History and exam

Key diagnostic factors

common

left lower quadrant abdominal pain

Is the most common presenting symptom in acute diverticulitis.[43]​ Onset of pain is usually acute or subacute.[44]

Rarely, particularly in patients of Asian heritage, the pain may be in the right lower quadrant.[9][10]

fever

A low-grade fever frequently accompanies left lower quadrant pain in episodes of diverticulitis.[44]

Other diagnostic factors

common

guarding in left lower quadrant

In acute diverticulitis.[1]

tenderness in left lower quadrant

In acute diverticulitis.[1]

rebound tenderness

In acute diverticulitis.[1]

uncommon

diffuse abdominal tenderness

In cases of free perforation and generalized peritonitis.

change in bowel habit

Patients with diverticulitis can experience episodes of diarrhea, which may alternate with periods of constipation. They may also report abdominal bloating.[27]

Absolute constipation may be a sign of complicated acute diverticulitis.[1]

palpable abdominal mass

May indicate abscess.[1]​

Risk factors

strong

age >50 years

Age is the strongest risk factor. Incidence of diverticular disease increases in older people and is extremely rare in children.[30] It may be due to decreasing mechanical strength of the colonic walls. Changes in collagen structure may cause age-associated decreases in the colonic wall strength.[31]

The prevalence of colonic diverticular disease increases with age, being around 25% of adults ages 40-49 years, approximately 35% at 50-59 years of age, approximately 50% in those ages 60-69 years, 65% in those ages 70-79 years, and around 70% in adults over 80 years of age.[11]​ In addition, there has been a rising incidence of diverticular disease among patients younger than 45 years old.[12]

low dietary fiber

High fiber intake (>30 g/day) may reduce the risk of diverticulitis compared to low fiber intake.​[3][32]​​​ One hypothesis for the pathogenesis of diverticulosis is that a low-fiber diet decreases stool weight and volume, and increases intestinal transit time, resulting in increased intraluminal pressure and colonic segmentation, which predispose to the formation of diverticula.[26][27]​​​ However, the precise mechanism is not completely understood, and this concept does not easily explain the right-sided disease seen in Asia.

weak

diet rich in salt, meat, and sugar

Salt-, meat-, and sugar-rich diets are associated with increased incidence of colonic diverticula. This diet results in low stool weight and increased transit time, which in turn results in increased segmental pressure in the colon leading to diverticula formation.[26][27]

obesity (BMI >30)

Obesity is a predisposing factor.[14]

Modest increases in body mass index (BMI) may increase the risk of uncomplicated and complicated diverticulitis.[15] Complications of diverticulitis, such as perforations and recurrent diverticulitis, are more common in people with a BMI greater than 30.[3][33][34]​​[35]

use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or opioids

Observational studies suggest an association between NSAID, corticosteroid, and opioid use and occurrence of diverticulitis, complicated diverticulitis, and perforation or bleeding of colonic diverticula.​[19][20][36][37]​​​​​​[38][39]​​​​​

tobacco smoking

There is a causal association between tobacco use and incidence of diverticular disease.​[16][18]

alcohol consumption

In a cross-sectional study, individuals who consumed alcohol were observed to have a 2-fold greater risk of diverticulosis.[40]

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