Introduction

The prevalence of perforated sigmoid diverticular disease in developed countries has increased from 2.4/100 000 in 1986 to 3.8/100 000 in 2000.1 Diverticular disease is one of the five most costly gastrointestinal disorders in the United States.2 Thirty years ago, the proportion of people who died from diverticular disease was decreasing.3 During the past 20 years, however, annual age standardised rates of admission and surgical intervention have increased by 16% from 20.1/100 000 to 23.2/100 000, whereas inpatient and population mortality remains unchanged.4

This increasing burden of disease means that clinicians in primary and secondary care will see increasing numbers of patients with diverticular disease and its complications. This review covers recent developments in the management of diverticular disease, including the current trend towards conservative rather than operative management after recovery from the initial episode.5

Sources and selection criteria

We searched Medline and the Cochrane Library to locate English language articles on diverticular disease and diverticulitis, from 1964 until April 2005. We obtained further articles from the references cited in the initial literature review. We prioritised evidence from well designed randomised controlled trials, when available.

Natural history of diverticular disease

The prevalence of diverticulosis (see box 1 for definitions) increases uniformly with age, affecting 50% of people by the fifth decade and 67% by the eighth decade,6 with similar frequency in men and women.7 Approximately three quarters of patients with anatomical diverticulosis remain asymptomatic throughout their lifetime.6 Asymptomatic disease is often an incidental finding during investigation of colonic disorders; these patients need no specific treatment or follow-up. Of the remaining 25% of patients who develop symptoms, approximately three quarters develop diverticulitis (a third of whom have complications; box 1), and a quarter develop diverticular haemorrhage, which is massive in a third of cases.8

Pathophysiology

Although diverticular disease is common, the pathogenesis …