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Acute colonic diverticulitis: Medical management

John H Pemberton, MD
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD


Diverticular disease of the colon is an important cause of hospital admissions and a significant contributor to healthcare costs in Western and industrialized societies [1,2]. In the United States, acute diverticulitis is the third most common gastrointestinal illness that requires hospitalization and the leading indication for elective colon resection [3,4].

The management of patients with acute colonic diverticulitis is discussed in this topic. The discussion pertains mostly to the treatment of sigmoid diverticulitis; a brief discussion of diverticulitis of the right colon can be found at the end of the topic (see 'Right-sided (cecal) diverticulitis' below). The epidemiology, pathophysiology, clinical manifestations, diagnosis, and surgical treatment of diverticulitis are discussed elsewhere:

(See "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis".)

(See "Clinical manifestations and diagnosis of acute diverticulitis in adults".)

(See "Acute colonic diverticulitis: Surgical management".)

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Literature review current through: Nov 2017. | This topic last updated: Oct 12, 2017.
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  1. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases. Gastroenterology 2009; 136:741.
  2. Shaheen NJ, Hansen RA, Morgan DR, et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 2006; 101:2128.
  3. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143:1179.
  4. Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140:681.
  5. Thompson WG, Patel DG. Clinical picture of diverticular disease of the colon. Clin Gastroenterol 1986; 15:903.
  6. Cheskin LJ, Bohlman M, Schuster MM. Diverticular disease in the elderly. Gastroenterol Clin North Am 1990; 19:391.
  7. Detry R, Jamez J, Kartheuser A, et al. Acute localized diverticulitis: optimum management requires accurate staging. Int J Colorectal Dis 1992; 7:38.
  8. Hachigian MP, Honickman S, Eisenstat TE, et al. Computed tomography in the initial management of acute left-sided diverticulitis. Dis Colon Rectum 1992; 35:1123.
  9. Kellum JM, Sugerman HJ, Coppa GF, et al. Randomized, prospective comparison of cefoxitin and gentamicin-clindamycin in the treatment of acute colonic diverticulitis. Clin Ther 1992; 14:376.
  10. Larson DM, Masters SS, Spiro HM. Medical and surgical therapy in diverticular disease: a comparative study. Gastroenterology 1976; 71:734.
  11. Biondo S, Parés D, Martí Ragué J, et al. Acute colonic diverticulitis in patients under 50 years of age. Br J Surg 2002; 89:1137.
  12. Young-Fadok TM, Roberts PL, Spencer MP, Wolff BG. Colonic diverticular disease. Curr Probl Surg 2000; 37:457.
  13. Dharmarajan S, Hunt SR, Birnbaum EH, et al. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum 2011; 54:663.
  14. Buchs NC, Konrad-Mugnier B, Jannot AS, et al. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg 2013; 100:976.
  15. Janes SE, Meagher A, Frizelle FA. Management of diverticulitis. BMJ 2006; 332:271.
  16. Alonso S, Pera M, Parés D, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis 2010; 12:e278.
  17. Moya P, Arroyo A, Pérez-Legaz J, et al. Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis. Tech Coloproctol 2012; 16:301.
  18. Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014; 57:284.
  19. Rueda JC, Jimenez A, Caro A, et al. Home treatment of uncomplicated acute diverticulitis. Int Surg 2012; 97:203.
  20. Biondo S, Golda T, Kreisler E, et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial). Ann Surg 2014; 259:38.
  21. Etzioni DA, Chiu VY, Cannom RR, et al. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis Colon Rectum 2010; 53:861.
  22. Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999; 42:470.
  23. Salzman H, Lillie D. Diverticular disease: diagnosis and treatment. Am Fam Physician 2005; 72:1229.
  24. Ribas Y, Bombardó J, Aguilar F, et al. Prospective randomized clinical trial assessing the efficacy of a short course of intravenously administered amoxicillin plus clavulanic acid followed by oral antibiotic in patients with uncomplicated acute diverticulitis. Int J Colorectal Dis 2010; 25:1363.
  25. Balasubramanian I, Fleming C, Mohan HM, et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg 2017; 34:151.
  26. Vennix S, Morton DG, Hahnloser D, et al. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis 2014; 16:866.
  27. Krobot K, Yin D, Zhang Q, et al. Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intra-abdominal infections requiring surgery. Eur J Clin Microbiol Infect Dis 2004; 23:682.
