What are the treatment options for acute uncomplicated diverticulitis?

From the Guidelines

Immunocompetent patients with uncomplicated acute diverticulitis without signs of systemic inflammation should not be prescribed antibiotic therapy. This approach is based on high-quality evidence from the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1. The current consensus is that uncomplicated acute diverticulitis may be a self-limiting condition in which local host defenses can manage the inflammation without antibiotics in immunocompetent patients.

Key Considerations

• A clear liquid diet is advised during the acute phase of uncomplicated diverticulitis, with advancement to a low-fiber diet as symptoms improve 1.
• Pain management with acetaminophen is preferred, while NSAIDs should be avoided due to the potential increased risk of complications.
• Patients should be advised to seek immediate medical attention if they develop fever above 101°F, severe abdominal pain, inability to tolerate oral intake, or signs of peritonitis.
• Follow-up imaging, typically a CT scan, is recommended 6-8 weeks after symptom resolution to exclude underlying malignancy, especially in patients with complicated diverticulitis or those at higher risk for colorectal cancer 1.

Management Approach

• For patients with uncomplicated diverticulitis, a watchful waiting approach without antibiotics may be appropriate, given the low risk of complications and the potential for spontaneous resolution.
• In patients requiring antibiotic therapy, oral administration is preferred whenever possible, with regimens such as amoxicillin-clavulanate or a combination of a fluoroquinolone and metronidazole being considered based on individual patient factors and local resistance patterns.
• Elective surgery may be considered in patients with recurrent or persistent diverticulitis, particularly those with complicated disease or significant symptoms, after a thorough discussion of the potential benefits and harms 1.

Evidence Basis

The recommendations are based on the most recent and highest-quality evidence available, including guidelines from reputable organizations such as the World Society of Emergency Surgery (WSES) and the American College of Physicians (ACP) 1. These guidelines emphasize a selective approach to antibiotic use and highlight the importance of individualized patient care in the management of acute uncomplicated diverticulitis.

From the Research

Acute Uncomplicated Diverticulitis Treatment

• The use of antibiotics in acute uncomplicated diverticulitis is a topic of debate, with some studies suggesting that they may not be necessary 2, 3.
• A systematic review of randomized controlled trials found that there may be little or no difference between antibiotics and no antibiotics in terms of short-term complications, and that the rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics 2.
• Another study found that societal guidelines do not recommend routine antibiotics for acute uncomplicated diverticulitis, based on several quality studies that found similar outcomes in cases treated with or without antibiotics 3.
• However, some studies suggest that antibiotics may still be beneficial in certain cases, such as in patients with symptomatic uncomplicated diverticular disease or acute colonic diverticulitis 4.
• Outpatient treatment with oral antibiotics has been shown to be safe and effective in patients with uncomplicated acute diverticulitis who are able to tolerate oral intake and have adequate family support 5.
• A meta-analysis of randomized clinical trials found that the use of antibiotics in acute uncomplicated diverticulitis could slightly increase complications and result in a minor or no difference in the risk of recurrence and need for urgent surgery, although the certainty of the evidence is low 6.

Antibiotic Use

• The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications 2.
• Some studies have found that antibiotics may be beneficial in reducing symptoms and improving outcomes in patients with uncomplicated diverticular disease or acute colonic diverticulitis 4.
• However, other studies have found that antibiotics may not be necessary in all cases of acute uncomplicated diverticulitis, and that their use may be associated with increased complications and longer hospital stays 3, 6.

Treatment Guidelines

• Societal guidelines do not recommend routine antibiotics for acute uncomplicated diverticulitis, based on several quality studies that found similar outcomes in cases treated with or without antibiotics 3.
• Outpatient treatment with oral antibiotics may be a safe and effective option for patients with uncomplicated acute diverticulitis who are able to tolerate oral intake and have adequate family support 5.
• The use of antibiotics in acute uncomplicated diverticulitis should be individualized, taking into account the patient's specific needs and circumstances 2, 4.