PRESENTATION

Imaging of Acute Diverticulitis

Saravanan Krishnamoorthy, MD* and Gary Israel, MDw

sound (US) and magnetic resonance imaging (MRI) may

CME Learning Objectives: On completion of this educational
activity, learners will be better able to: (1) Understand the
appearance of complications related to acute colonic diverticulitis
on computed tomography. (2) Differentiate other causes of colonic
thickening based on the findings on computed tomography.
Abstract: Diagnostic imaging plays an integral role in evaluating
patients with suspected acute colonic diverticulitis. The diagnosis
can be confirmed by imaging, and a combination of the location of
the disease, severity of inflammation, and complications will allow
clinicians to determine appropriate treatment. In the United States,
computed tomography is the modality of choice in evaluating
patients with suspected diverticulitis as it is widely available, easy
to perform, and is accurate in diagnosis.
Key Words: acute colonic diverticulitis, diagnostic imaging, plain
radiography, contrast enema, fluoroscopy, computed tomography,
ultrasound, magnetic resonance imaging
(J Clin Gastroenterol 2011;45:S27–S35)
be used.
PLAIN FILM RADIOGRAPHY
Although sometimes obtained to evaluate patients
with abdominal or pelvic pain, conventional radiography
has low sensitivity for diagnosing diverticulitis. In patients
with suspected perforated diverticulitis, conventional x-rays
may be used to evaluate pneumoperitoneum. However,
conventional x-rays should not be routinely taken in
patients with suspected diverticulitis.
CONTRAST ENEMA
Historically, barium enema was the examination of
choice to diagnose diverticulitis. However, barium enema is
no longer routinely used for diagnosing diverticulitis, and
CT scan has replaced barium enema. This is because CT
scan has been shown to be more sensitive (93% to 98%)
compared with enema (80% to 92%)1,6,7 that is easier to
perform, does not require a bowel preparation, and there is
no risk of iatrogenic perforation (as long as rectal contrast

D iverticular disease can occur throughout the gastro-

intestinal tract, but the most common site of involve-
ment is the large bowel. These pseudodiverticula occur at
is not administered).

CT
points of weakness or defects in the colonic wall, and Since Hulnick’s initial description of diverticulitis
consist of the mucosal and submucosal layers of the bowel using CT scan,8 multiple studies have shown high sensitivity
wall. It is interesting to note that these points coincide with (79% to 99%)2,9 and specificity9–13 in diagnosing diverti-
the locations of penetrating vessels such as the vasa recta.1 culitis with a CT scan. In 1990, Cho et al6 showed a
Colonic diverticulosis is very common, affecting 5% to 10%
of people of the age of 45 years and 80% of the age of 80
years.2 Up to 30% of patients with diverticulosis develop
acute diverticulitis, in which diverticula become inflamed.
In the setting of diverticulitis, 25% of patients develop
complicated disease resulting in hospital admission.3 The
most common location of diverticulitis is in the sigmoid
colon, although it can occur anywhere. Right-sided diverti-
culitis is more likely to affect patients under the age of 50
years and the Asian population.4 Before routine imaging
became a part of the workup of patients with left lower
quadrant pain, 25% to 30% of surgical specimens showed no
inflammation.5
Before the clinical implementation of computed
tomography (CT) in the 1980s, fluoroscopic barium enema
was the primary method of diagnosing diverticulitis. A CT
scan has now replaced barium enema in the evaluation of
left lower quadrant pain. In select circumstances, ultra-

From the *MR Center; and wSmilow Cancer Hospital, Yale University
School of Medicine, New Haven, CT.
No conflicts of interest.
Reprints: Gary Israel, MD, Professor of Diagnostic Radiology, Smilow
Cancer Hospital, Yale University School of Medicine, 2nd Floor FIGURE 1. Axial computed tomographic image performed with
North Pavilion in Room 2-245, New Haven, CT 06520 (e-mail: intravenous and oral contrast depicts thickening of the wall of the
gary.israel@yale.edu). sigmoid colon (short arrows) with surrounding stranding of
Copyright r 2011 by Lippincott Williams & Wilkins pericolonic fat (long arrows) consistent with diverticulitis.

