Signs and Symptoms

Pain is a hallmark symptom of diverticular disease. The pain of diverticulosis is often relieved by passing flatus or having a bowel movement and can be precipitated by ingesting food.[4] The lower left quadrant is the site of pain with left-sided disease. Likewise, lower right quadrant pain is present with right-sided disease.[7] In fact, many of the patients who suffer from pain associated with diverticulitis are often misdiagnosed as having inflammatory bowel disease (IBD).[3] Patients with symptomatic diverticulosis (without inflammation) often suffer from constipation rather than diarrhea.[4] However, diverticulitis patients may suffer from either diarrhea or constipation.[9] Other symptoms of uncomplicated diverticulitis include fever, left lower abdominal tenderness (with left-sided disease), mild-tomoderate leukocytosis, irregular bowel habits, urinary symptoms, and abdominal distention.[9,10]

Complicated diverticulitis is more critical and presents with additional symptoms depending on the complexity of the condition. Up to 25% of the cases of diverticulitis are complicated diverticulitis.[5] The majority of patients with complicated diverticulitis have no prior history of the disease.[2] Complicated diverticulitis can be associated with abscess, phlegmon, obstruction, fistulization, bleeding, sepsis, generalized peritonitis, and/or stricture.[3,9]

Often patients with complicated diverticulitis present with perforation first. Diverticulitis with perforation causes the most morbidity and mortality.[2] The perforation can be a micro- or a macroperforation. The infection after a microperforation is usually contained by the pericolonic fat, mesentery, or adjacent organs; therefore, a localized phlegmon occurs. However, the infection after a macroperforation is not restricted and can result in peritonitis or a pericolonic abscess.[4,9] Upon abdominal examination, the presence of a tender mass is suggestive of an abscess.[7] If the infection spreads to the adjacent structures, a fistula may develop.[4] Although they are atypical presentations of diverticulitis, the following may be present in complicated diverticulitis: chronic infections in the hip, knee, or thigh; inflammation in the perineum (the pelvic floor and associated structures) or genitalia; abscesses in the liver; subcutaneous emphysema (accumulation of air) of the legs, neck, and abdominal wall; and skin lesions.[2]

There can be diverticular bleeding, which may result in anemia.[7] However, rectal bleeding is less likely to be diverticulitis than ischemia, ulcerative colitis, or Crohn's disease.[10]

The symptoms of a fistula include pneumaturia (gas or air in the urine), fecaluria (feces in the urine), vaginal discharge, and recurrent urinary tract infections (UTIs).[10] Recurrent UTIs can occur with the presence of a colovesical fistula, which is a fistula between the colon and the bladder, and the most common fistula with diverticulitis. [3,7] Colovesical fistulas are more common in men than in women due to the fact that the uterus is between the colon and bladder in women.[4]