What is the diagnosis and treatment for Diverticulitis (inflammation of the diverticula)?

From the Guidelines

Diverticulitis treatment should prioritize a selective use of antibiotics, with a focus on managing symptoms and preventing complications, rather than routine antibiotic use for all cases, as supported by recent guidelines and studies 1.

Overview of Diverticulitis

Diverticulitis is an inflammation or infection of small pouches called diverticula that develop in the wall of the colon. The management of diverticulitis depends on its severity, ranging from mild cases that can be managed with oral antibiotics and dietary changes to more severe cases that may require hospitalization and surgical intervention.

Treatment Approach

• For mild cases, oral antibiotics like ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily for 7-10 days is typically recommended, along with a liquid or low-fiber diet until symptoms improve 1.
• More severe cases may require hospitalization for intravenous antibiotics, bowel rest, and possibly surgical intervention.
• Antibiotic treatment can be used selectively, rather than routinely, in immunocompetent patients with mild uncomplicated diverticulitis 1.
• Patients who are immunocompromised, have comorbidities, or present with refractory symptoms, vomiting, or signs of systemic inflammation (e.g., CRP >140 mg/L or baseline white blood cell count > 15 × 10^9 cells per liter) should be treated with antibiotics 1.

Prevention of Recurrence

• To prevent recurrence, maintaining a high-fiber diet (25-30g daily) once recovered, staying well-hydrated, exercising regularly, and avoiding NSAIDs when possible are recommended 1.
• Symptoms of diverticulitis include lower left abdominal pain, fever, nausea, and changes in bowel habits. If these symptoms occur, especially with fever or severe pain, seeking medical attention promptly is crucial to prevent complications like abscess, perforation, or obstruction.

Special Considerations

• Immunocompromised patients are at a higher risk for severe or complicated disease and should have a low threshold for cross-sectional imaging, antibiotic treatment, and consultation with a colorectal surgeon 1.
• The decision for elective resection after an episode of diverticulitis should be made on a case-by-case basis, considering patient-related factors, risk factors, complications, age, and severity of episodes, as well as the patient’s personal circumstances and comorbidities 1.

Conclusion is not allowed, so the response ends here.

From the Research

Diagnosis and Classification of Diverticulitis

• Radiological evidence of inflammation, using computed tomography (CT), is needed to diagnose the first occurrence of diverticulitis 2
• CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred 2
• Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms and patient history; this classification is used to direct management 2

Treatment of Uncomplicated Diverticulitis

• Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis 2
• Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 2
• Amoxicillin-clavulanate may be used as an alternative to metronidazole-with-fluoroquinolone, with no differences in 1-year admission risk, 1-year urgent surgery risk, or 3-year elective surgery risk 3

Treatment of Complicated Diverticulitis

• Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses 2
• Larger abscesses of 3-5 cm should be drained percutaneously 2
• Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration and urgent surgery 2
• Ceftriaxone and metronidazole was found to be non-inferior to piperacillin/tazobactam for the combined primary outcome of 30-day readmission or all-cause mortality 4

Surgical Management

• Surgical intervention with either Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy, is indicated for peritonitis or in failure of non-operative management 2
• The decision for elective surgery for diverticulitis has become preference sensitive 5
• New minimally invasive and robot-assisted techniques are being adopted for surgical management of diverticulitis 5