From the Guidelines
The management of diverticulitis should prioritize a staged approach, focusing on disease severity, with uncomplicated cases typically managed as outpatients and complicated cases requiring hospitalization and possibly interventional procedures, as recommended by the American College of Physicians (ACP) in their 2022 guideline 1.
Diagnosis and Management Approach
The diagnosis of acute left-sided colonic diverticulitis should start with a detailed history, physical examination, and laboratory findings. When diagnostic uncertainty remains, abdominal CT imaging can be used to complement these initial steps and establish the diagnosis, as it has high sensitivity and specificity for diverticulitis 1.
Outpatient vs. Inpatient Management
Most patients with acute uncomplicated left-sided colonic diverticulitis can be managed in an outpatient setting, as there is no evidence suggesting a benefit of routine hospitalization for these patients, and outpatient management may reduce the risk of potential harms associated with hospitalization and lower associated costs 1. However, this approach should be individualized, considering factors such as the availability of adequate home care and the patient's ability to continue treatment at home under medical supervision.
Use of Antibiotics
Antibiotic treatment can be used selectively in immunocompetent patients with mild uncomplicated diverticulitis, as recent evidence suggests there may be no benefit in using antibiotics routinely in these cases 1. However, antibiotics are advised for patients with comorbidities, those who are frail, present with refractory symptoms or vomiting, or have a high C-reactive protein level (>140 mg/L) or baseline white blood cell count > 15 × 10^9 cells per liter 1.
Dietary Recommendations
A clear liquid diet is recommended during the acute phase of uncomplicated diverticulitis, with the diet advancing as symptoms improve, aiming for patient comfort and minimizing potential mechanical obstruction or systemic inflammation associated with the disease 1. After recovery, a high-fiber diet (25-30g daily) is recommended to prevent recurrence.
Complicated Diverticulitis Management
Complicated diverticulitis, including cases with peritonitis, abscess >4 cm, obstruction, or perforation, requires hospitalization for IV antibiotics, bowel rest, and possibly interventional procedures such as percutaneous drainage or surgical intervention 1.
Special Considerations
Immunocompromised patients are at higher risk for severe or complicated disease and should have a low threshold for cross-sectional imaging, antibiotic treatment, and consultation with a colorectal surgeon 1. Elective surgery may be considered after multiple episodes, especially in younger patients or those with complications, to prevent future episodes and complications.
This approach to managing diverticulitis prioritizes morbidity, mortality, and quality of life outcomes, tailoring treatment to the severity of the disease and the individual patient's circumstances, based on the most recent and highest quality evidence available 1.
From the Research
Management Approach for Diverticulitis
The management of diverticulitis can be categorized into uncomplicated and complicated diverticulitis.
- Uncomplicated diverticulitis is localized diverticular inflammation, whereas complicated diverticulitis is diverticular inflammation associated with an abscess, phlegmon, fistula, obstruction, bleeding, or perforation 2.
- Patients with acute diverticulitis may present with left lower quadrant pain, tenderness, abdominal distention, and fever, as well as other symptoms such as anorexia, constipation, nausea, diarrhea, and dysuria 2.
Diagnosis and Treatment
- Computed tomography (CT) is the most commonly performed imaging test to establish the diagnosis and the extent and severity of disease, and to exclude complications in selected patients 2, 3.
- Initial laboratory studies include a complete blood count, basic metabolic panel, urinalysis, and measurement of C-reactive protein 2.
- For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 4, 3, 5.
- Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis, and may include a clear-liquid diet along with bowel rest for resolution of symptoms 5, 6.
Complicated Diverticulitis
- Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses, while larger abscesses of 3-5 cm should be drained percutaneously 3.
- Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration, and urgent surgery 2, 3.
- 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, 3.
Prevention of Recurrences
- Interventions to prevent recurrences of diverticulitis include increased intake of dietary fiber, exercise, cessation of smoking, and weight loss in persons with a body mass index of 30 kg per m(2) or higher 2.
- Patient education is critical to help prevent complications and improve outcomes for patients with diverticulitis 5.