What is the assessment and management plan for diverticulitis?

Assessment and Management of Diverticulitis

Patients with uncomplicated diverticulitis can be safely managed in an outpatient setting without antibiotics, while those with complicated disease or risk factors require hospitalization and antibiotic therapy. 1

Diagnosis and Assessment

Clinical Evaluation

• Assess for left lower quadrant abdominal pain, tenderness, fever, and altered bowel habits
• Evaluate for systemic inflammatory response: fever, tachycardia, hypotension
• Identify risk factors for complicated disease:
  • Immunosuppression
  • Advanced age
  • Significant comorbidities
  • Pain score >7 on visual analog scale
  • Symptoms lasting >5 days
  • Vomiting
  • High C-reactive protein levels (>140 mg/L)

Diagnostic Imaging

• CT scan is recommended when there is diagnostic uncertainty 1
  • Findings: colonic wall thickening, pericolic fat stranding, diverticula
  • Helps differentiate uncomplicated from complicated disease
  • Identifies complications: abscess, perforation, fistula, obstruction
• Ultrasound may be considered when CT is contraindicated or unavailable (90% sensitivity, 90% specificity) 1

Classification

1. Uncomplicated diverticulitis: Localized inflammation without abscess or perforation
2. Complicated diverticulitis: Presence of abscess, perforation, fistula, obstruction, or bleeding

Management Algorithm

Uncomplicated Diverticulitis

1. Outpatient management for patients who:

   • Have no systemic inflammatory response
   • Can tolerate oral intake
   • Have adequate social support
   • Can follow up as needed 1

2. Antibiotic therapy:

   • Selective rather than routine use of antibiotics is recommended 1
   • Consider antibiotics for:
     • Immunocompromised patients
     • Elderly patients with comorbidities
     • Systemic signs of infection 1
   • If antibiotics are needed:
     • Oral antibiotics covering gram-negative and anaerobic bacteria (e.g., ciprofloxacin + metronidazole)
     • 7-10 days duration 1

3. Supportive care:

   • Clear liquid diet initially, advancing as tolerated
   • Adequate hydration
   • Pain management

4. Follow-up:

   • Re-evaluation within 7 days 1
   • Earlier reassessment if symptoms worsen

Complicated Diverticulitis

1. Inpatient management for:

   • Abscess >4 cm
   • Free perforation
   • Peritonitis
   • Significant comorbidities
   • Inability to tolerate oral intake
   • Severe pain or systemic symptoms 1

2. Antibiotic therapy:

   • Intravenous antibiotics covering gram-negative and anaerobic bacteria
   • Consider early transition to oral antibiotics when clinically improving 1

3. Interventional procedures:

   • Percutaneous drainage for abscesses >5 cm 2
   • Surgical intervention for:
     • Free perforation with peritonitis
     • Failed conservative management
     • Large abscess not amenable to percutaneous drainage

Prevention of Recurrence

• Diet: High-fiber diet or fiber supplementation 1
• Lifestyle modifications:
  • Maintain normal body mass index
  • Regular physical activity 1
  • Smoking cessation
  • Avoid non-aspirin NSAIDs (except when prescribed for cardiovascular prevention) 1
  • No need to avoid seeds, nuts, or popcorn 1

Follow-up After Resolution

• Colonoscopy is recommended after resolution of symptoms if no recent high-quality examination of the colon has been performed 1
  • To exclude misdiagnosis of colonic neoplasm
  • Timing: after complete resolution of inflammation

Special Considerations

• Treatment failure rates are higher with:

  • Admission/CT between midnight and 6 AM
  • Higher Ambrosetti score (severity score)
  • Free air around the colon 3

• Cost considerations: Outpatient treatment can save approximately €1,600 per patient compared to inpatient management 4

• Elective surgery should not be based solely on the number of episodes but should consider:

  • Severity of disease
  • Patient's quality of life
  • Risk factors for complications 1

The management approach to diverticulitis has evolved significantly, with evidence supporting more conservative strategies for uncomplicated cases, reducing unnecessary antibiotic use and hospitalizations while maintaining excellent outcomes for patient morbidity and mortality.