• Sac-like protrusions of mucosa through the muscular colonic wall.
  • Predominantly occur in the sigmoid colon, except in Asian people where they can occur in the right colon.


  • Diverticula are present without symptoms.

Diverticular disease

  • Diverticula cause intermittent lower abdominal pain, without inflammation and infection.


  • Diverticula become inflamed and infected, causing marked lower abdominal pain usually accompanied by fever and general malaise.
  • Occasionally accompanied by large rectal bleeds


Diverticular disease

  • Intermittent pain in the lower abdomen, often in left lower quadrant
  • Tender on examination.
  • Pain may be exacerbated by eating, and may be relieved by the passage of stool or flatus.
  • Constipation
  • Diarrhoea
  • Occasional large rectal bleeds.
  • Bloating and the passage of mucus rectally


  • Constant abdominal pain
  • Severe and starting in the hypogastrium before localising in the left iliac fossa
  • Guarding and tenderness in the left iliac fossa on examination
  • Fever
  • Alteration in bowel habits
  • Dysuria and urinary frequency
  • Large rectal bleeds (uncommon)


Other abdominal causes:

  • Irritable bowel syndrome.
  • Appendicitis.
  • Colitis.
  • Bowel cancer.

Gynaecological causes:

  • Pelvic inflammatory disease.
  • Ovarian cyst.
  • Ovarian torsion.
  • Ectopic pregnancy.

Urological causes include:

  • Urinary tract infection e.g pyelonephritis.
  • Urinary tract obstruction e.g ureteric stone


  • Abdominal rigidity, guarding, and rebound tenderness on examination due to perforation and peritonitis
  • Abdominal mass on examination as a result of abscess formation

Laboratory investigations

FBC: Raised white cell count, C-reactive protein, or erythrocyte sedimentation rate, suggesting infection from diverticulitis

Radiological investigations to detect diverticulae

Barium enema

  • Diverticuli
  • Abscess
  • Perforation
  • Obstruction
  • Fistula


  • Single, multiple, or scattered diverticula, with or without acute mucosal inflammation

CT colonogram

  • Thickening of bowel wall
  • Masses
  • Abscess
  • Streaky mesenteric fat
  • May show gas in the bladder in cases of fistula


Diverticular disease

  • Advise a high fibre diet
  • Increase hydration
  • Consider bulk-forming laxatives if dietary changes are not sufficient
  • Paracetamol for pain relief if necessary - avoid prescribing nonsteroidal anti-inflammatory drugs and opioid analgesics (such as co-codamol) due to increased risk of diverticular perforation


  • Prescribe broad-spectrum antibiotics to cover anaerobes and Gram-negative rods:
    • Co-amoxiclav
    • Treatment should last for at least 7 days
  • Paracetamol for pain if required
  • Recommend clear liquids only
  • Gradually reintroduce solid food as symptoms improve over 2–3 days.
  • Review within 48 hours, or sooner if symptoms deteriorate
  • Start IV antibiotics if there is no improvement in 72 hours after oral antibiotics have been started or symptoms of acute diverticulitis

Recurrent diverticulitis

  • Consider elective colectomy for recurrent disease


  • Diverticular haemorrhage
    • Bleeding occurs where the penetrating vessels responsible for the bowel wall weakness run over the diverticulum, making them vulnerable to injury.
    • Bleeding is usually abrupt, painless, and large in volume.
    • Bleeding stops spontaneously in 70–80% of cases.
  • Dysuria and frequency, which may occur when inflamed bowel is in contact with the bladder.
  • Perforation and peritonitis
  • Abscess formation
  • Fistula formation, most commonly to the bladder, but also to the vagina, skin, or another part of the bowel.
  • Intestinal obstruction, from fibrosis and stricture formation following recurrent inflammatory episodes


  • Most patients with uncomplicated diverticulitis recover following medical treatment and do not require surgical intervention
  • Recurrent disease is associated with high mortality
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