Diverticulosis is a term denoting the presence of several sac-like structures that stem from the mucosa and submucosa of the intestinal wall, and it's almost exclusive location in the large intestine explains why the term "colonic diverticulosis" is used [1] [2] [3] [4] [5]. In recent years, it has become evident that colonic diverticulosis is quite commonly found in the senile population primarily living in the Western world, with the single most important risk factor being a low-fiber diet [2] [3] [6]. Furthermore, obesity and certain drug groups (opioids, corticosteroids, and non-steroidal anti-inflammatory drugs, or NSAIDs) have also been associated with colonic diverticulosis [2]. The clinical presentation is asymptomatic in 70-80% of patients, which is supported by the fact that they are one of the most frequent incidental findings on colonoscopy [2] [4] [5]. Symptoms may appear in the presence of an infection (termed diverticulitis), while diverticular disease refers to the development of typical lower gastrointestinal tract symptoms - abdominal pain (often on the left side), cramping, fever, and bloating [3] [4] [5] [6]. Altered bowel habits (more commonly constipation than diarrhea) and a sense of fullness in the lower left quadrant are also reported, whereas painless rectal bleeding (abrupt and sometimes voluminous) is a highly indicative sign of an ongoing disease in the lower gastrointestinal tract [5] [6]. Both acute and chronic course of illness has been reported [5].

• Abdominal Pain

  These regular rhythms are associated significantly with reporting of abdominal pain. [ncbi.nlm.nih.gov]

  The majority of patients are asymptomatic, whereas inflammatory changes and infections of diverticula can lead to symptoms such as fever, abdominal pain, bloating, and even lower gastrointestinal bleeding. [symptoma.com]

  Similarly, no serological or mucosal inflammation was associated with symptomatic cases of diarrhea or abdominal pain vs asymptomatic controls. [researchers.mq.edu.au]

• Hematochezia

  Diverticular bleeding manifests as painless hematochezia. Because the bleeding vessel is an arteriole, the amount of blood loss is usually moderate to severe. [merckmanuals.com]

  The single patient with probable diverticular bleeding presented with one-day history of recurrent moderate hematochezia. His previous colonoscopy was negative except for left-sided diverticulosis. [hindawi.com]

  Images in Clinical Medicine George Triadafilopoulos, M.D. 4 Citing Articles Figure 1 A 42-year-old man with a history of mild, intermittent pain on the lower left side of the abdomen presented with an episode of painless hematochezia. [nejm.org]

  Symptoms of SCAD include hematochezia, abdominal pain, and diarrhea. [msdmanuals.com]

• Rectal Pain

  Case 3) A 77 years old male presenting constipation and rectal pain for two weeks. Medical history revealed chagasic megacolon corrected by Duhamel's technique 14 years ago. [scielo.br]

• Suprapubic Pain

  - Marked by suprapubic pain, shifting to left iliac fossa. - Fever, nausea and vomiting. - ‘left-sided appendicitis’. - Local signs of peritonitis, colicky abdominal pain, raised WCC. - Change in bowel habit eg.constipation. • Perforated diverticulitis [slideshare.net]

• Grieving

  Brewster NT, Grieve DC, Saunders JH. Double-contrast barium enema and flexible sigmoidoscopy for routine colonic investigation. Br J Surg 1994; 81 : 445–447 [ PubMed ] 109. von Wagner C, Smith S, Halligan S, et al.. [ncbi.nlm.nih.gov]

The diagnosis of colonic diverticulosis must be considered in old-age patients who present with lower gastrointestinal tract related symptoms. A properly obtained history is the first step, during which assessment of risk factors, such as dietary intake of fiber and use of various drugs, as well as the course and progression of symptoms, should be noted. Physical examination can reveal tenderness in the lower left quadrant in symptomatic patients, while palpation of the sigmoid colon in this area is also seen in colonic diverticulosis [5]. To solidify the diagnosis, imaging studies need to be performed. Barium enema was previously considered as the gold standard in the evaluation of colonic diverticulosis, but in the presence of an intestinal perforation, the contrast material may reach extraintestinal tissue and cause complications [5]. For this reason, computed tomography (CT) has emerged as the optimal procedure [1] [3] [5]. The presence of air-filled pouches arising from the colonic wall, primarily located in the sigmoid colon, are hallmarks of colonic diverticulosis [1]. In addition, ultrasonography has been described as a beneficial method in certain studies, describing diverticula as hypoechoic or anechoic structures protruding from the colonic wall that shows signs of hypertrophy [5]. Finally, colonoscopy should be employed as a definite method if inconclusive findings are obtained from CT or ultrasonography, although CT colonography is becoming a suitable replacement, being less invasive but equally effective than colonoscopy [5].

1. Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics. 2000;20(2):399-418.
2. Feuerstein JD, Falchuk KR. Diverticulosis and Diverticulitis. Mayo Clin Proc. 2016;91(8):1094-1104.
3. Weizman AV, Nguyen GC. Diverticular disease: Epidemiology and management. Can J Gastroenterol. 2011;25(7):385-389.
4. Hobson KG, Roberts PL. Etiology and Pathophysiology of Diverticular Disease. Clin Colon Rectal Surg. 2004;17(3):147-153.
5. Salzman H, Lillie D. Diverticular disease: diagnosis and treatment. Am Fam Physician. 2005;72(7):1229-1334.
6. Boynton W, Floch M. New strategies for the management of diverticular disease: insights for the clinician. Therap Adv Gastroenterol. 2013;6(3):205-213.