Diverticulitis Clinical Presentation
- Author: Kamyar Shahedi, MD; Chief Editor: BS Anand, MD more...
The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Left lower quadrant pain is the most common presenting complaint and occurs in 70% of patients. Pain is often described as crampy and may be associated with a change in bowel habits. Other symptoms include nausea and vomiting, constipation, diarrhea, flatulence, and bloating. Symptoms of mild diverticulitis may be confused with overlapping symptoms of irritable bowel syndrome.
A microperforation, most likely walled off by adjacent structures, may present with no systemic signs of illness or infection.However, the disease may progress from a localized and walled-off process to one with peridiverticular inflammatory phlegmon and localized abscess. Systemic signs of infection (eg, fever) then develop. Because diverticula and, hence, diverticulitis can develop anywhere in the gastrointestinal tract, symptoms may mimic multiple conditions. Note the following:
Diverticulitis in the right colon or in a redundant sigmoid colon may be mistaken for acute appendicitis. Cecal diverticulitis can also mimic acute appendicitis, but cecal diverticulae are generally rare. Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis. Retroperitoneal involvement may present similar to renal disease. In women, lower quadrant pain may be difficult to distinguish from a gynecological process.
More severe diverticulitis is often accompanied by anorexia, nausea, and vomiting. Typically, the pain is localized and severe and present for several days prior to presentation. Altered bowel habits, especially constipation, are reported by most patients. A small percentage of patients may complain of urinary symptoms, such as dysuria, urgency, and frequency, due to inflammation adjacent to urinary tract structures.
Macroperforation with spillage of colonic contents into the peritoneum leads to generalized abdominal pain and peritonitis, or it may lead to a localized pelvic, left lower quadrant, or right lower quadrant abscess with more localized abdominal pain and peritonitis.
Leg pain possibly associated with a thigh abscess and leg emphysema secondary to retroperitoneal perforation from diverticulitis have been reported.
Diverticulitis can present with a range of physical findings, mirroring the severity of the inflammation and the presence of complications.
In simple diverticulitis, localized abdominal tenderness in the area of the affected diverticula and fever are common findings. Left lower quadrant tenderness is the most common physical finding, as most diverticula occur in the sigmoid colon. Right lower quadrant tenderness, mimicking acute appendicitis, can occur in right-sided diverticulitis.
In complicated diverticulitis with abscess formation, a tender palpable mass may be felt on physical examination. In fact, 20% of cases present with a palpable mass on abdominal, pelvic, or rectal examination. Peritonitis due to free perforation results in generalized tenderness with rebound and guarding on abdominal examination. The abdomen may be distended and tympanic to percussion. Bowel sounds can be diminished or absent.
Elderly patients and some patients taking corticosteroids may have unremarkable findings on physical examination even in the presence of severe diverticulitis. Such patients must be approached with a high index of suspicion to avoid a delay in establishing the correct diagnosis.
If a fistula forms, the findings vary depending on the type of fistula. Colovesicular fistulas may present with urinary tract symptoms, such as suprapubic, flank, or costovertebral angle tenderness. Fecaluria or pneumaturia can also be observed. Female patients with colovaginal fistulas may present with a purulent vaginal discharge.
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