What are diverticula?
Diverticula are small sac-like pouches of mucosa that protrude through weak points in the wall of the large bowel, mainly the sigmoid colon. We distinguish:
- Diverticulosis: the mere presence of diverticula, usually asymptomatic.
- Diverticular disease: when they cause symptoms or complications.
- Diverticulitis: inflammation/infection of one or more diverticula.
How common are they?
This is a very common condition in Western societies, with frequency rising sharply with age: more than 50% of people over 60 have diverticula. It is associated with a low-fiber diet, age and lifestyle.
The majority of people with diverticula will never develop symptoms.
How do they present?
Most diverticula are asymptomatic. When diverticulitis or a complication develops, the following appear:
- Pain in the lower left abdomen, often persistent.
- Fever, loss of appetite, nausea.
- Change in bowel habit (diarrhea or constipation), bloating.
- Rectal bleeding — a common cause of lower GI hemorrhage.
How is it diagnosed?
Work-up depends on the phase of disease:
- CT scan of the abdomen: the method of choice in the acute phase — confirms the diagnosis and stages any complications (abscess, perforation).
- Laboratory tests: inflammatory markers (CRP, white cell count).
- Colonoscopy: performed after the acute inflammation settles (usually 6–8 weeks later), to exclude malignancy.
How is diverticulitis staged?
Complicated diverticulitis is staged by Hinchey, which guides management:
- Stage I: pericolic or mesenteric abscess.
- Stage II: pelvic or distant abscess.
- Stage III: generalized purulent peritonitis.
- Stage IV: fecal peritonitis.
Stages I–II are often managed conservatively or with percutaneous drainage; stages III–IV require emergency surgery.
Modern treatment options
Management depends on severity. Uncomplicated diverticulitis is often treated conservatively, while surgery is reserved for complications or recurrent disease. The decision for elective surgery is individualised.
Conservative management
For uncomplicated diverticulitis: bowel rest, analgesia and —in selected cases— antibiotics. Many mild episodes are managed as outpatients, with a gradual return to a high-fiber diet.
Percutaneous abscess drainage
In Hinchey I–II diverticulitis with abscess formation, image-guided percutaneous drainage (CT or ultrasound) controls the infection and often avoids emergency surgery.
Elective sigmoid colectomy
Laparoscopic removal of the affected segment (usually sigmoid) is offered for recurrent or complicated disease, fistula or stricture. In elective surgery a stoma is usually not required.
Emergency surgery
In generalized peritonitis (Hinchey III–IV) emergency surgery is required — removal of the affected bowel, with washout or a temporary stoma (Hartmann's procedure) depending on the findings.
Frequently asked questions
Do I need surgery after one episode of diverticulitis?
Not automatically. The modern approach is individualised: surgery is mainly considered for recurrent or complicated disease, not after a single uncomplicated episode.
Should I avoid seeds and nuts?
This old advice is not supported by current evidence. On the contrary, a balanced, high-fiber diet is considered protective.
Will I need a stoma?
Elective laparoscopic surgery usually avoids a stoma. A temporary stoma may be needed mainly in emergency cases with peritonitis.
How can recurrences be prevented?
A high-fiber diet, adequate hydration, physical activity, maintaining a healthy weight and stopping smoking all reduce the risk.