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Clinical manifestations and diagnosis of acute

colonic diverticulitis in adults
Authors: John H Pemberton, MD, Anne Peery, MD, MSCR
Section Editor: J Thomas Lamont, MD
Deputy Editor: Shilpa Grover, MD, MPH, AGAF

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2022. | This topic last updated: Jan 05, 2023.

INTRODUCTION

Approximately 1 to 4 percent of patients with colonic diverticulosis develop acute

diverticulitis over seven years of follow-up [1]. Colonic diverticulitis is defined as
inflammation in and adjacent to a diverticulum.

This topic will review the clinical manifestations and diagnosis of acute diverticulitis.
The epidemiology of diverticulosis, diverticular disease, and diverticular bleeding
and the management of acute diverticulitis and diverticular bleeding are discussed
in detail, separately. (See "Colonic diverticulosis and diverticular disease:
Epidemiology, risk factors, and pathogenesis" and "Acute colonic diverticulitis:
Medical management" and "Diverticular fistulas" and "Colonic diverticular
bleeding".)

DEFINITIONS

● A diverticulum is a sac-like protrusion of the colonic wall.

● Diverticulosis merely describes the presence of diverticula.

 ● Acute diverticulitis is defined as inflammation, generally considered to be due
to microperforation of a diverticulum.

● Complicated diverticulitis is defined as diverticulitis with one of the following

associated complications: bowel obstruction, stricture, abscess, fistula, or
perforation.

● Simple or uncomplicated diverticulitis is defined as acute diverticulitis without

an associated complication. (See 'Acute complications' below.)

● Smoldering or chronic diverticulitis is diverticular inflammation that persists

for weeks to months.

CLINICAL FEATURES

Clinical manifestations — The clinical presentation of acute diverticulitis depends

on the severity of the underlying inflammatory process and the presence of
associated complications. Diverticulitis is most commonly managed in the
ambulatory setting but is also a common indication for hospital admission [2]. The
incidence of diverticulitis increases with age but is not uncommon in young adults
[3]. (See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors,
and pathogenesis", section on 'Epidemiology'.)

Abdominal pain is the most common complaint in patients with acute diverticulitis.
The pain is usually in the left lower quadrant due to involvement of the sigmoid
colon. However, patients may have right lower quadrant or suprapubic pain due to
the presence of a redundant inflamed sigmoid colon or, much less commonly, right-
sided (cecal) diverticulitis [4-6]. The pain is usually constant [7]. (See "Colonic
diverticulosis and diverticular disease: Epidemiology, risk factors, and
pathogenesis", section on 'Epidemiology' and "Acute colonic diverticulitis: Medical
management".)

Patients may also have a fever. Hemodynamic instability with hypotension and
shock are rare and are associated with perforation and peritonitis. A tender mass is
palpable in approximately 20 percent of patients due to pericolonic inflammation or
a peridiverticular abscess [8]. Patients may have localized peritoneal signs with
localized guarding, rigidity, and rebound tenderness. Rectal examination may reveal
a mass or tenderness to palpation in the presence of a distal sigmoid abscess. Stool
may be positive for occult blood. (See "Etiologies, clinical manifestations, and
diagnosis of mechanical small bowel obstruction in adults" and 'Acute complications'
below and "Evaluation of the adult with abdominal pain" and "Evaluation of occult
gastrointestinal bleeding", section on 'Testing for occult blood'.)

Acute diverticulitis may be associated with a change in bowel habits, with

constipation reported in approximately 50 percent of patients and diarrhea in 25 to
35 percent of patients [9,10]. Hematochezia is rare.

Approximately 10 to 15 percent of patients with acute diverticulitis have urinary

urgency, frequency, or dysuria due to irritation of the bladder from an inflamed
sigmoid colon [9].

Acute complications — Approximately 12 percent of patients with acute

diverticulitis have associated acute or chronic complications [3]. Patients may have
an acute complication of diverticulitis at initial presentation or may develop an acute
complication subsequently. Obstruction is the most complication followed by
perforation and abscess [11] (See 'Disease course' below.)

Obstruction — During an attack of acute diverticulitis, partial colonic obstruction

can occur because of relative luminal narrowing due to pericolonic inflammation or
compression from a diverticular abscess. However, high-grade colonic obstruction is
rare in the acute setting and is usually associated with the subsequent development
of a stricture due to chronic diverticular inflammation. (See 'Disease course' below.)

