What is the recommended treatment for uncomplicated diverticulitis?

Treatment of Uncomplicated Diverticulitis

Uncomplicated diverticulitis should be managed conservatively without antibiotics in most cases, with pain control (acetaminophen preferred) and a clear liquid diet initially, advancing as tolerated. 1

Definition and Diagnosis

• Diverticulitis is inflammation of colonic diverticula (outpouchings originating from intestinal lumen)
• Uncomplicated diverticulitis (85% of cases) is defined by absence of abscess, colon strictures, perforation, or fistula formation 2
• Diagnosis is best confirmed with CT imaging with IV contrast (98% sensitivity, 99% specificity) 1

Treatment Algorithm for Uncomplicated Diverticulitis

First-Line Management (No Antibiotics)

1. Conservative management without antibiotics:
   • Pain control with acetaminophen (preferred over NSAIDs)
   • Clear liquid diet initially, advancing as tolerated
   • Outpatient management is appropriate for most patients 1, 2

When to Consider Antibiotics

Antibiotics should be reserved for patients with:

• Systemic symptoms (persistent fever, chills)
• Increasing leukocytosis
• Age >80 years
• Pregnancy
• Immunocompromised status (chemotherapy, high-dose steroids, organ transplant)
• Significant comorbidities (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 1, 2

Antibiotic Regimens (When Indicated)

• Oral regimens:

  • Amoxicillin-clavulanate OR
  • Cefalexin with metronidazole

• IV regimens (for those unable to tolerate oral intake):

  • Ceftriaxone plus metronidazole
  • Piperacillin-tazobactam
  • Ampicillin/sulbactam 1

Evidence Supporting No-Antibiotic Approach

The American College of Physicians and World Society of Emergency Surgery recommend against routine antibiotic use for uncomplicated diverticulitis based on evidence that antibiotics do not:

• Accelerate recovery
• Prevent complications
• Prevent recurrence 1

A Cochrane review found that for uncomplicated diverticulitis, there may be little or no difference in short-term complications between antibiotic and no-antibiotic approaches (low-certainty evidence) 3.

Outpatient vs. Inpatient Management

• Outpatient treatment is viable in approximately 95% of uncomplicated cases 4
• Outpatient treatment has demonstrated similar safety and efficacy to inpatient treatment 4, 5
• Admission criteria include:
  • Inability to tolerate oral intake
  • Significant comorbidities
  • Inadequate family/social support 5

Prevention of Recurrence

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Avoidance of regular NSAID, opiate, and corticosteroid use 1

Follow-up

• Patients should be reassessed 4-7 days after starting treatment to confirm symptom improvement 5
• Colonoscopy is recommended 4-6 weeks after resolution of symptoms to rule out malignancy 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most uncomplicated cases resolve without antibiotics
2. Overlooking elderly patients: They may present atypically (only 50% with typical lower quadrant pain, 17% with fever) 1
3. Failing to recognize treatment failure: Persistent symptoms or worsening clinical condition warrant further investigation
4. Inappropriate NSAID use: Can worsen symptoms and should be avoided in favor of acetaminophen

The evidence clearly supports a conservative, non-antibiotic approach for most patients with uncomplicated diverticulitis, reserving antibiotics for specific high-risk groups or those with complicated disease.