J Clin Gastroenterol  Volume 45, Supp. 1, April 2011 www.jcge.com | S27

Krishnamoorthy and Israel J Clin Gastroenterol  Volume 45, Supp. 1, April 2011

FIGURE 2. Axial (A) and coronal reformatted (B) computed tomographic images taken with oral contrast shows mild thickening of the
fascia at the base of the sigmoid mesocolon (long arrow in A) and minimal pericolonic fat stranding (short arrows in A and B), consistent
with mild diverticulitis.

sensitivity of 93% and specificity of 100% using single-slice reported in 16% of cases.16 Microperforation can lead to
nonhelical CT scan. Today, with the latest multidetector the formation of an abscess. Initially, a phlegmon may be
CT scanners obtaining volumetric datasets in which images identified, which manifests as ill-defined soft tissue attenua-
can be reconstructed into any viewing plane, sensitivity and tion material in the adjacent pericolic fat. In some cases,
specificity may be higher than reported earlier. The this resolves with antibiotics but can progress to an abscess,
American College of Radiology advocates CT scanning of which appears as a well-defined fluid collection that may
the abdomen and pelvis with oral and/or rectal contrast as contain gas (Fig. 4A) and may have an enhancing wall
the modality of choice in the evaluation of diverticulitis.14 (Fig. 4B). Abscess occurs in a minority of cases of acute
diverticulitis, but has been reported to occur in 45% to 59%
Technique of cases in the literature.4,6,16 Most commonly, they occur
At Yale New Haven Hospital, CT scans for diverti- within (intramural abscess) or adjacent to the inflamed
culitis are performed with oral and intravenous contrast. colonic wall. However, abscesses can occur remotely from
Oral contrast helps to mark and distend the bowel to
minimize artifactual wall thickening from underdisten-
sion.15 The role of intravenous contrast is to evaluate the
differences in bowel wall enhancement and to help identify
complications of acute diverticulitis such as abscess and
fistula. Some experts advocate rectal contrast to increase
distal colonic distension, which may not have occurred after
oral contrast, to opacify fistulae and increase accuracy.12
We do not routinely administer rectal contrast at our
institution to minimize patient discomfort and avoid
complications such as iatrogenic perforation.

Findings
Most commonly, diverticulitis manifests as a short
segment of focal eccentric or circumferential bowel wall
thickening (70% to 94% of cases) with adjacent infiltration
of the pericolonic fat (98%)16 (Fig. 1). In approximately
30% of cases,16 the inflamed diverticulum can be identified.
When mild diverticulitis involves the sigmoid colon, fascial
thickening at the base of the sigmoid mesocolon adjacent
to the left pelvic side wall may be a helpful sign to confirm
the diagnosis (Fig. 2).16,17 Pericolic lymphadenopathy may
occur but is most common in the right-sided diverticulitis,
in which it is reported to be present in 90% of cases.18 FIGURE 3. Axial computed tomographic image taken with
intravenous and oral contrasts shows diverticulosis (arrowheads)
Complications with pericolic inflammation (black arrow) and a small bubble of
Microperforation (Fig. 3), with the resulting small foci extraluminal gas (white arrow), consistent with a microperfora-
of extraluminal free air is the most common complication, tion from acute sigmoid diverticulitis

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J Clin Gastroenterol  Volume 45, Supp. 1, April 2011 Imaging of Acute Diverticulitis

FIGURE 4. A, Axial computed tomographic (CT) image performed without contrast shows pericolic inflammation (arrowheads) and a
fluid and gas collection (arrow), consistent with sigmoid diverticulitis. B, Axial CT image of the same patient taken 2 days later but with
intravenous (i.v.) and oral contrasts shows a pericolic fluid collection with a well-defined enhancing wall, consistent with an abscess
(arrow). The use of i.v. and oral contrasts helps define and diagnose the abscess that is not as apparent in (A), carried out without
contrast material. The patient was treated with antibiotics and the abscess subsequently resolved.

the site of diverticulitis and may involve the psoas muscle
and musculature of the pelvic floor, uterus, and adnexa.
Most cases of microperforation can be treated con-
servatively, but some progress to frank perforation. When a
perforation is large, extraluminal oral contrast, fecal material,
or both may be present. Peritonitis may occur, which
manifests as generalized haziness of the peritoneal fat and
increased enhancement of the peritoneal lining.
Fistulas may complicate diverticulitis and have been
reported to be present in the bladder,19 vagina,20 skin,21
small bowel,22 uterus,23 ovary,24 psoas muscle,25 and the
hip.26 A review of the fistulas related to diverticulitis over a
20-year period found that colovesical and colovaginal
fistulas account for approximately 90% of all fistulae.22
Although colovesical fistula has been reported in 2% to
23%27 of cases of diverticulitis, a CT scan does not always
identify the fistula. CT findings of a fistula include an air-
filled or fluid-filled tract extending from the colon to the
affected organ (Figs. 5–7). In some cases, the fistula cannot
be definitely identified using a CT scan but secondary
findings such as focal thickening of the bladder wall,
tethering of the sigmoid colon to the bladder, and gas
within the lumen of the bladder are hints of a colovesical
fistula (Fig. 5).
Giant diverticula of the colon are defined as being larger
than 4 cm in diameter and are usually located in the sigmoid
colon.28 There are 2 theories on how these diverticula form.
One hypothesis is that an untreated abscess fistulizes to the
colon. After the abscess drains into the colon, the remaining
wall of the abscess forms a diverticulum-like structure that

