G a s t r o i n t e s t i n a l I m a g i n g R ev i ew

Flor et al.
Imaging of Colonic Diverticular Disease

Gastrointestinal Imaging
Review

The Current Role of Radiologic

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and Endoscopic Imaging in the

FOCUS ON:

Diagnosis and Follow-Up of Colonic

Diverticular Disease
Nicola Flor 1 OBJECTIVE. Colonic diverticular disease is among the most prevalent conditions in
Giovanni Maconi2 Western society and is a common cause for outpatient visits and hospitalizations. The role of
Gianpaolo Cornalba1 imaging is in evolution, but it has proven useful in confirming clinically suspected disease,
Perry J. Pickhardt 3 assessing severity and complications, and directing patient management.
CONCLUSION. This review focuses on the current role of radiologic and endoscopic
Flor N, Maconi G, Cornalba G, Pickhardt PJ imaging in distinct clinical scenarios of diverticular disease, with emphasis on diverticulitis
and its follow-up.

iverticulosis and diverticular dis- myochosis, consisting of elastin deposition

D ease of the colon are increasingly

Keywords: abdominal CT, acute diverticulitis,
colonoscopy, CT colonography, diverticular disease
DOI:10.2214/AJR.16.16138
Received January 21, 2016; accepted without revision
January 28, 2016.
1
Unit Operativa di Radiologia Diagnostica e
I nterventistica, Azienda Ospedaliera San Paolo,
Dipartimento di Scienze della Salute, Universit degli
Studi di Milano, Via di Rudin 8, 20142 Milan, Italy.
Address correspondence to N. Flor (nicola.flor@unimi.it).
2
Gastroenterology Unit, Department of Biomedical and
Clinical Sciences, L. Sacco University Hospital, Milan, Italy.
3 nostic approach to acute diverticulitis and its
Department of Radiology, University of Wisconsin
School of Medicine and Public Health, Clinical Science
Center, Madison, WI.
This article is available for credit.
Supplemental Data
Available online at www.ajronline.org.
AJR 2016; 207:1524
0361803X/16/207115
American Roentgen Ray Society
common clinical conditions that
are more frequently encountered
in elderly patients and in industrialized coun-
tries [1]. A significant increase in diverticular
disease, particularly acute diverticulitis, has
been reported in recent years, along with an in-
creasing rate of hospital admission, morbidity,
and mortality [1, 2]. Although diverticular dis-
ease of the colon and acute diverticulitis may
be clinically suspected, endoscopic or radiolog-
ic imaging is usually needed for confirmation
and to exclude malignancy and complications.
Moreover, as therapeutic strategies are differ-
entiated and continue to evolve, diagnostic im-
aging may also be useful to tailor appropriate
treatment to the patients specific clinical situa-
tion. The aim of this review is to discuss the
current role of radiologic and endoscopic imag-
ing in diverticular disease of the colon. In par-
ticular, the distinct clinical scenarios of diver-
ticulitis and follow-up of colonic diverticular
disease will be considered. Because the diag-
various complications are well established, this
review will focus more on the workup and
management of postacute, chronic, and other
related conditions of diverticular disease.
Definitions
The terms diverticulosis and divertic-
ular disease are often erroneously applied.
Colonic diverticulosis reflects the presence
of diverticula, regardless of symptoms, typi-
cally with associated colonic wall changes of
with thickening of the circular smooth mus-
cle, shortening of the taenia, and luminal nar-
rowing. It is a common condition in the West
and increases with age (frequency< 5% under
age 40 years but> 65% by age 85 years in the
United States) [3]. There is a strong predilec-
tion for the left colon (sigmoid and descending
segments). The true frequency of diverticulo-
sis is unknown, but it is increasing worldwide,
including in Asia, where right-sided diverticu-
la were previously more common.
In contrast to diverticulosis, diverticular
disease generally refers to clinically relevant
symptomatic diverticulosis, including acute
diverticulitis and more chronic complica-
tions [4, 5]. Acute diverticulitis reflects the
presence of macroscopic diverticular inflam-
mation and can be uncomplicated or compli-
cated. The chronic form of diverticular dis-
ease incorporates cases of recurrent acute
diverticulitis and symptomatic uncomplicat-
ed diverticular disease, in which persistent
abdominal symptoms related to diverticula
are not associated with acute inflammation.
Two other entities to be mentioned are diver-
ticular bleeding and segmental colitis asso-
ciated with diverticula (SCAD), a pattern of
inflammation that spares the diverticular or-
ifices, where diagnosis is based on specific
endoscopic and pathologic features.
Diagnosis of Acute Diverticulitis
The Role of Radiologic Imaging
The evaluation of patients with acute diver-
ticulitis includes medical history, physical ex-

