From the Guidelines
Management of acute diverticulitis with diverticular abscess requires a tailored approach based on abscess size and patient condition, with the most recent guidelines suggesting antibiotic therapy alone for small abscesses (< 4–5 cm) and percutaneous drainage combined with antibiotic therapy for larger abscesses 1. For small abscesses (< 4 cm), outpatient management with broad-spectrum antibiotics like ciprofloxacin 500 mg twice daily plus metronidazole 500 mg three times daily for 7-10 days is often sufficient.
- Key considerations include:
- Abscess size: small abscesses (< 4 cm) can be managed with antibiotics alone, while larger abscesses (> 4 cm) may require percutaneous drainage and intravenous antibiotics.
- Patient condition: patients with peritonitis, sepsis, or failed conservative management may require surgical intervention.
- Antibiotic selection: empiric antibiotic treatment should be chosen based on the underlying clinical condition, presumed pathogens, and risk factors for major antimicrobial resistance patterns 1. Larger abscesses (> 4 cm) typically require hospitalization for intravenous antibiotics such as piperacillin-tazobactam 3.375 g every 6 hours or ceftriaxone 1-2 g daily plus metronidazole 500 mg every 8 hours.
- Percutaneous drainage is indicated for abscesses > 4-5 cm or when there's no clinical improvement after 2-3 days of antibiotics.
- Patients should maintain a clear liquid diet initially, progressing to low-fiber foods as symptoms improve.
- Pain management with acetaminophen or, if necessary, opioids may be required. Surgical intervention becomes necessary for patients with peritonitis, sepsis, or failed conservative management.
- Following resolution, colonoscopy is recommended 6-8 weeks later to exclude malignancy. This approach balances the need to control infection while avoiding unnecessary invasive procedures, as many diverticular abscesses will resolve with appropriate antibiotic therapy and supportive care 1.
From the Research
Management of Acute Diverticulitis with Diverticular Abscess
- The management of acute diverticulitis with diverticular abscess can be approached through various methods, including percutaneous drainage, antibiotic therapy, and surgery 2, 3, 4, 5, 6.
- Percutaneous drainage is a minimally invasive approach that can be used to manage diverticular abscesses, especially in patients who are high-risk for surgery 2.
- Antibiotic therapy is a key component in the management of diverticulitis, and can be used as initial treatment for uncomplicated diverticulitis, as well as for complicated diverticulitis with small abscesses 3, 4, 5, 6.
- Surgery is indicated for patients with peritonitis, sepsis, or failure of non-operative management, and can be performed through either an open or laparoscopic approach 4, 6.
Treatment Options for Diverticular Abscess
- Percutaneous drainage can be used to manage diverticular abscesses, with a success rate of up to 70% 2, 5.
- Antibiotic therapy alone can be used as initial treatment for selected patients with large diverticular abscesses, with comparable outcomes to percutaneous drainage 5.
- Surgery is indicated for patients with large abscesses that fail percutaneous drainage or antibiotic therapy, or for those with peritonitis or sepsis 4, 6.
Guidelines for Management
- The management of diverticulitis should be guided by the classification of the disease as uncomplicated or complicated, based on CT scan, severity of symptoms, and patient history 6.
- Outpatient treatment is recommended for afebrile, clinically stable patients with uncomplicated diverticulitis, while hospitalization is indicated for patients with complicated diverticulitis or signs of peritonitis 4, 6.
- Colonoscopy is recommended for all patients with complicated diverticulitis, as well as for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 4, 6.