  28. Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA 2014; 311:287.
  29. Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for diverticulitis in the 21st century: a systematic review. JAMA Surg 2014; 149:292.
  30. Stocchi L. Current indications and role of surgery in the management of sigmoid diverticulitis. World J Gastroenterol 2010; 16:804.
  31. Ambrosetti P, Robert J, Witzig JA, et al. Prognostic factors from computed tomography in acute left colonic diverticulitis. Br J Surg 1992; 79:117.
  32. Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984; 200:466.
  33. Kuligowska E, Keller E, Ferrucci JT. Treatment of pelvic abscesses: value of one-step sonographically guided transrectal needle aspiration and lavage. AJR Am J Roentgenol 1995; 164:201.
  34. Schiller VL, Schreiber L, Seaton C, Sarti DA. Transvaginal sonographic diagnosis of sigmoid diverticulitis. Abdom Imaging 1995; 20:253.
  35. Neff CC, vanSonnenberg E, Casola G, et al. Diverticular abscesses: percutaneous drainage. Radiology 1987; 163:15.
  36. Lamb MN, Kaiser AM. Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis. Dis Colon Rectum 2014; 57:1430.
  37. Doringer E. Computerized tomography of colonic diverticulitis. Crit Rev Diagn Imaging 1992; 33:421.
  38. Schechter S, Eisenstat TE, Oliver GC, et al. Computerized tomographic scan-guided drainage of intra-abdominal abscesses. Preoperative and postoperative modalities in colon and rectal surgery. Dis Colon Rectum 1994; 37:984.
  39. Garfinkle R, Kugler A, Pelsser V, et al. Diverticular Abscess Managed With Long-term Definitive Nonoperative Intent Is Safe. Dis Colon Rectum 2016; 59:648.
  40. Siewert B, Tye G, Kruskal J, et al. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol 2006; 186:680.
  41. Brandt D, Gervaz P, Durmishi Y, et al. Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum 2006; 49:1533.
  42. Gaertner WB, Willis DJ, Madoff RD, et al. Percutaneous drainage of colonic diverticular abscess: is colon resection necessary? Dis Colon Rectum 2013; 56:622.
  43. Chabok A, Påhlman L, Hjern F, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99:532.
  44. Daniels L, Ünlü Ç, de Korte N, et al. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg 2017; 104:52.
  45. Stollman N, Smalley W, Hirano I, AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology 2015; 149:1944.
  46. Shah SD, Cifu AS. JAMA clinical guidelines synopsis: Management of acute diverticulitis. JAMA 2017; 318:291.
  47. Horgan AF, McConnell EJ, Wolff BG, et al. Atypical diverticular disease: surgical results. Dis Colon Rectum 2001; 44:1315.
  48. Boostrom SY, Wolff BG, Cima RR, et al. Uncomplicated diverticulitis, more complicated than we thought. J Gastrointest Surg 2012; 16:1744.
  49. Lau KC, Spilsbury K, Farooque Y, et al. Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded? Dis Colon Rectum 2011; 54:1265.
  50. Mortensen LQ, Burcharth J, Andresen K, et al. An 18-Year Nationwide Cohort Study on The Association Between Diverticulitis and Colon Cancer. Ann Surg 2017; 265:954.
  51. Rose J, Parina RP, Faiz O, et al. Long-term Outcomes After Initial Presentation of Diverticulitis. Ann Surg 2015; 262:1046.
  52. Perkins JD, Shield CF 3rd, Chang FC, Farha GJ. Acute diverticulitis. Comparison of treatment in immunocompromised and nonimmunocompromised patients. Am J Surg 1984; 148:745.
  53. Biondo S, Trenti L, Elvira J, et al. Outcomes of colonic diverticulitis according to the reason of immunosuppression. Am J Surg 2016; 212:384.
  54. Mpofu S, Mpofu CM, Hutchinson D, et al. Steroids, non-steroidal anti-inflammatory drugs, and sigmoid diverticular abscess perforation in rheumatic conditions. Ann Rheum Dis 2004; 63:588.
  55. Young-Fadok T, Sgambati S, Wolff B. Increased morbidity and mortality after colectomy in patients with lupus: A case-matched series (abstract). Dis Colon Rectum 2000; 43:A57.
  56. Painter NS. Diverticular disease of the colon. The first of the Western diseases shown to be due to a deficiency of dietary fibre. S Afr Med J 1982; 61:1016.
  57. Brodribb AJ. Treatment of symptomatic diverticular disease with a high-fibre diet. Lancet 1977; 1:664.
  58. Ornstein MH, Littlewood ER, Baird IM, et al. Are fibre supplements really necessary in diverticular disease of the colon? A controlled clinical trial. Br Med J (Clin Res Ed) 1981; 282:1353.
  59. Aldoori WH, Giovannucci EL, Rockett HR, et al. A prospective study of dietary fiber types and symptomatic diverticular disease in men. J Nutr 1998; 128:714.
  60. Strate LL, Liu YL, Syngal S, et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 2008; 300:907.