Acute diverticulitis can also cause a small bowel obstruction if a loop of small
intestine becomes incorporated in a pericolonic inflammatory mass, or due to
localized irritation and the development of an ileus.

Depending on the degree and site of obstruction, patients may have abdominal
pain, nausea, vomiting, abdominal distension, constipation, or obstipation. Patients
with an ileus or obstruction may have abdominal distention and tympany on
percussion due to the presence of dilated loops of bowel. Bowel sounds may be
either high-pitched with obstruction or hypoactive in the case of ileus. (See
"Etiologies, clinical manifestations, and diagnosis of mechanical small bowel
obstruction in adults", section on 'Intra-abdominal inflammation or infection' and
"Etiologies, clinical manifestations, and diagnosis of mechanical small bowel
obstruction in adults", section on 'Clinical presentations'.)

Abscess — Diverticular abscesses occur in approximately 17 percent of patients

hospitalized with acute diverticulitis [12,13]. The symptoms of a diverticular abscess
are similar to acute diverticulitis. A diverticular abscess may be noted on abdominal
CT scan at initial presentation or may develop subsequently. A diverticular abscess
should therefore be suspected in patients with uncomplicated diverticulitis who
have no improvement in abdominal pain or a persistent fever despite three days of
antibiotic treatment. (See "Acute colonic diverticulitis: Medical management",
section on 'Abscess'.)

In rare cases, patients may develop a pyogenic liver abscess due to the spread of
infection through the portal circulation. (See "Pyogenic liver abscess", section on
'Clinical manifestations'.)

Perforation — Perforation with generalized peritonitis may result from rupture of

a diverticular abscess into the peritoneal cavity or free rupture of an inflamed
diverticulum with fecal contamination of the peritoneum. Although only 1 to 2
percent of patients with acute diverticulitis have a perforation with purulent or fecal
peritonitis, mortality rates approach 20 percent [14-17]. In patients with a free
perforation, the abdomen is distended and diffusely tender to light palpation. There
is diffuse guarding, rigidity, and rebound tenderness, and bowel sounds are absent.
(See "Evaluation of the adult with abdominal pain".)

Fistula — Inflammation from acute diverticulitis may result in the formation of a

fistula between the colon and adjacent viscera. Fistulas most commonly involve the
bladder [18]. (See "Diverticular fistulas", section on 'Introduction'.)

Patients with a colovesical fistula may have pneumaturia, fecaluria, or dysuria.

Patients with a colovaginal fistula may report vaginal passage of feces or flatus. The
clinical manifestations, diagnosis, and treatment of fistulas in patients with acute
diverticulitis are discussed in detail separately. (See "Diverticular fistulas", section on
'Clinical manifestations'.)

Laboratory findings — Patients with acute diverticulitis may have an elevated C-

reactive protein and a mild leukocytosis [19,20]. However, the white count may be
normal in up to 45 percent of patients [21]. C-reactive protein is not reliable for
ruling out complicated disease [22]. Serum amylase and lipase may be normal or
mildly elevated, especially in patients with a free perforation and peritonitis. (See
"Approach to the patient with elevated serum amylase or lipase", section on
'Causes'.)

Urinalysis may reveal sterile pyuria due to adjacent inflammation. The presence of
colonic flora on urine culture suggests the presence of a colovesical fistula. (See
"Sampling and evaluation of voided urine in the diagnosis of urinary tract infection
in adults", section on 'Sterile pyuria' and "Diverticular fistulas", section on 'Clinical
manifestations'.)

Imaging — Several features may be seen on imaging in patients with acute

diverticulitis.

Computed tomography scan — Computed tomography (CT) findings suggestive

of acute diverticulitis include the presence of localized bowel wall thickening (>4
mm), an increase in soft tissue density within the pericolonic fat secondary to
inflammation or fat stranding, and the presence of colonic diverticula
( image 1A-B) [23-25]. The sensitivity and specificity of abdominal CT for the
diagnosis of acute diverticulitis are 94 and 99 percent, respectively [26].

Complications of diverticulitis can also be visualized on abdominal CT scan.

Abscesses are identified as fluid collections surrounded by an area with
inflammatory changes. The center of the collection may contain air, air-fluid levels,
or tissue with low attenuation representing necrotic debris [27]. Abdominal CT scan
findings in patients with a bowel obstruction due to acute diverticulitis include the
presence of dilated loops of bowel with air-fluid levels in proximity of an area with
pericolonic inflammation (fat stranding). Extracolonic air collections within organs
other than the bowel and the abdominal wall are suggestive of a fistula. In patients
with peritonitis, free air can be seen on abdominal CT scan. (See "Diverticular
fistulas", section on 'Diagnosis'.)

Abdominal ultrasound — Ultrasound features suggestive of acute diverticulitis

include:
 ● A hypoechoic peridiverticular inflammatory reaction
● Mural and peridiverticular abscess formation with or without gas bubbles
● Bowel wall thickening (segmental mural thickening greater than 4 mm) at the
point of maximal tenderness
● Presence of diverticula in the surrounding segments

Complications of diverticulitis may also be visualized by ultrasonography. An

abscess appears as an anechoic masses containing echogenic debris ( image 2).
Features suggestive of a fistula include the presence of a hypoechoic area next to
inflamed diverticula with extraluminal air bubbles extending in the bladder, vagina,
or abdominal wall. In patients with peritonitis, ascites, diffuse peritoneal thickening,
and scattered loculated fluid collections may be seen. (See "Transabdominal
ultrasonography of the small and large intestine", section on 'Diverticulitis'.)

High-resolution, graded, compression ultrasound has comparable sensitivity and

specificity for acute diverticulitis as compared with abdominal CT scan [28].
Ultrasound also has the advantage that it is widely available, inexpensive, and
avoids radiation exposure. However, abdominal ultrasound is operator dependent
and cannot exclude other causes of abdominal pain. (See 'Differential diagnosis'
below.)

Magnetic resonance imaging — Abdominal magnetic resonance imaging (MRI)

findings suggestive of acute diverticulitis include colonic wall thickening, presence
of diverticula, and pericolonic exudates and edema [29,30]. Nonspecific findings that
can be seen on MRI include segmental narrowing of the colon, ascites, and an
abscess.

MRI has the advantage of avoiding radiation exposure. However, before MRI can
routinely be used to diagnose acute diverticulitis and rule out other causes of
abdominal pain, more studies are needed to compare the sensitivity, specificity, and
cost-effectiveness of abdominal MRI with CT scan. In most institutions where both
abdominal CT and MRI are available, CT is usually obtainable more expeditiously.

Abdominal and chest radiographs — Nonspecific abnormalities can be seen on

abdominal radiographs in 30 to 50 percent of patients with acute diverticulitis [31].
These findings include air-fluid levels with small or large intestinal dilation due to an
ileus or obstruction and soft tissue densities due to the presence of an abscess. An
upright chest radiograph may demonstrate the presence of pneumoperitoneum
with air under the diaphragm in 3 to 12 percent of patients with acute diverticulitis
[31].

DIAGNOSTIC APPROACH

Diagnosis — The diagnosis of acute diverticulitis should be suspected in a patient

with lower abdominal pain and abdominal tenderness on physical examination. The
pain is usually in the left lower quadrant in Western populations but may be
suprapubic or in the right lower quadrant, particularly in patients with right-sided
diverticulitis. Laboratory findings of an elevated CRP (>50 mg/dL) leukocytosis, while
not sensitive or specific for acute diverticulitis, can support the diagnosis. We
perform abdominal imaging (preferably computed tomography [CT] scan) to
establish the diagnosis of acute diverticulitis. (See 'Imaging' above.)

The authors' practice is to perform an abdominal CT scan with oral and intravenous
(IV) contrast to establish the diagnosis of acute diverticulitis because it has a high
sensitivity and specificity for acute diverticulitis and can exclude other causes of
abdominal pain. However, some guidelines suggest that imaging can be performed
more selectively, and that a diagnosis can be made without abdominal imaging in
patients with localized left lower quadrant pain in the absence of vomiting, a
CRP>50 mg/dL, and/or a prior history of acute diverticulitis [32]. (See 'Computed
tomography scan' above and 'Differential diagnosis' below.)

Evaluation — The goal of the evaluation is to establish the diagnosis of acute

diverticulitis and to rule out other causes of abdominal pain. Evaluation should
begin with a history and physical examination, which includes a pelvic examination
in women to rule out pelvic pathology. (See 'Clinical manifestations' above and
'Differential diagnosis' below and "Evaluation of the adult with abdominal pain",
section on 'Lower abdominal pain' and "The gynecologic history and pelvic
examination", section on 'Components of the examination'.)

Laboratory evaluation should include a complete blood count, electrolytes, and

urine analysis. A pregnancy test should be performed in all women of childbearing
age. The presence of leukocytosis is supportive of the diagnosis of acute
diverticulitis. (See 'Laboratory findings' above.)

