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Rapidly worsening abdominal pain with a hard, board-like abdomen, high fever and vomiting is an emergency. Do not wait — call the emergency number 112 immediately.
In diverticulitis, small pouches in the bowel wall have become inflamed. These pouches are called diverticula — sac-like bulges of the inner bowel lining pushing outwards, usually at weak points where blood vessels pass through the muscle layer. They most commonly sit in the last section of the large intestine, the so-called sigmoid colon on the left side. This is why the condition is often also referred to as sigmoid diverticulitis.
It is important to distinguish two terms that are constantly confused. Diverticulosis refers only to the presence of such pouches — without inflammation, without symptoms. It is extremely common and harmless in itself: many people carry diverticula throughout their lives without ever noticing them. Only when one or more diverticula become inflamed does this turn into diverticulitis — and this can range from a mild, easily manageable inflammation to a serious emergency.
How does the inflammation come about? It is thought that stool becomes lodged in a diverticulum, irritating the lining at that spot and impairing its blood supply. Bacteria can multiply on the irritated wall, the wall becomes inflamed, swells and, in unfavourable cases, may develop small tears. If it remains a local inflammation, this is called uncomplicated diverticulitis. If the inflammation spreads, an abscess (a collection of pus) forms or the bowel wall tears through completely, it becomes complicated diverticulitis — and that belongs in hospital.
Not all diverticula are the same. So that doctors can consistently assess how serious the situation is and which treatment fits, diverticular disease is divided into stages. In Germany, the so-called CDD classification (Classification of Diverticular Disease) is the relevant standard. It sounds technical but translates well into everyday language — here is the overview:
| Type (CDD) | What it means | Typical situation |
|---|---|---|
| Type 0 | Diverticulosis — pouches only, no inflammation | Incidental finding, no symptoms |
| Type 1 | Acute uncomplicated diverticulitis | Pain and inflammation, but locally confined |
| Type 2 | Acute complicated diverticulitis | Abscess, contained perforation or free perforation |
| Type 3 | Chronic diverticular disease | Recurring flares or persistent symptoms |
| Type 4 | Diverticular bleeding | Bleeding from a diverticulum, usually without inflammation |
The most important dividing line runs between Type 1 and Type 2. An uncomplicated diverticulitis (Type 1) is a locally confined inflammation without a collection of pus and without perforation — it can often be treated on an outpatient basis. A complicated diverticulitis (Type 2) means that an abscess has formed or the bowel wall has torn; this requires inpatient treatment and sometimes surgery. Type 3 covers the chronic courses in which symptoms keep recurring, and Type 4 stands for diverticular bleeding, which often presents quite differently — namely as a sudden, usually painless passage of blood in the stool.
The key symptom of acute diverticulitis is persistent pain in the left lower abdomen. Because the diverticula usually sit in the left section of the large intestine, diverticulitis is sometimes described as "appendicitis of the left side". The pain is typically dull and pressing, lasts for days and can worsen when walking or straining. Other companions to this abdominal pain are:
Not every case of diverticulitis shows the full picture. Older people in particular, or those taking anti-inflammatory medication, sometimes feel less pain than the inflammation would suggest — this can mean that a serious course is initially underestimated. In diverticular bleeding (Type 4), pain and fever are often absent altogether; here the sudden passage of bright to dark red blood is the prominent feature. Such passage of blood should always be investigated by a doctor, because other causes may also lie behind it.
For diverticulitis to develop, diverticula must first be present. These form over years, when the bowel wall gives way to the internal pressure at weak points. Why some people develop many diverticula and others hardly any is not fully understood — an interplay of predisposition, age and lifestyle plays a role.
A persistent myth concerns grains and nuts: for a long time people were advised to avoid nuts, grains and small seeds because they supposedly got caught in diverticula and triggered inflammation. This connection has not been confirmed. According to current knowledge, people with diverticula do not need to avoid such foods — on the contrary, a fibre-rich diet with wholegrains, pulses and nuts is actually beneficial in the symptom-free state. More on this in the chapter on diet.