AJR:207, July 2016 15

 Flor et al.
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A B
Fig. 157-year-old woman with uncomplicated acute sigmoid diverticulitis who presented with left lower quadrant abdominal pain.
A, Image from pelvic ultrasound shows eccentric focal wall thickening of sigmoid colon, associated with inflamed diverticulum (arrows). Inflammation results in
increased blood flow on color Doppler evaluation. No adnexal abnormality was seen.
B, Contrast-enhanced CT performed after ultrasound confirms uncomplicated acute sigmoid diverticulitis, with extraluminal inflammatory changes surrounding sigmoid
diverticula (arrow). No abscess was present.

amination, and laboratory testing, but cross-
sectional imaging often plays a pivotal role
in verifying the diagnosis. In practice, clini-
cal diagnosis without imaging confirmation is
unreliable [6, 7]. Different radiologic tests can
be applied for the diagnosis of acute diverticu-
litis, including ultrasound, CT, and MRI. Both
CT colonography (CTC) and double-contrast
barium enema are contraindicated in the set-
ting of suspected acute diverticulitis.
Although it is used infrequently in the Unit-
ed States, ultrasound is considered a front-line
radiologic test by some, because it is safe,
widely available, and easily accessible with-
in the emergency department. It is a fast, low-
cost, and noninvasive examination as well. In
particular, ultrasound may be a reasonable
consideration in thin patients and in female
patients of childbearing age, for whom radia-
tion exposure is best avoided. Another advan-
tage of ultrasound is the ability to correlate
imaging findings with the region of greatest
tenderness in real time. Relative disadvantag-
es of ultrasound include the operator depen-
dence and difficulties in evaluation of deep
abdominal sites, especially in obese patients.
When performed by expert examiners, ul-
trasound can be reasonably effective [8]. In
some cases, CT may be deemed necessary to
confirm a suspected ultrasound-guided di-
agnosis (Fig. 1) and to assess for complica-
tions. Two meta-analyses have reported that
ultrasound and CT have comparable accu-
racy in the evaluation of acute diverticulitis
[9, 10], although these data may be somewhat
biased. Contrast-enhanced ultrasound could
play a role in the evaluation of acute diver-
ticulitis in the near future by facilitating the
assessment of increased mural microvascu-

A B
Fig. 2Five different patients with complications related to left colonic diverticulitis who underwent contrast-enhanced CT.
A, Patient with peridiverticular abscess. Image shows large complex fluid collection (arrow) with gas and surrounding phlegmonous changes.
B, Patient with diffuse peritonitis. Image shows widespread thickening and enhancement of parietal and visceral peritoneum associated with free
fluid. Lack of localized encapsulation is uncommon.

(Fig. 2 continues on next page)

16 AJR:207, July 2016

 Imaging of Colonic Diverticular Disease
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C D E
Fig. 2 (continued)Five different patients with complications related to left colonic diverticulitis who underwent contrast-enhanced CT.
C, Patient with colocolonic fistula. Image shows air-filled track (arrow) that parallels and communicates with diverticular segment, resulting in double-track appearance.
D, Patient with impending colovesical fistula. Image shows diverticular extension to bladder submucosa (arrow). Focal bulge without frank opening was seen at
cystoscopy (inset).
E, Patient with hepatic abscesses (arrow) related to pylephlebitis from sigmoid diverticulitis. Patient presented with nonspecific right upper quadrant symptoms.
Changes of smoldering sigmoid diverticulitis are partially visualized on this coronal view.