FIGURE 5. Computed tomographic images with intravenous and oral contrasts in the axial (A) and coronal reconstructed (B) planes
depict a colovesical fistula secondary to diverticulitis. Imaging findings include focal thickening of the bladder wall (arrow in A),
tethering to the sigmoid colon (arrow in B) to the bladder, and gas (G) within the bladder lumen.

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Krishnamoorthy and Israel
FIGURE 6. A 63-year-old woman who is status post hysterectomy with acute diverticulitis and a colovaginal fistula. A, Axial computed
tomographic image taken with intravenous and oral contrast shows oral contrast and gas within the vaginal cuff (arrow), suggestive of a
colovaginal fistula. B, A water-soluble contrast enema shows the fistula (arrow) from the sigmoid colon (*) to the vaginal cuff (arrow).
communicates with the colon.29 Alternatively, preexisting
diverticula grow in size through a ball-valve effect as trapped
air causes the divertculum to grow.30 Giant diverticula can
present secondary to complications in up to 19% of cases.31
They can become infected and develop acute diverticulitis. On
CT scanning, the findings are a large gas-filled cavity with
wall thickening, enhancement of the diverticular wall, and
peridiverticular fat stranding (Fig. 8).32 These features are
also found with large abscesses and therefore differentiating
the 2 processes can be difficult. Importantly, up to half of
FIGURE 7. Axial computed tomography image taken with oral
contrast shows sigmoid diverticulosis (black arrow) and a gas-
filled fistula (white arrows) between the sigmoid colon and left
psoas muscle (*), which contains an abscess (*). The lack of
significant pericolic inflammation suggests that the fistula may
have been formed from an earlier episode of diverticulitis.
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J Clin Gastroenterol  Volume 45, Supp. 1, April 2011
these cases can cause free peritoneal perforation.33 The typical
treatment is surgical resection of the diverticulum or partial
colectomy.34
Other rare complications include small bowel obstruc-
tion35 and pyelophlebitis.36,37 In patients with small bowel
obstruction, secondary to diverticulitis, the inflammation
related to diverticulitis extends to a small bowel loop and its
adjacent mesentery, resulting in focal peritonitis, spasm, and
possibly adhesions. Pyelophlebitis may occur in approxi-
mately 3% of cases of diverticulitis.36,37 This begins as
thrombophlebitis of small veins draining the infected segment
of the colon, which can then propagate into the portal vein
(Fig. 9). Rarely, this process can progress to suppurative
pyelophlebitis, a condition in which the venous thrombus is
associated with bacteremia. Suppurative pyelophlebitis can be
life threatening as it can be unresponsive to antibiotics.38
Limitations in Diagnosis
Perforated colonic adenocarcinoma may be difficult to
differentiate from diverticulitis using a CT scan. Both
conditions can present with focal colonic wall thickening,
pericolic inflammation, and perforation. Imaging findings
that suggest carcinoma (Fig. 10) and not diverticulitis include
wall thickening >2 cm, eccentric wall thickening, a homo-
geneously enhanced bowel wall, and pericolic adenopa-
thy.39,40 Colonic obstruction should raise the concern for
neoplasm.41 A long segment (>10 cm) of colonic involvement
and a striated pattern of bowel wall enhancement (the target
sign) suggest diverticulitis.42,43 Given the overlap in CT
findings, some researchers advocate follow-up colonoscopy in
patients diagnosed with diverticulitis using a CT scan.44
Alternative Diagnoses
Right-sided diverticulitis (Fig. 11) can clinically mimic
appendicitis, epiploic appendagitis, omental infarct, and
inflammatory bowel disease.45 In most cases, this differentia-
tion can be made by using a CT scan. Acute appendicitis
(Fig. 12) manifests as a distended appendix with appendiceal
wall thickening, edema at the base of the cecum, and
periappendiceal fat stranding. However, in cases of perfo-
rated appendicitis in which the appendix is not visualized by
imaging, differentiation from diverticulitis can be difficult.
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J Clin Gastroenterol  Volume 45, Supp. 1, April 2011 Imaging of Acute Diverticulitis

FIGURE 8. A, Coronal scout computed tomography (CT) image shows a gas-filled (G) cavity in the mid-pelvis. B, CT with intravenous
and oral contrasts reformatted in the coronal plane depicts the giant diverticulum (*) with an enhancing thickened wall and surrounding
inflammation (arrow).

