What is the recommended treatment for diverticulitis in older adults?

Treatment of Diverticulitis in Older Adults

For elderly patients with diverticulitis, treatment should be stratified based on disease severity, with uncomplicated diverticulitis managed conservatively without antibiotics while complicated forms require antibiotics, possible drainage procedures, or surgery depending on specific complications. 1

Diagnosis and Classification

• Initial evaluation should include CT scan with IV contrast (or US/MRI if contrast is contraindicated due to allergy or kidney disease) 2
• Treatment is guided by the World Society of Emergency Surgery (WSES) staging:
  • Stage 0: Uncomplicated diverticulitis
  • Stage 1a-1b: Complicated diverticulitis with pericolic air bubbles or small abscess
  • Stage 2a-2b: Complicated diverticulitis with larger abscesses
  • Stage 3-4: Diffuse peritonitis

Treatment Algorithm for Elderly Patients (>65 years)

Uncomplicated Diverticulitis (WSES Stage 0)

• Conservative management without antibiotics 2, 1
• Bowel rest and hydration
• Pain management with acetaminophen 3
• Gradual reintroduction of clear liquid diet, advancing as tolerated

Complicated Diverticulitis (WSES Stage 1a-1b)

• Broad-spectrum antibiotic therapy 2, 1
• Options include:
  • Oral: amoxicillin/clavulanic acid or cefalexin with metronidazole 3
  • IV: ceftriaxone plus metronidazole, piperacillin-tazobactam, or ampicillin/sulbactam 3
• Short course (3-5 days) is sufficient with adequate source control 2
• Consider percutaneous drainage for abscesses if appropriate 2

Complicated Diverticulitis with Larger Abscesses (WSES Stage 2a)

• Source control surgery is indicated 2
• Percutaneous drainage should be attempted first if feasible 1
• IV antibiotics as described above

Perforated Diverticulitis with Peritonitis (WSES Stage 2b, 3-4)

• Surgical management is mandatory 2, 1
• Both Hartmann operation and resection with primary anastomosis are reasonable options 2
• For physiologically unstable patients, consider Damage Control Surgery (emergency laparotomy, source control, open abdomen, and vacuum-assisted closure) 2
• In stable patients, laparoscopic sigmoidectomy can be performed by experienced surgeons 2
• Laparoscopic lavage is not recommended due to higher risk of failure to control sepsis 2

Special Considerations for Elderly Patients

• Antibiotic selection should consider:

  • Patient's clinical condition
  • Likely pathogens
  • Risk factors for resistant organisms 2
  • Comorbidities and drug interactions common in elderly

• Indications for antibiotics even in uncomplicated cases: 3

  • Age >80 years
  • Immunocompromised status
  • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes)
  • Persistent fever or chills
  • Increasing leukocytosis

• Monitoring for treatment failure:

  • Further investigation is warranted if signs of peritonitis or systemic illness persist beyond 5-7 days of treatment 2
  • Risk factors for treatment failure include Ambrosetti score of 4 and free air around the colon 1

Post-Acute Management

• Elective sigmoid resection should be considered only in cases of: 1
  • Fistulae
  • Stenosis
  • Recurrent diverticular bleeding
  • Immunocompromised patients
  • Very symptomatic patients with quality of life impact

Caveats and Pitfalls

• Evidence quality: Most recommendations for elderly patients are based on low or very low-quality evidence due to lack of high-quality studies specifically focusing on this population 2
• Mortality risk: Emergency surgery carries significantly higher mortality (10.6%) compared to elective procedures (0.5%) 3
• Antibiotic stewardship: Avoid unnecessary antibiotics in uncomplicated cases to prevent resistance and side effects 1, 3
• Outpatient management: While studies show success rates of over 92% for outpatient treatment in general populations 4, 5, elderly patients often require more careful assessment for outpatient management due to comorbidities and potential for complications