What is the management of complicated diverticulitis?

From the Guidelines

Management of complicated diverticulitis requires prompt intervention based on the severity of complications, with a focus on reducing morbidity, mortality, and improving quality of life. For patients with localized abscesses smaller than 4-5 cm, antibiotics alone may be sufficient, typically using broad-spectrum coverage with combinations like ciprofloxacin 500 mg twice daily plus metronidazole 500 mg three times daily, or piperacillin-tazobactam 3.375 g IV every 6 hours for 7-14 days, as suggested by the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1.

Key Considerations

• Larger abscesses (>5 cm) generally require percutaneous drainage guided by CT or ultrasound, along with antibiotic therapy.
• For peritonitis, immediate surgical intervention is necessary, often involving resection of the affected colon segment with either primary anastomosis or temporary colostomy depending on the patient's condition and extent of contamination.
• Patients with fistulas may require surgical repair after controlling the acute infection.
• During hospitalization, patients should receive nothing by mouth initially, intravenous fluids, pain management, and close monitoring of vital signs and laboratory values.
• After resolution of the acute episode, colonoscopy is recommended 6-8 weeks later to exclude malignancy, as emphasized in the AGA clinical practice update on medical management of colonic diverticulitis 1.

Antibiotic Therapy

• The choice of antibiotic regimen should be based on the underlying clinical condition of the patient, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns, with consideration of local epidemiological data and resistance profiles 1.
• A 4-day period of postoperative antibiotic therapy in complicated acute diverticulitis is suggested if source control has been adequate, as recommended by the WSES guidelines 1.

Surgical Intervention

• Elective segmental colectomy may be considered for patients with a history of complicated diverticulitis, particularly those who are chronically immunosuppressed, to prevent recurrent episodes and improve quality of life, as discussed in the AGA clinical practice update 1.
• However, the decision to recommend elective resection should be personalized, taking into account the patient's comorbidities, severity of diverticulitis, and patient preferences and values.

Quality of Life

• The goal of management is not only to reduce morbidity and mortality but also to improve quality of life, which may involve a multidisciplinary approach including surgical, medical, and supportive care.
• Patients should be informed about the risks and benefits of different management strategies, including the potential for recurrent episodes and the impact on quality of life, as highlighted in the AGA clinical practice update 1.

From the Research

Management of Complicated Diverticulitis

The management of complicated diverticulitis involves a combination of medical and surgical interventions.

• 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.

Antibiotic Therapy

Antibiotic therapy plays a crucial role in the management of complicated diverticulitis.

• The general recommendation is to use antibiotics with activity against common gram-negative and anaerobic pathogens 3.
• A number of single agents and combination regimens provide such activity, but there is little evidence on which to base selection of specific antimicrobial regimens 3.
• Episodes of diverticulitis severe enough to warrant hospitalization should be managed initially with intravenous antibiotics 3.
• Oral therapy can be used for outpatient treatment or when the patient's condition improves 3.

Other Interventions

Other interventions that may be used in the management of complicated diverticulitis include:

• Computed tomography (CT)-guided percutaneous drainage for patients with a localized abscess 4.
• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation 2.
• 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 4.

Surgical Intervention

Surgical intervention may be necessary in some cases of complicated diverticulitis.

• Laparoscopic surgery results in a shorter length of stay, fewer complications, and lower in-hospital mortality compared with open colectomy 4.
• The decision to proceed to surgery in patients with recurrent diverticulitis should be individualized and based on patient preference, comorbidities, and lifestyle 4.