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18. Benign Colon: Diverticular Disease 389
• Other relatively common fi stulas associated with diverticular
disease are colocutaneous, colovaginal, and coloenteric.
• Most patients who develop a colovaginal fi stula have had a previous hysterectomy. Other fi stulas have rarely been described
and include colocolic, ureterocolic, colouterine, colosaphingeal, coloperineal, sigmoido-appendiceal, colovenous, and
even fi stulas to the thigh (a variant of a colocutaneous fi stula).
• The diagnosis of a diverticular fi stula is generally clinical. Many
fi stulas will not be directly identifi able by imaging studies.
• Gas seen in the bladder on a CT scan in a patient who has not
had their urethra or bladder instrumented is the most sensitive/
common fi nding with a colovesical fi stula.
• The primary aim of a diagnostic workup is not to see the fi stula
but to determine the etiology [diverticulitis, cancer, infl ammatory bowel disease (IBD), etc.] so that appropriate therapy can
be initiated.
Stricture
• The development of a phlegmon with repeated attacks of acute
disease or long-term persistent disease may result in a stricture.
• It is necessary to rule out carcinoma as the true cause of the
stricture. Colonoscopy is the fi rst choice to help make this distinction; however, it is not uncommon for associated bowel
angulation and fi xation to prevent endoscopic visualization.
• Contrast studies may assist the evaluation in such instances but
resection may be necessary to make a diagnosis.
Obstruction
• On rare occasions, complete obstruction may occur. If caused by
diverticular disease, most patients will respond to initial medical
management allowing an elective resection at a later date.
• Persistence of an obstruction may require a Hartmann’s procedure or primary anastomosis with proximal diversion for management.
Ureteral Obstruction
• The ureter is infrequently involved with diverticular disease.
When involved, it is most frequently the left ureter.
390 The ASCRS Manual of Colon and Rectal Surgery
• A stricture may occur but compression is more common. This
can result from retroperitoneal fi brosis secondary to diverticular
infl ammation.
Phlegmon
• A phlegmon represents an infl ammatory mass. It may or may
not be associated with a central abscess.
• A phlegmon can signifi cantly complicate the technical aspects
of resection.
• Many phlegmons will resolve with antibiotic therapy.
• If resection is planned because of recurrent episodes of disease,
it is best to treat the acute phlegmon, to resolution if possible,
before resection.
• On occasion, operation becomes necessary in the face of an
acute phlegmon.
Saint’s Triad
• Saint’s triad is a described association of diverticulosis,
cholelithiasis, and hiatal hernia. Although it has been suggested that the triad occurs in 3–6% of the general population, it is of unknown clinical signifi cance and likely
represents the normal concomitant distribution of these
common maladies.
H. Diagnostic Tests
Endoscopy
• Endoscopy in the face of acute diverticulitis must be undertaken with extreme caution because of risk of gross perforation and decreased chance of success for complete colonic
evaluation.
• It can provide important information before operation but will
change acute management in less than 1% of cases.
• Generally, in the absence of an urgent indication, colonoscopy should be delayed until resolution of the acute episode is
complete.
18. Benign Colon: Diverticular Disease 391
Abdominal X-rays
• When used, plain fi lms of the abdomen should be done supine
and upright/left lateral decubitus because the primary value
is to rule out pneumoperitoneum or to assess for a possible
obstruction. However, either of these two complications can
also be assessed with CT scan, so in many centers, the plain
abdominal fi lm is rarely used.
Contrast Studies
• Barium or water-soluble contrast studies have proponents for
their use but CT scan offers an examination of much broader
scope in one evaluation making it the preferred imaging study
in many centers.
• Contrast studies have been shown to identify fi stulas, most
often colovaginal or coloenteric.
• Some clinicians prefer the anatomic view of the entire colon
provided by BE because it distinguishes the extent of diverticulosis throughout the colon and can assess for stricture and
colonic length. In most centers, contrast studies, if used at all,
are used in a limited manner to evaluate the anatomy of the
colon before an operation.
CT Scan
• An important advantage to a CT scan is the ability to document diverticulitis, even if uncomplicated, when the diagnosis
is in doubt.
