INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Pathophysiology

Diverticula are small mucosal herniations protruding through the intestinal layers and the smooth muscle along the natural openings created by the vasa recta or nutrient vessels in the wall of the colon. These herniations create small pouches lined solely by mucosa. Diverticula can occur anywhere in the gastrointestinal tract but are usually observed in the colon. The sigmoid colon has the highest intraluminal pressures and is most commonly affected. Diverticulosis is defined as the condition of having uninflamed diverticula. The cause of diverticulosis is not yet conclusive, but it appears to be associated with a low-fiber diet, constipation, and obesity.

Diverticulitis is defined as an inflammation of one or more diverticula. Its pathogenesis remains unclear.  Fecal material or undigested food particles may collect in a diverticulum, causing obstruction. This obstruction may result in distension of the diverticula secondary to mucous secretion and overgrowth of normal colonic bacteria. Vascular compromise and subsequent microperforation or macroperforation then ensue. Alternatively, some believe that increased intraluminal pressure or inspissated food particles cause erosion of the diverticular wall, resulting in inflammation, focal necrosis, and perforation. The disease is frequently mild when pericolic fat and mesentery wall off a small perforation. However, larger perforations and more extensive disease lead to abscess formation and, rarely, intestinal rupture or peritonitis.

Fistula formation is a complication of diverticulitis. Fistulas to adjacent organs and the skin may develop, especially in the presence of an abscess. In men, colovesicular fistulas are the most common. In women, the uterus is interposed between the colon and the bladder, and this complication is only seen following a hysterectomy. The uterus precludes fistula formation from the sigmoid colon to the urinary bladder. However, colovaginal and colocutaneous fistulas can form but are uncommon.

Recurrent attacks of diverticulitis can result in the formation of scar tissue, leading to narrowing and obstruction of the colonic lumen.

Frequency

United States

Asymptomatic diverticulosis is a common condition. The incidence of diverticulosis increases with age, from less than 5% before age 40 years to greater than 65% by age 85 years.

Diverticulitis appears to be more common in patients with the largest number of diverticula; 15-20% of those with diverticulosis develop diverticulitis. While diverticulitis is generally considered a disease of the elderly population, as many as 20% of patients with diverticulitis are younger than 50 years.

International

Diverticulosis occurs more frequently in Western countries and industrialized societies. As it is less common in underdeveloped countries, diverticulitis is also less common. The reason is unclear but presumably secondary to lifestyle and dietary factors. In fact, after adopting a more Western lifestyle, the prevalence of diverticulosis has increased in Japan.  For unclear reasons, right-sided disease is more common in Asian people, accounting for as many as 75% of cases of diverticulitis in that group. 

Mortality/Morbidity

Of patients with diverticulosis, 80-85% remain asymptomatic. Approximately 5% develop diverticulitis; 15-25% of those with diverticulitis develop complications leading to surgery. These complications include abscess formation, intestinal rupture, peritonitis, and fistula formation. 

Diverticulitis may be a more severe illness in patients who are immunocompromised, in patients with significant comorbid conditions, and in those taking anti-inflammatory medications.  

• Patients with diverticulitis who are managed conservatively (ie, do not receive surgery) have a recurrence rate of 20-35%. 
• In one study of 252 patients, a recurrence rate of 50% was reported after 7 years. The rate of surgery in these patients was 8% at 7 years and rose to 14% by 13 years.  Recurrence rates after surgical resection range from 1-3%. The mortality rate from complications in patients with recurrent disease in this small study was 1%.
• Another study of 337 patients hospitalized for complicated diverticulitis revealed an association of perforation and mortality in those with no prior history of diverticulitis.  Of these patients with complicated diverticulitis, 53% presented on a first event.
• These morbidity and mortality data, as well as recurrence rates, are based on a retrospective review of relatively short-term data.

Race

Genetics are believed to play a role, in addition to dietary factors. Left-sided diverticula predominate in the United States. Asians, including Asian Americans, have a predominance of right-sided diverticula.

Sex

Prevalence is similar in men and women.

