Diverticulitis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Ahmed Elsaiey, MBBCH [3], James Nasr[4]
Overview
Diverticulitis is a common disease of the digestive tract that affects the colon. Diverticulitis develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results when one of these diverticula becomes inflamed, usually due to fecal trapping with bacterial translocation, microperforation, and altered gut microbiome and immune response.[1][2][3] Diverticulitis is classified as complicated or uncomplicated. In the United States the annual incidence of diverticulitis is around 180 per 100 000 people.[4] Among those with diverticulosis, only about 1% to 4% will develop diverticulitis in their lifetime.[5][6] The highest incidence occurs in patients older than 60, with rising incidence in adults younger than 50, particularly among men. Men are more commonly affected before age 50, while females are more commonly affected after age 50.[7] Risk factors include age, obesity, genetics, connective-tissue disorders, NSAIDs, steroids, opioids, hypertension, and type 2 diabetes.[8] Diverticulitis can cause many complications as abscess, perforation, peritonitis, and fistula formation. Symptoms of diverticulitis include left lower abdominal pain, fever, cramps, and constipation.[9] Common physical examination findings include tachycardia, fever, abdominal tenderness, guarding and rebound tenderness, and presence of a palpable mass.[10][11] Uncomplicated diverticulitis is managed with observation and pain management, with or without antibiotics.[12] Complicated diverticulitis is treated with intravenous antibiotics and, when indicated, percutaneous drainage or surgical resection.[13][14]
Historical Perspective
Diverticulitis was first described by Dr. Lavater in the 1700s. In the 18th century, Dr. Littre was the first person to describe the diverticular disease. Dr. Meckel gave a full description of the diverticulum in 1812.
Classification
Diverticulitis may be classified according to the 2014 guidelines by the German Societies of Gastroenterology (DGVS) and of Visceral Surgery (DGAV). They unanimously agreed on a classification system (Classification of Diverticular Disease (CDD)), that takes practical algorithms (symptomatic, asymptomatic, complicated, uncomplicated, acute, recurrent), ongoing surgical aspects (purulent versus fecal peritonitis), and contemporary diagnostic standards in clinical practice into account. As a result, this classification comprises the entire spectrum of diverticular disease. While the CDD system remains in use in some European centers, current U.S. guidance, including the 2025 JAMA review, primarily classifies diverticulitis as uncomplicated or complicated, with severity stratified using the modified Hinchey classification.[8]
Pathophysiology
Diverticula are sac-like protrusions of the mucosal and submucosa through weak points in the muscular wall, and occur more commonly in the sigmoid colon. Diverticulitis is the inflammation of a diverticulum. The first steps in the pathogenesis of diverticulitis are an increase in intraluminal pressure, change in intestinal motility, and bacterial colonization.[3] The inflammation is caused by histamine, tumor necrosis factor, and metalloproteinases, which have been found in diverticulitis patients' tissue biopsies. Obstruction of the diverticula leads to bacterial colonization, which causes inflammation.
Causes
Common causes of diverticulitis include diverticulosis, and is believed to result from obstruction of a diverticulum by fecal material leading to bacterial translocation and mucosal inflammation, increased intraluminal pressure causing microperforation, and alterations in the gut microbiome and bile acids that disrupt the mucosal barrier and immune response.[1][2][3]
Differentiating Diverticulitis from Other Diseases
Diverticulitis must be differentiated from other diseases that cause lower abdominal pain and fever, such as appendicitis, inflammatory bowel disease, colon cancer, cystitis, and endometritis. Diverticulitis must be also differentiated from diseases causing peritonitis.
Epidemiology and Demographics
The lifetime risk of diverticulitis among individuals with diverticulosis is approximately 1% to 4%.[5][6] The highest incidence is in patients older than 60. Men are more commonly affected before age 50, while females are more commonly affected after age 50. The prevalence of diverticulitis has increased in developed countries.[7] In the United States, approximately 200,000 cases are admitted to the hospitals annually.[8] In Japan, more cases of right side diverticulitis have been reported than cases of left side diverticulitis.
Risk Factors
Risk factors for diverticulitis include older age, obesity, genetic predisposition, connective-tissue disorders (polycystic kidney disease, Marfan syndrome, and Ehlers-Danlos syndrome), hypertension, type 2 diabetes, and use of NSAIDs, corticosteroids, and opioids.[8]
Screening
There is insufficient evidence to recommend routine screening for diverticulitis.
Natural History, Complications, and Prognosis
Diverticulitis natural history is still being clarified. Diverticulitis can cause many complications that can be fatal in some cases. These complications include abscess, perforation, peritonitis, and fistula formation. Prognosis of diverticulitis is excellent; more than 90% of patients with uncomplicated diverticulitis improve with conservative management, and recurrence risk is lower than previously believed.[15]
Diagnosis
History and Symptoms
The most common symptoms of diverticulitis include left lower abdominal pain, fever, cramps, and constipation. A positive history of change in bowel habits is suggestive of diverticulitis. Less common symptoms include flatulence, nausea, and vomiting.[9]
Physical Examination
Patients with diverticulitis usually appear toxic due to pain. Common physical examination findings include tachycardia, fever, abdominal tenderness, guarding and rebound tenderness, and presence of a palpable mass. Diverticulitis diagnosis depends on taking a proper history, performing a physical examination, and imaging conifrmation. The known diagnostic criteria for diverticulitis include abdominal tenderness, especially in the left lower quadrant, and leukocytosis. CT scan findings help in disease confirmation.
