What are the treatment options for diverticulitis?

Treatment Options for Diverticulitis

The treatment of diverticulitis should be tailored based on disease severity, with uncomplicated cases often managed conservatively without antibiotics in immunocompetent patients, while complicated diverticulitis requires antibiotics and possibly surgical intervention depending on the specific complications present. 1

Classification of Diverticulitis

Diverticulitis is classified into two main categories:

1. Uncomplicated Diverticulitis

   • Inflammation limited to colonic wall and surrounding tissue
   • No abscess, perforation, fistula, or obstruction

2. Complicated Diverticulitis (based on WSES classification)

   • Stage 1A: Pericolic air bubbles or small amount of pericolic fluid without abscess
   • Stage 1B: Abscess ≤ 4 cm
   • Stage 2A: Abscess > 4 cm
   • Stage 2B: Distant gas (> 5 cm from inflamed bowel segment)
   • Stage 3: Diffuse fluid without distant free gas (purulent peritonitis)
   • Stage 4: Diffuse fluid with distant free gas (fecal peritonitis)

Diagnosis

• CT scan with IV contrast is the gold standard imaging modality with 98% sensitivity and 99% specificity 1
• Clinical findings alone are unreliable with misdiagnosis rates of 34-68% 1
• Ultrasound may be used to reduce CT examinations in select cases 1

Treatment of Uncomplicated Diverticulitis

1. Antibiotic Therapy

   • Selective rather than routine use of antibiotics in immunocompetent patients with mild uncomplicated diverticulitis 1
   • When antibiotics are indicated:
     • Amoxicillin-clavulanate 875/125 mg every 12 hours for 4-7 days
     • For penicillin allergy: Ciprofloxacin 500 mg twice daily plus metronidazole 500 mg three times daily 2

2. Outpatient Management

   • Appropriate for patients who:
     • Can tolerate oral intake
     • Have adequate pain control with oral analgesics
     • Have appropriate home support
     • Have stable vital signs
     • Have no significant comorbidities 2

3. Follow-up

   • Re-evaluation within 7 days of diagnosis
   • Consider repeat imaging if symptoms persist beyond 7 days 2

Treatment of Complicated Diverticulitis

1. Diverticular Abscess (Stage 1B/2A/2B)

   • Small abscess (< 4 cm): Antibiotics alone
   • Large abscess (≥ 4 cm): Percutaneous drainage plus antibiotics 1
   • Antibiotic regimen should cover gram-negative and anaerobic bacteria 1, 3

2. Peritonitis (Stage 3-4)

   • Prompt and effective source control surgery is recommended 1
   • Surgical options:
     • Hartmann's procedure (sigmoid resection with end colostomy)
     • Resection with primary anastomosis (in stable patients) 1
     • Damage control surgery with open abdomen in physiologically deranged patients 1

3. Antibiotic Duration

   • 4-day period of postoperative antibiotic therapy if source control has been adequate 1
   • Extended therapy (5-7 days) if signs of ongoing infection persist 1

Elective Surgery Considerations

Elective sigmoid resection should be considered in:

1. Patients with persistent symptoms affecting quality of life 1
2. Patients with complications such as stenosis, fistulae, or recurrent diverticular bleeding 1
3. Immunocompromised patients (if fit for surgery) 1

Elective surgery should NOT be based solely on the number of episodes but rather on individual risk factors, complications, and patient preferences 1

Prevention of Recurrence

• High-fiber diet
• Regular physical activity
• Maintaining normal BMI
• Smoking cessation
• Avoiding non-aspirin NSAIDs 1, 2

Special Considerations

1. Immunocompromised Patients

   • Lower threshold for imaging and antibiotic treatment
   • Extended antibiotic duration (10-14 days)
   • Higher risk for complicated disease 2

2. Elderly Patients

   • Higher risk for complications
   • More aggressive monitoring and management 1, 2

3. Follow-up Colonoscopy

   • Recommended after resolution of complicated diverticulitis to exclude malignancy
   • Not routinely required after uncomplicated diverticulitis 2

Common Pitfalls to Avoid

1. Overuse of antibiotics in mild uncomplicated cases in immunocompetent patients
2. Delaying surgical intervention in cases of diffuse peritonitis
3. Recommending elective surgery based solely on number of episodes
4. Failing to consider patient-specific factors when determining management
5. Inadequate follow-up after initial treatment

The management of diverticulitis has evolved significantly in recent years, with a trend toward more conservative approaches for uncomplicated disease and targeted interventions for complicated cases, always with the goal of reducing morbidity and mortality while preserving quality of life.