Age

Diverticular disease increases in incidence with age, reaching a prevalence of greater than 65% in those older than 85 years. The mean age at presentation with diverticulitis appears to be about 60 years.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

The clinical presentation of diverticulitis 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.  Pain is often described as crampy and may be associated with a change in bowel habits. Other symptoms include nausea and vomiting, constipation, diarrhea, flatulence, and bloating.  Symptoms of mild diverticulitis may be confused with overlapping symptoms of irritable bowel syndrome.   

A microperforation, most likely walled off by adjacent structures, may present with no systemic signs of illness or infection. On the other hand, 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. Because diverticula and, hence, diverticulitis can develop anywhere in the gastrointestinal tract, symptoms may mimic multiple conditions.

• Diverticulitis in the right colon or in a redundant sigmoid colon may be mistaken for acute appendicitis. Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis. Retroperitoneal involvement may present similar to renal disease. In women, lower quadrant pain may be difficult to distinguish from a gynecological process.
• More severe diverticulitis is often accompanied by anorexia, nausea, and vomiting. Typically, the pain is localized and severe and present for several days prior to presentation. Altered bowel habits, especially constipation, are reported by most patients. A small percentage of patients may complain of urinary symptoms, such as dysuria, urgency, and frequency, due to inflammation adjacent to urinary tract structures.
• Macroperforation with spillage of colonic contents into the peritoneum leads to generalized abdominal pain and peritonitis.
• Leg pain possibly associated with a thigh abscess and leg emphysema secondary to retroperitoneal perforation from diverticulitis have been reported.

Physical

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

• In simple diverticulitis, localized abdominal tenderness in the area of the affected diverticula and fever are common findings. Left lower quadrant tenderness is the most common physical finding, as most diverticula occur in the sigmoid colon. 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 felt on physical examination. In fact, 20% of cases present with a palpable mass on abdominal, pelvic, or rectal examination. Peritonitis due to free perforation results in generalized tenderness with rebound and guarding on abdominal examination. The abdomen may be distended and tympanic to percussion. Bowel sounds can be diminished or absent.
• Elderly patients and some patients taking corticosteroids may have unremarkable findings on physical examination even in the presence of severe diverticulitis. Such patients must be approached with a high index of suspicion to avoid a delay in establishing the correct diagnosis.
• If a fistula forms, the 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 can also be observed. Female patients with colovaginal fistulas may present with a purulent vaginal discharge.

Causes

See Pathophysiology.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab 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

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical Care

The approach to the treatment of diverticulitis can be broadly classified into either uncomplicated disease or complicated disease, with a few other special considerations to take into account. Acute uncomplicated diverticulitis is successfully treated in 70-100% of patients with conservative management. 

