eMedicine Specialties > Gastroenterology > Colon

Diverticulitis: Differential Diagnoses & Workup

Author: Minh Chau T Nguyen, MD, Assistant Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center; Physician Specialist, Department of Ambulatory Medicine, Olive View-University of California at Los Angeles Medical Center
Coauthor(s): Yuvrajsinh Narendrasinh Chudasama, MD, Staff Physician, Department of Internal Medicine, University of California at Los Angeles, Olive View Medical Center; Stanley K Dea, MD, Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated Training Program in Gastroenterology; Andrea Cooperman, MD, Associate Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center
Contributor Information and Disclosures

Updated: Jun 30, 2008

Differential Diagnoses

Appendicitis
Intra-abdominal Sepsis
Biliary Colic
Irritable Bowel Syndrome
Biliary Disease
Liver Abscess
Biliary Obstruction
Mesenteric Artery Ischemia
Cholangitis
Mesenteric Artery Thrombosis
Cholecystitis
Nephrolithiasis
Chronic Mesenteric Ischemia
Nephrolithiasis: Acute Renal Colic
Colonic Obstruction
Ovarian Cysts
Colovesical Fistula
Pancreatitis, Acute
Constipation
Pelvic Inflammatory Disease
Duodenal Ulcers
Pyelonephritis, Acute
Gastric Ulcers
Pyogenic Hepatic Abscesses
Gastritis, Acute
Rectovaginal Fistula
Gastroenteritis, Viral
Urinary Tract Infection, Females
Gynecologic Pain
Urinary Tract Infection, Males
Inflammatory Bowel Disease
Urinary Tract Obstruction
Intestinal Perforation

Workup

Laboratory Studies

  • The diagnosis of acute diverticulitis can usually be made on the basis of history and physical examination. Laboratory tests may be of help when the diagnosis is in question.
  • A hemogram may reveal leukocytosis and a left shift, indicating infection. However, the absence of leukocytosis does not rule out diverticulitis, as 20-40% of patients have a normal white blood cell count. This is particularly true in patients who are immunocompromised, in elderly patients, and in those with less severe disease. A hemoglobin level is important when the patient reports hematochezia.
  • Chemistries may be helpful in the patient who is vomiting or has diarrhea to assess electrolyte abnormalities. Renal function is assessed prior to the administration of most intravenous contrast material.
  • Liver tests and lipase may help to exclude other causes of abdominal pain.
  • If a colovesicular fistula is suspected, urinalysis may reveal red or white blood cells. However, inflammation and infection due to diverticulitis adjacent to the ureters or the bladder may be the source of the cells. A urine culture may confirm sterile pyuria due to inflammation versus polymicrobial infection in the case of a fistula.
  • Blood cultures should be obtained prior to the administration of empiric parenteral antimicrobial therapy in patients who are severely ill or in those with complicated disease.
  • A pregnancy test must be performed in any female of childbearing age who presents with abdominal pain to rule out ectopic pregnancy, as well as prior to radiologic studies and before administering certain antibiotics to protect a viable fetus.

Imaging Studies

  • The diagnosis of diverticulitis can be made on clinical grounds, but a CT scan of the abdomen is considered the best imaging method to confirm the diagnosis. 
    • CT scans are preferred over intraluminal examinations (eg, barium enema), since the bulk of inflammation is extraluminal. CT scans can help assess disease severity, the presence of complications, and clinical staging. In the acute setting, CT scans are safer than contrast studies. Sensitivity and specificity, especially with helical CT and colonic contrast, can be as high as 97%.   
    • Possible CT findings include the following: pericolic fat stranding due to inflammation, colonic diverticula, bowel wall thickening, soft tissue inflammatory masses, phlegmon, and abscesses. Peritonitis, fistula formation, and obstruction can also be assessed. It can be used to guide percutaneous drainage of an abscess.
  • Contrast enema is not the imaging modality of choice during an acute episode of abdominal pain and should only be considered in mild-to-moderate uncomplicated cases of diverticulitis when the diagnosis is in doubt. A water-soluble contrast should be used, as leakage of barium into the peritoneum would be catastrophic.
  • Plain radiograph films are not helpful in making the diagnosis of diverticulitis. However, plain abdominal radiograph series with supine and upright films can demonstrate bowel obstruction or ileus. If free air is present, this can indicate bowel perforation.

Procedures

  • Endoscopy is not recommended in the acute setting given the risk of worsening diverticulitis and bowel perforation.  After the diverticulitis has subsided, colonoscopy can be used to evaluate the extent of diverticulosis or to rule out a malignancy masquerading as a benign postinflammatory stricture.

Staging

Several staging schemes have been proposed based on clinical findings, extent on imaging studies, and the presence of complications.  Probably, the simplest method is to differentiate among asymptomatic diverticulosis, uncomplicated diverticulitis, and complicated diverticulitis.

Clinical staging by Hinchey's classification is geared toward choosing the proper surgical procedure when diverticulitis is complicated, as follows:

  • Stage I disease - Small or confined pericolic or mesenteric abscess
  • Stage II disease - Large abscess, often confined to the pelvis
  • Stage III disease - Perforated diverticulitis causing generalized purulent peritonitis
  • Stage IV disease - Rupture of diverticula into the peritoneal cavity with fecal contamination causing generalized fecal peritonitis

More on Diverticulitis

Overview: Diverticulitis
Differential Diagnoses & Workup: Diverticulitis
Treatment & Medication: Diverticulitis
Follow-up: Diverticulitis
References
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Further Reading

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Contributor Information and Disclosures

Author

Minh Chau T Nguyen, MD, Assistant Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center; Physician Specialist, Department of Ambulatory Medicine, Olive View-University of California at Los Angeles Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Yuvrajsinh Narendrasinh Chudasama, MD, Staff Physician, Department of Internal Medicine, University of California at Los Angeles, Olive View Medical Center
Yuvrajsinh Narendrasinh Chudasama, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Stanley K Dea, MD, Chief of Endoscopy, Acting Chief of Gastroenterology, Consulting Gastroenterologist Olive View-University of California at Los Angeles Medical Center; Director of Enteral Feeding, West Los Angeles Veterans Affairs Medical Center; Director of Endoscopic Training, University of California at Los Angeles Affiliated Training Program in Gastroenterology
Stanley K Dea, MD is a member of the following medical societies: American Society for Gastrointestinal Endoscopy and Southern California Society of Gastroenterology
Disclosure: Nothing to disclose.

Andrea Cooperman, MD, Associate Clinical Professor of Medicine, David Geffen School of Medicine at UCLA, Olive View-UCLA Medical Center
Andrea Cooperman, MD is a member of the following medical societies: Alpha Omega Alpha and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Medical Editor

Waqar A Qureshi, MD, Chief of Endoscopy, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and VA Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

BS Anand, MD, Department of Internal Medicine, Division of Gastroenterology, Professor, Baylor University College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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