• It has been demonstrated that CT can recognize and stratify
patients according to the severity of their disease. It can distinguish uncomplicated disease with predictably short length
of stay from complicated disease as defi ned by abscess, fi stula, peritonitis, or obstruction and a predictably long length
of stay.
• It also provides information about extracolonic pathology and
anatomic variation useful for surgical planning.
• Early CT-guided drainage of abscesses allows downstaging
of complicated diverticulitis to convert an otherwise urgent or
emergent operation with attendant increases in morbidity and
mortality to the safety of an elective operation.
392 The ASCRS Manual of Colon and Rectal Surgery
Ultrasonography
• Transrectal ultrasound (TRUS) may prove to be a useful
adjunct in selected cases of rectosigmoid diverticulitis and perirectal involvement by diverticular disease in centers where CT
scanning is not readily available.
Magnetic Resonance Imaging
• Preliminary studies using magnetic resonance imaging
colonography have shown a high correlation with CT fi ndings
in patients with diverticular disease without exposure to
ionizing radiation.
• These comprehensive three-dimensional models, rather than
BE, may have a role in presurgical planning with concurrent
assessment of the residual colon.
I. Differential Diagnosis
• The differential diagnosis for diverticular disease includes IBS,
carcinoma, IBD, appendicitis, bowel obstruction, ischemic
colitis, gynecologic disease, and urologic disease. Of these,
IBS is perhaps the most diffi cult to differentiate in many
patients.
Irritable Bowel Syndrome (IBS)
• The distinction between noninfl ammatory diverticular disease
and IBS relies on the diagnostic acumen of the clinician and
the long-term outcomes of resection.
• Because of the prevalence of diverticular disease, many patients
with IBS will have concomitant diverticular disease. However,
because diverticular disease is usually asymptomatic, the presence of diverticulosis in these patients will often not be the
source of their symptoms but rather just a source of confusion
in the differential.
• It is helpful to be familiar with the Rome II criteria (Table 18.2 )
for the diagnosis of IBS in order to sort through this differential.
18. Benign Colon: Diverticular Disease 393
Table 18. 2. The Rome II criteria for IBS
IBS can be diagnosed based on at least 12 weeks (which need not be
consecutive) in the preceding 12 months, of abdominal discomfort or pain
that has two of three of these features :
1. Relieved with defecation; and/or
2. Onset associated with a change in frequency
of stool; and/or
3. Onset associated with a change in form
(appearance) of stool.
Symptoms that cumulatively support the diagnosis of IBS:
1. Abnormal stool frequency (>3 stools per day
or <3 stools per week)
2. Abnormal stool form (lumpy/hard or loose/watery stool)
3. Abnormal stool passage (straining, urgency, or feeling
of incomplete evacuation);
4. Passage of mucus
5. Bloating or feeling of abdominal distension
Red Flag symptoms that are not typical of IBS:
1. Pain that often awakens/interferes with sleep
2. Diarrhea that often awakens/interferes
with sleep
3. Blood in stool (visible or occult)
4. Weight loss
5. Fever
6. Abnormal physical examination
Colon Neoplasia
• Distinguishing diverticular disease from cancer can be diffi cult.
Imaging techniques can provide signifi cant diagnostic assistance, but occasionally a resection is necessary to be certain.
• Several features of BE studies support a diagnosis of diverticular disease including preservation of the mucosa, long strictures, and the presence of diverticula. A BE is preferred by
some clinicians to assess the extent of the diverticulosis and
evaluate the length of the colon before resection.
• Although colonoscopy can frequently resolve this issue, it is not
always successful because of acute angulations or narrowing
of the lumen.
394 The ASCRS Manual of Colon and Rectal Surgery
• CT evaluates the entire abdomen, can identify concurrent disease,
and may give clues as to the underlying colonic pathology.
• Polyps and cancer must be considered whenever a diagnostic
workup for diverticular disease is begun.
• Although historically diverticular disease is not believed to
have an etiologic link to colon cancer, a causal association has
been identifi ed between left-sided colon cancer and diverticulitis. In a review of 7,159 patients from the Swedish Cancer
Registry, patients with diverticulitis had a long-term increased
risk of left-sided colon cancer compared with patients with
asymptomatic diverticulosis (odds ratio n = 4.2).
Infl ammatory Bowel Disease
• Crohn’s disease can be a particularly diffi cult differential to
make. Both Crohn’s and diverticular disease may present
with similar complications including fi stulas, phlegmons,
and abscesses. Rectal involvement, anal disease, extracolonic
signs, and bleeding suggest Crohn’s.
• Recurrent “diverticulitis” requiring a repeat resection should
always raise the question of possible Crohn’s disease.
• Ulcerative colitis is rarely a signifi cant differential problem
because bleeding is not a prominent symptom of diverticulitis
and a simple endoscopic examination showing infl ammation
within the rectum should suffi ce to rule out diverticular disease.
Other Colitides, Appendicitis, Gynecologic
and Urologic Disease
• Endoscopy can be an important adjunct in differentiating IBD,
ischemic colitis, and other forms of colitis although caution
must be used in the acute setting.
• A major advantage of the CT scan is the ability to evaluate for
many of the other potential differentials including appendicitis,
gynecologic and urologic disease.
Associated Conditions
• There is such a high incidence of diverticulosis among patients
with autosomal dominant polycystic kidney disease that some
consider it an extrarenal manifestation. These patients undergoing
renal transplantation are at particularly high risk for devastating
18. Benign Colon: Diverticular Disease 395
infectious complications because of their immunocompromised state.
• Many transplant centers recommend prophylactic sigmoid
resection in those polycystic kidney patients scheduled for
transplantation with a documented history of diverticulitis.
J. Uncommon Presentations
Diverticulitis in Young Patients
• Young patients with diverticular disease are usually male, obese,
and have a higher incidence of right-sided diverticulitis.
• Young patients undergoing operation are frequently misdiagnosed preoperatively with appendicitis being the most
common misdiagnosis.
• Historically, diverticular disease in patients younger than 50
years of age has been described as more virulent and with more
serious complications. Many recommend that patients younger
than age 50 have an elective resection after a single episode of
acute disease. Recent evidence is mixed.
• In some series, young people present with more severe disease at
fi rst presentation but less frequently have a resection at that time.
Reasons for this include missed diagnoses and rapid response
to therapy. With fewer resections for more complex disease, a
higher percentage of young patients return with delayed complications and the appearance of more aggressive disease. Elective
resection after the fi rst episode of diverticulitis is thus advised.
• Others have recommended elective resections at a younger age
to avoid the increased morbidity and mortality associated with
urgent or emergent surgery in the elderly (0% vs. 34.9%).
• There is evidence that diverticular disease in young patients
is changing. It is not as rare as it used to be and continues to
become more common. Recent evidence suggests there is not
increased risk of complications from diverticular disease in the
young. Based on these fi ndings, resection after a single episode
of diverticulitis is not recommended.
• Data are diffi cult to interpret because the presentations of
diverticular disease are so varied and most studies are small
and retrospective with risks of unrecognized selection bias.
However, it does seem that diverticular disease is more common
396 The ASCRS Manual of Colon and Rectal Surgery
in young patients than generally recognized. Obesity may be a
risk factor, probably related to diet.
• The issue of male predominance could be a result of missed
diagnoses in females.
• Current recommendations for resection are based on the predicted risk of developing a serious complication that would lead
to emergency surgery with increased morbidity and mortality
and frequent use of colostomy in this setting.
• Age alone does not seem to be a reliable factor. The use of CT
to identify “severe” or “complex” diverticular disease seems
most promising.
• The risk of complications within 5 years of a fi rst attack of
diverticulitis exceeds 50% if CT shows severe diverticulitis at
the initial episode.
• Severe fi ndings are defi ned as abscess and/or extraluminal air
and/or extraluminal contrast.
• In a recent study, the incidence of remote complications was
the highest (54% at 5 years) for young patients with severe
diverticulitis on CT and the lowest (19% at 5 years) for older
patients with mild disease.
Rectal Diverticula
• Rectal diverticula are rare. They are typically true diverticula
because they include the muscular layer of the rectum in their
wall, and are frequently solitary. Infl ammation can generally
be managed with antibiotics.
Cecal and Right-Sided Diverticulitis
• Right-sided diverticular disease is much more common in the
Far East than in the West, representing 35–84% of diverticula
in that region.