In patients with a suspected perforation and diffuse peritonitis, serum

aminotransferases, alkaline phosphatase, bilirubin, amylase, and lipase levels
should be obtained to rule out other causes of acute abdominal pain. (See
"Evaluation of the adult with abdominal pain", section on 'Initial workup'.)

Stool studies should be performed only in patients with diarrhea to rule out
infectious etiologies. Stool studies should include stool Clostridioides difficile toxin,
routine stool cultures (Salmonella, Shigella, Campylobacter, Yersinia), specific testing
for E. coli O157:H7, microscopy for ova and parasites (three samples), and a Giardia
stool antigen test. In patients with a clear diagnosis of diverticulitis on imaging
studies, stool studies are rarely indicated.

We perform an abdominal CT scan with oral and intravenous (IV) contrast to

establish the diagnosis of acute diverticulitis. High-resolution, graded, compression
ultrasound should be performed if abdominal CT scan is unavailable [33,34].
Abdominal CT scan and ultrasound features suggestive of acute diverticulitis are
reviewed above ( image 1A-B) [23-25]. (See 'Computed tomography scan' above
and 'Abdominal ultrasound' above.)

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of acute diverticulitis includes other etiologies of lower

abdominal pain. Acute diverticulitis can be distinguished from most other causes of
lower abdominal pain based on the clinical features, physical examination,
laboratory studies, and abdominal computed tomography (CT) scan.

● Irritable bowel syndrome (IBS) – The abdominal discomfort seen in patients

with IBS can be similar to patients with diverticulitis. However, the symptoms
of abdominal pain and altered bowel habits are chronic in patients with IBS.
Patients with IBS usually also have symptoms of bloating, distension, and
diarrhea and/or constipation. CT scan is diagnostic in patients with
diverticulitis and normal in patients with IBS. (See "Clinical manifestations and
diagnosis of irritable bowel syndrome in adults".)
● Colorectal cancer – Patients with colorectal cancer (CRC) and acute
diverticulitis may present with similar clinical features and have bowel wall
thickening on abdominal CT. However, the presence of pericolonic and
mesenteric inflammation, involvement of greater than 10 cm of the colon, and
absence of enlarged pericolonic lymph nodes on abdominal CT are suggestive
of acute diverticulitis [35,36]. In 10 to 20 percent of patients, it remains difficult
to distinguish between acute diverticulitis and a CRC on abdominal CT scan,
and a CRC can only be excluded with a colonoscopy after resolution of acute
inflammation [37,38]. (See "Clinical presentation, diagnosis, and staging of
colorectal cancer", section on 'Clinical presentation' and 'Exclusion of an
underlying malignancy' below.)

● Acute appendicitis – Classic symptoms of appendicitis include right lower

quadrant abdominal pain, anorexia, fever, nausea, and vomiting. The
abdominal pain is initially periumbilical and subsequently in the right lower
quadrant. Abdominal CT scan can differentiate between acute appendicitis and
acute diverticulitis. The abdominal CT scan findings in patients with acute
appendicitis are discussed in detail, separately. (See "Acute appendicitis in
adults: Diagnostic evaluation", section on 'Computed tomography' and "Acute
appendicitis in adults: Clinical manifestations and differential diagnosis",
section on 'Computed tomography findings'.)

● Inflammatory bowel disease – In patients with inflammatory bowel disease

(IBD), diarrhea rather than abdominal pain is the predominant symptom. In
addition, patients have symptoms for several months prior to presentation.
Although abdominal CT scan may demonstrate wall thickening in both acute
diverticulitis and IBD, the presence of diverticulosis and peridiverticular
inflammation are suggestive of acute diverticulitis. (See "Clinical
manifestations, diagnosis, and prognosis of ulcerative colitis in adults", section
on 'Imaging'.)

● Infectious colitis – In patients with infectious colitis, diarrhea is the

predominant symptom. Patients may have a history of prior antibiotic use or
recent travel. Stool cultures may identify the causative pathogen. While an
abdominal CT may demonstrate wall thickening in infectious colitis,
peridiverticular inflammation, as seen in patients with acute diverticulitis, is
 absent. (See 'Evaluation' above.)

● Ischemic colitis – Patients with ischemic colitis usually present with rapid
onset of abdominal pain, hematochezia, or bloody diarrhea. Patients may have
risk factors for ischemic colitis (eg, age >60 years, hemodialysis, hypertension,
diabetes mellitus, dehydration, or stimulant laxative use). On abdominal CT
scan, segmental bowel wall thickening can be seen, similar to patients with
acute diverticulitis, but pericolonic inflammation is absent. (See "Colonic
ischemia", section on 'Clinical features' and "Colonic ischemia", section on
'Diagnosis'.)