larization caused by inflammation, as well as
the diagnosis of complications such as fistu-
las or covered perforations [11].
All the limitations associated with ultra-
sound can be overcome by conventional ab-
dominal CT, which is generally considered
as the preferred front-line radiologic test for
evaluating patients with suspected acute di-
verticulitis. Strengths of CT examination in-
clude its reproducibility, operator indepen-
dence, wide availability, and high accuracy
for diagnosing acute disease [9, 10]. CT allows
comprehensive evaluation, including the grad-
ing of severity and detection of complications
that affect therapeutic management. Diagno-
sis can be made directly on the basis of lo-
calized bowel wall thickening that is centered
on an inflamed diverticulum, with surround-
ing peridiverticular inflammation of the peri-
colonic fat (Fig. 1). Because diverticulitis is
primarily an extraluminal disease, cross-sec-
tional imaging holds a distinct advantage over
luminal studies. Covered or free perforations
can be rapidly and reliably diagnosed by the
direct detection of air inclusions outside the
intestinal lumen, often associated with mesen-
teric fasciae thickening and free fluid.
There has been some controversy over the
appropriate CT protocol regarding the use of
oral, rectal, and IV contrast agents. In gen-
eral, the use of IV contrast agent should be
encouraged in cases of suspected compli-
cated disease to confirm the severity of the
event and better diagnose complications such
as abscesses and fistulas. In our experience,
neither oral nor rectal contrast agent is tru-
ly necessary. The utility of luminal contrast
agent is primarily limited to thin patients
without ample pericolonic fat and for better
differentiating alternative conditions from
acute diverticulitis. CT evaluation is valuable
for its appraisal of disease severity, which af-
fects therapeutic management. In particular,
different severity scores and guidelines [12
16] strive to divide patients into two main
categoriesnamely, those with uncompli-
cated and complicated acute diverticulitis.
In uncomplicated cases, the CT findings are
generally limited to phlegmonous reaction
of pericolonic fat tissue, whereas complicat-
ed features include peridiverticular abscess,
significant pneumoperitoneum, and diffuse
peritonitis (Fig. 2). Moreover, CT grading
of acute diverticulitis has prognostic signifi-
cance in terms of disease recurrence after an
initial episode of acute disease [17]. In addi-
tion to being highly accurate for acute diver-
ticulitis itself, CT is also the most accurate
test for diagnosing alternative conditions [18,
19], including acute appendicitis [20].
CTC and double-contrast barium enema
are contraindicated in patients with acute di-
verticulitis and add no additional useful in-
formation to conventional CT evaluation for
acute management. Because both examina-
tions include active colonic distention with
either room air or carbon dioxide, there is
at least a theoretic concern for extension of
the typical microperforation associated with
acute diverticulitis to more frank perfora-
tion and peritonitis. Double-contrast bari-
um enema in particular is an obsolete test
and should be abandoned, regardless of the
clinical scenario. This test has a lower accu-
racy than CTC and optical colonoscopy for
colorectal evaluation [21], is associated with
higher ionizing radiation exposure [22], and
is less acceptable for patients [23]. On occa-
sion, findings of unsuspected mild acute or
subacute diverticulitis may be encountered at
CTC in patients with only minimal or no ap-
parent symptoms (Fig. 3).
MRI currently does not play an important
role in the workup of patients with suspected
acute diverticulitis but can be considered in
selected cases, such as pregnant women. Al-
though there are some advantages compared
with other radiologic tests (e.g., lack of ion-
izing radiation exposure and high intrinsic
contrast resolution), the availability of MRI
in the emergency department is currently
limited in most hospital settings. To date,
there is relatively little evidence regarding

AJR:207, July 2016 17

 the accuracy of MRI for acute diverticulitis,
Flor et al.
and it is limited to small select patient co-
horts [24, 25]. However, because of the rapid
technologic progress in terms of MRI speed
and resolution and the increasing availability
of MRI, its role in the setting of nontraumat-
ic acute abdominal pain appears to be rapid-
ly expanding. The imaging findings of MRI
are analogous to those of CT, but there may
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be a learning curve in diagnostic interpreta-

tion [26] (Fig. 4).

