Does Chronic Diverticulitis Exist?
Yes, chronic diverticulitis exists as a recognized clinical entity, though it represents distinct conditions rather than a single disease: smoldering diverticulitis (persistent inflammation after acute episodes) and chronic symptoms following acute diverticulitis (often due to visceral hypersensitivity rather than ongoing inflammation).
Recognized Forms of Chronic Diverticular Disease
The 2021 AGA guidelines explicitly acknowledge chronic manifestations of diverticulitis 1:
- Smoldering diverticulitis affects approximately 5% of patients after acute uncomplicated diverticulitis, characterized by persistent abdominal pain and continued evidence of inflammation on CT scan 1
- Post-diverticulitis chronic symptoms occur in approximately 45% of patients at 1-year follow-up, with periodic abdominal pain being the most common complaint 1
- These chronic symptoms represent a shift in understanding diverticular disease from purely an acute surgical illness to a chronic bowel disorder with recurrent symptoms and considerable psychosocial impact 2
Critical Distinction: Inflammation vs. Visceral Hypersensitivity
When evaluating patients with chronic symptoms after diverticulitis, you must exclude ongoing inflammation before attributing symptoms to visceral hypersensitivity 1:
- Obtain CT scan of abdomen/pelvis with oral and IV contrast to assess for ongoing diverticular inflammation, stricture, or fistula 1
- Perform colonoscopy to exclude alternative diagnoses including ischemic colitis, constipation, and inflammatory bowel disease 1
- If imaging and endoscopy are negative, visceral hypersensitivity is the likely cause in the majority of cases 1
- Chronic pain from visceral hypersensitivity can be treated with low to modest doses of tricyclic antidepressants 1
Related Chronic Condition: SCAD
Segmental colitis associated with diverticular disease (SCAD) is a distinct chronic entity characterized by diverticular colitis that spares the rectum, likely on the spectrum of inflammatory bowel diseases 1, 3
Clinical Implications for Surgery
The existence of chronic symptoms has important surgical implications 1:
- Surgery does not reliably resolve chronic symptoms: 22-25% of patients continue to have ongoing abdominal pain after colectomy 1
- Elective resection improves quality of life at 5-year follow-up in patients with recurrent diverticulitis or ongoing symptoms compared to conservative management 1
- However, surgery reduces but does not eliminate diverticulitis risk (15% recurrence rate at 5 years post-surgery vs. 61% with non-operative management) 1
Common Pitfall to Avoid
Do not assume all chronic abdominal symptoms after diverticulitis represent ongoing inflammation requiring antibiotics or surgery. The majority of chronic symptoms are due to visceral hypersensitivity rather than active inflammation 1. Always complete diagnostic workup with both imaging and endoscopy before concluding the etiology 1.