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Am Fam Physician. 2022;106(2):150-156

This clinical content conforms to AAFP criteria for CME.

Author disclosure: Dr. Dattani reports serving as a proctor for Intuitive Surgical. Drs. Bailey and Jennings have no relevant financial relationships.

Diverticulitis should be suspected in patients with isolated left lower quadrant pain, abdominal distention or rigidity, fever, and leukocytosis. Initial laboratory workup includes a complete blood count, basic metabolic panel, urinalysis, and C-reactive protein measurement. Computed tomography with intravenous contrast is the preferred imaging modality, if needed to confirm diagnosis and assess for complications of diverticulitis. Treatment decisions are based on the categorization of disease as complicated vs. uncomplicated. Selected patients with uncomplicated diverticulitis may be treated without antibiotics. Complicated diverticulitis is treated in the hospital with modified diet or bowel rest, antibiotics, and pain control. Abscesses that are 3 cm or larger should be treated with percutaneous drainage. Emergent surgery is reserved for when percutaneous drainage fails or the patient's clinical condition worsens despite adequate therapy. Colonoscopy should not be performed during the flare-up, but should be considered six weeks after resolution of symptoms in patients with complicated diverticulitis who have not had a high-quality colonoscopy in the past year. Diverticulitis prevention measures include consuming a vegetarian diet or high-quality diet (high in fruits, vegetables, whole grains, and legumes), limiting red meat and sweets, achieving or maintaining a body mass index of 18 to 25 kg per m2, being physically active, and avoiding tobacco and long-term nonsteroidal anti-inflammatory drugs. Partial colectomy is not routinely recommended for diverticulitis prevention and should be reserved for patients with more than three recurrences or abscess formation requiring percutaneous drainage.

A diverticulum is a protrusion through the intestinal wall, and diverticulosis is the presence of multiple diverticula. Acute diverticulitis is inflammation of diverticula. Possible causes include abnormal colonic motility, colonic wall resistance, intraluminal pressures, and colonic wall defects.1,2 Diverticular bleeding, the most common cause of lower gastrointestinal tract bleeding in adults, was reviewed previously in American Family Physician (https://www.aafp.org/afp/2009/1101/p977.html). The current article provides a summary of the best evidence on diagnosis and management of diverticular disease.

From 1980 to 2007, the incidence of diverticulitis rose from 115 per 100,000 person-years to 188 per 100,000 person-years.
A high-fiber diet is associated with a lower incidence of diverticular disease, but evidence regarding whether it prevents the recurrence of diverticulitis is lacking.
A 2019 meta-analysis of nine randomized controlled trials showed that in patients with uncomplicated acute diverticulitis, those treated without antibiotics had shorter hospital stays than those treated with antibiotics, and there was no difference in complication or readmission rates.
Clinical recommendation Evidence rating Comments
Avoiding popcorn, nuts, or seeds does not decrease the risk of diverticulitis or diverticular complications.7 B Prospective cohort study
Tobacco cessation, reduced meat intake, physical activity, and weight loss are recommended interventions to decrease the risks of diverticulitis recurrence.811 C Practice guideline and two prospective cohort studies
Computed tomography of the abdomen and pelvis is the most appropriate initial imaging modality in the assessment of suspected complicated diverticulitis.8,9,1517 C Practice guidelines and American College of Radiology Appropriateness Criteria
Selected patients with uncomplicated diverticulitis can be treated without antibiotics.8,9,16,2024 A Practice guideline, multiple randomized controlled trials, and a meta-analysis
Imaging-guided percutaneous drainage is recommended for stable patients with abscesses ≥ 3 cm in size.8,9,2933 B Practice guideline, systematic review, multicenter cohort study, retrospective cohort study, and population-based study
Prophylactic partial colectomy should be considered in patients who had an abscess requiring drainage.8,38,39 B Practice guideline, retrospective cohort study, and retrospective review
Colonoscopy should be considered six to eight weeks after resolution of a complicated case of diverticulitis unless the patient has had a high-quality colonoscopy in the past year.8,9,41,42 C Practice guideline, expert consensus, systematic review, and meta-analysis with disease-oriented outcomes

Epidemiology

  • Incidence of diverticulitis is increasing. From 1980 to 2007, the incidence increased from 115 per 100,000 person-years to 188 per 100,000 person-years.3

