Management of Diverticulitis in Elderly Patients
The management of diverticulitis in elderly patients should be stratified based on disease severity, with uncomplicated diverticulitis (WSES stage 0) managed conservatively without antibiotics, while complicated forms require antibiotics, possible drainage procedures, or surgery depending on the specific complications. 1
Diagnostic Approach
- CT scan with IV contrast is the preferred imaging modality to confirm diagnosis and distinguish complicated from uncomplicated diverticulitis
- For patients with contrast allergies or kidney disease, alternatives include ultrasound, MRI, or non-contrast CT scan
Management Algorithm Based on Disease Severity
Uncomplicated Diverticulitis (WSES Stage 0)
- Conservative management without antibiotics for immunocompetent elderly patients
- Bowel rest and hydration
- Monitor for clinical improvement
Localized Complicated Diverticulitis (WSES Stage 1a)
- Broad-spectrum antibiotic therapy
- Options include ampicillin, gentamicin, metronidazole, piperacillin-tazobactam, or ciprofloxacin with metronidazole 1, 2
- Short course (3-5 days) is reasonable with adequate source control
Diverticulitis with Abscess (WSES Stage 1b-2a)
- Broad-spectrum antibiotic therapy
- For abscesses >4 cm: add percutaneous drainage when facilities and skills are available
- Obtain cultures from drainage to guide antibiotic therapy
- Consider interval sigmoid resection after resolution, especially in immunocompromised patients
Diverticulitis with Distant Intraperitoneal Free Air (WSES Stage 2b)
- Surgical management is recommended
- Non-operative management is not advised
Diffuse Peritonitis (WSES Stage 3-4)
- Prompt surgical source control is mandatory
- Options include:
- Hartmann procedure or primary anastomosis (both reasonable options)
- For physiologically unstable patients: consider damage control surgery
- For stable patients: laparoscopic sigmoidectomy by experienced surgeons
- Broad-spectrum antibiotics tailored to likely pathogens and resistance patterns
Post-Episode Management
- Early colonic evaluation after resolution of acute episode
- Elective sigmoid resection is NOT recommended after a conservatively treated episode in asymptomatic patients
- Consider elective sigmoid resection for:
- Immunocompromised patients (if fit for surgery)
- Patients with stenosis, fistulae, or recurrent diverticular bleeding
- Patients with very symptomatic disease affecting quality of life
Important Considerations for Elderly Patients
- Assess comorbidities and physiological reserve before deciding on surgical intervention
- Outpatient treatment can be considered for uncomplicated and mild complicated diverticulitis in carefully selected patients 3
- Risk factors for treatment failure include Ambrosetti score of 4 and free air around the colon
- Antibiotic duration should be limited to 3-5 days after adequate source control
- Further investigation is warranted if signs of peritonitis or systemic illness persist beyond 5-7 days of treatment
Surgical Approach When Indicated
- Laparoscopic lavage is not recommended for acute peritonitis due to higher risk of failure to control sepsis
- For perforated diverticulitis with generalized peritonitis, both Hartmann operation and resection with primary anastomosis are reasonable options
- Patient selection is critical when considering surgical approaches
The management of diverticulitis in elderly patients requires careful assessment of disease severity, patient comorbidities, and physiological status to determine the optimal treatment strategy that will minimize morbidity and mortality while preserving quality of life.