The Role of the Endoscopy

The use of endoscopy in patients with sus-
pected acute diverticulitis is contraindicat-
A B ed because of the high risk of perforation
and bleeding and because of the disadvan-
tages related to pain and discomfort for the
patient. If, for any reason, colonoscopy has
to be performed in patients with suspected
acute diverticulitis, gentle manipulation with
minimal air inflation is required, and if a di-
agnosis of acute diverticulitis is confirmed,
the procedure should be terminated. Howev-
er, unsuspected and relatively asymptomatic
acute uncomplicated diverticulitis may be in-
advertently encountered and diagnosed dur-
ing colonoscopy. Its main endoscopic find-
C D ings are granulation tissue protruding from
Fig. 3Three patients with unsuspected acute or resolving diverticulitis at screening who underwent CT a diverticular opening, erythema and edema
colonography (CTC).
A, 57-year-old woman. CTC shows diverticulum off descending colon with surrounding mild inflammatory of the diverticular opening, or pus emanating
changes (arrow), consistent with uncomplicated diverticulitis. from a diverticulum [27] (Fig. 3).
B, 63-year-old woman. CTC shows more extensive soft-tissue inflammatory changes surrounding sigmoid
diverticulum (arrow), which was thought to represent resolving or recurrent diverticulitis.
C and D, 51-year-old woman. Image from CTC screening (C) shows masslike eccentric wall thickening of Endoscopic Follow-Up of
sigmoid colon with surrounding soft-tissue stranding (arrow). Although diverticular cause was favored, AcuteDiverticulitis
patient was sent for sigmoidoscopy (D) to exclude cancer, which showed residual mural inflammation and pus The precise role of colonoscopy after an
emanating from diverticular orifice.
episode of acute diverticulitis remains con-
troversial. Regarding its safety, early colon-
oscopy (performed 311 days after the acute
episode) is considered as safe as late colonos-
copy (performed 619 weeks after the acute

A B C
Fig. 435-year-old man with acute uncomplicated sigmoid diverticulitis seen at MRI (with CT confirmation) who presented with acute left lower quadrant abdominal pain.
AC, Coronal T2-weighted single-shot fast spin-echo (A) and T1-weighted contrast-enhanced gradient-echo (B) images show subtle inflammation and enhancement
surrounding sigmoid diverticulum (arrows), which was confirmed and more obvious on subsequent CT (arrow, C).

