What is the assessment and management plan for diverticulitis?

Assessment and Management Plan for Diverticulitis

For most patients with uncomplicated diverticulitis, outpatient management without antibiotics is safe and effective, with CT imaging reserved for cases with diagnostic uncertainty or suspected complications. 1

Diagnosis and Assessment

Diagnostic Approach

• Clinical presentation: Left lower quadrant abdominal pain, tenderness, fever, and altered bowel habits
• Laboratory evaluation: Complete blood count, C-reactive protein (CRP), basic metabolic panel
  • Leukocytosis >13.5 × 10^9 cells/L and CRP >140 mg/L suggest higher risk for complications 1

Imaging

• CT imaging: Indicated when:
  • Diagnostic uncertainty exists
  • Suspected complications (perforation, abscess, obstruction)
  • Symptoms lasting >5 days before presentation
  • Pain score >7 on visual analog scale
  • Immunocompromised patients
  • CT findings of diverticulitis: Colonic wall thickening, pericolic fat stranding, diverticula 1

Classification

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

Management Plan

Uncomplicated Diverticulitis

1. Outpatient management for immunocompetent patients without:

   • Systemic inflammatory response
   • Inability to tolerate oral intake
   • Significant comorbidities
   • Inadequate home support 1

2. Antibiotic therapy:

   • Selective use rather than routine in immunocompetent patients 1
   • Indicated for:
     • Immunocompromised patients
     • Systemic inflammatory response
     • Elderly patients with comorbidities 1
   • When prescribed:
     • Oral antibiotics covering gram-negative bacilli and anaerobes
     • Common regimens: Ciprofloxacin + Metronidazole or Amoxicillin/clavulanate 2, 3
     • Duration: 7-10 days 3

3. Supportive care:

   • Adequate hydration
   • Gradual reintroduction of diet as symptoms improve
   • Pain management with acetaminophen (avoid NSAIDs) 1

4. Follow-up:

   • Re-evaluation within 7 days 1
   • Earlier reassessment if clinical deterioration occurs

Complicated Diverticulitis

1. Inpatient management for:

   • Abscess >4 cm
   • Free perforation
   • Peritonitis
   • Obstruction
   • Inability to tolerate oral intake
   • Significant comorbidities 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 4
   • Surgical intervention for free perforation or failed conservative management

Prevention of Recurrence

1. Lifestyle modifications:

   • High-fiber diet or fiber supplementation 1
   • Maintain normal body mass index
   • Regular physical activity 1
   • Smoking cessation
   • Avoid NSAIDs (except aspirin for cardiovascular prevention) 1

2. Follow-up colonoscopy:

   • Perform after resolution of acute episode if no recent high-quality colon examination
   • To exclude misdiagnosed colonic neoplasm 1

Special Considerations

Risk Factors for Treatment Failure

• Symptoms lasting >5 days before presentation
• Initial pain score >7
• CT showing free air around colon
• Ambrosetti score of 4 (severe diverticulitis) 5

Indications for Surgery

• Free perforation with peritonitis
• Failed conservative management
• Recurrent episodes significantly affecting quality of life 4
• Note: Elective colonic resection should not be based solely on number of episodes 1

Pitfalls to Avoid

1. Overuse of antibiotics in uncomplicated cases without risk factors
2. Unnecessary hospitalization of stable patients who can be managed as outpatients
3. Failure to recognize complications requiring more aggressive management
4. Recommending dietary restrictions (seeds, nuts, popcorn) without evidence 1
5. Automatic surgical referral based solely on number of episodes rather than disease severity and patient factors

By following this evidence-based approach, most patients with diverticulitis can be managed effectively with reduced healthcare costs and minimal complications.