From the Guidelines
Diverticulitis should be managed based on its severity, with mild cases typically managed at home with oral antibiotics and a clear liquid diet, while severe cases require hospitalization for intravenous antibiotics, bowel rest, and possibly surgery. The management of diverticulitis involves several key considerations, including diagnosis, treatment, and prevention of recurrence.
- Diagnosis: According to the American College of Physicians guideline 1, abdominal CT imaging is recommended when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis.
- Treatment: The guideline also suggests that most patients with acute uncomplicated left-sided colonic diverticulitis can be managed in an outpatient setting 1, and that antibiotic treatment can be used selectively, rather than routinely, in immunocompetent patients with mild uncomplicated diverticulitis 1.
- Prevention of recurrence: Maintaining a high-fiber diet, drinking plenty of water, exercising regularly, and avoiding NSAIDs when possible can help prevent recurrence 1. It is essential to note that the decision to perform an elective resection after one or more episodes of acute diverticulitis should be undertaken on a case-by-case basis, taking into account risk factors, complications, age, and severity of episodes as well as the patient’s personal circumstances and comorbidities 1. Some key points to consider in the management of diverticulitis include:
- The use of abdominal CT imaging to establish the diagnosis of diverticulitis when there is diagnostic uncertainty 1
- The potential harms of CT imaging, including incidental findings, radiation exposure, and side effects of or allergic reactions to any contrast used 1
- The importance of informed decision making with patients, including discussion of potential patient burdens related to CT imaging 1
- The role of antibiotic treatment in the management of diverticulitis, including the potential benefits and harms of antibiotic use 1
- The importance of maintaining a high-fiber diet, drinking plenty of water, exercising regularly, and avoiding NSAIDs when possible to prevent recurrence 1
From the Research
Diverticulitis Treatment
- The treatment of acute diverticulitis has become more conservative over the years, with a focus on patient subgroups that may suffer from a more virulent disease course or higher recurrence rates 2.
- Uncomplicated diverticulitis patients can be treated without antibiotics, without bed rest, and without dietary restrictions, and a selected group of patients can be treated as outpatients 2.
- Patients with isolated pericolic extraluminal air can also be treated conservatively 2.
- The use of antibiotics in uncomplicated diverticulitis is questionable, as the condition may be inflammatory rather than infectious 3.
- Studies have shown that antibiotics may not have a significant benefit in reducing the duration of the disease or preventing recurrence in uncomplicated diverticulitis 3, 4.
Patient Subgroups
- Patients on immunosuppression or non-steroidal anti-inflammatory drugs may have a higher risk of complicated diverticulitis 2.
- Young patients do not seem to have a higher risk of complicated diverticulitis, and the risk of recurrent diverticulitis in young patients is comparable to elderly patients 2.
- Patients with suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria should undergo colonoscopy 4.
Management of Diverticulitis
- Outpatient treatment is recommended for afebrile, clinically stable patients with uncomplicated diverticulitis 4, 5.
- For patients with uncomplicated diverticulitis, antibiotics should only be used selectively, and treatment should consist of oral antibiotics for 7 days 5.
- Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses, while larger abscesses should be drained percutaneously 4.
- Surgical intervention is indicated for peritonitis or in failure of non-operative management 4.