What is the treatment and management for diverticulitis, including potential complications like perforation?

Management of Diverticulitis and Potential Perforation

Diverticulitis should be managed based on disease severity, with uncomplicated cases potentially treated without antibiotics in immunocompetent patients, while complicated diverticulitis with perforation requires prompt surgical intervention and broad-spectrum antibiotics to reduce mortality and morbidity. 1

Clinical Presentation and Diagnosis

Symptoms and Signs

• Left lower quadrant abdominal pain (most common)
• Elevated temperature
• Localized tenderness in left lower quadrant
• Absence of vomiting in uncomplicated cases 1

Laboratory Findings

• Increased white blood cell count
• Leucocyte shift to left (>75%)
• Elevated C-reactive protein (CRP)
• Elevated procalcitonin (in severe cases) 1

Imaging

• CT with IV contrast is the gold standard (sensitivity/specificity 95%)
• Ultrasound is an alternative when CT is contraindicated
• Key findings include:
  • Intestinal wall thickening
  • Pericolonic fat inflammation
  • Signs of perforation (extraluminal gas, intra-abdominal fluid)
  • Presence of abscess 1

Treatment Algorithm

1. Uncomplicated Diverticulitis (WSES Stage 0-1)

• Conservative management without antibiotics in immunocompetent patients with mild disease 1
• Clear liquid diet during acute phase, advancing as symptoms improve 1
• Consider antibiotics if:
  • Patient is immunocompromised
  • Comorbidities or frailty present
  • CRP >140 mg/L or WBC >15 × 10^9/L
  • Vomiting or refractory symptoms
  • Longer segment of inflammation on CT 1

2. Diverticulitis with Small Abscess (WSES Stage 1b-2a)

• Antibiotic therapy alone for 7 days for small diverticular abscesses
• Outpatient management possible if:
  • Patient can tolerate oral intake
  • No severe comorbidities
  • Adequate family support 1, 2
• Recommended antibiotics:
  • Oral: Amoxicillin-clavulanate or Ciprofloxacin plus Metronidazole 1, 3
  • IV (if hospitalized): Piperacillin/tazobactam or Ertapenem 1

3. Diverticulitis with Large Abscess (WSES Stage 2b)

• Percutaneous drainage combined with antibiotic therapy for 4 days 1
• If drainage not feasible:
  • In stable, immunocompetent patients: antibiotics alone
  • In critically ill or immunocompromised patients: surgical intervention 1

4. Perforated Diverticulitis with Peritonitis (WSES Stage 3-4)

• Prompt surgical intervention is mandatory 1
• Surgical options:
  • Primary resection and anastomosis (stable patients without comorbidities)
  • Hartmann's procedure (critically ill patients with comorbidities) 1
• Broad-spectrum antibiotics:
  • Meropenem, Doripenem, or Imipenem/cilastatin by extended infusion
  • Eravacycline as alternative 1
• Duration: 4 days in immunocompetent patients; up to 7 days in immunocompromised or critically ill patients 1

Special Considerations

Immunocompromised Patients

• Lower threshold for imaging, antibiotics, and surgical consultation
• Higher risk for progression to complicated disease
• Longer antibiotic course (10-14 days)
• Consider elective sigmoid resection after recovery 1

Follow-up

• Colonoscopy recommended 6-8 weeks after acute episode:
  • Mandatory after complicated diverticulitis
  • Advised after first episode of uncomplicated diverticulitis
  • Can be deferred if high-quality colonoscopy performed within 1 year 1

Prevention of Recurrence

• High-quality diet rich in fiber from fruits, vegetables, whole grains
• Maintain normal body mass index
• Regular physical activity
• Smoking cessation
• Avoid NSAIDs when possible 1

Common Pitfalls

1. Misdiagnosis: Colon cancer can mimic diverticulitis (1.9% prevalence among diverticulitis patients, higher in complicated cases at 7.9%) 1
2. Delayed recognition of perforation: Watch for extraluminal gas, free fluid, or clinical deterioration
3. Inadequate source control: Ongoing signs of infection beyond 7 days warrant further investigation 1
4. Overuse of antibiotics: Not routinely needed for uncomplicated diverticulitis in immunocompetent patients 1
5. Failure to recognize high-risk patients: Immunocompromised patients require more aggressive management 1