknown reasons, only a small percentage of patients ticular disease, but no large placebo-controlled trials have
with diverticulosis develop symptomatic diverticular dis- been performed. Nevertheless, a high-fiber diet, fiber
ease. Some researchers have proposed that more painful supplementation, or both generally are recommended
disease is associated with an increased motility index and and are likely to do no harm. Historically, physicians have
increased intraluminal pressure.8 Prospective studies9,10 recommended avoiding ingestion of seeds, corn, popcorn,
in men have shown no connection between symptomatic and nuts for fear that they might become entrapped in

1230  American Family Physician www.aafp.org/afp Volume 72, Number 7 ◆ October 1, 2005
 Diverticular Disease
TABLE 1
Comparison of Diverticular Syndromes

Disease Features Treatment

Asymptomatic Diverticula in the absence of clinical High-fiber diet

symptoms
Symptomatic Diverticula and abdominal pain, with High-fiber diet
or without change in bowel habits;
no inflammation
Diverticulitis: uncomplicated Abdominal pain, fever, leukocytosis; Oral antibiotics (to cover anaerobes and gram-negative
(in stable patients) able to tolerate oral fluids rods); clear liquid diet; avoid morphine (Duramorph)
if possible because of risk of increasing intracolonic
pressure
Diverticulitis: uncomplicated Abdominal pain, fever, leukocytosis; IV antibiotics (to cover anaerobes and gram-negative
(in older or ill patients) able to tolerate oral fluids, or rods); IV fluids; bowel rest, nothing by mouth;
patient is older than 85 years meperidine (Demerol)
Diverticulitis: complicated Abdominal pain, fever, leukocytosis; Stabilization with fluids and antibiotics; surgical
with or without sepsis, perforation, consultation; percutaneous drainage
abscess, fistula, obstruction

IV = intravenous.

diverticula, but no controlled studies support this dietary entery, or adjacent organs, and a localized phlegmon
restriction. Similarly, no evidence supports the use of occurs. With macro-perforation, the resultant infection
antispasmodic agents, despite the cramping and bloating is less restricted, and peritonitis or a pericolonic abscess
often associated with symptomatic diverticular disease.3 can occur. If this septic process erodes into adjacent
structures, it may result in fistula formation.
Diverticulitis
diagnosis
Classically, diverticulitis is characterized by acute, con-
stant abdominal pain most often occurring in the left The diagnosis of diverticulitis is suspected most often
lower quadrant. The location varies depending on the site on the basis of clinical history and physical examination.
of the involved diverticulum. Fever and leukocytosis gen- Laboratory studies and imaging can be used judiciously to
erally are present. Other commonly associated symptoms confirm a diagnosis of diverticulitis and to exclude other
include nausea, vomiting, and constipation or diarrhea. potential causes of similar symptoms (Table 2). The white
Some patients may complain of dysuria and frequency, blood cell count usually is elevated with a predominance
reflecting what has been called “sympathetic cystitis” of polymorphonuclear cells. Immature band forms may
induced by bladder irritation from the adjacent inflamed be present. An acute abdominal radiographic series should
colon. On physical examination, localized tenderness be obtained in all patients with significant abdominal pain
generally is found in the left lower quadrant and may be
associated with guarding and rebound tenderness. Right-
sided pain, however, does not preclude diverticulitis TABLE 2
because some patients have redundant sigmoid colons, Differential Diagnosis of Symptomatic
and right-sided diverticula can occur, particularly in Diverticular Disease and Diverticulitis
Asian populations. Bowel sounds often are decreased but
may be normal early in the condition or increased in the Acute appendicitis Ovarian cyst, abscess,
Colorectal cancer or neoplasm
presence of obstruction. Hematochezia is rare and should
Complicated ulcer disease Ovarian torsion
suggest other diagnoses.3
Crohn’s disease Pancreatic disease
pathogenesis Cystitis Pelvic inflammatory disease
Ectopic pregnancy Peritonitis
Diverticulitis is believed to develop as the result of a
Gallbladder disease Pseudomembranous colitis
micro- or macro-perforation of a diverticulum, which
Incarcerated hernia Renal disease
may be caused by erosion of the luminal wall by increased
Ischemic colitis Small bowel obstruction
intraluminal pressure or thickened fecal material in the
Mesenteric infarction Ulcerative colitis
neck of the diverticulum. After a micro-perforation,
infection generally is contained by pericolonic fat, mes-

