From the Guidelines
Management of diverticulitis should prioritize a selective approach to antibiotic use, with consideration of the patient's immune status, severity of symptoms, and presence of complications. For uncomplicated diverticulitis, outpatient management without antibiotics is recommended for immunocompetent patients without signs of systemic inflammation, as supported by the 2020 update of the WSES guidelines 1. However, for patients with complicated diverticulitis or those who are immunocompromised, antibiotic treatment is advised, with a regimen that includes broad-spectrum agents with gram-negative and anaerobic coverage, as suggested by the AGA clinical practice update on medical management of colonic diverticulitis 1. The optimal duration of antibiotic therapy after surgical source control in diffuse peritonitis due to diverticular perforation is suggested to be 4 days, as recommended by the 2020 update of the WSES guidelines 1. Patients should follow a clear liquid diet initially, gradually advancing to low-fiber foods as symptoms improve, then transitioning to a high-fiber diet for prevention once the acute episode resolves. Pain management with acetaminophen or non-steroidal anti-inflammatory drugs is recommended, and patients with severe pain, inability to tolerate oral intake, significant comorbidities, or complications like abscess, perforation, or obstruction require hospitalization for intravenous antibiotics, bowel rest, and possibly percutaneous drainage or surgery. After recovery from an acute episode, colonoscopy is typically recommended 6-8 weeks later to exclude other pathologies, particularly colorectal cancer. Long-term management focuses on preventing recurrence through high-fiber diet, regular physical activity, maintaining healthy weight, and avoiding smoking. Some key points to consider in the management of diverticulitis include:
- The use of abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis, as recommended by the American College of Physicians 1.
- The management of most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting, as suggested by the American College of Physicians 1.
- The initial management of select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics, as recommended by the American College of Physicians 1. It is essential to consider the individual patient's circumstances, including their immune status, severity of symptoms, and presence of complications, when determining the best course of management for diverticulitis.
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
Management of Uncomplicated Diverticulitis
- Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis 2
- For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 2, 3
- Recent studies suggest that changes in gut microbiota could contribute to development of symptoms and complication, and antibiotics play a key role in the management of uncomplicated diverticulitis 4
- Rifaximin has demonstrated to be effective in obtaining symptoms relief at 1 year in patients with uncomplicated diverticulitis 4
Management of Complicated Diverticulitis
- Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses; 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
- 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
- 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 in patients with complicated diverticulitis 5
Follow-up and Colonoscopy
- Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 2