● Other – Alternative diagnoses should also be considered in the differential

diagnosis of acute diverticulitis. These include tubo-ovarian abscess, ovarian
cyst, ovarian torsion, ectopic pregnancy, cystitis, and nephrolithiasis. These can
be differentiated from acute diverticulitis by history, physical examination,
laboratory studies, and imaging and are discussed in detail, separately. (See
"Evaluation of the adult with abdominal pain", section on 'Lower abdominal
pain'.)

EXCLUSION OF AN UNDERLYING MALIGNANCY

Colonoscopy has no role in establishing the diagnosis of acute diverticulitis as the

inflammation is peridiverticular. Endoscopic evaluation of the colon should be
avoided in the acute setting due to the risk of perforation or exacerbation of the
existing inflammation. After the complete resolution of symptoms associated with
acute diverticulitis (typically in six to eight weeks), a colonoscopy is performed to
rule out missed malignancy, except for those who have had a colonoscopy within
the previous year [6,39,40]. The risk of a missed malignancy is higher in patients
with a history of complicated diverticulitis as compared to uncomplicated
diverticulitis [41]. Patients with recurrent acute diverticulitis should follow routine
screening and surveillance intervals after the baseline colonoscopy unless alarm
symptoms develop. (See "Acute colonic diverticulitis: Medical management", section
on 'Colonoscopy for all patients'.)
NATURAL HISTORY

Patients with acute diverticulitis present with lower abdominal pain, usually in the
left lower quadrant and a low-grade fever.

Disease course — Disease course depends on multiple factors including patient

characteristics, prior history of diverticular disease, and severity of the episode [3].

The most common presentation of diverticulitis is acute uncomplicated disease.

Most patients with this presentation recover from the acute episode. Median time to
recovery is 14 days [42]. Among patients with acute uncomplicated diverticulitis at
initial presentation, 5 percent will develop a complication, usually within 10 days of
presentation. Obstruction is the most common complication followed by perforation
and abscess [11].

Ongoing abdominal discomfort is common after resolution of acute inflammation.

In a cohort study of patients with imaging-confirmed acute uncomplicated
diverticulitis, 45 percent of patients reported abdominal pain and 33 percent
reported altered bowel habits at one-year follow-up. The differential diagnosis for
ongoing symptoms is broad. Imaging and colonoscopy may need to be considered
to rule out an alternative diagnosis or ongoing inflammation. In approximately 5
percent of patients, chronic abdominal pain is due to chronic or smoldering
diverticulitis with persistent chronic diverticular inflammation [43].

After recovery from an acute episode managed conservatively, patients are at risk
for recurrent episodes. The risk of recurrence depends on the number of prior
episodes and disease severity. After a first episode of diverticulitis, the risk of a
second episode is 22 percent within 10 years. After a second episode, the risk of a
third episode is 55 percent. The risk of recurrence increases with every episode.
Diverticulitis complicated by abscess or perforation is usually the first or sometimes
the second presentation. Recurrent diverticulitis is not associated with an increased
risk of perforation or abscess [3].

A fibrotic diverticular stricture can develop after an episode of acute diverticulitis.

Recurrent episodes are not a risk factor for the development of a diverticular
stricture [44]. Patients with a colonic stricture usually present with obstructive
symptoms without diverticulitis or sometimes with more insidious symptoms of
abdominal pain and constipation. Fistulizing disease from diverticulitis is rare, but
the risk increases with recurrence [44]. (See "Acute colonic diverticulitis: Medical
management", section on 'Obstruction'.)

Mortality — In patients with acute diverticulitis, mortality rates vary depending on

the presence of complications and patient comorbidities. In patients with acute
uncomplicated diverticulitis, conservative treatment is successful in 70 to 100
percent of patients and mortality is negligible [45]. (See "Acute colonic diverticulitis:
Medical management".)