• Acute diverticulitis tends to be more severe in very elderly people and in patients who are immunocompromised or who have debilitating comorbid conditions, such as diabetes and renal failure.
• Patients with mild diverticulitis, typically with Hinchey stage I disease, can be started on an outpatient treatment regimen. This consists of a clear liquid diet and 7-10 days of oral broad-spectrum antimicrobial therapy, which covers anaerobic microorganisms, such as Bacteroides fragilis and Peptostreptococcus and Clostridium organisms, as well as aerobic microorganisms, such as Escherichia coli and Klebsiella, Proteus, Streptococcus, and Enterobacter organisms. Single and multiple antibiotic regimens are equally effective as long as both groups of organisms are covered.  
• • One typical oral antibiotic regimen is a combination of ciprofloxacin (or trimethoprim-sulfamethoxazole) and metronidazole. Moxifloxacin is appropriate monotherapy for outpatient treatment of uncomplicated diverticulitis. Amoxicillin/clavulanic acid monotherapy is acceptable as well.
  • Patients should be instructed to be on a clear liquid diet only and can advance the diet slowly as tolerated after clinical improvement, which usually occurs within 2-3 days. 
• Hospitalization is required with evidence of severe diverticulitis, such as systemic signs of infection or peritonitis. Patients who are unable to tolerate oral hydration, who fail outpatient therapy (ie, persistent or increasing fever, pain, or leukocytosis after 2-3 d), who are immunocompromised, or who have comorbidities may also require hospitalization. Pain may be severe enough to require parenteral narcotic analgesia. 
• • Initiate bowel rest and intravenous fluid hydration. Start broad-spectrum intravenous antibiotic coverage until culture results, if obtained, are available.
  • Monotherapy with beta-lactamase inhibiting antibiotics or carbapenems provides broad antibacterial coverage and is appropriate for patients who are moderately ill and require admission. Such antibiotics include the following: piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid, imipenem, or meropenem.
  • Multiple drug regimens are also appropriate options in the hospital setting and may consist of metronidazole and a third-generation cephalosporin or a fluoroquinolone. Such antibiotics include the following: ceftriaxone, cefotaxime, ciprofloxacin, or levofloxacin.  Previously, gentamicin was recommended as part of a multiple drug regimen. Although it is still a reasonable choice, substitution with a third-generation cephalosporin or a fluoroquinolone has been advocated to avoid the risk of aminoglycoside nephrotoxicity.
  • When severe penicillin allergy is a concern, tigecycline is a good choice for monotherapy.
  • For patients who are immunocompromised, imipenem or meropenem may be preferred over ertapenem for better enterococcal and pseudomonal coverage.
  • Pain management is important. Morphine is acceptable for pain control and is preferable over meperidine given the adverse effects associated with meperidine. Although early recommendations for pain management favored meperidine based on a theoretical risk of affecting bowel tone and sphincters, randomized prospective studies comparing the narcotic options are not available.  Use of nonsteroidal anti-inflammatory drugs and corticosteroids have been associated with a greater risk of colon perforation and should be avoided whenever possible.
  • Within 2-3 days of hospitalization, the patient's fever, pain, and leukocytosis should begin to resolve. The patient can then be started on a clear liquid diet and advanced as tolerated. If tolerating oral intake and clinically stable, the patient can be discharged to complete a 7- to 10-day course of oral antibiotic therapy.
  • If fever and leukocytosis do not resolve after 2-3 days of treatment or if serial examinations reveal worsening signs or new peritoneal findings, a repeat CT scan of the abdomen is advisable to rule out an abdominal abscess or other complications.
  • If a patient is found to have a peridiverticular abscess that measures more than 4 cm in diameter (Hinchey stage II disease), a CT–guided percutaneous drainage is indicated. This usually leads to a prompt (<72 h) reduction in pain, fever, and leukocytosis. Percutaneous drainage is also beneficial in that it may allow for elective surgery rather than emergency surgery and increase the likelihood of a successful 1-stage procedure.
  • For abscess cavities containing gross fecal material or when there is perforation, early surgical intervention is required.
• Once the acute episode has resolved, the patient may advance diet as tolerated and then maintain a lifelong high-fiber diet. Colonoscopy or, alternatively, barium enema with flexible sigmoidoscopy should be done after resolution of an initial episode (typically 2-6 wk after recovery) to exclude other diagnoses, such as cancer, ischemia, and inflammatory bowel disease.

Surgical Care

About 15-25% of patients presenting with a first episode of acute diverticulitis have complicated disease that requires surgery.