October 1, 2005 ◆ Volume 72, Number 7 www.aafp.org/afp American Family Physician  1231
Diverticular Disease

and suspected diverticulitis to identify pneumoperito-

neum if macro-perforation has occurred. Otherwise, find-
ings often are nonspecific and include small or large bowel
dilation or ileus, or evidence of bowel obstruction.
CT with intravenous and oral contrast is the test of
choice to confirm a suspected diagnosis of diverticuli-
tis.13 The finding of pericolic fat infiltration (Figure 1)
is diagnostic.14 Other common findings include thick-
ened fascia (78.9 percent), muscular hypertrophy
(26.3 percent), and an “arrowhead sign” (23.7 percent).
The arrowhead sign consists of focal thickening of the
colonic wall with an arrowhead-shaped lumen point-
ing to the inflamed diverticula (Figure 2).14 In one large
prospective study,15 investigators demonstrated the abil-
ity of CT to accurately predict medical treatment failure
or risk of complications by determining the presence of
severe disease (abscess or extraluminal air or contrast).
Although the sensitivity is excellent (97 percent), a nor- Figure 1. Computed tomographic scan revealing marked
mal CT does not preclude the diagnosis. eccentric thickening of the wall of the ascending colon and
Uncommonly, ultrasonography is used to confirm pericolic inflammatory fat and fascia (white arrowheads).
the diagnosis, primarily in patients with right-sided Fecal material is seen at the center of the inflammatory com-
plex indicating an inflamed diverticulum (black arrows).
pain in whom other diseases (e.g., ovarian pathology)
are suspected. In such cases, ultrasonography reveals a Reprinted with permission from Shen SH, Chen JD, Tiu CM, Chou YH,
Chang CY, Yu C. Colonic diverticulitis diagnosed by computed tomography
hypoechoic or anechoic structure protruding from a seg- in the ED. Am J Emerg Med 2002;20:552.
mentally thickened colonic wall. Ultrasonography was
found to have a specificity of 99.8 percent in one large Because of the theoretic potential to exacerbate per-
retrospective study.16 foration, endoscopic examination is acutely contrain-
Although barium enema was used commonly in the dicated unless inflammatory bowel disease, ischemic
past, it is no longer recommended because of the risk colitis, or carcinoma is highly suspected.17 Colonoscopy
of extravasation of contrast material if perforation has always should be performed six to eight weeks after
occurred. If barium enema is performed, water-soluble recovery from acute diverticulitis to exclude coexisting
contrast should be used. Typical findings include spicu- neoplastic disease.
lation of the mucosa, spasm, abscess, or evidence of frank
management
perforation.
The severity of the inflammatory and infectious processes,
as well as the underlying health of the patient, determines
The Authors the appropriate treatment for patients with diverticulitis.
Holly Salzman, M.D., is associate professor in the Department In patients with uncomplicated diverticulitis who are
of Family and Preventive Medicine at the University of California, clinically stable and able to tolerate fluids, outpatient
San Diego (UCSD), School of Medicine. She received her medical
degree from the University of California, Los Angeles, School of
treatment with broad-spectrum antibiotics covering anaer-
Medicine, and completed a residency in family medicine at Long obes and gram-negative rods is appropriate (Table 36).
Beach (Calif.) Memorial Medical Center. Common choices are metronidazole (Flagyl) plus a qui-
nolone; metronidazole plus trimethoprim-sulfamethoxa-
Dustin Lillie, M.D., is a faculty member in the Department of
zole (Bactrim, Septra); or amoxicillin-clavulanic acid
Family and Preventive Medicine at the UCSD School of Medicine.
He received his medical degree from the Keck School of Medicine at (Augmentin).6 Patients also should follow a clear liq-
the University of Southern California, Los Angeles, and completed uid diet. Morphine (Duramorph) should be avoided if
a residency in family medicine at the UCSD School of Medicine. possible because of its propensity to increase intraco-
lonic pressure.3,10 Patients should improve within 48 to
Address correspondence to Holly Salzman, M.D., UCSD Scripps
Ranch Family Medicine, 9909 Mira Mesa Blvd., Suite 200, San
72 hours, at which time the diet may be advanced cau-
Diego, CA 92131 (e-mail: [email protected]). Reprints are not tiously. Close follow-up is recommended, and hospital-
available from the authors. ization should be considered if the patient experiences

