From the Guidelines
The management of diverticulitis should prioritize outpatient care for uncomplicated cases, with selective use of antibiotics based on patient risk factors and clinical presentation, as supported by the most recent guidelines from the American College of Physicians 1.
Diagnosis and Management Approach
The approach to managing diverticulitis involves a combination of diagnostic imaging, medical therapy, and sometimes surgical intervention, depending on the severity of the disease. For patients with suspected acute left-sided colonic diverticulitis, abdominal CT imaging is recommended when there is diagnostic uncertainty 1. This imaging modality helps in confirming the diagnosis and assessing the severity of the disease, which is crucial for deciding the management strategy.
Uncomplicated Diverticulitis Management
For most patients with acute uncomplicated left-sided colonic diverticulitis, management in an outpatient setting is suggested, provided they have no evidence of systemic inflammatory response, are immunocompetent, and can continue treatment at home with adequate support and follow-up 1. The use of antibiotics in uncomplicated diverticulitis has been reevaluated, with recent guidelines suggesting that antibiotics may not be necessary for all patients, especially those who are immunocompetent and have mild disease without signs of systemic inflammation 1.
Antibiotic Use
Antibiotics should be used selectively in patients with uncomplicated diverticulitis, reserving them for those with comorbidities, refractory symptoms, vomiting, high C-reactive protein levels, or specific CT findings indicating a higher risk of complications 1. The choice of antibiotics, when necessary, should cover both gram-negative and anaerobic bacteria, with options including amoxicillin-clavulanate or a combination of a fluoroquinolone and metronidazole for outpatient treatment 1.
Complicated Diverticulitis
Patients with complicated diverticulitis, characterized by the presence of an abscess, perforation, obstruction, or fistula, require more aggressive management, often necessitating hospitalization for intravenous antibiotics and possibly surgical or radiological interventions 1. Percutaneous drainage may be indicated for abscesses larger than 4cm, and surgical intervention is considered for cases with perforation, obstruction, fistula formation, or failure of medical management.
Follow-Up and Prevention
After recovery from an acute episode of diverticulitis, a colonoscopy is recommended 6-8 weeks later to exclude malignancy, especially in patients who have not had a recent colonoscopy 1. Preventive measures include a high-fiber diet to reduce the risk of recurrence and potentially decrease the risk of developing diverticulitis in the first place.
Key Considerations
- Patient Selection: Outpatient management is suitable for most immunocompetent patients with uncomplicated diverticulitis who can be monitored and treated at home.
- Antibiotic Stewardship: The decision to use antibiotics should be based on the presence of systemic inflammation, comorbidities, and specific risk factors for complications.
- Imaging: CT imaging is crucial for diagnosis and assessing the severity of diverticulitis, guiding the management approach.
- Follow-Up: Regular follow-up and preventive measures, including dietary changes and colonoscopy when indicated, are essential for managing diverticulitis and preventing recurrence.
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
Treatment of Uncomplicated Diverticulitis
- Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis 2
- Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 2, 3, 4
- Treatment without antibiotics, without bed rest, and without dietary restrictions is possible for uncomplicated diverticulitis patients 3
- A selected group of patients can be treated as outpatients 3
Treatment of Complicated Diverticulitis
- Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses 2
- 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
Role of Antibiotics in Diverticulitis Management
- Antibiotics play a key role in the management of both uncomplicated and complicated diverticular disease 5
- Rifaximin has demonstrated to be effective in obtaining symptoms relief at 1 year in patients with uncomplicated diverticular disease and to improve symptoms and maintain periods of remission following acute colonic diverticulitis (AD) 5
- The use of antibiotics in uncomplicated diverticulitis is uncertain, with low-certainty evidence suggesting little or no difference between antibiotics and no antibiotics 4
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