In patients with complicated diverticulitis undergoing an operation, the mortality

rate is approximately 0.6 to 5 percent [46-48]. Although mortality rates are up to 20
percent in patients with perforated diverticulitis with purulent or fecal peritonitis,
these complications are rare in the absence of diffuse peritonitis [14-17]. (See "Acute
colonic diverticulitis: Medical management" and "Acute colonic diverticulitis: Surgical
management".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links:
Colonic diverticular disease".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials. Beyond the
Basics patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical
jargon.
Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

● Basics topics (see "Patient education: Diverticulitis (The Basics)")

● Beyond the Basics topics (see "Patient education: Diverticular disease (Beyond
the Basics)")

SUMMARY AND RECOMMENDATIONS

● Definition – Acute diverticulitis is defined as inflammation and/or infection of

a diverticulum. (See 'Definitions' above.)

Diverticulitis is most commonly managed in the ambulatory setting. The

incidence of diverticulitis increases with age but is not uncommon in young
adults.

● Clinical manifestations – Abdominal pain is the most common complaint in

patients with acute diverticulitis. The pain is left sided in approximately 85
percent of patients. However, patients may present with right lower quadrant
or suprapubic pain due to the presence of a redundant inflamed sigmoid colon
or right-sided (cecal) diverticulitis. Patients may also have a low-grade fever.
Other associated symptoms include nausea, vomiting, constipation, and
diarrhea. (See 'Clinical features' above.)

● Acute complications – Approximately 12 percent of patients with acute

diverticulitis have associated complications. Acute complications include bowel
obstruction, development of an abscess, fistula, stricture, or a colonic
perforation into the peritoneum and peritonitis. Diverticulitis complicated by
an abscess or perforation is usually the first or second presentation of the
disease. Recurrent episodes are not a risk factor for developing perforation or
abscess. (See 'Acute complications' above and 'Disease course' above.)

● Diagnosis – The diagnosis of acute diverticulitis should be suspected in a

 patient with lower abdominal pain with tenderness to palpation on physical
examination. Laboratory findings of leukocytosis, while not sensitive or specific
for acute diverticulitis, can support the diagnosis. Abdominal imaging is
required to establish the diagnosis of acute diverticulitis. We perform an
abdominal computed tomography (CT) scan with oral and intravenous contrast
to establish the diagnosis of acute diverticulitis because it has a high sensitivity
and specificity for acute diverticulitis and can exclude other causes of
abdominal pain.

CT scan findings suggestive of acute diverticulitis include the presence of

localized bowel wall thickening (>4 mm), an increase in soft tissue density
within the pericolonic fat secondary to inflammation, and the presence of
colonic diverticula. (See 'Diagnosis' above and 'Computed tomography scan'
above.)

● Role of delayed colonoscopy – Colonoscopy has no role in establishing the

diagnosis of acute diverticulitis and should not be performed in the acute
setting due to the risk of perforation. However, a colonoscopy should generally
be performed at least six weeks after recovery to definitively rule out the
presence of an underlying colorectal cancer, unless the patient has had a
colonoscopy within the previous year. Patients with recurrent uncomplicated
diverticulitis should follow routine screening and surveillance intervals after
the baseline colonoscopy unless alarm symptoms develop. (See 'Exclusion of
an underlying malignancy' above.)

● Natural history – Ongoing abdominal discomfort is common after resolution

of acute inflammation. The differential for ongoing symptoms is broad.
Imaging and colonoscopy may need to be considered to rule out an alternative
diagnosis or ongoing inflammation.

ACKNOWLEDGMENT

The editorial staff at UpToDate acknowledge Tonia Young-Fadok, MD, and Per Olav
Vandvik, MD, PhD, who contributed to an earlier version of this topic review.
 Use of UpToDate is subject to the Terms of Use.

Topic 2633 Version 39.0

GRAPHICS

Mild diverticulitis of the sigmoid colon on CT

A CT scan of the pelvis in a patient with mild acute diverticulitis.

There is mild induration of the perisigmoid fat (arrow) and
thickening of the sigmoid mesocolon (dashed arrow). Multiple
diverticula are noted (arrowheads).

CT: computed tomography.

Graphic 80808 Version 11.0

Diverticular abscess of the sigmoid colon

Single axial CT scan of the pelvis demonstrates an abscess

surrounding and compressing the sigmoid colon (arrow) which is
markedly narrowed. There is a small amount of gas within the
abscess (arrowhead).

CT: computed tomography.

Courtesy of Norman Joffe, MD.

Graphic 75134 Version 3.0

Diverticulitis on ultrasound

Ultrasound images showing a hypoechoic region adjacent to the

sigmoid colon representing a diverticular abscess (ABSZ top panel).
Regression was demonstrated after five days of conservative
treatment (bottom).

Courtesy of Christoph F Dietrich, MD.

Graphic 56822 Version 3.0