investigations - diverticular disease

Last edited 01/2020

Diverticular disease is a diagnosis of exclusion. Hence, investigation must first rule out other treatable causes of similar symptomatology, e.g. ulcerative colitis, Crohn's disease, ischaemic colitis and colorectal carcinoma.

Classically, barium enema was used as first-line investigations. However CT has now become the standard for diagnosis of diverticular disease (abdomen and pelvis)

  • when compared with contrast enemas, sensitivity and specificity is significantly better in CT
  • intravenous, oral, and rectal contrast is used

Contrast enemas have limited value due to diverticulitis being and extraluminal process. Finding suggestive of a diagnosis include: extravasated contrast material outlining an abscess cavity, intramural sinus tract, or fistula (1).

A chest x-ray with the patient upright may help in detecting pneumoperitonium. An abdominal x-ray may reveal abnormalities such as small or large bowel dilation or ileus, pneumoperitoneum, bowel obstruction, or soft-tissue densities suggesting abscesses.  (2)

NICE suggest (3):

Do not routinely refer people with suspected diverticular disease unless:

  • routine endoscopic and/or radiological investigations cannot be organised from primary care or colitis is suspected or the person meets the criteria for a suspected cancer pathway

If the person meets the criteria for a suspected cancer pathway, refer by this route


  1. Feuerstein JD, Falchuk KR. Diverticulosis and Diverticulitis. Mayo Clin Proc. 2016 Aug;91(8):1094-104
  2. Stollman N, Raskin JB. Diverticular disease of the colon. Lancet. 2004;363(9409):631-9
  3. NICE (November 2019). Diverticular disease: diagnosis and management