Diverticulitis Clinical Presentation

Updated: Aug 06, 2019
  • Author: Elie M Ghoulam, MD, MS; Chief Editor: BS Anand, MD  more...
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Presentation

History

The clinical presentation of diverticulitis, in which diverticula become inflamed or infected, 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. The pain is often described as crampy and may be associated with a change in the bowel habit. Right-sided diverticulitis of the cecum or ascending colon may present with right lower quadrant pain, which may be confused for acute appendicitis. Even in simple, uncomplicated cases, patients may have fever and/or leukocytosis (an elevated white blood cell count). Symptoms of mild diverticulitis may be confused with overlapping symptoms of irritable bowel syndrome.

The usual initial symptoms of diverticulitis include the following:

  • Abdominal pain (most commonly in the left lower quadrant)

  • Nausea

  • Vomiting

  • Constipation or obstipation

  • Fever

  • Flatulence

  • Bloating

Other signs and symptoms in diverticulitis may arise due to an increasing severity of inflammation and the development of complications. Feared complications of diverticulitis include, but are not limited to, abscess (infected collection of pus), perforation (full thickness tearing of the colon), and fistula (abnormal connection between two organs).

Note that immunosuppressed individuals, including those taking corticosteroids, and the elderly are more likely to have an atypical presentation, or may not be symptomatic at all.

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.

Diverticulitis can mimic other conditions

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 diverticula are generally rare. Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis. Retroperitoneal involvement may present similarly to renal disease. In women, lower quadrant pain may be difficult to distinguish from a gynecologic process.

  • More severe diverticulitis is often accompanied by anorexia, nausea, and vomiting. Typically, the pain is localized, severe, and present for several days prior to presentation. An altered bowel habit, especially constipation, is reported by most patients. A small percentage of patients may complain of urinary symptoms, such as dysuria, urgency, and frequency, due to the inflammation adjacent to urinary tract structures.

  • Macroperforation with spillage of colonic contents into the peritoneum can lead 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.

Next:

Physical Examination

Diverticulitis can present with a range of physical findings, mirroring the severity of the inflammation and the presence of complications, including the following:

  • Localized abdominal tenderness

  • Abdominal distention

  • Tympanic abdomen to percussion

  • A tender mass (abscess formation)

  • Hypo- or hyperactive bowel sounds

  • Absent bowel sounds (perforation)

  • Generalized abdominal pain with rebound and guarding (perforation)

  • Urinary tract findings (colovesicular/colovaginal fistula) include suprapubic, flank, costovertebral tenderness; pneumaturia (air in urine); fecaluria (stool in urine); or purulent vaginal discharge

Simple and complicated diverticulitis

In simple diverticulitis, fever and localized abdominal tenderness in the area of the affected diverticula are common findings. Left lower quadrant tenderness is the most common physical finding, as most diverticula occur in the sigmoid colon. [15] 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 noted. In fact, 20% of cases present with a palpable mass on abdominal, pelvic, or rectal examination. Peritonitis due to a free perforation results in generalized tenderness with rebound and guarding on abdominal examination. The abdomen may be distended and tympanic to percussion. Bowel sounds may be diminished or absent.

Elderly and immunocompromised patients

Elderly patients and individuals taking corticosteroids may have unremarkable findings on physical examination even in the presence of severe diverticulitis. Such patients must be evaluated with a high index of suspicion to avoid a delay in establishing the correct diagnosis.

The presence of fistulas

If a fistula forms, physical examination 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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