  • Prevalence of diverticulitis is less than 10% in people older than 45 years vs. 80% in those older than 85 years.1,2

  • Only 1% to 4% of patients with diverticular disease will develop diverticulitis in their lifetime.4

  • Risk factors for diverticulitis include increasing age, constipation, low-fiber diet, smoking, red meat consumption, obesity, weight gain, lack of exercise, genetic susceptibility, and nonsteroidal anti-inflammatory drug and aspirin use.1,5,6

  • Consumption of popcorn, nuts, and seeds is not a risk factor for developing diverticulitis.7

Screening and Prevention

  • Screening for diverticular disease is not recommended. It is often found incidentally on screening colonoscopy or imaging studies performed for other reasons.

  • Measures for preventing recurrence of diverticulitis include consuming a vegetarian diet or high-quality diet (high in fruits, vegetables, whole grains, and legumes), limiting red meats and sweets, achieving or maintaining a body mass index of 18 to 25 kg per m2, being physically active, and avoiding tobacco and long-term nonsteroidal anti-inflammatory drugs.811

  • A high-fiber diet is associated with a lower incidence of diverticular disease, but evidence regarding whether it prevents the recurrence of diverticulitis is lacking.12

Diagnosis

SIGNS AND SYMPTOMS

  • Tenderness to palpation located only in the left lower quadrant of the abdomen is the most specific finding for diverticulitis (likelihood ratio [LR] = 10.4). Tenderness in the left lower quadrant plus other locations is less useful (LR = 3.4).13

  • History of left lower quadrant tenderness (LR = 3.3), fever (LR = 1.4), and absence of vomiting (LR = 1.4) also support the diagnosis13 (Table 11).

  • Other nonspecific signs and symptoms may include abdominal rigidity, anorexia, dysuria, hypoactive bowel sounds, rectal bleeding, or tenderness on rectal examination.1,13

  • Fecaluria, pneumaturia, pyuria, and stool per vagina should raise suspicion for fistula formation.8

  • Studies have found that right-sided diverticulitis is more common in Asian countries.14

  • The differential diagnosis of diverticulitis is shown in Table 2.1

Signs and symptomsLR+LR−
Localized tenderness only in the left lower quadrant10.40.7
History of left lower quadrant pain3.30.5
Absence of vomiting1.40.2
History of fever1.40.8
Laboratory or imaging findings
 Computed tomography*940.1
 Ultrasonography*9.20.09
 Magnetic resonance imaging*7.80.07
 C-reactive protein level > 5 mg per dL (50 mg per L)2.20.3
Combination of left lower quadrant pain, the absence of vomiting, and a C-reactive protein level > 5 mg per dL180.65
Gastrointestinal
Bowel obstruction
Colitis (infectious and ischemic)
Colon cancer
Inflammatory bowel disease
Irritable bowel syndrome
Perforation
Gynecologic
Ectopic pregnancy
Endometriosis
Ovarian cyst
Pelvic inflammatory disease
Torsion
Tubo-ovarian abscess
Urinary
Nephrolithiasis
Urinary tract infection

DIAGNOSTIC EVALUATION

  • Initial tests include complete blood count (white blood cell count may be normal in 45% of patients), basic metabolic panel to evaluate electrolyte and renal status, urinalysis to rule out urinary tract infection, and C-reactive protein (level greater than 20 mg per dL [200 mg per L] is suggestive of perforation).13

  • Other tests to consider in selected patients include a beta-human chorionic gonadotropin test to rule out ectopic pregnancy and if surgery is needed in a patient who could become pregnant, and a lipase test to rule out acute pancreatitis (mild elevation of lipase may occur with perforation).

  • Imaging should be considered if the diagnosis is uncertain or there is concern for complicated diverticulitis.

  • If imaging is performed, computed tomography with contrast is the diagnostic test of choice because of its availability and high sensitivity (94%) and specificity (99%).8,9,15,16

  • Magnetic resonance imaging has good diagnostic accuracy and avoids radiation exposure but may not be as readily available as computed tomography.8,17

  • Ultrasonography can be effective in the diagnosis of diverticulitis, but operator experience affects accuracy. Its ability to assess for free air or the extent of large abscesses is limited.8,17

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