18 AJR:207, July 2016

 Imaging of Colonic Diverticular Disease
episode), even if it is usually advised to wait
at least 6 weeks after an episode of acute di-
verticulitis [28]. However, a major concern
regards the utility of endoscopy in this clini-
cal setting. Most practice guidelines advise
performing colonoscopy after an episode
of acute diverticulitis to rule out underly-
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ing malignancy, but this is mainly supported
only by expert opinion and lacks robust sci-
entific evidence. In fact, systematic reviews
show that colonoscopy is generally not nec-
essary to rule out colon cancer after an ep-
isode of acute uncomplicated diverticulitis
[29, 30]. However, other studies caution that
early colonoscopy may be warranted in cases
where concerning findings are identified at
CT diagnosis, such as focal mass lesion, ob-
struction, wall thickness greater than 6 mm,
abscess, or prominent lymph nodes [3133].
On the other hand, it has been pointed out
by a recent retrospective study from Portugal
[34] that advanced neoplasia may be found in
nearly 25% of patients undergoing colonos-
copy after a CT diagnosis of acute divertic-
ulitis and that the frequency increases with
advancing age and male sex. Furthermore,
follow-up colonoscopy can also detect resid-
ual signs of inflammation after an acute epi-
sode of diverticulitis, which may have some
prognostic role. However, these findings re-
quire external confirmation [35].
In the follow-up of patients with acute di-
verticulitis, colonoscopy may also play a role
in the management of colonic obstruction,
confirm the cause of obstruction, obtain tis-
sue for diagnosis and ruling out malignan-
cy, and provide treatment. Endoscopic thera-
py mainly consists of balloon dilatation, but
A B
AJR:207, July 2016 19
this procedure carries a relatively high risk
of perforation. Therefore, elective surgery
is usually recommended for patients with
symptomatic diverticular disease complicat-
ed by stenosis [5].
Acute Gastrointestinal Bleeding
Related to Colonic Diverticulosis
A diverticular source, along with angio-
ectasia, is one of the most common causes
of acute lower gastrointestinal bleeding. For-
tunately, the bleeding ceases spontaneous-
ly in most cases, with a reported recurrent
bleeding rate of 1438% [36, 37]. In patients
with bleeding of suspected diverticular ori-
gin, prompt colonoscopy (i.e., within 1224
hours) may be considered for diagnosis and
to direct therapy [5]. After clinical evalu-
ation and stabilization of patients, colon-
oscopy may be the first diagnostic test per-
formed, but it requires bowel preparation.
When performed within 48 hours of an acute
episode, the diagnostic yield of early colon-
oscopy reportedly ranges from 48% to 90%
and is associated with shorter hospital stays
[38]. Identification of the source of bleeding
(Fig. 5) is essential to achieve hemostasis and
prevent recurrence, with therapy mainly by
thermal contact modalities (e.g., heat probe),
epinephrine injection, or endoscopic vascu-
lar clip placement [39]. However, in cases of
massive diverticular bleeding, it may not be
possible to identify the source by colonosco-
py, and angiographic or surgical therapy may
be necessary [36, 40, 41].
Given the delay associated with bowel
preparation and the difficulty of endoscopic
visualization in the setting of large-volume
hemorrhage, CT angiography has played an
increasing role in the initial workup of acute
lower gastrointestinal bleeding [4244] (Fig.
5). This CT-based test has largely replaced
RBC-labeled scintigraphy in many centers as
the first radiologic investigation and is sensi-
tive for bleeding rates as low as 0.2 mL/min
[45]. Furthermore, CT provides more infor-
mation regarding localization and potential
structural causes for the bleeding. A posi-
tive CT angiography study can be followed
by catheter-based angiography or surgery in
cases where bleeding continues.
Both CT and colonoscopy may be useful in
patients with gastrointestinal bleeding to rule
out malignancy and diagnose other causes.
Colonoscopy also allows histopathologic di-
agnosis of inflammatory conditions, wheth-
er associated with diverticula (e.g., SCAD)
or not (e.g., inflammatory bowel disease and
angioectasia). SCAD includes a spectrum of
variable pathologic entities characterized by
chronic inflammation involving the interdi-
verticular mucosa of the left colon but spar-
ing the rectum and right colon [46]. Multiple
(at least four) biopsies on the borders of the
diverticula and in the apparently normal adja-
cent mucosa, as well as in both the rectum and
colon proximal to the diverticular area, are of
paramount importance to obtain the correct
diagnosis and differentiate SCAD from Crohn
disease and other inflammatory conditions.
Diagnosis of Chronic Diverticular
Disease of the Colon: The Role
ofImaging
In contrast to acute diverticulitis, the role
of imaging in chronic diverticular disease
Fig. 567-year-old
man with active
colonic diverticular
bleeding at
endoscopy and CT.
A, Image from
colonoscopy shows
active bleeding from
colonic diverticulum
(arrow).
B, Image from CT
angiography shows
extravasation of
contrast agent
(arrow) from colonic
diverticulum into
colonic lumen.
 Flor et al.
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A B C

D E F
Fig. 6Three patients with sigmoid diverticular disease versus cancer at CT colonography (CTC).
AC, 63-year-old woman. Two-dimensional transverse (A), 2D coronal (B), and 3D endoluminal (C) CTC images show circumferential segmental wall thickening and
luminal narrowing of sigmoid colon (arrows) associated with multiple diverticula. Presence of diverticula is key for excluding cancer. This was diverticular stricture.
D and E, 45-year-old woman. Two-dimensional transverse (D) and sagittal (E) CTC images also show circumferential segmental wall thickening and luminal narrowing of
sigmoid colon. Note absence of diverticula and shouldered appearance, which are more concerning for carcinoma, which this proved to be.
F, 59-year-old-woman. Transverse 2D CTC image shows focal sigmoid wall thickening with severe luminal narrowing, shoulder formation (arrow), and diverticula adjacent
to but not within affected segment. Patient underwent same-day colonoscopy with biopsies, and colorectal cancer diagnosis was confirmed. Pathologic analysis after
surgery revealed adenocarcinoma (pT3N2b).