1232  American Family Physician www.aafp.org/afp Volume 72, Number 7 ◆ October 1, 2005
 Diverticular Disease

ability of a third episode surpasses 50 percent, and

subsequent attacks are less likely to respond to medical
therapy and also have a higher mortality rate.19 Surgical
referral should be considered for patients with recurrent
episodes or aggressive disease at a young age.
Several surgical options are available, including resec-
tion with primary anastomosis, resection with colostomy
and closure of the rectal stump, transverse colostomy
and drainage, and laparoscopic colectomy. The decision
about which option to choose is best guided by an expe-
rienced surgeon and the patient’s preference.
Figure 2. Computed tomographic scan showing eccentric complications
thickening of the colon wall with arrowhead-shaped
lumen contrasted by air (arrow). Complications of diverticulitis include abscess, fistula,
bowel obstruction, and free perforation. These complica-
Reprinted with permission from Shen SH, Chen JD, Tiu CM, Chou YH,
Chang CY, Yu C. Colonic diverticulitis diagnosed by computed tomography tions all require surgical consultation.
in the ED. Am J Emerg Med 2002;20:553. Abscesses occur when the pericolic tissues fail to
control the spread of the inflammatory process. Abscess
increasing pain, fever, or an inability to tolerate fluids. Anti- formation should be suspected when fever, leukocytosis,
biotic treatment should be continued for seven to 10 days. or both persist despite an adequate trial of appropriate
Hospitalization is recommended if patients show antibiotics. A tender mass may be palpable on physical
signs of significant inflammation, are unable to take examination. If right upper quadrant pain or elevated
oral fluids, are older than 85 years, or have significant transaminase levels occur, evidence of a pyogenic liver
comorbid conditions. These patients should be placed
on bowel rest and treated with intravenous fluids and
intravenous antibiotics (Table 36). Appropriate choices, TABLE 3
based on expert consensus rather than randomized tri- Consensus Antibiotic Treatment for Patients
als, include anaerobic coverage with metronidazole or with Diverticulitis
clindamycin (Cleocin) and gram-negative coverage with
an aminoglycoside, a monobactam, or a third-genera- Outpatient
tion cephalosporin.6 Single-agent coverage with intra- Amoxicillin-clavulanate (Augmentin)
venous second-generation cephalosporins (i.e., cefoxitin Trimethoprim-sulfamethoxazole (Bactrim, Septra)
and metronidazole (Flagyl)
[Mefoxin] or cefotetan [Cefotan]), or beta-lactamase
Fluoroquinolone and metronidazole
inhibitor combinations such as ampicillin-sulbactam
(Unasyn) or ticarcillin-clavulanate (Timentin) also have Inpatient
been advocated.3 Meperidine (Demerol) is the opiate of Metronidazole or clindamycin (Cleocin)
choice because it has been shown to decrease intralumi- plus
nal pressure. Nasogastric suction is not indicated unless Aminoglycoside (gentamicin [Garamycin] or
there is significant ileus. As with patients receiving out- tobramycin [Tobrex])
patient therapy, hospitalized patients should improve or
within 48 to 72 hours. The diet then can be advanced, Monobactam (aztreonam [Azactam])
and the patient discharged to complete a seven- to or
10-day course of oral antibiotics. Third-generation cephalosporin (ceftriaxone [Rocephin],
ceftazidime [Fortaz], cefotaxime [Claforan])
Most patients with acute diverticulitis respond to
alternatively
conservative medical management, although 15 to
Second-generation cephalosporin (cefoxitin [Mefoxin],
30 percent may require surgery during hospital admis- cefotetan [Cefotan])
sion because of lack of response to treatment or because Beta-lactamase inhibitor combinations (ampicillin-sulbactam
of development of complications.18 Surgery typically [Unasyn], ticarcillin-clavulanate [Timentin])
is not indicated after an uncomplicated first episode
because only 7 to 35 percent of patients experience a Information from reference 6.
recurrent episode. After a second episode, the prob-

October 1, 2005 ◆ Volume 72, Number 7 www.aafp.org/afp American Family Physician  1233
Diverticular Disease

abscess should be sought. CT-guided percutaneous Members of various family medicine departments develop articles for
“Practical Therapeutics.” This article is one in a series coordinated by
drainage may be appropriate for small abscesses or while the Department of Family and Preventive Medicine at the University of
patients with sepsis are being stabilized for surgery.3,6 California, San Diego. The coordinator of the series is Tyson Ikeda, M.D.
Peridiverticular abscesses can progress to form fis-
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