From the Guidelines
The management of diverticulitis depends on disease severity, with uncomplicated cases typically managed as outpatients using oral antibiotics such as amoxicillin-clavulanate (875/125 mg twice daily), ciprofloxacin (500 mg twice daily) plus metronidazole (500 mg three times daily), or trimethoprim-sulfamethoxazole plus metronidazole for 7-10 days, while complicated diverticulitis requires hospitalization for IV antibiotics, bowel rest, and IV fluids. The approach to managing diverticulitis should prioritize the patient's overall health status, immune status, severity of presentation, and CT findings.
- For uncomplicated diverticulitis, outpatient management with oral antibiotics and a clear liquid diet is often sufficient, with the patient gradually advancing to low-fiber foods as symptoms improve 1.
- For complicated diverticulitis, hospitalization for IV antibiotics, bowel rest, and IV fluids is necessary, with potential need for percutaneous drainage or surgical intervention in severe cases with perforation, abscess, obstruction, or peritonitis 1.
- The use of antibiotics should be selective, rather than routine, in patients with acute uncomplicated diverticulitis, with consideration given to the patient's comorbidities, symptoms, and laboratory findings 1.
- Patients with immunosuppression, significant comorbidities, or signs of sepsis should be treated with antibiotics, and those with large abscesses may require percutaneous drainage in addition to antibiotic therapy 1.
- After recovery, patients should gradually increase dietary fiber, stay well-hydrated, exercise regularly, and avoid NSAIDs when possible to prevent recurrence 1. The most recent and highest quality study, published in 2022, provides guidance on the diagnosis and management of acute left-sided colonic diverticulitis, including the use of abdominal CT imaging, outpatient management, and antibiotic treatment 1.
From the Research
Management Approach for Diverticulitis
The management approach for diverticulitis can be categorized into uncomplicated and complicated diverticulitis.
- Uncomplicated diverticulitis is characterized by inflammation limited to the colonic wall and surrounding tissue 2.
- Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture, or obstruction 3.
Diagnosis and Treatment
- 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.
- Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis 2, 4.
- 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 2, 3.
- A clear-liquid diet along with bowel rest is recommended for resolution of symptoms in patients with uncomplicated diverticulitis 5.
Surgical Intervention
- Surgical intervention is indicated for peritonitis or in failure of non-operative management 2.
- Surgical approaches include loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure), and sigmoidectomy with primary colorectal anastomosis 3.
- Primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis 3.
Patient Selection and Risk Stratification
- Patient selection is critical in determining the best course of treatment for diverticulitis 3.
- Risk stratification is necessary to identify patients who would benefit from surgical intervention or other management strategies 3.
- Modifiable patient comorbidities should be optimized before elective colectomy 3.