The suspicion of diverticulitis usually already arises from the description of the symptoms and the physical examination: persistent pain in the left lower abdomen, tenderness, often fever. To confirm the diagnosis and, above all, to assess the severity, several building blocks come together:
The timing is important: during the acute inflammatory flare a colonoscopy is avoided, because the air and pressure of the examination could cause the inflamed, weakened bowel wall to tear. Only once the inflammation has healed is a colonoscopy performed — above all to make sure that no malignant process producing similar symptoms lies behind the complaints.
How diverticulitis is treated depends crucially on its severity — that is, on whether an uncomplicated (Type 1) or a complicated (Type 2) form is present. The central decision is therefore: can the inflammation heal on an outpatient basis at home, or is inpatient monitoring in hospital needed?¹
A modern and, for many, surprising point: in mild, uncomplicated diverticulitis without risk factors, antibiotics are often not necessary. Studies have shown that these cases heal just as well under close observation — with rest, sufficient fluids and an adapted diet. Antibiotics are then used selectively when risk factors are present, the inflammatory markers are high or the course is complicated.
Who needs inpatient treatment is decided not by the CT image alone, but also by general condition, age, accompanying illnesses and whether safe care at home is possible. People with a weakened immune system — for example on cortisone or after an organ transplant — are generally treated more cautiously and more often as inpatients, because complications are harder to predict in them.
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Hardly any topic is as often misunderstood as diet with diverticula. The reason: what is right during an acute flare is exactly wrong in the symptom-free interval — and vice versa. These two phases must be kept strictly apart.¹,²
| Phase | Recommendation | Why |
|---|---|---|
| Acute flare | Light, low-fibre food, plenty of fluids; in severe cases a brief break from food | The inflamed bowel should be relieved |
| Subsiding phase | Slowly increase fibre again | Step-by-step return to normal digestion |
| Symptom-free interval | Permanently fibre-rich, drink plenty | Prevents new flares |
During the acute flare, the rule is: relieve the inflamed bowel. This means initially light, low-fibre food and enough fluids — that is, easily tolerated things such as clear soups, white bread, boiled potatoes, rusks or steamed vegetables in small amounts. In a more severe course, solid food can also be avoided altogether for a short time. Fibre-rich foods such as wholegrains, pulses and raw vegetables are unfavourable in this phase, because they place additional demands on the bowel.
As soon as the inflammation subsides, fibre is gradually increased again. And in the symptom-free interval the recommendation reverses completely: now the goal is a permanently fibre-rich diet with wholegrain products, vegetables, fruit and pulses, combined with plenty of fluids and regular exercise. Fibre makes the stool softer and more voluminous, lowers the pressure in the bowel and thus prevents new flares. This is exactly where many guides confuse the phases — advising a bland diet across the board, even though it would be counterproductive in the symptom-free state.
The good news first: most uncomplicated diverticulitis flares heal within a few days to weeks without lasting effects. After a first flare, some of those affected remain permanently symptom-free; in others the inflammation returns. Whether and how often further flares occur cannot be predicted with certainty in the individual case.
If a course becomes complicated, the main problems that threaten are:
A planned operation in the symptom-free interval is recommended much more cautiously today than in the past. It is no longer the mere number of flares that decides, but the burden of suffering and the individual risk: for example with persistent symptoms, complications such as fistulas or narrowings, or in people with a weakened immune system. The decision is weighed up together — the benefit of surgery against its risks. An emergency operation, on the other hand, is unavoidable in the case of a free perforation with peritonitis.
Record in brite when flares occur and how your symptoms develop — ideal for your next appointment.
Between flares, a few habits can do a lot for the bowel. They do not replace medical treatment, but they demonstrably lower the risk of new inflammation:
Diverticulitis is treated over days to weeks — with antibiotics, painkillers and a diet that changes depending on the phase. The treatment only works if it runs reliably and symptoms stay in view. That is exactly where brite supports you.