FIGURE 9. A, Axial computed tomographic (CT) image obtained with intravenous and oral contrasts in a patient with sigmoid
diverticulitis shows a thrombus within the inferior mesenteric vein (arrow). B, Axial CT image obtained at the level of the portal vein
shows that thrombus has propagated into the portal vein (arrow).

FIGURE 10. A 54-year-old woman referred for computed tomography (CT) who was thought to have diverticulitis. A, Axial CT image
obtained with intravenous and oral contrast shows diverticulosis of the transverse colon and pericolic inflammation (arrow). These
findings suggest diverticulitis. B, Coronal reformatted image of the same CT scan shows a short segment of very focal concentric
transverse colonic wall thickening that enhances homogeneously (arrow) with pericolic inflammation. Although the findings can be
seen with diverticulitis, adenocarcinoma was diagnosed at subsequent colonoscopy followed by surgical resection.

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Krishnamoorthy and Israel
FIGURE 11. Axial unenhanced computed tomographic image of
a patient who thought to have right-sided renal colic shows a
diverticulum (black arrow) of the ascending colon and mild
surrounding inflammation (white arrow). The findings are
consistent with right-sided diverticulitis. The patient improved
with antibiotic treatment.
Pericolic inflammatory changes, distal to the ileocecal valve,
may suggest diverticulitis.42 However, this finding is not
specific as this can also be seen in diverticulitis. Crohn’s
disease can also be confused with appendicitis. Features that
favor Crohn’s disease (Fig. 13) are a long length of wall
FIGURE 12. A 60-year-old man presented with right lower
quadrant pain and leukocytosis. An axial oblique computed
tomography (CT) image with intravenous and oral contrasts
shows the appendix is distended with increased enhancement of
the wall (arrowhead) and periappendiceal stranding (white
arrows). Note that the appendix does not fill with oral contrast,
although the cecum (C), ileum (I), and sigmoid colon (black
arrow) contant intraluminal oral contrast. These findings are
consistent with acute appendicitis. The patient was treated with
emergent appendectomy and acute appendicitis was confirmed
on histopathology.
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J Clin Gastroenterol  Volume 45, Supp. 1, April 2011
FIGURE 13. Computed tomography scan with oral contrast was
performed on a patient with diarrhea and diffuse abdominal
pain. An axial image at the junction of the sigmoid and
descending portions of the colon shows cicumferential colonic
wall thickening (white arrow) with pericolonic stranding (black
arrow) and prominence of the vasa recta (arrowheads), con-
sistent with inflammatory bowel disease. Crohn’s colitis was
confirmed on optical endoscopy with biopsies.
thickening involving the distal ileum, skip lesions separated
by normal-appearing bowel, fibrofatty proliferation around
the bowel, and submucosal fat deposition.46
Epiploic appendagitis (Fig. 14) is caused by torsion of
an epiploic appendage and most commonly occurs at the
FIGURE 14. A coronal reformatted computed tomographic
image obtained with intravenous and oral contrasts depicts an
ovoid fat density mass (arrow) with mild surrounding inflamma-
tion adjacent to the sigmoid colon, consistent with epiploic
appendagitis.
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J Clin Gastroenterol  Volume 45, Supp. 1, April 2011
FIGURE 15. Axial computed tomographic image obtained with
oral contrast in a patient with diarrhea and pain after a prolonged
course of antibiotics. There is severe wall thickening of the
transvere colon (arrows) with a “thumbprinting” pattern
associated with mild pericolic inflammation consistent with
colitis. The diagnosis of pseudomembranous colitis was con-
firmed by positive fecal toxin testing.
sigmoid colon. Clinically, distinguishing epiploic appenda-
gitis from diverticultitis can be difficult. However, by CT
scanning this differentiation is not problematic because
epiploic appendagitis appears as an ovoid fat density
structure adjacent to the colon with minimal surrounding
inflammation and a central linear density, which is thought
to represent a thrombosed vessel.47–49 Differentiating these
2 entities is important as epiploic appendagitis does not
need to be treated with antibiotics.45
In most cases, colitis (infectious or ischemic) can be
easily differentiated from diverticulitis using a CT scan.
This is because colitis frequently affects a longer segment of
the colon, and appears as circumferential wall thickening
with thumbprinting morphology, has a stratified bowel wall
FIGURE 16. Patient with left lower quadrant pain who underwent computed tomography (CT) colonography. A, The 3-dimensional
