What is the treatment for an acute diverticulitis (inflammatory diverticular disease) flare-up?

From the Guidelines

To treat a diverticulitis flare-up, antibiotics can be safely omitted in patients with a first episode of uncomplicated (Hinchey 1a) acute left-sided colonic diverticulitis, and management can be done in an outpatient setting with supportive care, including bowel rest and hydration, as suggested by the American College of Physicians 1.

Treatment Approach

• Start with a clear liquid diet for 2-3 days to rest the bowel, then gradually transition to a low-fiber diet until symptoms improve.
• For pain relief, use acetaminophen (Tylenol) up to 3000mg daily rather than NSAIDs like ibuprofen, which may irritate the digestive tract.
• Apply a heating pad to the abdomen for comfort.
• Stay well-hydrated with water, broth, and clear juices.
• Rest adequately while maintaining gentle movement like short walks.

Antibiotic Use

• Antibiotics are not necessary for all patients with uncomplicated diverticulitis, especially those who are immunocompetent and have mild symptoms, as shown in a recent study 1.
• However, antibiotics may be considered in patients with comorbidities, refractory symptoms, vomiting, or elevated CRP levels (>140 mg/L) 1.
• When antibiotic treatment is necessary, a broad-spectrum regimen with gram-negative and anaerobic coverage, such as ciprofloxacin and metronidazole, can be used for 7-10 days.

Monitoring and Follow-up

• Patients should be monitored for signs of complications, such as severe pain, persistent fever, inability to keep liquids down, or worsening symptoms.
• If complications occur, hospitalization may be necessary for intravenous antibiotics or possible surgical intervention.
• Once the acute phase resolves, gradually increase fiber intake and maintain good hydration to prevent future episodes.

Important Considerations

• The treatment approach should be individualized based on patient characteristics, such as comorbidities, immune status, and severity of symptoms.
• Patients with complicated diverticulitis or high-risk features, such as abscess, perforation, or obstruction, require prompt medical attention and antibiotic treatment.
• The use of antibiotics should be balanced with the risk of antibiotic resistance and potential side effects.

From the Research

Treatment Options for Diverticulitis Flare Up

• Medical treatment plays a crucial role in managing diverticulitis, with most cases requiring only liquid diet and antibiotics 2, 3
• For uncomplicated diverticulitis, outpatient treatment with oral antibiotics, liquid diet, and oral analgesics can be effective and safe 2
• The use of antibiotics in uncomplicated diverticulitis is questionable, with some studies suggesting no proven benefit in reducing the duration of the disease or preventing recurrence 4, 5
• For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses, while larger abscesses may require percutaneous drainage 3, 5

Antibiotic Treatment

• Commonly used antibiotics for diverticulitis include metronidazole and ciprofloxacin, or amoxicillin-clavulanate 2, 6
• The comparative effectiveness of metronidazole-with-fluoroquinolone versus amoxicillin-clavulanate for diverticulitis is uncertain, with some studies suggesting no differences in outcomes 6
• Treating diverticulitis with amoxicillin-clavulanate may reduce the risk of fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 6

Surgical Intervention

• Surgical intervention is indicated for peritonitis, sepsis, or failure of non-operative management 3, 5
• 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 5