SUDD (Symptomatic uncomplicated diverticular disease) can mimic IBS (Irritable Bowel Syndrome)

In a recent post we talked about diverticulosis and diverticulitis, and I promised that I would devote a post to SUDD. What is SUDD? The Sudd is a vast swamp in South Sudan, but SUDD in gastroenterology  is ‘Symptomatic Uncomplicated Diverticular Disease’. Let’s break this down. Uncomplicated diverticulosis means there is no inflammation (diverticulitis) or bleeding, and no ischemia, lack of blood supply. It is the mere presence of diverticula, but these are causing symptoms.

What are symptoms of SUDD (Symptomatic Uncomplicated Diverticular Disease)?

Typically patients will have recurrent abdominal pain and discomfort, bloating, and altered bowel function with constipation or diarrhea.

What causes SUDD?

Somehow the diverticula are associated with or cause low-grade inflammation, a changed microbial composition, a hypersensitive gut, and abnormal colonic motility. All of these factors may coexist or influence each another.  Indeed, both the symptoms and the possible causes of SUDD are very similar to IBS (Irritable Bowel Syndrome).

How is SUDD diagnosed?

Most clinicians who know about SUDD use clinical information and colonoscopy findings to make a diagnosis. Pain in SUDD is normally in the left iliac fossa (on the other side of the appendix), persistent, often lasting more than 24 hours, and is not relieved by bowel movements. Patients tend to be older than IBS patients and they may not have had symptoms until later in life.

Pain in SUDD tends to be persistent and located in the left iliac fossa.

Some clinicians use stool calprotectin to help differentiate SUDD from IBS; it is mildly elevated in the former but not the latter.

How is SUDD treated?

Data are currently still sparse but it appears that Rifaximin in conjunction with fiber helps more than fiber alone. Rifaximin, sold under the trade name Xifaxan in the US, is FDA-approved for traveler’s diarrhea, irritable bowel syndrome, and hepatic encephalopathy. It is not absorbed into the blood stream and stays in the gut, and unlike broad-spectrum antibiotics, does not appear to destroy the ‘good’ bacteria in the gut.

However, for certain patients, surgical removal of the segment of the colon most affected by diverticulosis may be the best strategy. These are complex decisions to make.

As always these issues should be carefully weighed and discussed with your gastroenterologist. Please make an appointment with Dr. Klaus Gottlieb in Templeton, CA, or San Luis Obispo, CA, if you have bowel symptoms that keep bothering you.


Scaioli E, Colecchia A, Marasco G, Schiumerini R, Festi D. Pathophysiology and therapeutic strategies for symptomatic uncomplicated diverticular disease of the colon. Digestive diseases and sciences. 2016 Mar 1;61(3):673-83.

Tursi A, Brandimarte G, Elisei W, Giorgetti GM, Inchingolo CD, Aiello F. Faecal calprotectin in colonic diverticular disease: a case–control study. International journal of colorectal disease. 2009 Jan 1;24(1):49-55.

Bianchi M, Festa V, Moretti A, Ciaco A, Mangone M, Tornatore V, Dezi A, Luchetti R, De Pascalis B, Papi C, Koch M. Meta‐analysis: long‐term therapy with rifaximin in the management of uncomplicated diverticular disease. Alimentary pharmacology & therapeutics. 2011 Apr 1;33(8):902-10.

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