is in evolution and still is subject to debate.
Among the radiologic examinations, CTC
has the potential to play a pivotal role because
of the unique 2D and 3D combination that al-
lows comprehensive endoluminal and ex-
traluminal evaluation (Fig. S1, supplemental
images, can be viewed in the AJR electronic
supplement to this article, available at www.
ajronline.org). In particular, CTC looks prom-
ising in evaluating patients who have recently
recovered from an episode of acute divertic-
ulitis (Fig. S2, supplemental images, can be
viewed in the AJR electronic supplement to
this article, available at www.ajronline.org),
representing a natural extension of the imag-
ing performed during the acute phase. One
major strength of CTC over double-contrast
barium enema, ultrasound, and MRI is relat-
ed to its ability to confirm the diagnosis of
diverticular disease or suggest superimposed
colorectal cancer (CRC) (Fig. 6). CTC can
also explain persistent symptoms due to un-
known complications, such as peridiverticu-
lar abscesses or fistulas, and determine the
severity of disease, which may affect thera-
peutic management decisions (Fig. 7). More-
over, a high-quality CTC examination can
generally be obtained even in cases of severe
luminal stenosis [47, 48], allowing adequate
accuracy in diagnosing proximal colonic pol-
yps and CRC [49, 50] (Fig. S2). This has par-
ticular value in the setting of right-sided ad-
vanced neoplasia, which could be ignored for
a prolonged period because of an incomplete
optical colonoscopy (Fig. S2).
With CTC, diverticula can be easily rec-
ognized as outpouchings of the colonic wall,
which can be air filled, contrast agent filled, or
impacted with stool. Because of colonic dis-
tention, CTC is also able to reveal the pres-
ence of associated wall thickening and lumi-
nal stenosis. Wall thickening can reach 1015
mm and typically involves a long colonic seg-
ment. Short-segment wall thickening should
raise concern for CRC in the differential di-
agnosis, although most cases represent pseu-
dotumoral diverticular masses (Fig. 6) or, less
commonly, mucosal prolapse. To reduce both
the risk of perforation and the likelihood of a
residual acute inflammatory component, CTC
should be performed at least 2 or 3 months af-
ter the acute episode of diverticulitis.
CT Colonography Protocol
In our opinion, it may be advisable to
modify the standard CTC protocol slightly
in the setting of known complicated divertic-