• The classic surgical indications include some features characteristic of Hinchey stage III or IV disease and are as follows:
• • Free-air perforation with fecal peritonitis
  • Suppurative peritonitis secondary to a ruptured abscess
  • Uncontrolled sepsis
  • Abdominal or pelvic abscess (unless CT-guided aspiration is possible)
  • Fistula formation
  • Inability to rule out carcinoma
  • Intestinal obstruction
  • Failing medical therapy
  • Immunocompromised status
  • Extremes of age
  • Recurrent episodes of acute diverticulitis (Elective surgery was previously recommended in any patient who had 2 or more episodes of diverticulitis that were successfully treated medically; however, recent data call this practice into question when the patient is otherwise healthy.)
• Preoperative preparation with antibiotics should be given in all patients.  Single and multiple drug regimens, as discussed in Medical Care, are appropriate choices.  However, for patients with more extensive contamination, a single drug regimen (with either imipenem/cilastin or piperacillin/tazobactam) or a multiple drug regimen (with ampicillin, gentamicin, and metronidazole) may be warranted for peritonitis.  Bowel preparation is usually possible for nonemergent situations.
• The American Society of Colon and Rectal Surgeons most recent guidelines from 2006 recommend emergency surgery for patients with diffuse peritonitis or for those who fail nonoperative management. Also, patients who are immunosuppressed or immunocompromised are at an increased risk of failing medical therapy or perforation and should be approached with a lower threshold.
• A 2-stage surgical approach is the most common surgical procedure performed today for the emergency treatment of acute diverticulitis.
• • A traditional Hartmann procedure is commonly performed, which involves resection of the diseased segment of bowel, an end-colostomy, and closure of the rectal stump. Typically, 3 months later, a second procedure can be performed to close the rectal stump; however, this second operation can be technically difficult and is not performed in many patients. This is the preferred approach in patients with fecal peritonitis and in most cases of purulent peritonitis. 
  • An alternative to the Hartmann procedure includes resection of the diseased colon, primary anastomosis (with or without intraoperative colonic lavage), and proximal diverting stoma, either colostomy or ileostomy. The second procedure in this course would be to close the stoma. This approach is primarily used when there are relative contraindications to primary anastomosis but no purulent or feculent peritonitis and there is nonedematous bowel. The advantage is that it avoids the technically difficult second stage used in the Hartmann procedure.
  • Extensive and unnecessary dissections, which open up tissue planes to infection and increase blood loss, have no role.
• The decision to proceed with elective surgery, typically at least 6 weeks after recovery from acute diverticulitis, should be made on a case-by-case basis.  This decision should consider age and medical condition of the patient, frequency and severity of attacks, and the presence of any persistent symptoms after the acute episode. Other appropriate indications for elective colectomy include inability to exclude carcinoma, after an episode of complicated diverticulitis treated nonoperatively, or after percutaneous drainage of a diverticular abscess.
• • Regarding frequency, after one attack, about one third of patients will have a later second attack of acute diverticulitis. After a second episode, a further one third will have yet another attack. 
  • Regarding severity, most patients who present with complicated diverticulitis do so at the time of their first episode. Therefore, once a patient's initial presentation has been determined to be uncomplicated or complicated, the patient's future episodes are likely to follow a similar course.
  • A 1-stage surgical approach with resection and primary anastomosis is often possible in elective settings since the disease is well localized and/or significantly resolved. The bowel must be well vascularized, nonedematous, tension free, and well prepared. The proximal margin should be an area of pliable colon without hypertrophy or inflammation. The distal margin should extend to the upper third of the rectum where the taenia coalesces. Not all of the diverticula-bearing colon must be removed, since diverticula proximal to the descending or sigmoid colon are unlikely to result in further symptoms.
  • Patients with Hinchey stage I or II disease can usually have preoperative bowel preparation.
• The classic 3-stage surgical approach is now rarely indicated because of high associated morbidity and mortality and is considered only in critical situations in which resection cannot safely be performed.
• • In this approach, the initial operation is simply drainage of the diseased segment and creation of a proximal diversion colostomy, without resection.
  • The second operation is performed 2-8 weeks later to resect the diseased bowel and perform a primary anastomosis.
  • A third operation, performed 2-4 weeks after the second operation, closes the stoma.
• Increasing experience with laparoscopic techniques for colon resection suggests that some of its advantages include less pain, a smaller scar, and shorter recovery time.  There is no change in early or late complications and cost and outcome are comparable to open procedures. This approach is best suited for patients in whom the episode of acute diverticulitis has resolved and in patients with Hinchey stage I or II disease.
• Special considerations exist for some forms of complicated diverticulitis. 
• • For diffuse peritonitis, an appropriate initial empiric antibiotic regimen must include either single agent therapy with imipenem/cilastin or piperacillin/tazobactam or multiple drug therapy with ampicillin, gentamicin, and metronidazole. 
  • Obstruction needs to be differentiated from carcinoma, and, even if biopsy results are negative, resection may be necessary to exclude carcinoma if there is enough suspicion based upon appearance alone.
  • Abscesses without peritonitis may be amenable to percutaneous drainage with an elective single-stage operation after the episode has resolved.  Drainage is usually through the anterior abdominal wall but may be done transgluteally or through the rectum or the vagina, depending on the location of the abscess.  Catheter drainage may be helpful in patients who cannot undergo surgery and should be left in place until drainage is less than 10 mL in 24 hours. Catheter sinograms can be performed periodically to monitor the resolution of the abscess cavity before the catheter is removed.
  • Fistulas generally do not close spontaneously, but they may be managed with an elective 1-stage procedure in most cases. Also, in the absence of urinary tract obstruction, observation appears safe in patients with contraindications to surgery.
  • Patients who are immunosuppressed are at an increased risk of perforation, and surgery is necessary in almost all patients who are either already immunosuppressed or are about to start immunosuppressive therapy.

