What is the treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis, conservative management with pain control and dietary modification is recommended, while antibiotics should be reserved for patients with specific risk factors or systemic symptoms. Complicated diverticulitis requires antibiotics and potentially interventional procedures. 1

Diagnosis and Classification

• Uncomplicated diverticulitis: No abscess, phlegmon, fistula, obstruction, bleeding, or perforation
• Complicated diverticulitis: Presence of any of the above complications (occurs in ~12% of cases)
• Diagnostic imaging: CT scan with IV contrast is recommended when diagnostic uncertainty exists (98% sensitivity, 99% specificity) 1, 2

Treatment Algorithm

Uncomplicated Diverticulitis

1. Conservative management 1, 2:

   • Pain control (acetaminophen preferred over NSAIDs)
   • Clear liquid diet initially, advancing as tolerated
   • Close monitoring with watchful waiting

2. Antibiotics only for select patients 1, 2:

   • Systemic symptoms (persistent fever, chills)
   • Increasing leukocytosis
   • Age >80 years
   • Immunocompromised status
   • Significant comorbidities (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes)
   • Pregnancy

3. Antibiotic regimens when indicated 1, 2:

   • Oral: Amoxicillin/clavulanic acid or cefalexin with metronidazole
   • IV (if unable to tolerate oral): Ceftriaxone plus metronidazole, piperacillin-tazobactam, or ampicillin/sulbactam

Complicated Diverticulitis

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

   • Antibiotic therapy alone

2. Large abscesses (≥4-5 cm) 1:

   • Percutaneous drainage plus antibiotics

3. Peritonitis or sepsis 1, 2:

   • Immediate surgical intervention
   • Fluid resuscitation
   • Prompt broad-spectrum antibiotics
   • In hemodynamically unstable patients, damage control surgery may be considered

Special Considerations

• Elderly patients (>65 years): Lower threshold for CT imaging and antibiotic therapy due to atypical presentation 1
• Follow-up: Colonoscopy recommended 4-6 weeks after resolution of complicated diverticulitis to rule out malignancy 1
• Treatment failure: Persistent symptoms or worsening clinical condition warrant further diagnostic investigation 1

Prevention Strategies

• High-fiber diet: Focus on fruits, vegetables, whole grains, and legumes 1
• Regular physical activity 1
• Smoking cessation 1
• Avoid regular use of NSAIDs, opiates, and corticosteroids 1

Common Pitfalls to Avoid

1. Overuse of antibiotics in uncomplicated cases without risk factors
2. Delaying surgical intervention in cases of peritonitis or sepsis
3. Failing to recognize complications requiring more aggressive management
4. Not considering colonoscopy after resolution of complicated diverticulitis
5. Neglecting preventive strategies after an acute episode

The mortality rate differs significantly between elective and emergency surgical management (0.5% for elective colon resection vs. 10.6% for emergent colon resection), highlighting the importance of appropriate and timely management 2.