endoluminal view showed a linear abnormality that spanned the lumen of the sigmoid colon. B, A reconstructed sagittal CT image with
bone windowing depicts a thin linear radiodense foreign body consistent with a bone in the sigmoid colon. This was removed at optical
colonscopy and a fishbone was confirmed.
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Imaging of Acute Diverticulitis
enhancement pattern, and pericolic inflammation (Fig. 15).
However, at times when colitis affects a short segment of
the colon, differentiation from diverticulitis may be difficult.
Sometimes ingestion of a foreign body, such as
toothpicks, chicken bones, or fish bones, can cause colonic
perforation and mimic diverticulitis clinically at CT
scanning. Earlier surgery, strictures, existing inflammation,
and obstruction can predispose a patient to foreign body
obstruction or perforation. The most common sites in the
bowel are the ileocecal region and rectosigmoid colon.50
Metallic or calcified objects can be easily identified on CT
scan, which helps in making the correct diagnosis (Fig. 16).
However, as toothpicks are made of wood, that are not
readily seen at CT scan, identifying the foreign body is very
difficult51 and proper diagnosis may not be possible. In
these cases, CT scan can identify pericolic inflammatory
changes, abscess, perforation, and peritonitis, which may
mimic the findings of diverticulitis. In up to 20% of cases of
foreign body ingestion, endoscopic removal is necessary,
and in 1% of cases, surgery is performed.52
US
In the United States, US is not routinely used to
diagnose diverticulitis. The technique includes using a 2 to
5-MHz transabdominal probe that gives an overview of the
colon and identifies regions of free or focal fluid. Sub-
sequently, a high-frequency linear probe is needed for
detailed evaluation of the colon. The haustrated pattern of
the colon in the longitudinal plane will help to differentiate
the colon from the small bowel. The 3 layers of the bowel
wall on US are the hypoechoic inner mucosa, the
intermediate hyperechoic submucosa, and an outermost
hypoechoic muscularis propria; the sum of these layers is
usually 4 mm or less in thickness.53 Gentle compression
with the high frequency probe helps to displace overlying
small bowel loops.
US findings of acute diverticulitis include wall thicken-
ing (>4 to 5 mm), increased echogenicity in pericolonic fat
from inflammation,54 and pericolonic abscess. Unfortu-
nately, these findings are not specific for diverticulitis, and
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Krishnamoorthy and Israel
FIGURE 17. Magnetic resonance imaging was performed on a patient with left lower quadrant pain. Axial T2-weighted (A) and gadolinium-
enhanced fat-suppressed T1-weighted (B) images shows diverticulosis with associated thickening of the wall of the sigmoid colon (white
arrowhead), pericolic stranding (white arrow), and a fluid and gas (G) collection, consistent with sigmoid diverticulitis and abscess.
differentiation from other infectious, inflammatory, and
ischemic conditions that affect the colon is usually not
possible. Therefore, US is not routinely performed in cases
with suspected diverticultitis.
MRI
Ionizing radiation from medical imaging has become a
concern because of the potential risk of inducing cancer
from the cumulative radiation. As MRI does not expose
patients to radiation, it may play a role in evaluating
patients for diverticulitis. MRI can show diverticula,
colonic wall thickening, and pericolic inflammation and
therefore diverticulitis can be diagnosed (Fig. 17). Further-
more, MRI has greater soft tissue contrast when compared
with CT scan, and therefore it may be more sensitive to
minimal pericolic inflammation in cases of very early/mild
diverticulitis. However, MRI is more operator dependent,
requires greater scan times, and is not as sensitive as CT
scan in evaluating for extraluminal gas. In addition,
patients with pacemakers cannot undergo MR examina-
tions and much of the data on the use of MRI in evaluating
the bowel suggest using an antiperistaltic agent to reduce
artifact from bowel motion.55–57 Early studies suggest that
MRI may be useful in evaluating patients for diverticulitis
and further studies are necessary to determine whether
MRI has a role in the routine evaluation of patients with
suspected diverticulitis.55–57
CONCLUSIONS
Diverticulitis is common, and CT scan has become the
standard imaging modality in evaluating patients with
suspected diverticulitis. CT scan is not only accurate in
making this diagnosis, but it can also suggest alternative
diagnoses when diverticulitis is not present. However, as we
become more aware of the risks of ionizing radiation
associated with CT scanning, other imaging modalities such
as MRI may play a larger role in the future.
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