What is the treatment for diverticulitis?

Treatment of Diverticulitis

For acute diverticulitis, treatment should be based on disease severity with uncomplicated cases managed with outpatient care and possibly without antibiotics, while complicated diverticulitis requires antibiotics, possible drainage procedures, and surgical intervention when indicated. 1

Classification and Diagnosis

• Uncomplicated diverticulitis: Localized inflammation without complications
• Complicated diverticulitis: Inflammation with abscess, phlegmon, fistula, obstruction, bleeding, or perforation 2

Diagnostic approach:

• CT scan with oral and IV contrast is the gold standard (92.2% sensitivity) 1
• Laboratory studies: Complete blood count, basic metabolic panel, C-reactive protein, urinalysis 2
• Colonoscopy should be delayed 6-8 weeks after acute episode resolution 1

Treatment Algorithm

1. Uncomplicated Diverticulitis

• Outpatient management for patients with:

  • Mild symptoms
  • Ability to tolerate oral intake
  • No significant comorbidities
  • Adequate social support 1

• Antibiotics: Recent evidence suggests antibiotics may not be necessary for mild uncomplicated diverticulitis 2, 3

  • When used, cover gram-negative and anaerobic organisms 1
  • Options include ciprofloxacin with metronidazole or rifaximin 4

• Supportive care:

  • Bowel rest as needed
  • Adequate hydration
  • Pain management

2. Complicated Diverticulitis

Abscess Management

• Abscesses <4-5 cm: Trial of antibiotic therapy alone
• Abscesses ≥4-5 cm: Percutaneous drainage under CT guidance plus antibiotics 1

Fistula Management

• Surgical intervention with resection of diseased colon segment and primary anastomosis
• For colovesical fistulas: Repair of bladder defect and placement of omental flap between bowel anastomosis and bladder 1

Perforation Management

• Intravenous broad-spectrum antibiotics
• Surgical intervention with either:
  • Resection with primary anastomosis (preferred when possible)
  • Hartmann procedure (resection with end colostomy) for severe cases 5

Inpatient vs. Outpatient Decision

Hospitalization criteria:

• Signs of peritonitis
• Suspected complicated diverticulitis
• Inability to tolerate oral intake
• Severe pain or significant comorbidities 2

Inpatient management:

• IV fluid resuscitation
• IV antibiotics
• Close monitoring for clinical improvement within 2-3 days 1

Follow-up and Prevention

• Follow-up colonoscopy: 4-6 weeks after resolution, especially for complicated cases to exclude malignancy (7.9% prevalence in complicated diverticulitis) 1, 2

• Prevention strategies:

  • High-fiber diet (most established preventive measure) 1, 2
  • Regular exercise
  • Smoking cessation
  • Weight loss for patients with BMI ≥30 kg/m² 2
  • Mesalazine (alone or with antibiotics) may help prevent recurrence 4
  • Probiotics may be beneficial in preventing recurrence 4

Important Caveats

• Clinical improvement should be seen within 2-3 days; lack of improvement warrants reassessment 1
• Prolonged antibiotic therapy beyond 4 days after adequate source control has not shown benefit 1
• Laparoscopic surgery results in shorter hospital stays, fewer complications, and lower mortality compared to open colectomy when surgery is needed 2
• The decision for elective surgery in recurrent diverticulitis should be based on symptom severity, frequency, and impact on quality of life rather than simply the number of episodes 6
• Obesity and immunosuppression are significant risk factors for complicated diverticulitis 6