Consultations

• Surgical consultation
• Gastroenterological consultation

Diet

• In mild episodes, a clear liquid diet is advised.  Clinical improvement should occur within 2-3 days, and the diet can then be advanced as tolerated.
• Administer nothing by mouth in episodes of moderate-to-severe acute diverticulitis.
• Studies imply a high-fiber diet will prevent progression of diverticulosis.  However, after patients have become symptomatic, the benefit of fiber supplementation is less clear. Recommending to patients to avoid seeds and nuts is currently less common, since it is now thought that seeds and nuts may not play a significant role in the development of diverticulitis, as believed in the past.
• Long-term management probably includes a high-fiber, low-fat diet.

Activity

Normal activity is possible after resolution of the acute episode.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Diverticulosis is treated with lifelong dietary modification. Antibiotics are used for every stage of diverticulitis. Empiric therapy requires broad-spectrum antibiotics effective against known enteric pathogens. For complicated cases of diverticulitis in hospitalized patients, carbapenems are the most effective empiric therapy because of increasing bacterial resistance to other regimens.

Drug Category: Antibiotics

Empiric antimicrobial therapy is essential and should cover all pathogens likely to cause diverticulitis.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Emergency colectomy is performed when severe complications arise or when the patient does not respond to medical treatment. Complications requiring surgical intervention include the following: purulent peritonitis, uncontrolled sepsis, fistula, and obstruction. In one retrospective study of over 3000 patients, about 20% of patients admitted for acute diverticulitis required emergency colectomy.
• Elective resection of the involved bowel segment after 2 episodes of uncomplicated diverticulitis to prevent further attacks has been advocated for years. In addition, earlier resection for younger patients with diverticulitis as well as for patients who are immunocompromised has been proposed.  As most complicated diverticulitis occurs on the first presentation and data for elective resection have come from small retrospective studies, this recommendation remains controversial.
• Successful percutaneous drainage of a diverticular abscess has not been associated with greater recurrence or more severe disease and does not necessitate elective colectomy.

Further Outpatient Care

• After recovering from acute diverticulitis, patients should have their colons examined to rule out malignancy. Current modalities include colonoscopy, barium enema, and CT colography (virtual colonoscopy). 
• • Biopsy of suspicious lesions or strictures can be performed during colonoscopy, which is advantageous. 
  • Virtual colonoscopy may be helpful in evaluating diverticulitis in the elective setting. This procedure combines insufflation of the colon in conjunction with a CT scan to provide data that allow computer generation of a 3-dimensional image. At this time, though, the technology is not widely available and does not allow sampling of suspicious lesions.

Deterrence/Prevention

• A lifelong high-fiber diet for those with asymptomatic diverticular disease may reduce the incidence of diverticulitis and its complications.

Complications

• Abscess
• Intestinal fistula
• Intestinal perforation
• Intestinal obstruction
• Peritonitis
• Sepsis and septic shock
• Diverticular bleeding (more common in diverticulosis than diverticulitis)

Prognosis

• Prognosis depends on the severity of illness, the presence of complications, and any coexisting medical problems. Younger patients with diverticulitis may have more severe disease, possibly due to a delay in diagnosis and treatment.

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Diverticulosis and Diverticulitis and Abdominal Pain in Adults.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Failure to realize that the symptoms of diverticulitis may mimic those of multiple conditions is a medicolegal pitfall.
• • Diverticulitis in the transverse colon may mimic peptic ulcer disease, pancreatitis, or cholecystitis.
  • Diverticulitis in the right colon may be confused with acute appendicitis.
• Failure to diagnose colon cancer mimicking diverticular disease leads to a delay in appropriate therapy.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors, Ahmed Sherif, MD, Norvin Perez, MD, and David Greenwald, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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