This 73-year-old woman presents for colonoscopy with a one year history of diffuse lower abdominal pain, associated with 30 lbs of unintentional weight loss. During the procedure, she is identified to have the following. What are the four potential complications of this condition?

This patient has diverticulosis, which is the development of multiple sac-like protrusions along the length of the gastrointenstinal tract (red arrows). These can occasionally make it difficult to discern where the true lumen (green arrow) is during endoscopy, particularly to the untrained eye. Importantly, accidentally passing the scope into a diverticula and insufflating can result in excessively high pressures, which can result in perforation.

While diverticula can form in both the small and large intestine, the most common location is the sigmoid colon. The vast majority of colonic diverticula are considered “false” diverticula, as the mucosa and submucosa herniate through a defect in the muscularis propria, and are covered externally by serosa only. “True” diverticula are quite uncommon (ex. Meckel’s diverticulum), and involve the outpouching of all layers of the intestinal wall (mucosa, muscularis, and serosa).

Diverticular disease is typically asymptomatic, however patients can be symptomatic when one of the following complications occur:

1. Diverticulitis – micro- or macroscopic perforation of a diverticulum presenting with fever and left lower quadrant pain 
2. Segmental colitis associated with diverticula (SCAD) – localized inflammation of the colon in regions that are affected by diverticulosis, patients present with abdominal pain, bleeding, and chronic diarrhea 
3. Diverticulosis-associated pain – typically this presents as post-prandial left lower quadrant pain, that is relieved with bowel movements
4. Diverticular bleeding – painless bleeding, related to the proximity of diverticula to the vasa recta

Source: Nallapeta NS, Farooq U, Patel K. Diverticulosis. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430771/