Laboratory Findings
Diverticulitis diagnosis starts by taking history precisely and performing a physical examination. Lab tests are important in excluding other causes of abdominal pain and any other gastrointestinal disease. These lab tests include CBC, CRP, urinalysis, and liver tests. Imaging procedures including CT scan and colonoscopy are important measures in diagnosing diverticulitis.[16][17]
CT scan
Contrast-enhanced CT scan is the diagnostic test of choice for diverticulitis. It confirms the diagnosis, evaluates for complications such as abscess, perforation, and obstruction, and can guide percutaneous abscess drainage when needed.[15] [18]
MRI
On abdominal MRI, diverticulitis is characterized by thickening of the colon wall, the presence of the diverticula, and exudates from the colon. It may also show the presence of multiple abscesses. MRI is a good imaging modality that can be used in the diagnosis of diverticulitis since it has the advantage that it doesn't involve exposure to radiation and rules out other abdominal causes of acute abdomen.[19] However, MRI is not the best diagnostic procedure for diverticulitis; CT scan is preferred.[15]
Ultrasound
On abdominal ultrasonography, diverticulitis is characterized by abscess formation, hypoechoic pericolic fat, the presence of diverticula, and thickening of the colon segments. Extra diverticular exudates and fluids can be also observed. [20]
X-ray
On abdominal X-ray, diverticulitis is characterized by multiple air and fluid levels if there is an intestinal perforation. Chest X-ray should be done in patients with diverticulitis to investigate for pneumoperitoneum, which is a harbinger of a critical illness and will lead to a change in the management plan for the case. X-ray can be used if CT is not available and in uncomplicated cases.
Other imaging findings
There are no other specific imaging findings for diverticulitis. Other studies such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Other diagnostic studies
There are no other specific diagnostic studies for diverticulitis. Other studies such as barium enema and colonoscopy are contraindicated in the acute phase of diverticulitis due to the risk of perforation.
Treatment
Medical Therapy
Uncomplicated diverticulitis is managed with observation and pain management, with or without antibiotics.[12] Complicated diverticulitis is treated with intravenous antibiotics and, when indicated, percutaneous drainage or surgical resection.[13][14]
Surgery
Surgery is not the first-line treatment option for patients with diverticulitis. Emergency or urgent surgery is usually reserved for patients complicated with peritonitis, who are unresponsive to treatment, who have intestinal obstruction, or with abscess formation. Elective surgery may be performed and it depends on many factors like the age of the patient, severity score, and persistence of symptoms.[12]
Prevention
Primary prevention of diverticulitis focuses on overall lifestyle improvements. Physical activity, and weight loss to achieve a BMI less than 25.0 may reduce diverticulitis incidence.[21] High-fiber diets have been associated with general bowel health, although they have not been shown to prevent diverticulosis or diverticulitis.[22]
References
- ↑ 1.0 1.1 Humes D, Simpson J, Spiller RC. Colonic diverticular disease. BMJ Clin Evid. 2007 Aug 15;2007:0405. PMID: 19454119; PMCID: PMC2943810.
- ↑ 2.0 2.1 von Rahden BH, Germer CT. Pathogenesis of colonic diverticular disease. Langenbecks Arch Surg. 2012 Oct;397(7):1025-33. doi: 10.1007/s00423-012-0961-5. Epub 2012 Jun 20. PMID: 22711236.
- ↑ 3.0 3.1 3.2 Strate LL, Morris AM. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019 Apr;156(5):1282-1298.e1. doi: 10.1053/j.gastro.2018.12.033. Epub 2019 Jan 17. PMID: 30660732; PMCID: PMC6716971.
- ↑ Bharucha AE, Parthasarathy G, Ditah I, Fletcher JG, Ewelukwa O, Pendlimari R, Yawn BP, Melton LJ, Schleck C, Zinsmeister AR. Temporal Trends in the Incidence and Natural History of Diverticulitis: A Population-Based Study. Am J Gastroenterol. 2015 Nov;110(11):1589-96. doi: 10.1038/ajg.2015.302. Epub 2015 Sep 29. PMID: 26416187; PMCID: PMC4676761.
- ↑ 5.0 5.1 Stollman N, Smalley W, Hirano I; AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015;149(7):1944-1949. doi:10. 1053/j.gastro.2015.10.003
- ↑ 6.0 6.1 Shahedi K, Fuller G, Bolus R, Cohen E, Vu M, Shah R, Agarwal N, Kaneshiro M, Atia M, Sheen V, Kurzbard N, van Oijen MG, Yen L, Hodgkins P, Erder MH, Spiegel B. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol. 2013 Dec;11(12):1609-13. doi: 10.1016/j.cgh.2013.06.020. Epub 2013 Jul 12. PMID: 23856358; PMCID: PMC5731451.