20 AJR:207, July 2016


ular disease. For example, it can be useful to
perform the CTC examination with IV con-
trast agent. In particular, a contrast-enhanced
regimen should be considered in the pres-
ence of severe wall thickening and luminal
stenosis, when the differential diagnosis be-
tween diverticular disease and CRC is more
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relevant. Another scenario generally requir-
ing IV contrast agent is when there is poten-
tial concern for diverticular complications,
such as abscesses or fistula [51] (Fig. 7). Eval-
uation with soft-tissue windowing improves
the assessment for these complications over
the standard CTC polyp window. In patients
with severe diverticular disease, an addition-
al third scan obtained with the patient in the
right lateral decubitus position (after scans
obtained with the patient in the supine and
prone positions) can be valuable to confirm
the severity of both luminal stenosis and wall
thickening, avoiding mistakes due to spasm
[5153]. To achieve the best distention of the
sigmoid colon, which is most commonly in-
volved in diverticular disease, the right lat-
eral decubitus position is generally obtained
for gravitational reasons.
To optimize distention of the entire colon,
which is critical for high-quality examina-
tion, automated carbon dioxide insufflation
is preferred [54]. In addition, an antispas-
molytic agent may help optimize distention
as well. Taylor et al. [55] found significant-
ly improved distention using hyoscine butyl-
bromide as a hypotonic drug in CTC; it was
especially useful in patients with diverticulo-
sis. Unfortunately, this agent is not available
for this use in the United States. Carbon di-
oxide insufflation with an automatic device
is preferable when evaluating patients with
diverticular disease because of the continu-
ous low pressure and reproducible distention.
When using room air, the risk of perforation
is increased because of the high pressure val-
A B
AJR:207, July 2016 21
Imaging of Colonic Diverticular Disease
ues that can be achieved. If the patient has
only recently recovered from acute divertic-
ulitis, it may be reasonable to scan the en-
tire abdomen and pelvis before initiating in-
sufflation. If the preinsufflation scan shows
signs suggesting persistent acute diverticuli-
tis (Fig. 7), active colonic distention should
be aborted.
The Diverticular Disease Severity
Score Based on CT Colonography
It is unreliable to describe the degree of
severity of diverticular disease in a subjec-
tive manner. Recently, a diverticular disease
severity score based on CTC findings [51]
has been proposed. The score is based on the
varying degrees of two CTC findingswall
thickening and lumen stenosisand consists
of four grades (diverticular disease severity
score 14). In the case of a diverticular dis-
ease severity score of 4, where marked wall
thickening is associated with severe lumi-
nal stenosis (Fig. 8), surgical options should
be considered. In practice, the simultaneous
presence of severe stenosis and the inabili-
ty to exclude CRC are both potential indica-
tions for surgery [56]. Moreover, this validat-
ed CTC-based diverticular disease severity
score seems to have prognostic value in the
follow-up of acute diverticulitis [57].
Differential Diagnosis Between
Diverticular Disease and
ColorectalCancer
In patients with diverticular disease, it can
be challenging to recognize a superimposed
CRC, but these two entities are both relative-
ly common in elderly patients and can, there-
fore, coexist. This differential diagnosis is
particularly tricky in cases of marked wall
thickening and severe luminal stenosis from
diverticular disease. Some authors [58, 59]
have described a number of CTC findings as
being useful in differentiating these two dis-
ease entities. Of these various findings, the
absence of diverticula in the affected seg-
ment and the presence of a shoulder phenom-
enon are the two most important findings for
CRC (Fig. 6). Other CTC signs in favor of
cancer include shorter length with straight-
ening of the involved segment, absence of
mesenteric fascia thickening, presence of
distorted folds, and the presence of promi-
nent local lymph nodes.
Lips et al. [59] have reported that, for
about 45% of their population, findings
of advanced diverticular disease, instead of
CRC, are present. We believe that this fre-
quency could be substantially higher in some
settings, including those patients recover-
ing from a prior episode of acute diverticu-
litis who underwent CTC. The aforemen-
tioned criteria are useful in ruling out CRC,
but sometimes the CTC findings will overlap
with those of acute diverticulitis. In these se-
lected cases, referral to optical colonoscopy
or flexible sigmoidoscopy may be necessary
to allow direct mucosal evaluation and biop-
sy. In other cases, the surgical option may be
indicated regardless of the underlying cause.
Preoperative Surgical Information
There are a variety of treatment options
for patients with chronic diverticular disease,
leading to some controversy in the surgical
guidelines [56]. In particular, the surgical op-
tion takes into account multiple factors, in-
cluding patient age, number of recurrent epi-
sodes of acute diverticulitis, and presence of
complications. Before elective surgery, sur-
geons could benefit from detailed anatomic
information regarding the entire colon, and
CTC, in our opinion, represents the test of
choice in providing this information (Figs.
S1, S2, and 8). In this regard, CTC is clearly
superior to both optical colonoscopy and the
Fig. 7Two patients with unsuspected persistent
complications from diverticulitis detected at CT
colonography (CTC).
A, 48-year-old man. Transverse 2D axial CT image
taken before carbon dioxide insufflation shows
air bubbles (arrows) around sigmoid colon related
to perforation and ongoing inflammation. Thus,
scheduled CTC was not performed and patient was
referred for therapeutic management.
B, 63-year-old woman. Transverse 2D supine
contrast-enhanced CTC image shows presence of
thick-walled abscess containing air-fluid level and
involving left ureter, as complication of previous
episode of acute diverticulitis. Patient underwent
surgery.

