Diverticular disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 15 Apr 2025

Last updated: 27 Feb 2025

Acute diverticulitis typically presents with left lower quadrant abdominal pain, often together with fever and leukocytosis.

Laboratory test results are not consistently reliable and computed tomography scan is the imaging modality of choice for acute diverticulitis.

Complications of diverticulitis include perforation, abscess, peritonitis, fistula, stricture, obstruction, or chronic inflammation.

Treatment for acute diverticulitis may include bowel rest, analgesics, antibiotics, and surgical intervention.

Diverticulosis is the presence of diverticula without symptoms. It is usually an incidental finding and requires no treatment, although patients may benefit from dietary changes to reduce the risk of progression to diverticulitis.

Definition

Colonic diverticulosis refers to herniation of the mucosa and submucosa through the muscular layer of the colonic wall. Diverticulosis is the presence of diverticula without symptoms.[1] Diverticulitis indicates inflammation of a diverticulum or diverticula; it is described as "complicated" where there is acute inflammation with an abscess, phlegmon, fistula, obstruction, or perforation, with or without peritonitis, or "uncomplicated" where there is acute onset of inflammation but without any of these complications.[2][3] Complications of acute diverticulitis most commonly include abscess, perforation, peritonitis, fistula formation, and obstruction, while segmental colitis, and chronic/smoldering diverticulitis, can also occur.

History and exam

Key diagnostic factors

left lower quadrant abdominal pain
fever

Full details

Other diagnostic factors

guarding in left lower quadrant
tenderness in left lower quadrant
rebound tenderness
diffuse abdominal tenderness
change in bowel habit
palpable abdominal mass

Full details

Risk factors

age >50 years
low dietary fiber
diet rich in salt, meat, and sugar
obesity (BMI >30)
use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or opioids
tobacco smoking
alcohol consumption

Full details

Diagnostic tests

1st tests to order

CBC with differential
CRP
basic metabolic panel
contrast CT scan of abdomen

Full details

Tests to consider

blood culture
ABG and serum lactate
noncontrast CT scan of abdomen
abdominal ultrasound (graded-compression)
abdominal MRI scan
colonoscopy or sigmoidoscopy
diagnostic laparoscopy/exploratory laparotomy

Full details

Treatment algorithm

ACUTE

asymptomatic diverticulosis

acute uncomplicated diverticulitis

acute complicated diverticulitis

ONGOING

recurrent diverticulitis

Contributors

Authors

Marilyse Boutros, MD, FACS, FRCSC

Vice-Chair and Regional Director of Research for the Digestive Disease Institute, Cleveland Clinic Weston Hospital

Colorectal Surgeon, Cleveland Clinic Florida

Weston

Clinical Affiliate Professor of Surgery, Florida Atlantic University

Boca Raton

Professor of Surgery, McGill University

Montreal

Canada

Disclosures

MB has received teaching honorarium from Ethicon and Johnson and Johnson.

Sameh Hany Emile, MBBCh, MSc, MD, FACS

Project Scientist

Department of Colorectal Surgery

Cleveland Clinic Florida

Weston

Clinical Affiliate Associate Professor of Surgery

Florida Atlantic University

Boca Raton

Associate Professor of Surgery

Mansoura University Faculty of Medicine

Mansoura City

Egypt

Disclosures

SHE receives consultancy fees from Becton, Dickinson and Company.

Acknowledgements

Dr Marilyse Boutros and Dr Sameh Hany Emile would like to gratefully acknowledge Dr Mohamed A. Thaha, Dr Jayan D. Jayasinghe, Dr Emma Carrington, Ms Kathryn Lynes, Professor Norman S. Williams, and Dr Abbasi Akhtar, the previous contributors to this topic.

Disclosures

MAT declares he has no competing interests. JDJ declares that he has no competing interests. EC has received honoraria for teaching, and acts as a consultant for Laborie Medical Management Systems. KL has received funding for a research fellowship from the David Johnston Fellowship through the Royal College of Surgeons of England. NSW is an author of a reference cited in this topic. AA declares that he has no competing interests.

Peer reviewers

Ned Snyder, MD, FACP

Professor of Medicine

Chief of Clinical Gastroenterology and Hepatology

University of Texas Medical Branch

Galveston

Disclosures

NS declares that he has no competing interests.

Nicolas Regenet, MD

Clinic of digestive and endocrine surgery

University Hospital

Nantes

France

Disclosures

NR declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Hall J, Hardiman K, Lee S, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020 Jun;63(6):728-47.Full text Abstract

Sartelli M, Weber DG, Kluger Y, et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg. 2020 May 7;15(1):32.Full text Abstract

Stollman N, Smalley W, Hirano I; AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of acute diverticulitis. Gastroenterology. 2015 Dec;149(7):1944-9.Full text Abstract

Peery AF, Shaukat A, Strate LL. AGA clinical practice update on medical management of colonic diverticulitis: expert review. Gastroenterology. 2021 Feb;160(3):906-11.e1.Full text Abstract

American College of Radiology. ACR appropriateness criteria: left lower quadrant pain. 2023 [internet publication].Full text

Qaseem A, Etxeandia-Ikobaltzeta I, Lin JS, et al; Clinical Guidelines Committee of the American College of Physicians. Diagnosis and management of acute left-sided colonic diverticulitis: a clinical guideline from the American College of Physicians. Ann Intern Med. 2022 Mar;175(3):399-415.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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- Colorectal cancer
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Guidelines
- Diagnosis and management of acute left-sided colonic diverticulitis
- 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting
More Guidelines
Patient information
Appendicitis
Constipation in adults
More Patient information
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Diverticular disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

asymptomatic diverticulosis

acute uncomplicated diverticulitis

acute complicated diverticulitis

recurrent diverticulitis

Contributors

Authors

Marilyse Boutros, MD, FACS, FRCSC

Disclosures

Sameh Hany Emile, MBBCh, MSc, MD, FACS

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Ned Snyder, MD, FACP

Disclosures

Nicolas Regenet, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice