The management of diverticulitis: a review of the guidelines

Hayley You, Amy Sweeny, Michelle L Cooper, Michael Von Papen and James Innes
Med J Aust 2019; 211 (9): . || doi: 10.5694/mja2.50276
Published online: 29 July 2019


  • Radiological evidence of inflammation, using computed tomography (CT), is needed to diagnose the first occurrence of diverticulitis. CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred.
  • Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms and patient history; this classification is used to direct management.
  • Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis.
  • For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively.
  • For complicated diverticulitis, non‐operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses; larger abscesses of 3–5 cm should be drained percutaneously. Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration and urgent surgery.
  • Surgical intervention with either Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy, is indicated for peritonitis or in failure of non‐operative management.
  • Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria.

  • 1 Griffith University, Gold Coast, QLD
  • 2 Gold Coast Hospital and Health Service, Gold Coast, QLD
  • 3 Research Support Network, Queensland Emergency Medicine Foundation, Brisbane, QLD


Amy Sweeny receives funding from the Emergency Medicine Foundation as a member of the Research Support Network.

Competing interests:

No relevant disclosures.

  • 1. Hong MK, Skandarajah AR, Hayes IP. Diverticulosis, diverticular disease and diverticulitis — definitions and differences. Journal of Stomal Therapy Australia 2015; 35: 8–10.
  • 2. Shahedi K, Fuller G, Bolus R, et al. Long‐term risk of acute diverticulitis among patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol Hepatol 2013; 11: 1609–1613.
  • 3. Gaglia A, Probert C. Diverticular disease. Medicine 2015; 43: 320–323.
  • 4. Matrana M, Margolin D. Epidemiology and pathophysiology of diverticular disease. Clin Colon Rectal Surg 2009; 22: 141–146.
  • 5. Jeyarajah S, Papagrigoriadis S. Review article: the pathogenesis of diverticular disease — current perspectives on motility and neurotransmitters. Aliment Pharmacol Ther 2011; 33: 789–800.
  • 6. Feingold D, Steele S, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014; 57: 284–294.
  • 7. Andeweg C, Mulder I, Felt‐Bersma R, et al. Guidelines of diagnostics and treatment of acute left‐sided colonic diverticulitis. Dig Surg 2013; 30: 278–292.
  • 8. Andersen J, Bundgaard L, Elbrønd H, et al. Danish national guidelines for treatment of diverticular disease. Dan Med J 2012; 59: 4453.
  • 9. McNamara M, Lalani T, Camacho M, et al. ACR appropriateness criteria: left lower quadrant pain — suspected diverticulitis. J Am Coll Radiol 2014; 7.
  • 10. Royal College of Surgeons. 2014 Commissioning guide: colonic diverticular disease. London: RCS, 2017. (viewed Sept 2018).
  • 11. 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: 1944–1949.
  • 12. Tursi A, Picchio M, Elisei W, et al. Management of patients with diverticulosis and diverticular disease: consensus statements from the 2nd International symposium on diverticular disease. J Clin Gastroenterol 2016; 50: S101–S107.
  • 13. Binda GA, Cuomo R, Laghi A, et al. Practice parameters for the treatment of colonic diverticular disease: Italian Society of Colon and Rectal Surgery (SICCR) guidelines. Techn Coloproctol 2015; 19: 615–626.
  • 14. Vennix S, Morton DG, Hahnloser D, et al; Research Committee of the European Society of Coloproctology. Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis 2014; 16: 866–878.
  • 15. Laméris W, van Randen A, Bipat S, et al. Graded compression ultrasonography and computed tomography in acute colonic diverticulitis: meta‐analysis of test accuracy. Eur Radiol 2008; 18: 2498.
  • 16. Liljegren G, Chabok A, Wickbom M, et al. Acute colonic diverticulitis: a systematic review of diagnostic accuracy. Colorectal Dis 2007; 9: 480–488.
  • 17. Sarma D, Longo W. Diagnostic imaging for diverticulitis. J Clin Gastroenterol 2008; 42: 1139–1141.
  • 18. Destigter K, Keating D. Imaging update: acute colonic diverticulitis. Clin Colon Rectal Surg 2009; 22: 147–155.
  • 19. Öistämö E, Hjern F, Blomgvist L, et al. Cancer and diverticulitis of the sigmoid colon. Differentiation with computed tomography versus magnetic resonance imaging: preliminary experiences. Acta Radiol 2013; 54: 237–241.
  • 20. Heverhagen J, Sitter H, Zielke A, Klose K. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoidal diverticulitis. Dis Colon Rectum 2008; 51: 1810–1815.
  • 21. Käser SA, Fankhauser G, Glauser PM, et al. Diagnostic value of inflammation markers in predicting perforation in acute sigmoid diverticulitis. World J Surg 2010; 34: 2717–2722.
  • 22. Sai V, Velayos F, Neuhaus J, Westphalen A. Colonoscopy after CT diagnosis of diverticulitis to exclude colon cancer: a systematic literature review. Radiol 2012; 263: 383–390.
  • 23. Sharma P, Eglinton T, Hider P, Frizelle F. Systematic review and meta‐analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg 2014; 259: 263–272.
  • 24. Andrade P, Ribeiro A, Ramalho R, et al. Routine colonoscopy after acute uncomplicated diverticulitis — challenging a putative indication. Dig Surg 2017; 34: 197–202.
  • 25. Cancer Council Australia: Cancer guidelines wiki: clinical practice guidelines for the prevention, early detection and management of colorectal cancer [website]. (viewed Oct 2017).
  • 26. Jenkins MA, Quakrim DA, Boussioutas A, et al. Revised Australian national guidelines for colorectal cancer screening: family history. Med J Aust 2018; 209: 455–460.
  • 27. Alonso S, Pera M, Parés D, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis 2010; 12: 278–282.
  • 28. Tursi A. Efficacy, safety, and applicability of outpatient treatment for diverticulitis. Drug Healthc Patient Saf 2014; 6: 29–36.
  • 29. van Dijk S, Bos K, de Boer M, et al. A systematic review and meta‐analysis of outpatient treatment for acute diverticulitis. Int J Colorectal Dis 2018; 33: 505–512.
  • 30. Etzioni D, Chiu V, Cnnom R, et al. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis Colon Rectum 2010; 53: 861–865.
  • 31. Ünlü C, Gunadi P, Gerhards M, et al. Outpatient treatment for acute uncomplicated diverticulitis. Euro J Gastroenterol Hepatol 2013; 25: 1038–1043.
  • 32. Carabotti M, Annibale B. Treatment of diverticular disease: an update on latest evidence and clinical implications. Drugs Context 2018; 7: 212526.
  • 33. Young‐Fadock TM, Solomon CG; editors. Diverticulitis. N Engl J Med 2018; 379: 1635–1642.
  • 34. Chabok A, Påhlman L, Hjern F, et al. Randomised clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 2012; 99: 532–539.
  • 35. Shabanzadeh D, Wille‐Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev 2012; 11: CD009092.
  • 36. Swanson S, Strate LL. Acute colonic diverticulitis. Ann Intern Med 2018; 168: 65–80.
  • 37. Paolillo C, Sartelli M, Miele V, et al. A three‐step approach to patients with suspected acute diverticulitis in the emergency department: an interdisciplinary algorithm proposal. Emerg Care J 2018; 14: 46–50.
  • 38. Dharmarajan S, Hunt S, Birnbaum E, et al. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum 2011; 54: 663–671.
  • 39. Fozard J, Armitage N, Schofield J, Jones O. ACPGBI position statement on elective resection for diverticulitis. Colorectal Dis 2011; 13: 1–11.
  • 40. Abbas S. Resection and primary anastomosis in acute complicated diverticulitis: a systematic review of the literature. Int J Colorectal Dis 2007; 22: 351–357.
  • 41. Morris A, Regenbogen S, Hardiman K, Hendren S. Sigmoid diverticulitis: a systematic review. J Am Med Assoc 2014; 311: 287–297.
  • 42. Regenbogen S, Hardman K, Hendren S, Morris A. Surgery for diverticulitis in the 21st century: a systematic review. J Am Med Assoc 2014; 149: 292–302.
  • 43. Floch M, Longo W. United States guidelines for diverticulitis treatment. J Clin Gastroenterol 2016; 50: 53–56.
  • 44. Zingg U, Pasternak I, Dietrich M, et al. Primary anastomosis vs Hartmann's procedure in patients undergoing emergency left colectomy for perforated diverticulitis. Colorectal Dis 2010; 12: 54–60.
  • 45. Aune D, Sen A, Leitzmann M, et al. Body mass index and physical activity and the risk of diverticular disease: a systematic review and meta‐analysis of prospective studies. Eur J Nutr 2017; 56: 2423–2438.
  • 46. Aune D, Sen A, Leitzmann M, et al. Tobacco smoking and the risk of diverticular disease — a systematic review and meta‐analysis of prospective studies. Colorectal Dis 2017; 19: 621–623.
  • 47. Cao Y, Strate L, Keeley B, et al. Meat intake and risk of diverticulitis among men. Gut 2018; 67: 466–472.
  • 48. Strate L, Liu Y, Aldoori W, Giovannucci E. Physical activity decreases diverticular complications. Am J Gastroenterol 2009; 104: 1221–1230.
  • 49. Strate L, Liu Y, Syngal S, et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA 2008; 300: 907–914.
  • 50. Strate L. Lifestyle factors and the course of diverticular disease. Dig Dis 2012; 30: 35–45.
  • 51. National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, 1999.; (viewed June 2019).


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