- Author: Kamyar Shahedi, MD; Chief Editor: BS Anand, MD more...
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 colovesical 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.
The diagnosis of diverticulitis can be made on clinical grounds, but a computed tomography (CT) scan of the abdomen is considered the best imaging method to confirm the diagnosis. The American College of Radiology (ACR) 2008 Appropriateness Criteria for left lower quadrant pain support this recommendation because of the specificity and sensitivity of CT scans, which allow for the diagnosis of causes of left lower quadrant pain that resembles diverticulitis. Note the following:
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 scan 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. According to the 2008 ACR Appropriateness Criteria, contrast enema may be an option when CT scans do not absolutely differentiate between diverticulitis and colonic carcinoma.
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.
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.
Several staging schemes have been proposed based on the 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 - Phlegmon or localized pericolic or mesenteric abscess
Stage II disease - Walled-off pelvic, intra-abdominal, or retroperitoneal abscess
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
[Guideline] World Gastroenterology Organisation (WGO). Practice Guidelines 2007. Diverticular disease. Available at http://www.worldgastroenterology.org/diverticular-disease.html. Accessed: 10 June 2011.
Shahedi K, Fuller G, Bolus R, et al. Long-term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol. 2013 Dec. 11(12):1609-13. [Medline].
Shahedi K, Fuller G, Bolus R, et al. Progression from Incidental Diverticulosis to Acute Diverticulitis. Gastroenterol. 2012 May. 142(5) Suppl 1:S-144. [Full Text].
Strate LL, Modi R, Cohen E, Spiegel BM. Diverticular disease as a chronic illness: evolving epidemiologic and clinical insights. Am J Gastroenterol. 2012 Oct. 107(10):1486-93. [Medline].
Lahat A, Avidan B, Sakhnini E, Katz L, Fidder HH, Meir SB. Acute Diverticulitis: A Decade of Prospective Follow-up. J Clin Gastroenterol. 2013 Jan 16. [Medline].
Brandl A, Kratzer T, Kafka-Ritsch R, et al. Diverticulitis in immunosuppressed patients: A fatal outcome requiring a new approach?. Can J Surg. 2016 Jun 1. 59 (4):12915. [Medline].
Peery AF. Recent advances in diverticular disease. Curr Gastroenterol Rep. 2016 Jul. 18 (7):37. [Medline].
Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology. 2009 Jan. 136(1):115-122.e1. [Medline]. [Full Text].
[Guideline] Miller FH, Bree RL, Rosen MP, et al. Expert Panel on Gastrointestinal Imaging. ACR Appropriateness Criteria left lower quadrant pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. [Full Text].
Ricciardi R, Baxter NN, Read TE, Marcello PW, Hall J, Roberts PL. Is the decline in the surgical treatment for diverticulitis associated with an increase in complicated diverticulitis?. Dis Colon Rectum. 2009 Sep. 52(9):1558-63. [Medline].
Alonso S, Pera M, Pares D, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2009 Nov 10. [Medline].
Sanchez-Velazquez P, Grande L, Pera M. Outpatient treatment of uncomplicated diverticulitis: a systematic review. Eur J Gastroenterol Hepatol. 2016 Jun. 28 (6):622-7. [Medline].
Trivedi CD, Das KM. Emerging therapies for diverticular disease of the colon. J Clin Gastroenterol. 2008 Nov-Dec. 42(10):1145-51. [Medline].
Stollman N, Magowan S, Shanahan F, Quigley EM. A Randomized Controlled Study of Mesalamine After Acute Diverticulitis: Results of the DIVA Trial. J Clin Gastroenterol. 2013 Feb 18. [Medline].
Riansuwan W, Hull TL, Millan MM, Hammel JP. Nonreversal of Hartmann's procedure for diverticulitis: derivation of a scoring system to predict nonreversal. Dis Colon Rectum. 2009 Aug. 52(8):1400-8. [Medline].
