What are the symptoms and treatment options for diverticulosis?

Symptoms of Diverticulosis

Key Clinical Distinction

Diverticulosis itself is asymptomatic in the vast majority of patients—the presence of colonic diverticula does not cause abdominal pain, bloating, or altered bowel habits. 1

The critical distinction is between diverticulosis (asymptomatic presence of diverticula) and diverticular disease (symptomatic conditions). Most individuals with diverticulosis remain completely asymptomatic throughout their lives. 2

What Diverticulosis Does NOT Cause

Recent high-quality prospective cohort data definitively demonstrates that diverticulosis is not associated with:

• Abdominal pain lasting >24 hours 1
• Irritable bowel syndrome symptoms 1
• Constipation (contrary to widespread belief) 1
• Altered stool consistency 1

The controversial diagnosis of "symptomatic uncomplicated diverticular disease" (SUDD) must be reconsidered, as evidence shows diverticulosis does not cause chronic gastrointestinal symptoms. 1

The Only Association: Bowel Movement Frequency

Diverticulosis is associated with more frequent bowel movements per day, particularly in patients with >10 diverticula. 1 This represents the only documented symptomatic association with diverticulosis itself.

When Symptoms Develop: Progression to Diverticular Disease

Approximately 25% of individuals with diverticulosis will develop symptomatic diverticular disease, which includes: 2

Acute Diverticulitis (1-4% lifetime risk)

• Left lower quadrant abdominal pain (the hallmark symptom) 3
• Fever and chills 3
• Nausea and vomiting 3
• Leukocytosis (elevated white blood cell count) 3

The pain in acute diverticulitis is typically persistent, often lasting more than 24 hours, and is not relieved by bowel movements. 4

Diverticular Hemorrhage

• Painless rectal bleeding (a complication distinct from diverticulitis) 2

Clinical Algorithm for Symptom Evaluation

If a patient with known diverticulosis reports abdominal symptoms:

1. Consider alternative diagnoses first - The presence of diverticula does not explain chronic abdominal pain, bloating, or bowel habit changes 1

2. Evaluate for acute diverticulitis if:

   • Left lower quadrant pain is present 3
   • Fever >100.4°F 3
   • Persistent symptoms >24 hours 4
   • Nausea/vomiting 3

3. Obtain CT imaging with IV contrast if acute diverticulitis is suspected (98-99% sensitivity, 99-100% specificity) 3

4. Exclude other conditions including irritable bowel syndrome, inflammatory bowel disease, ischemic colitis, and malignancy through appropriate imaging and endoscopy 5

Common Clinical Pitfall

Do not attribute chronic abdominal symptoms to diverticulosis alone. The widespread practice of diagnosing "symptomatic uncomplicated diverticular disease" lacks evidence-based support, as prospective data shows no association between diverticulosis and chronic gastrointestinal symptoms. 1 Patients with persistent symptoms and diverticulosis require evaluation for alternative diagnoses rather than treatment directed at the diverticula themselves.