What is the treatment for diverticulitis?

From the Guidelines

For immunocompetent patients with uncomplicated acute diverticulitis, antibiotics should not be prescribed as they do not provide any significant benefit in terms of clinical resolution or prevention of complications. This approach is based on the most recent and highest quality evidence available, including a study published in 2020 by the World Journal of Emergency Surgery 1, which recommends against antibiotic therapy in such cases. The study suggests that local host defenses can manage the inflammation without antibiotics in immunocompetent patients, making the condition potentially self-limiting.

Key Considerations for Treatment

• For patients with uncomplicated diverticulitis, a watchful waiting approach with symptomatic treatment may be appropriate, as supported by a prospective, single-arm study overviewed in the 2020 guidelines 1.
• Antibiotics are recommended for patients with complicated diverticulitis or those with uncomplicated diverticulitis who have comorbidities, are frail, present with refractory symptoms or vomiting, or have elevated CRP or white blood cell count, as suggested by the 2021 AGA clinical practice update 1.
• The choice of antibiotics should include broad-spectrum agents with gram-negative and anaerobic coverage, such as oral fluoroquinolones and metronidazole for outpatient treatment, or intravenous ceftriaxone plus metronidazole for inpatient treatment.

Management and Prevention

• Patients should be advised to maintain a high-fiber diet, stay well-hydrated, exercise regularly, and avoid constipation to prevent recurrence, as suggested by the 2015 American Gastroenterological Association institute guideline 1.
• Colonoscopy should be considered after resolution of acute diverticulitis to exclude misdiagnosis of a colonic neoplasm, especially if a high-quality examination of the colon has not been recently performed.
• Elective colonic resection may be considered in individual cases, particularly for patients with recurrent diverticulitis, but the decision should be based on patient-specific factors and the potential risks and benefits of surgery.

From the Research

Treatment Options for Diverticulitis

The treatment for diverticulitis depends on the severity of the condition and can range from outpatient care with antibiotics and a liquid diet to surgical intervention for complicated cases.

• For uncomplicated diverticulitis, treatment typically involves:
  • A liquid diet to rest the bowel
  • Oral antibiotics, such as metronidazole and ciprofloxacin, for 10 days 2, 3
  • Oral analgesics, like acetaminophen, for pain management 2
• Outpatient treatment has been shown to be safe and effective for uncomplicated diverticulitis, with success rates over 92% and significant cost savings compared to inpatient treatment 2, 3
• For complicated diverticulitis, treatment may include:
  • Intravenous antibiotics for severe infections
  • Bowel rest
  • Percutaneous drainage for abscesses
  • Surgical intervention for peritonitis, sepsis, or failure of non-operative management 4, 5
• The use of antibiotics in uncomplicated diverticulitis is still a topic of debate, with some studies suggesting no proven benefit in reducing disease duration or preventing recurrence 5
• Other therapies, such as mesalazine and probiotics, have been explored for the treatment of diverticulitis, with promising results in improving symptoms and preventing recurrence 6

Classification and Diagnosis

Diverticulitis is classified as complicated or uncomplicated based on CT scan findings, severity of symptoms, and patient history 5.

• CT scans are used to diagnose and assess the severity of diverticulitis
• Classification of diverticulitis guides management decisions, with uncomplicated cases often treated outpatient and complicated cases requiring more intensive interventions 5

Surgical Intervention

Surgical intervention may be necessary for complicated diverticulitis, including:

• Hartmann procedure
• Primary anastomosis with or without diverting loop ileostomy
• Percutaneous drainage for abscesses 4, 5
• Surgical decisions are guided by the severity of the condition, patient stability, and response to non-operative management 4, 5