Fleming FJ, Gillen P. Reversal of Hartmann's procedure following acute diverticulitis: is timing everything?. Int J Colorectal Dis. 2009 Oct. 24(10):1219-25. [Medline].
Rink AD, John-Enzenauer K, Haaf F, et al. Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption. Dis Colon Rectum. 2009 Oct. 52(10):1738-45. [Medline].
Crowe FL, Appleby PN, Allen NE, Key TJ. Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. BMJ. 2011 Jul 19. 343:d4131. [Medline]. [Full Text].
Ambrosetti P, Robert JH, Witzig JA, Mirescu D, Mathey P, Borst F, et al. Acute left colonic diverticulitis in young patients. J Am Coll Surg. 1994 Aug. 179(2):156-60. [Medline].
Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spectrum of disease and outcome of complicated diverticular disease. Am J Surg. 2003 Dec. 186(6):696-701. [Medline].
Bordeianou L, Hodin R. Controversies in the surgical management of sigmoid diverticulitis. J Gastrointest Surg. 2007 Apr. 11(4):542-8. [Medline].
Broderick-Villa G, Burchette RJ, Collins JC, Abbas MA, Haigh PI. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg. 2005 Jun. 140(6):576-81; discussion 581-3. [Medline].
Caterino JM, Emond JA, Camargo CA Jr. Inappropriate medication administration to the acutely ill elderly: a nationwide emergency department study, 1992-2000. J Am Geriatr Soc. 2004 Nov. 52(11):1847-55. [Medline].
Chapman J, Davies M, Wolff B, Dozois E, Tessier D, Harrington J, et al. Complicated diverticulitis: is it time to rethink the rules?. Ann Surg. 2005 Oct. 242(4):576-81; discussion 581-3. [Medline].
Dominguez EP, Sweeney JF, Choi YU. Diagnosis and management of diverticulitis and appendicitis. Gastroenterol Clin North Am. 2006 Jun. 35(2):367-91. [Medline].
Evans JP, Cooper J, Roediger WE. Diverticular colitis - therapeutic and aetiological considerations. Colorectal Dis. 2002 May. 4(3):208-212. [Medline].
Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med. 1998 May 21. 338(21):1521-6. [Medline].
Floch MH, White JA. Management of diverticular disease is changing. World J Gastroenterol. 2006 May 28. 12(20):3225-8. [Medline].
Freeman SR. Diverticulitis. McNally PR, ed. GI/Liver Secrets. Philadelphia, Pa: Hanley & Belfus; 1996. 332-338.
Hackethal V. Diverticulitis Surgery Often Avoidable, New Standard Needed. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/819310. Accessed: January 20, 2014.
Isselbacher KJ, Epstein A. Diverticular disease. Braunwald E, Longo DL, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. McGraw-Hill; 1998. 1648-1649.
Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007 Nov 15. 357(20):2057-66. [Medline].
Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ. 2006 Feb 4. 332(7536):271-5. [Medline].
Kazzi AA. Diverticular disease. Medscape Reference. 2006. [Full Text].
Kornitzer BS, Manace LC, Fischberg DJ, Leipzig RM. Prevalence of meperidine use in older surgical patients. Arch Surg. 2006 Jan. 141(1):76-81. [Medline].
Marinella MA, Mustafa M. Acute diverticulitis in patients 40 years of age and younger. Am J Emerg Med. 2000 Mar. 18(2):140-2. [Medline].
Miura S, Kodaira S, Shatari T, Nishioka M, Hosoda Y, Hisa TK. Recent trends in diverticulosis of the right colon in Japan: retrospective review in a regional hospital. Dis Colon Rectum. 2000 Oct. 43(10):1383-9. [Medline].
Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, et al. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol. 2005 Jun. 17(6):649-54. [Medline].
