What is the treatment for diverticulitis?

From the Guidelines

Treatment for diverticulitis should be based on the severity of the disease, with mild cases managed through rest, liquid diet, and selective use of antibiotics, while severe cases require hospitalization and possibly surgical intervention. The management of diverticulitis depends on the severity of the disease, with uncomplicated cases often treated with antibiotics and bowel rest, while complicated cases may require more aggressive interventions such as percutaneous drainage or surgery 1.

Uncomplicated Diverticulitis

For patients with uncomplicated diverticulitis, antibiotics may not be necessary in immunocompetent patients without signs of sepsis or systemic inflammation 1. A high-fiber diet, staying hydrated, exercising regularly, and avoiding NSAIDs can help prevent recurrence 1.

Complicated Diverticulitis

In cases of complicated diverticulitis, such as those with abscesses or perforation, broad-spectrum antibiotics and possibly percutaneous drainage or surgery may be necessary 1. The decision to perform elective sigmoid resection should be personalized based on the patient's risk factors, symptoms, and quality of life 1.

Preventive Measures

After recovery, preventive measures include maintaining a high-fiber diet, staying hydrated, exercising regularly, and avoiding NSAIDs 1. Probiotics may help maintain gut health, though evidence is limited 1. Patients should seek immediate medical attention if they experience severe abdominal pain, fever, inability to pass gas or stool, or rectal bleeding.

Key Considerations

• The use of antibiotics should be selective, especially in immunocompetent patients with mild acute uncomplicated diverticulitis 1.
• Elective sigmoid resection may be considered in high-risk patients or those with complicated disease 1.
• Colonoscopy may be recommended after an episode of acute left-sided colonic diverticulitis to rule out colorectal cancer or advanced colonic neoplasia, especially in patients with complicated disease or higher risk for CRC 1.

From the Research

Treatment Overview

• The treatment of diverticulitis has become more conservative over the years, with a focus on patient-specific approaches 2.
• Uncomplicated diverticulitis can be treated without antibiotics, bed rest, or dietary restrictions, and some patients can be managed as outpatients 2.
• The use of antibiotics in uncomplicated diverticulitis is still debated, with some studies suggesting no benefit in reducing disease duration or preventing recurrence 3, 4.

Medical Treatment

• Antibiotics play a key role in the management of diverticular disease, particularly in complicated cases 3.
• Rifaximin has been shown to be effective in obtaining symptom relief and improving symptoms in patients with uncomplicated diverticulitis 3.
• Mesalazine does not have a beneficial effect on preventing recurrent diverticulitis, while the efficacy of rifaximin and probiotics is still uncertain 2.

Classification and Management

• Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms, and patient history, which guides management decisions 5.
• Outpatient treatment is recommended for afebrile, clinically stable patients with uncomplicated diverticulitis, while non-operative management is indicated for small abscesses 5.
• Surgical intervention is considered for peritonitis, sepsis, or failure of non-operative management, with options including Hartmann procedure or primary anastomosis 5, 6.

Evidence-Based Strategies

• Evidence-based treatment strategies for acute diverticulitis have evolved over time, with a focus on risk-adapted approaches and operative decision-making based on patient and disease factors 6.
• Clinical trials have demonstrated the effectiveness of laparoscopic lavage for select patients with Hinchey III disease, and primary resection with anastomosis and defunctioning stoma for some cases of Hinchey IV disease 6.
• The quality of evidence for antibiotic treatment in uncomplicated acute diverticulitis is low, and more trials are needed to obtain precise effect estimates 4.