What is the treatment for diverticulitis in Alberta?

Treatment of Diverticulitis in Alberta

For uncomplicated diverticulitis, conservative treatment without antibiotics is recommended in immunocompetent patients, while antibiotics should be reserved for specific high-risk patients or those with complicated disease. 1

Diagnosis and Classification

Clinical Presentation

• Left lower quadrant abdominal pain
• Elevated temperature
• Localized tenderness in left lower quadrant
• Increased white blood cell count
• Elevated C-reactive protein

Imaging

• CT scan with IV contrast is the preferred diagnostic method
• Key findings: intestinal wall thickening, inflammation in pericolonic fat, thickening of lateroconal fascia
• Signs of complications: extraluminal gas, intra-abdominal fluid, abscess

Treatment Algorithm for Diverticulitis

Uncomplicated Diverticulitis

1. Diet Management:

   • Clear liquid diet during acute phase
   • Advance diet as symptoms improve 1
   • If unable to advance diet after 3-5 days, immediate follow-up is required

2. Antibiotic Therapy:

   • Immunocompetent patients without risk factors: Conservative treatment without antibiotics 1
   • High-risk patients: Antibiotic therapy for no more than 7 days 1
     • High-risk defined as: immunocompromised, elderly, significant comorbidities, CRP >140 mg/L, WBC >15×10⁹/L, vomiting, or symptoms >5 days 1

3. Treatment Setting:

   • Outpatient management for patients without significant comorbidities who can take fluids orally 1
   • Inpatient management for patients with significant comorbidities or inability to take fluids orally
   • Re-evaluation within 7 days (earlier if clinical condition deteriorates) 1

4. Antibiotic Options (when indicated):

   • Outpatient: Oral fluoroquinolone + metronidazole OR amoxicillin-clavulanate 1
   • Inpatient: Piperacillin/tazobactam 4g/0.5g q6h OR Eravacycline 1mg/kg q12h 1
   • Beta-lactam allergy: Eravacycline 1mg/kg q12h OR Tigecycline 100mg loading dose then 50mg q12h 1

Complicated Diverticulitis

Small Diverticular Abscess (<4cm)

• Antibiotic therapy alone for 7 days 1
• Outpatient management possible for selected patients 2

Large Diverticular Abscess (≥4cm)

• Percutaneous drainage + antibiotic therapy for 4 days 1
• If drainage not feasible:
  • Non-critically ill, immunocompetent patients: antibiotics alone
  • Critically ill or immunocompromised patients: surgical intervention

Peritonitis

• Stable patients without comorbidities: Primary resection and anastomosis with/without diverting stoma 1
• Critically ill patients or those with multiple comorbidities: Hartmann's procedure 1

Special Considerations

Immunocompromised Patients

• Lower threshold for cross-sectional imaging, antibiotic treatment, and surgical consultation 1
• Higher risk of severe or complicated disease
• Longer antibiotic duration (10-14 days) 1

Oral vs. Intravenous Antibiotics

• Oral antibiotics are equally effective as intravenous antibiotics for uncomplicated diverticulitis 1, 3
• Early transition from IV to oral antibiotics can facilitate earlier discharge

Follow-up

• Colonoscopy recommended 6-8 weeks after an episode of complicated diverticulitis or first episode of uncomplicated diverticulitis 1
• Patients with recurrent uncomplicated diverticulitis should follow routine colorectal cancer screening

Prevention of Recurrence

• High-quality diet (high in fiber from fruits, vegetables, whole grains)
• Achieve/maintain normal BMI
• Regular physical activity
• Smoking cessation 1

Common Pitfalls to Avoid

1. Unnecessary antibiotic use in uncomplicated diverticulitis in immunocompetent patients
2. Delaying surgical consultation for critically ill patients or those with large abscesses when percutaneous drainage is not feasible
3. Failing to recognize high-risk patients who require antibiotic therapy despite having uncomplicated disease
4. Performing colonoscopy too early (before 6-8 weeks) after an acute episode