From the Guidelines
Diverticulitis should be treated with antibiotics in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 109 cells per liter, as well as in patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan, according to the 2021 AGA clinical practice update 1.
Diagnosis
The diagnosis of diverticulitis is based on clinical presentation, laboratory tests, and imaging studies. Patients with diverticulitis typically present with abdominal pain, tenderness, and changes in bowel habits. Laboratory tests such as CRP and white blood cell count can help identify patients with systemic inflammation. Imaging studies such as CT scans can help confirm the diagnosis and identify complications such as abscess or perforation.
Treatment
The treatment of diverticulitis depends on the severity of the disease. Patients with mild uncomplicated diverticulitis can be treated with oral antibiotics such as ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily for 7-10 days 1. Patients who are immunocompromised or have evidence of systemic inflammation, abscess, perforation, or obstruction should be treated with antibiotics and may require hospitalization. The duration of treatment is usually 4-7 days but can be longer based on general health status, immune status, severity of presentation, CT findings, and patient expectations.
Management
In addition to antibiotics, patients with diverticulitis should be managed with a liquid or low-fiber diet during the acute phase, gradually transitioning to a high-fiber diet (25-30g daily) once symptoms improve. Pain can be managed with acetaminophen, avoiding NSAIDs which may irritate the digestive tract. After recovery, prevention focuses on maintaining a high-fiber diet, staying well-hydrated, exercising regularly, and avoiding constipation.
Key Points
- Antibiotics are recommended for patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 109 cells per liter 1.
- Patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan should be treated with antibiotics.
- The treatment of diverticulitis depends on the severity of the disease, with mild cases typically managed at home with oral antibiotics and severe cases requiring hospitalization for IV antibiotics, bowel rest, and possibly surgical intervention.
From the Research
Diagnosis and Treatment of Diverticulitis
- The diagnosis of diverticulitis is typically based on medical history, physical examination, and abdominopelvic computed tomography (CT) scanning 2.
- The treatment of diverticulitis depends on the severity of the condition, with uncomplicated diverticulitis typically being treated with liquid diet and oral antimicrobials, such as ciprofloxacin and metronidazole 3.
- For complicated diverticulitis, hospitalization, bowel rest, and intravenous antibacterial agents are mandatory 3.
Antibiotic Treatment
- The use of antibiotics in the treatment of uncomplicated diverticulitis is uncertain, with some studies suggesting that there may be little or no difference between antibiotics and no antibiotics in terms of short-term complications 4.
- However, other studies have found that outpatient treatment with oral antibiotics, such as metronidazole and ciprofloxacin, can be safe and effective in the treatment of uncomplicated diverticulitis 2, 5, 6.
- A randomized non-inferiority control trial found that oral antibiotics were equally as safe and efficacious as intravenous antibiotic treatment in the outpatient management of uncomplicated diverticulitis 5.
Outpatient Treatment
- Outpatient treatment of uncomplicated diverticulitis has been shown to be safe and effective, with success rates of over 92% in some studies 2.
- Ambulatory treatment protocols, which include oral antibiotics, a clear liquid diet, and pain control with oral acetaminophen, can be applicable, safe, and efficacious in most patients with uncomplicated acute diverticulitis 6.
- However, patients with vomiting, severe comorbidities, or without an appropriate family environment may require hospitalization 6.