On abdominal X-ray, diverticulitis is characterized by multiple air and fluid levels if there is an intestinal perforation. Chest X-ray should be done in patients with diverticulitis to investigate for pneumoperitoneum, which is a harbinger of a critical illness and will lead to a change in the management plan for the case. X-ray can be used if CT is not available and in uncomplicated cases.

• X-ray barium enema is not the first choice diagnostic procedure to diagnose acute diverticulitis. However, it may be useful in case CT is not available.^[1][2][3][4]
• Barium enema has been used in the diagnosis of acute diverticulitis, but is not the best procedure to diagnose the disease. Enema has many disadvantages which include:^[5]
  • Enema rupture, which may cause cellulitis and peritonitis.
  • If enema fails, it will delay other imaging procedures like CT scan, endoscopy, and angiography.
  • It may cause acute intestinal obstruction.
• The radiological findings in the abdominal X-ray include the following:
  • Intestinal obstruction
  • Multiple air-fluid levels in the case of perforation

• The single contrast technique may be preferred over the double contrast technique in the following cases:
  • The patient is unable to turn quickly/effectively since the double contrast technique requires rapid changes in patient position
  • When only the position and length of a structure is required
  • Evaluation for acute diverticulitis when CT is unavailable
  • Evaluation for a colonic fistula
  • Evaluation for postoperative leak after colon surgery

• Contraindications of the barium enema include the following:^[6]
  • Patients with pneumoperitoneum shown in the chest X ray.
  • Patients who had a recent deep rectal biopsy.