Your Global Health Resource

 &

&

 I write this article with great affection, as it was the first research topic I undertook when I was a young physician.
Over the years, I have learned that this condition is more common in industrialized countries than in others, although its symptoms remain unchanged.
I also came to understand that its complications can be life-threatening.
Abdominal pain can be much more than just a simple pain.

1. Introduction
Diverticular diseases of the colon are among the most frequent gastrointestinal conditions in industrialized countries. The clinical spectrum ranges from asymptomatic diverticulosis to complicated diverticulitis, characterized by perforation and peritonitis.
A diverticulum is a small sac-like herniation of the mucosa and submucosa through the muscular layer of the colon, occurring at natural weak points in the intestinal wall, usually where the vasa recta penetrate (Figure 1).
Its formation is primarily associated with increased intraluminal pressure and structural changes in the intestinal wall that occur with aging.
Its prevalence rises with age and with certain dietary and lifestyle factors, representing a major cause of emergency visits and hospital admissions.
This article provides a comprehensive review of its definition, diagnosis, treatment, and complications, according to the most recent guidelines (AGA, WSES, ASCRS).
2. Definitions and Key Differences
Characteristic Diverticulosis Diverticulitis
Definition: Presence of diverticula without inflammation. Inflammation and infection of one or more diverticula
Symptom:s Generally asymptomatic; may cause painless bleeding. Localized abdominal pain, fever, and altered bowel habits
Usual location: Sigmoid colon (West), right colon (Asia) (Figure 2). Same as diverticulosis, but with inflammatory signs
Complications: Massive lower GI bleeding, Abscess, perforation, fistula, stricture, obstruction
Diagnosis: Incidental finding on colonoscopy or CT Contrast-enhanced abdominopelvic CT (gold standard)
Treatment: High-fiber diet, hydration, exercise. Antibiotics, dietary modification, drainage or surgery according to severity
3. Epidemiology and Risk Factors
Age: >60% in those over 60 years; <10% in those under 40.
Sex: Equal overall incidence; in patients <50 years, higher risk of complications in men.
Low-fiber diet: Main dietary factor; increases segmental intraluminal pressure.
Chronic constipation: Promotes formation and impaction of fecaliths.
Obesity and sedentary lifestyle: Independent risk factor for diverticulitis.
Drugs: NSAIDs, corticosteroids, opioids, and COX-2 inhibitors increase perforation risk.
Genetics: Estimated heritability of 40–50%.
Connective tissue disorders: Ehlers-Danlos, Marfan, polycystic kidney disease.
4. Clinical Presentation
Condition Symptoms Signs Complications
Diverticulosis: Asymptomatic or painless lower GI bleeding, None or incidental finding, Massive bleeding
Uncomplicated diverticulitis:s LLQ pain (West) or right flank pain (Asia), fever, nausea, constipation/diarrhea. Localized guarding, tenderness, Risk of progression
Complicated diverticulitis Same as above + signs of sepsis or peritoneal irritation Acute abdomen Abscess, perforation, fistula, stricture, obstruction
5. Hinchey Classification (Complicated Diverticulitis)
Hinchey Stage Description Management
I Pericolic or mesenteric abscess Antibiotics ± drainage
II Pelvic abscess Image-guided percutaneous drainage
III Purulent peritonitis: Urgent surgery
IV Fecal peritonitis Urgent surgery (Hartmann procedure or primary anastomosis)
6. Diagnosis
Laboratory
Leukocytosis, elevated CRP, and blood cultures if high fever or sepsis.
Imaging
Contrast-enhanced abdominopelvic CT: gold standard in the acute phase (Figure 4).
Abdominal ultrasound: useful in young patients or pregnancy.
Colonoscopy: contraindicated in the acute phase; recommended 6–8 weeks later.
7. Clinical Management
(Figure 5: Visual clinical management algorithm)
7.1 Diverticulosis
Fiber intake 25–35 g/day.
Hydration ≥2 L/day.
Regular physical activity.
Avoid NSAIDs and chronic constipation.
7.2 Uncomplicated Diverticulitis
Liquid or low-residue diet.
Oral antibiotics: amoxicillin–clavulanate or ciprofloxacin + metronidazole.
Reassessment at 48–72 hours.
7.3 Complicated Diverticulitis
Abscess <4 cm: antibiotics.
Abscess ≥4 cm: percutaneous drainage.
Peritonitis or failed conservative management: surgery.
8. Severe Complications
Free perforation → fecal peritonitis and septic shock.
Intra-abdominal abscesses.
Fistulas (colovesical, colovaginal, colocutaneous).
Stricture and bowel obstruction.
Massive lower GI bleeding.
9. Prognosis
> 85% response to conservative management in uncomplicated cases.
10-year recurrence rate: 20–30%.
Favorable prognosis with early diagnosis and timely treatment.
10. References (Vancouver)
1. Strate LL, Morris AM. Epidemiology, pathophysiology, and treatment of diverticulitis. Gastroenterology. 2019;156(5):1282-1298.e1.
2. Sartelli M, et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis. World J Emerg Surg. 2020;15(1):32.
3. Feingold D, et al. The ASCRS clinical practice guidelines for the treatment of left-sided colonic diverticulitis. Dis Colon Rectum. 2020;63(6):728-747.
4. Tursi A, et al. The management of diverticulitis: a review of the guidelines. United European Gastroenterol J. 2020;8(7):790-800.
Raulayalamd
@mydoctoroncall.com