• Patients present an average of 20 years younger than with
sigmoid diverticulitis.
• It is estimated that 13% of patients with cecal diverticulosis
develop diverticular infl ammation.
• Cecal diverticulitis can be graded according to the extent of the
infl ammation. Grade I disease refers to an easily recognizable
projecting infl amed cecal diverticulum. Grade II is an infl amed
18. Benign Colon: Diverticular Disease 397
cecal mass. Grade III encompasses a localized abscess or fi stula.
Grade IV is a free perforation or ruptured abscess with diffuse
peritonitis.
• Cecal diverticulitis is correctly diagnosed preoperatively only
5% of the time. Appendicitis is the preoperative diagnosis in
more than two-thirds of cases.
• If a correct diagnosis of uncomplicated cecal diverticulitis
can be made preoperatively, then antibiotics and treatment similar to left-sided disease is appropriate. This is rare,
however.
• When discovered intraoperatively, the options for treatment
include:
– Appendectomy, nonresection of the diverticulum and
postoperative antibiotic therapy.
– Appendectomy with diverticulectomy for Grade I and
identifi able Grade II disease. For not readily identifi able
Grade II, Grade III, and Grade IV disease, failed treatment,
or when cancer is a consideration, right hemicolectomy
is the procedure of choice. Appendectomy should always
accompany nonresection or diverticulectomy whenever
the base of the appendix is not infl amed. This is to avoid
confusion at a later date.
Giant Colonic Diverticulum
• Giant diverticula of the colon are rare entities associated with
sigmoid diverticular disease. They are generally pseudo-diverticula with infl ammatory rather than colonic mucosal walls.
• Diagnosis is by plain fi lm of the abdomen which shows a large,
solitary, gas-fi lled cavity. Communication with the colon can
be demonstrated with contrast enema.
• The differential includes congenital duplication of the
colon, cholecystenteric fi stula, colonic volvulus, emphysematous cholecystitis, infected pancreatic pseudocyst, pneumatosis
cystoides intestinalis, Meckel’s diverticulum, intraabdominal
abscess, giant duodenal diverticulum, dilated intestinal loop,
gastric dilatation, tuboovarian abscess, and mesenteric cyst.
• The treatment of choice is resection of the diverticulum and adjacent colon at time of diagnosis if the patient is symptomatic.
398 The ASCRS Manual of Colon and Rectal Surgery
Diverticular Disease of the Transverse Colon
• This is an exceedingly rare condition. Clinical presentation
most often mimics appendicitis, cholecystitis, or, less frequently, ischemic or Crohn’s colitis.
• Treatment parallels that of sigmoid diverticulitis; however, resection is usually performed because a preoperative diagnosis is
more diffi cult and a carcinoma frequently cannot be ruled out.
K. Treatment
Medical and Dietary Management
• The primary management of asymptomatic diverticular disease
is diet. The goal of dietary manipulation is to increase the
bulkiness of stool thus increasing lumen size, decreasing transit
time, and decreasing intraluminal pressures. This decreases
segmentation which has been described as a signifi cant factor
in the development of diverticular disease.
• The ideal amount of fi ber is not known; however, the recommended daily amount is 20–30 g. In general, fi ber can be
obtained by consuming foods high in fi ber or through supplementation with one or more of a large variety of bulk laxatives.
• Epidemiologic evidence strongly suggests a diet high in fi ber
can reduce the risk of developing diverticulosis. What is less
clear is whether a high fi ber diet can prevent diverticulitis and
its complications in patients who already have diverticulosis.
Recent evidence is building in support of this concept.
Acute Diverticulitis
• In the absence of systemic signs and symptoms (high fever,
marked leukocytosis, tachycardia, and hypotension), most
patients experiencing symptoms of diverticulitis will respond
to a regimen of bowel rest and antibiotics as outpatients.
• Diet is usually restricted to low residue or clear liquids during
the acute illness but with resolution of the acute symptoms, a
high fi ber diet should be instituted.
• There is no need to restrict the ingestion of seeds or hulls
because there are no data to substantiate this practice.
• Appropriate antibiotics should be instituted to include coverage
of Gram-negative and anaerobic bacteria. The most predominant
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