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usmle step 2 ck

Diverticular Disease

Colonic diverticulosis with possible painless bleeding or diverticulitis from microperforation causing left lower quadrant pain and inflammation

Review date
reviewed 2026-05-04
Reading time
8 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Gastroenterology & Hepatologycommonacute
On this page
Condition details
Gastroenterology & Hepatology
common
8 min read
reviewed 2026-05-04
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About This Page

This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.

Key points

  • Diverticulosis is usually asymptomatic but can cause painless hematochezia
  • Acute diverticulitis: LLQ pain, fever, leukocytosis, bowel habit change
  • CT abdomen/pelvis with contrast confirms diverticulitis and complications
  • Antibiotics are selective in mild uncomplicated disease but used in complicated/systemic/high-risk disease
  • Colonoscopy is avoided during acute diverticulitis and usually performed after recovery if not recently done

Overview

Diverticula are mucosal/submucosal outpouchings through weak points in the colonic wall. Diverticulitis results from inflammation and microperforation. Diverticular bleeding results from injury to vasa recta and is typically painless and abrupt.

Epidemiology

Diverticulosis increases with age and is common in Western populations. Risk factors include low-fiber dietary patterns, obesity, inactivity, smoking, NSAIDs, and genetics. Right-sided diverticular bleeding can be brisk.

Clinical Features

Symptoms
Diverticulosis: asymptomatic or painless hematochezia
Diverticulitis: constant LLQ pain
Fever, nausea, constipation or diarrhea
Pneumaturia/fecaluria suggests colovesical fistula
Diffuse peritonitis suggests perforation
Signs
LLQ tenderness
Fever and tachycardia
Rectal blood with diverticular hemorrhage
Peritoneal signs in perforation

Investigations

First-line
CBC, CMP, urinalysisLeukocytosis; UA may show sterile pyuria or fistula clues
CT abdomen/pelvis with IV contrastWall thickening, fat stranding, diverticula, abscess, perforation
Pregnancy testBefore CT in reproductive-age patients
Second-line
Colonoscopy after recoveryEvaluate malignancy if not up to date; avoid during acute episode
CTAFor brisk diverticular bleeding
Specialist
Percutaneous drainageAbscess generally >=3-4 cm or failure of antibiotics
SurgeryPeritonitis, uncontrolled sepsis, obstruction, fistula, recurrent complicated disease

Management

AGA Clinical Practice Update on Diverticulitis
1
Uncomplicated diverticulitis
  • Outpatient care if mild and reliable follow-up
  • Clear liquids/comfort diet initially
  • Selective antibiotics in immunocompetent mild cases
2
Complicated diverticulitis
  • IV fluids, bowel rest, broad antibiotics
  • Abscess drainage when large or not improving
  • Emergency surgery for free perforation/peritonitis
3
Prevention/follow-up
  • High-quality diet, activity, weight management, smoking cessation
  • Do not routinely avoid nuts/corn/popcorn
  • Colonoscopy after recovery if no recent high-quality exam

Complications

  • Abscess: Localized perforation.
  • Free perforation: Purulent/feculent peritonitis.
  • Fistula: Colovesical fistula causes pneumaturia/fecaluria.
  • Stricture/obstruction: Chronic inflammation and fibrosis.
USMLE Step 2 CK Exam Tips
  • 1Painless hematochezia = diverticular bleeding; painful LLQ fever = diverticulitis
  • 2CT diagnoses diverticulitis; colonoscopy is avoided acutely
  • 3Do not tell patients to avoid nuts/seeds/popcorn routinely
  • 4Mild uncomplicated diverticulitis may not need antibiotics
  • 5Pneumaturia/fecaluria = colovesical fistula
  • 6Right-sided diverticular bleed can be massive
  • 7After diverticulitis, colonoscopy excludes cancer once inflammation resolves

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regional clinical guidance

Diverticular Disease: guidance by region

Recommendations, thresholds and pathways can differ. Open the page written for the jurisdiction you need.

United StatesColonic diverticulitisDigestive · reviewed 2026-08-20

Verified Sources & References

AGA Clinical Practice Update: Colonic Diverticulitis
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