barium enema. In particular, CTC provides
detailed information on colon anatomy, total
number and distribution of diverticula, and
the degree of wall thickening and luminal ste-
nosis (Fig. 1). Surgical treatment is often con-
sidered when CTC detects unsuspected com-
plications, such as abscess or fistula. CTC can
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also guide clinicians and surgeons when the
appropriate therapeutic management is un-
certain. For example, CTC diagnosis of un-
suspected severe luminal stenosis could be a
key factor in deciding on a surgical option.
The surgical approach is generally laparo-
scopic, and surgeons could benefit from infor-
mation about the vascular map derived from
CTC [60, 61]. Of course, to obtain this level of
detail requires a contrast-enhanced CTC pro-
tocol, adding an arterial contrast phase to the
standard portal venous phase. In general, the
initial position (e.g., prone) is obtained before
IV contrast agent is administered to allow as-
sessment of enhancement.
The Role of Endoscopy
Specific chronic forms of diverticular dis-
ease include symptomatic uncomplicated di-
verticular disease of the colon and SCAD.
Regarding SCAD, it has been already men-
tioned that this entity may look more like
inflammatory bowel disease than divertic-
ulosis. Colonoscopy coupled with biopsy is
essential for the diagnosis, as is recognition
of the endoscopic appearance [62], which
may be quite similar to that of inflammato-
ry bowel disease but carries a different prog-
nostic significance and clinical management
[63]. Unlike SCAD, the role of endoscopic
assessment in colonic symptomatic uncom-
plicated diverticular disease is uncertain and
lacks formal investigation. There appears to
be general consensus that either colonosco-
py or CTC can be considered as the first-line
test to diagnose or rule out colonic diverticu-
lar disease. The choice between CTC or co-
lonoscopy may depend on patient age, risk
factors, clinical status, and preference. The
symptoms and laboratory findings of diver-
ticular disease of the colon are quite nonspe-
cific and frequently overlap with other con-
ditions, including irritable bowel syndrome.
For this reason, diagnostic imaging of the co-
lon with CTC or colonoscopy represents the
front-line diagnostic approach.
As mentioned, patient age, risk factors for
polyps or malignancy, overall clinical condi-
tion of the patient, patient preference, imaging
availability, and local expertise may all influ-
ence the choice between CTC and colonos-
22 AJR:207, July 2016
Flor et al.
A B
Fig. 862-year-old woman with recurrent diverticulitis (diverticular disease severity score 4) who underwent
CT colonography.
A and B, Coronal 2D image (A) and 3D colon map (B) show marked sigmoid wall thickening (star, A) and luminal
narrowing (arrows, B) associated with diverticula in setting of sigmoid diverticular disease, classified as
diverticular disease severity score 4. Patient underwent elective surgery and pathologic analysis revealed
diverticular disease with acute and chronic inflammation.
copy [64]. In reality, these two imaging tech- garding the development and validation of an
niques provide complementary information. endoscopic classification of diverticular dis-
In general, for patients with a low probability ease of the colon (i.e., the Diverticular Inflam-
of an organic lesion, such as those with nega- mation and Complication Assessment classifi-
tive biochemical test findings, negative fecal cation) have been recently reported [14].
occult blood test results, and negative findings
for fecal calprotectin, CTC may be the pre- Conclusion
ferred initial test. In particular, a less-invasive CT represents the best radiologic test for
approach may be advisable for both elderly evaluating patients with suspected acute di-
and frail individuals, for whom colonoscopy verticulitis and its attendant complications, al-
and sedation might be harmful. However, this though the diagnostic roles of both ultrasound
less-invasive approach may also be more ap- and MRI are increasing somewhat. In the set-
propriate in some younger patients at very low ting of suspected active lower gastrointestinal
risk for malignancy, such as those likely suf- bleeding of diverticular origin, both colonos-
fering from irritable bowel syndrome, where copy and CT angiography can play an impor-
discomfort and pain may preclude effective tant role. CTC is an accurate examination for
colonoscopy. In this regard, female sex, ir- differentiating colon cancer from diverticular
ritable bowel syndrome, anxiety, low body disease, but follow-up endoscopy may be re-
mass index, and previous pelvic surgery have quired in some cases. Going forward, the role
all been identified as predictors of discomfort of CTC for the diagnostic workup of symp-
and incomplete colonoscopy [65, 66]. tomatic chronic diverticular disease will like-
For cases with higher suspicion for an or- ly continue to expand as colorectal surgeons
ganic lesion or ongoing colonic inflammation, gain more appreciation for the wealth of diag-
or where the need for histologic assessment is nostic information that can be obtained from
deemed more likely, colonoscopy would gen- this comprehensive test.
erally be favored. Irrespective of the indica-
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