Can diverticulitis cause chest pain?

Can Diverticulitis Cause Chest Pain?

Yes, diverticulitis can rarely present with chest pain as a referred pain phenomenon, though this is an atypical presentation that should only be considered after excluding life-threatening cardiac, pulmonary, and esophageal causes.

Understanding This Atypical Presentation

The classic presentation of diverticulitis involves left lower quadrant abdominal pain, fever, and leukocytosis 1, 2, 3. However, a documented case report describes an 80-year-old patient with sigmoid diverticulitis who presented with only lower anterior chest pain, which was determined to be referred pain from the diseased sigmoid colon 4. This represents an extremely rare presentation pattern.

Clinical Approach When Chest Pain Is Present

Initial Assessment Priority

• First, exclude major causes of chest pain including acute coronary syndrome, pulmonary embolism, aortic dissection, pneumothorax, and esophageal rupture before attributing chest pain to an abdominal source 4.
• Look for accompanying symptoms that suggest diverticulitis: nausea, vomiting, anorexia, constipation, diarrhea, dysuria, fever, or any abdominal tenderness 2, 3.
• Check for fever, leukocytosis, and elevated C-reactive protein, which are typical inflammatory markers in diverticulitis 2, 3.

When to Consider Diverticulitis as the Cause

• Diverticulitis should only be suspected as a cause of chest pain after other major causes have been definitively excluded 4.
• The patient should have risk factors for diverticular disease: age over 65 years, history of diverticulosis, obesity (BMI ≥30), use of NSAIDs/opioids/steroids, hypertension, or type 2 diabetes 2.
• Consider this diagnosis particularly in elderly patients where referred pain patterns may be atypical 4.

Diagnostic Imaging Requirements

Gold Standard Imaging

• Contrast-enhanced CT of the abdomen and pelvis with IV and oral contrast is essential, with 98-99% sensitivity and 99-100% specificity for diverticulitis 5, 2.
• CT will show characteristic findings: pericolonic fat stranding, bowel wall thickening >5mm, inflamed diverticula, and potential complications like abscess or perforation 6, 2.

Critical Imaging Pitfall

• Never attribute symptoms to incidental diverticulosis seen on imaging—this is one of the most common diagnostic errors 5.
• Diverticulitis requires demonstration of active inflammation (pericolonic fat stranding, bowel wall thickening, or complications), not just the presence of diverticula 5, 6.

Red Flags Requiring Immediate Evaluation

Regardless of imaging results, these clinical findings mandate urgent assessment 5:

• Fever with severe tenderness and guarding
• Inability to pass gas or stool
• Vomiting
• Bloody stools
• Marked leukocytosis

Management Implications

If Diverticulitis Is Confirmed

• Uncomplicated diverticulitis (85% of cases): Observation with pain management (acetaminophen), clear liquid diet, and selective antibiotic use 2.
• Antibiotics are indicated for: persistent fever/chills, increasing leukocytosis, age >80 years, pregnancy, immunocompromise, or chronic conditions like cirrhosis or poorly controlled diabetes 2.
• First-line oral antibiotics: amoxicillin/clavulanic acid or cefalexin plus metronidazole 2.

If Complicated Diverticulitis

• IV antibiotics (ceftriaxone plus metronidazole or piperacillin-tazobactam) are required 2.
• Percutaneous drainage for abscesses ≥3cm 6.
• Emergent surgery for generalized peritonitis 2.

Key Clinical Caveat

The presence of chest pain in a patient ultimately diagnosed with diverticulitis represents a highly unusual referred pain pattern. This diagnosis should never be made presumptively—it requires both definitive exclusion of thoracic pathology AND confirmation of active diverticular inflammation on contrast-enhanced CT imaging 4. The vast majority of patients with diverticulitis will have left lower quadrant pain, not chest pain 1, 2, 3.