  61. Floch MH, White JA. Management of diverticular disease is changing. World J Gastroenterol 2006; 12:3225.
  62. Sheth AA, Longo W, Floch MH. Diverticular disease and diverticulitis. Am J Gastroenterol 2008; 103:1550.
  63. Stollman N, Magowan S, Shanahan F, et al. A randomized controlled study of mesalamine after acute diverticulitis: results of the DIVA trial. J Clin Gastroenterol 2013; 47:621.
  64. Rafferty J, Shellito P, Hyman NH, et al. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49:939.
  65. Hall JF, Roberts PL, Ricciardi R, et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum 2011; 54:283.
  66. Binda GA, Arezzo A, Serventi A, et al. Multicentre observational study of the natural history of left-sided acute diverticulitis. Br J Surg 2012; 99:276.
  67. Mäkelä JT, Kiviniemi HO, Laitinen ST. Spectrum of disease and outcome among patients with acute diverticulitis. Dig Surg 2010; 27:190.
  68. Chautems R, Ambrosetti P, Ludwig A. Long-term follow-up after first acute episode of sigmoid diverticulitis: Is surgery mandatory. Dis Colon Rectum 2001; 44:A5.
  69. Ritz JP, Lehmann KS, Frericks B, et al. Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery 2011; 149:606.
  70. Kaiser AM. Complicated diverticulitis: it is not yet time to rethink the rules! Ann Surg 2006; 243:707.
  71. Janes S, Meagher A, Frizelle FA. Elective surgery after acute diverticulitis. Br J Surg 2005; 92:133.
  72. Chapman JR, Dozois EJ, Wolff BG, et al. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes? Ann Surg 2006; 243:876.
  73. Klarenbeek BR, Samuels M, van der Wal MA, et al. Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010; 251:670.
  74. Colorectal Writing Group for the SCOAP-CERTAIN Collaborative. The impact of delaying elective resection of diverticulitis on laparoscopic conversion rate. Am J Surg 2015; 209:913.
  75. Schauer PR, Ramos R, Ghiatas AA, Sirinek KR. Virulent diverticular disease in young obese men. Am J Surg 1992; 164:443.
  76. Freischlag J, Bennion RS, Thompson JE Jr. Complications of diverticular disease of the colon in young people. Dis Colon Rectum 1986; 29:639.
  77. Pautrat K, Bretagnol F, Huten N, de Calan L. Acute diverticulitis in very young patients: a frequent surgical management. Dis Colon Rectum 2007; 50:472.
  78. Ambrosetti P, Robert JH, Witzig JA, et al. Acute left colonic diverticulitis in young patients. J Am Coll Surg 1994; 179:156.
  79. Ouriel K, Schwartz SI. Diverticular disease in the young patient. Surg Gynecol Obstet 1983; 156:1.
  80. Chautems RC, Ambrosetti P, Ludwig A, et al. Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients. Dis Colon Rectum 2002; 45:962.
  81. Acosta JA, Grebenc ML, Doberneck RC, et al. Colonic diverticular disease in patients 40 years old or younger. Am Surg 1992; 58:605.
  82. Ritz JP, Lehmann KS, Stroux A, et al. Sigmoid diverticulitis in young patients--a more aggressive disease than in older patients? J Gastrointest Surg 2011; 15:667.
  83. Chodak GW, Rangel DM, Passaro E Jr. Colonic diverticulitis in patients under age 40: need for earlier diagnosis. Am J Surg 1981; 141:699.
  84. Vignati PV, Welch JP, Cohen JL. Long-term management of diverticulitis in young patients. Dis Colon Rectum 1995; 38:627.
  85. Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975; 4:53.
  86. Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of diverticular disease. Ann R Coll Surg Engl 1994; 76:117.
  87. Rothenberger DA, Wiltz O. Surgery for complicated diverticulitis. Surg Clin North Am 1993; 73:975.
  88. Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorectal Dis 1994; 9:158.
  89. Simonowitz D, Paloyan D. Diverticular disease of the colon in patients under 40 years of age. Am J Gastroenterol 1977; 67:69.
  90. Cunningham MA, Davis JW, Kaups KL. Medical versus surgical management of diverticulitis in patients under age 40. Am J Surg 1997; 174:733.
  91. Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut 1969; 10:336.
  92. Fischer MG, Farkas AM. Diverticulitis of the cecum and ascending colon. Dis Colon Rectum 1984; 27:454.
  93. Ngoi SS, Chia J, Goh MY, et al. Surgical management of right colon diverticulitis. Dis Colon Rectum 1992; 35:799.
  94. Sugihara K, Muto T, Morioka Y, et al. Diverticular disease of the colon in Japan. A review of 615 cases. Dis Colon Rectum 1984; 27:531.
  95. Markham NI, Li AK. Diverticulitis of the right colon--experience from Hong Kong. Gut 1992; 33:547.
  96. Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996; 171:244.
  97. Oudenhoven LF, Koumans RK, Puylaert JB. Right colonic diverticulitis: US and CT findings--new insights about frequency and natural history. Radiology 1998; 208:611.
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