What is the treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis, first-line therapy is observation and pain control with acetaminophen, while antibiotics should be reserved for patients with specific risk factors including persistent fever, increasing leukocytosis, age >80, pregnancy, immunocompromise, or chronic medical conditions. 1, 2

Classification and Diagnosis

Diverticulitis is classified as:

• Uncomplicated: Localized inflammation without perforation or abscess (~85% of cases)
• Complicated: Presence of abscess, perforation, fistula, or obstruction

Diagnosis is best confirmed with:

• CT scan with IV contrast: Sensitivity 98%, specificity 99% 1
• Key findings: intestinal wall thickening, pericolonic fat inflammation, thickening of lateroconal fascia

Treatment Algorithm

Uncomplicated Diverticulitis

1. Outpatient management for clinically stable, afebrile patients 1, 3

   • Observation with pain management (typically acetaminophen)
   • Dietary modification with clear liquid diet initially
   • Gradual advancement to normal diet as tolerated

2. Antibiotics only for patients with:

   • Persistent fever or chills
   • Increasing leukocytosis
   • Age >80 years
   • Pregnancy
   • Immunocompromised status (chemotherapy, high-dose steroids, organ transplant)
   • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2

3. Antibiotic options when indicated:

   • Oral: amoxicillin/clavulanic acid or cefalexin with metronidazole 2
   • IV (if unable to tolerate oral intake): ceftriaxone plus metronidazole, ampicillin/sulbactam, or piperacillin-tazobactam 1, 2
   • Duration: 4-7 days 1

   Recent evidence shows oral antibiotics are equally effective as IV antibiotics for outpatient management 4

Complicated Diverticulitis

1. Small abscesses (<4-5 cm):

   • Antibiotic therapy alone for 7 days
   • Close clinical monitoring for improvement 1

2. Large abscesses (≥4-5 cm):

   • Percutaneous drainage plus antibiotics for 4 days
   • Surgical intervention if no improvement or worsening of symptoms 1

3. Peritonitis or sepsis:

   • Fluid resuscitation
   • Rapid antibiotic administration (IV)
   • Urgent surgery 3
   • Surgical options: Hartmann procedure or primary anastomosis (with or without diverting loop ileostomy) 3

Follow-up Care

• After complicated diverticulitis: Colonoscopy recommended 4-6 weeks after resolution to rule out malignancy 1
• After uncomplicated diverticulitis: Routine colonoscopy not required unless patient meets age-appropriate screening criteria or has suspicious features on CT 1, 3

Prevention Strategies

1. Dietary modifications:

   • High-fiber diet (fruits, vegetables, whole grains, legumes) 1

2. Lifestyle changes:

   • Regular physical activity, particularly vigorous activity
   • Maintain normal BMI
   • Smoking cessation
   • Avoid regular use of NSAIDs and opiates 1

Clinical Pearls and Pitfalls

• Pitfall: Overuse of antibiotics in uncomplicated diverticulitis. Evidence shows they have no proven benefit in reducing disease duration or preventing recurrence in uncomplicated cases without risk factors 3

• Pitfall: Keeping patients NPO unnecessarily. Patients who can tolerate oral intake can safely take oral medications and don't require IV administration 1, 4

• Caveat: Immunocompromised patients and those with significant comorbidities have higher risk of complications and should be monitored more closely 1

• Important note: The mortality rate differs significantly between elective (0.5%) and emergent (10.6%) colon resection for diverticulitis, emphasizing the importance of appropriate management to avoid emergency surgery 2