Novak JS, Tobias J, Barkin JS. Nonsurgical management of acute jejunal diverticulitis: a review. Am J Gastroenterol. 1997 Oct. 92(10):1929-31. [Medline].
Oliver G, Lowry A, Vernava A, Hicks T, Burnstein M, Denstman F, et al. Practice parameters for antibiotic prophylaxis--supporting documentation. The Standards Task Force. The American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2000 Sep. 43(9):1194-200. [Medline]. [Full Text].
Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol. 1975 Jan. 4(1):53-69. [Medline].
Patel DG, Thomson WG. Diverticulitis and diverticular hemorrhage. Clinical Practice of Gastroenterology. Philadelphia, Pa: Churchill Livingstone; 1999. 727-732.
Pemberton JH, Armstrong DN, Dietzen CD. Diverticulitis. Yamada T, Alpers DH, et al, eds. Textbook of Gastroenterology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1995. 1876-1888.
Poletti PA, Platon A, Rutschmann O, Kinkel K, Nyikus V, Ghiorghiu S, et al. Acute left colonic diverticulitis: can CT findings be used to predict recurrence?. AJR Am J Roentgenol. 2004 May. 182(5):1159-65. [Medline].
Rafferty J, Shellito P, Hyman NH, Buie WD. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. 2006 Jul. 49(7):939-44. [Medline].
Rampton DS. Diverticular colitis: diagnosis and management. Colorectal Dis. 2001 May. 3(3):149-53. [Medline].
Rao PM, Rhea JT, Novelline RA, Dobbins JM, Lawrason JN, Sacknoff R, et al. Helical CT with only colonic contrast material for diagnosing diverticulitis: prospective evaluation of 150 patients. AJR Am J Roentgenol. 1998 Jun. 170(6):1445-9. [Medline].
Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg. 1989 Mar. 26(3):133-89. [Medline].
Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for Diverticulitis in the 21st Century: A Systematic Review. JAMA Surg. 2014 Jan 15. [Medline].
Ripolles T, Agramunt M, Martinez MJ, Costa S, Gomez-Abril SA, Richart J. The role of ultrasound in the diagnosis, management and evolutive prognosis of acute left-sided colonic diverticulitis: a review of 208 patients. Eur Radiol. 2003 Dec. 13(12):2587-95. [Medline].
Schoetz DJ Jr. Uncomplicated diverticulitis. Indications for surgery and surgical management. Surg Clin North Am. 1993 Oct. 73(5):965-74. [Medline].
Schreyer AG, Furst A, Agha A, Kikinis R, Scheibl K, Scholmerich J, et al. Magnetic resonance imaging based colonography for diagnosis and assessment of diverticulosis and diverticulitis. Int J Colorectal Dis. 2004 Sep. 19(5):474-80. [Medline].
Silverman ME, Shih RD, Allegra J. Morphine induces less nausea than meperidine when administered parenterally. J Emerg Med. 2004 Oct. 27(3):241-3. [Medline].
Wu JS, Baker ME. Recognizing and managing acute diverticulitis for the internist. Cleve Clin J Med. 2005 Jul. 72(7):620-7. [Medline].
Yacoe ME, Jeffrey RB Jr. Sonography of appendicitis and diverticulitis. Radiol Clin North Am. 1994 Sep. 32(5):899-912. [Medline].
Harvey J, Roberts PL, Schoetz DJ, et al. Do appendicitis and diverticulitis share a common pathological link?. Dis Colon Rectum. 2016 Jul. 59 (7):656-61. [Medline].
Wright GP, Flermoen SL, Robinett DM, Charney KN, Chung MH. Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis. Am J Surg. 2016 Jun. 211 (6):1035-40. [Medline].
Mali JP, Mentula PJ, Leppäniemi AK, Sallinen VJ. Symptomatic treatment for uncomplicated acute diverticulitis: a prospective cohort study. Dis Colon Rectum. 2016 Jun. 59 (6):529-34. [Medline].