- ↑ 7.0 7.1 Long B, Werner J, Gottlieb M. Emergency medicine updates: Acute diverticulitis. Am J Emerg Med. 2024;76:1-6. doi:10.1016/j.ajem.2023.10.051.
- ↑ 8.0 8.1 8.2 8.3 Peery AF, Wilson GC, Crockett SD. Diverticulitis: A Review. JAMA. 2025;333(2):158-168. doi:10.1001/jama.2024.23427.
- ↑ 9.0 9.1 Longstreth GF, Iyer RL, Chu LH, Chen W, Yen LS, Hodgkins P, Kawatkar AA. Acute diverticulitis: demographic, clinical and laboratory features associated with computed tomography findings in 741 patients. Aliment Pharmacol Ther. 2012 Nov;36(9):886-94. doi: 10.1111/apt.12047. PMID: 22967027.
- ↑ Zaidi E, Daly B. CT and clinical features of acute diverticulitis in an urban U.S. population: rising frequency in young, obese adults. AJR Am J Roentgenol. 2006 Sep;187(3):689-94. doi: 10.2214/AJR.05.0033. PMID: 16928931.
- ↑ Al-Saadi H, Abdulrasool H, Murphy E. Evaluation of Clinical Assessment in Predicting Complicated Acute Diverticulitis. Cureus. 2023 Feb 6;15(2):e34709. doi: 10.7759/cureus.34709. PMID: 36777973; PMCID: PMC9907385.
- ↑ 12.0 12.1 12.2 Garfinkle R, Bennett RD, Dantu S, Gasior A, Hawkins AT, Holland J, Ore AS, Shaffer VO, Taylor JP, Sylla P, McLemore EC, Boutros M. SAGES white paper on antibiotic omission in the management of acute uncomplicated diverticulitis: why, when, who, and most importantly, how. Surg Endosc. 2025 Jun;39(6):3456-3465. doi: 10.1007/s00464-025-11738-w. Epub 2025 Apr 22. PMID: 40263135.
- ↑ 13.0 13.1 Gregersen R, Mortensen LQ, Burcharth J, Pommergaard HC, Rosenberg J. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg. 2016 Nov;35:201-208. doi: 10.1016/j.ijsu.2016.10.006. Epub 2016 Oct 11. PMID: 27741423.
- ↑ 14.0 14.1 Garfinkle R, Kugler A, Pelsser V, Vasilevsky CA, Morin N, Gordon P, Feldman L, Boutros M. Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe. Dis Colon Rectum. 2016 Jul;59(7):648-55. doi: 10.1097/DCR.0000000000000624. PMID: 27270517.
- ↑ 15.0 15.1 15.2 Brown RF, Lopez K, Smith CB, Charles A. Diverticulitis: A Review. JAMA. Published online July 24, 2025. doi:10.1001/jama.2025.10234
- ↑ Rafferty J, Shellito P, Hyman NH, Buie WD, Standards Committee of American Society of Colon and Rectal Surgeons (2006). "Practice parameters for sigmoid diverticulitis". Dis Colon Rectum. 49 (7): 939–44. doi:10.1007/s10350-006-0578-2. PMID 16741596.
- ↑ Käser SA, Fankhauser G, Glauser PM, Toia D, Maurer CA (2010). "Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis". World J Surg. 34 (11): 2717–22. doi:10.1007/s00268-010-0726-7. PMID 20645093.
- ↑ Destigter KK, Keating DP. Imaging update: acute colonic diverticulitis. Clin Colon Rectal Surg. 2009 Aug;22(3):147-55. doi: 10.1055/s-0029-1236158. PMID: 20676257; PMCID: PMC2780264.
- ↑ Heverhagen JT, Sitter H, Zielke A, Klose KJ. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum. 2008 Dec;51(12):1810-5. doi: 10.1007/s10350-008-9330-4. Epub 2008 Apr 29. PMID: 18443876.
- ↑ Laméris W, van Randen A, Bipat S, Bossuyt PM, Boermeester MA, Stoker J. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta-analysis of test accuracy. Eur Radiol. 2008 Nov;18(11):2498-511. doi: 10.1007/s00330-008-1018-6. Epub 2008 Jun 4. PMID: 18523784.
- ↑ Liu PH, Cao Y, Keeley BR, Tam I, Wu K, Strate LL, Giovannucci EL, Chan AT. Adherence to a Healthy Lifestyle is Associated With a Lower Risk of Diverticulitis among Men. Am J Gastroenterol. 2017 Dec;112(12):1868-1876. doi: 10.1038/ajg.2017.398. Epub 2017 Nov 7. PMID: 29112202; PMCID: PMC5736501.
- ↑ Peery AF, Barrett PR, Park D, Rogers AJ, Galanko JA, Martin CF, Sandler RS. A high-fiber diet does not protect against asymptomatic diverticulosis. Gastroenterology. 2012 Feb;142(2):266-72.e1. doi: 10.1053/j.gastro.2011.10.035. Epub 2011 Nov 4. PMID: 22062360; PMCID: PMC3724216.