From the Guidelines
Diverticulitis symptoms should be managed with a selective approach to antibiotic treatment, emphasizing the importance of a high-quality diet, normal body mass index, physical activity, and avoidance of nonsteroidal anti-inflammatory drugs, as outlined in the 2021 clinical practice update by the American Gastroenterological Association 1. Diverticulitis typically presents with left lower quadrant abdominal pain, fever, nausea, vomiting, and changes in bowel habits, which can be managed with evidence-based best practices. The symptoms often develop gradually over several days and may worsen with movement. Other common symptoms include:
- Bloating
- Tenderness when pressing on the abdomen
- Rectal bleeding In more severe cases, patients may experience:
- Chills
- Loss of appetite
- Fatigue Complications can include abscess formation, bowel obstruction, perforation, or fistula development, which may cause additional symptoms like severe pain, inability to pass gas or stool, or drainage from abnormal connections between the colon and other organs. According to the clinical practice update, antibiotic treatment can be used selectively, rather than routinely, in immunocompetent patients with mild acute uncomplicated diverticulitis 1. However, antibiotic treatment is strongly advised in immunocompromised patients. To reduce the risk of recurrence, patients should:
- Consume a high-quality diet
- Have a normal body mass index
- Be physically active
- Not smoke
- Avoid nonsteroidal anti-inflammatory drug use except aspirin prescribed for secondary prevention of cardiovascular disease As outlined in the study, patients should be educated that the risk of complicated diverticulitis is highest with the first presentation, and an elective segmental resection should be personalized to consider severity of disease, patient preferences and values, as well as risks and benefits 1.
From the Research
Diverticulitis Symptoms
- Patients with acute diverticulitis may present with left lower quadrant pain, tenderness, abdominal distention, and fever 2
- Other symptoms may include anorexia, constipation, nausea, diarrhea, and dysuria 2
- Uncomplicated diverticulitis is localized diverticular inflammation, whereas complicated diverticulitis is diverticular inflammation associated with an abscess, phlegmon, fistula, obstruction, bleeding, or perforation 2
Diagnosis and Treatment
- Computed tomography is the most commonly performed imaging test, useful to establish the diagnosis and the extent and severity of disease, and to exclude complications in selected patients 2
- Initial laboratory studies include a complete blood count, basic metabolic panel, urinalysis, and measurement of C-reactive protein 2
- In mild, uncomplicated diverticulitis, antibiotics do not accelerate recovery, or prevent complications or recurrences 2, 3
- Hospitalization should be considered if patients have signs of peritonitis or there is suspicion of complicated diverticulitis 2
Outpatient Treatment
- Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable to most patients with tolerance to oral intake and without severe comorbidity and having appropriate family support 4
- Outpatient diverticulitis is commonly treated with either a combination of metronidazole and a fluoroquinolone or amoxicillin-clavulanate alone 5
- Treating diverticulitis in the outpatient setting with amoxicillin-clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 5
Management Variations
- Variations in the management of uncomplicated sigmoid diverticulitis are noted among colon and rectal surgeons, especially in terms of antibiotic choice, discharge instructions, and follow-up outpatient studies 6
- A survey conducted among colon and rectal surgeons showed that the majority chose an abdominal computed tomographic scan as the initial diagnostic test, and used a single intravenous antibiotic with second-generation cephalosporins and ampicillin/sulbactam being the most common 6