What is the best treatment for diverticulitis of the small bowel?

Treatment of Small Bowel Diverticulitis

The treatment of small bowel diverticulitis should be guided by the patient's clinical presentation, with conservative management using antibiotics as first-line therapy for uncomplicated cases and surgical intervention reserved for complicated cases or those failing medical management.

Diagnostic Approach

• CT scan with IV contrast is the preferred imaging modality for diagnosis
• Look for intestinal wall thickening, signs of inflammation in surrounding fat, and potential complications (perforation, abscess)
• Laboratory evaluation should include:
  • Complete blood count (elevated WBC with left shift)
  • C-reactive protein
  • Procalcitonin (in severe cases)

Treatment Algorithm

Uncomplicated Small Bowel Diverticulitis

1. Conservative management:

   • Bowel rest with clear liquid diet advancing as symptoms improve 1
   • Broad-spectrum antibiotic therapy for 4-7 days 2, 3
   • Preferred antibiotic regimens:
     • Amoxicillin-clavulanate (oral) OR
     • Ciprofloxacin plus metronidazole (oral) 1

2. Monitoring:

   • Close follow-up within 7 days
   • Evaluate for symptom resolution and ability to tolerate oral intake
   • Consider repeat imaging if symptoms persist beyond 7 days 2

Complicated Small Bowel Diverticulitis

Small Abscess (<4-5 cm)

• Antibiotic therapy alone for 7 days 2
• Preferred regimens:
  • Piperacillin/tazobactam 4g/0.5g q6h OR
  • Meropenem 1g q6h by extended infusion OR
  • Eravacycline 1 mg/kg q12h (for beta-lactam allergic patients) 2

Large Abscess (>4-5 cm)

• Percutaneous drainage combined with antibiotic therapy for 4 days 2
• If percutaneous drainage not feasible:
  • In immunocompetent, non-critically ill patients: antibiotics alone 2
  • In immunocompromised or critically ill patients: surgical intervention 2

Perforation, Peritonitis, or Failed Medical Management

• Surgical intervention is required 3
• Surgical options:
  • Limited resection of affected segment with primary anastomosis (stable patients) 2
  • Resection with temporary diversion (unstable or severely compromised patients) 2

Special Considerations

Immunocompromised Patients

• Lower threshold for antibiotic treatment and surgical consultation
• Extended antibiotic duration (10-14 days)
• Higher risk for complicated disease 1

Critically Ill Patients

• Aggressive fluid resuscitation
• Early surgical consultation
• Broad-spectrum IV antibiotics:
  • Meropenem 1g q6h by extended infusion OR
  • Doripenem 500mg q8h by extended infusion OR
  • Imipenem/cilastatin 500mg q6h by extended infusion 2

Outpatient vs. Inpatient Management

• Outpatient management appropriate for:

  • Immunocompetent patients
  • Uncomplicated diverticulitis
  • Ability to tolerate oral intake
  • Adequate pain control with oral analgesics
  • Stable vital signs
  • Appropriate home support 1, 4

• Inpatient management indicated for:

  • Inability to tolerate oral intake
  • Significant comorbidities
  • Inadequate pain control
  • Lack of home support
  • Signs of systemic inflammation 4

Pitfalls and Caveats

• Small bowel diverticulitis is rare and can mimic other acute abdominal conditions
• Unlike colonic diverticulitis, there are limited specific guidelines for small bowel diverticulitis 3
• Conservative treatment has shown success in uncomplicated cases, avoiding unnecessary surgery 3
• Failure to improve within 2-3 days on conservative therapy should prompt reassessment and consideration of surgical intervention
• Patients with recurrent episodes may require elective surgical intervention to prevent future attacks

Remember that while small bowel diverticulitis is less common than colonic diverticulitis, the principles of management are similar, with the goal of resolving inflammation, preventing complications, and improving patient outcomes.