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Background
Diverticular disease is common and characterized by intestinal outpouchings that may be inflamed or infected. Uncomplicated diverticulitis can be managed conservatively, but emergent surgery in complicated cases harbors an estimated mortality rate of 10%. Diagnostic imaging is integral for characterizing and stratifying diverticular disease, particularly in complicated cases for presurgical planning. Through a systematic review of diverticular complications and its surgical implications, the radiologist serves an important role to optimize patient care.

Educational Goals / Teaching Points
To identify key imaging findings of complicated diverticular disease and the related surgical implications. Additional goals include tailoring reports to guide clinical and surgical management. Lastly, this exhibit will review postoperative complications associated with diverticular disease to encompass all facets of diverticular management.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
There are many imaging features of diverticulitis, and the complicated cases are more nuanced. Computed Tomography (CT) is frequently used to assess the size of diverticular abscesses, a determinant of surgical versus medical treatment. Even rarer complicated abscesses can occur, such as tuboovarian abscesses, that may copresent with coloovarian fistulas. Enemas and fistulograms can often be used to delineate a patent fistula, and CT and Magnetic Resonance Imaging (MRI) can characterize the adnexal based enhancing collection. A multifaceted approach is imperative for surgical planning, which varies from percutaneous drainage, salpingo-oophorectomy with low anterior resection, or Hartmann’s procedure. Repeat episodes of diverticulitis predispose to unique complications such as stricturing. Barium enema can demonstrate focal luminal narrowing thinly opacified by contrast compared to normal caliber bowel. Strictures impart significant symptomatology and may be managed surgically or endoscopically with metallic stenting. Occasionally, severe diverticular inflammation causes bleeding. CTA is a standard initial diagnostic tool and shows intraluminal contrast extravasation on arterial or portal venous phase imaging depending on the vascular source. Tagged red blood cells scans help elucidate even slower bleeds. With the ultimate goal of hemostasis through the least invasive means, detecting and quantifying the bleed may guide conservative management, embolization, or surgical resection. Diverticular disease has a complex array of unique complications, which have varying degrees of surgical implications the radiologist must know. Thorough review of these complications is imperative to adequately manage a common disease with often uncommon manifestations.

Conclusion
Knowledge of diverticular disease and its various complications, including those postoperatively, is important for radiologists in making accurate diagnoses and guiding appropriate management. This educational exhibit highlights imaging features that are used in planning operative management, as well as the post-operative complications that impact patient outcomes.