What is the treatment for diverticulitis?

Diverticulitis Treatment

For uncomplicated diverticulitis, first-line treatment is observation with pain management and dietary modification, with antibiotics reserved for specific patient populations, while complicated diverticulitis requires intravenous antibiotics and potential invasive management. 1

Classification and Diagnosis

Accurate diagnosis is essential before initiating treatment:

• Clinical suspicion alone is correct in only 40-65% of cases 2
• CT scan with oral and IV contrast is the gold standard (98-99% sensitivity/specificity) 2
• Laboratory markers include increased WBC count, leukocyte shift to left, elevated CRP, and procalcitonin 2

Treatment Algorithm

Uncomplicated Diverticulitis (85% of cases)

1. Initial Management:

   • Observation with pain management (typically acetaminophen)
   • Clear liquid diet
   • Antibiotics only for specific populations 1:
     • Persistent fever or chills
     • Increasing leukocytosis
     • Age >80 years
     • Pregnancy
     • Immunocompromised patients
     • Chronic medical conditions (cirrhosis, CKD, heart failure, poorly controlled diabetes)

2. Antibiotic Options (if indicated):

   • Oral regimens:
     • First choice: Amoxicillin-clavulanate 2, 1
     • Alternative: Cefalexin with metronidazole 2, 1
     • For penicillin allergy: Ciprofloxacin plus metronidazole 2, 3

3. Duration: Typically 7-10 days 2

Complicated Diverticulitis

1. Inpatient Management Required for:

   • Abscess, phlegmon, fistula, obstruction, bleeding, or perforation 2
   • Inability to tolerate oral intake 3
   • Severe comorbidities 3
   • Inadequate family support 3

2. Antibiotic Options:

   • IV regimens:
     • Ceftriaxone plus metronidazole 2, 1
     • Piperacillin-tazobactam 2, 1
     • Ampicillin/sulbactam 2
     • For severe penicillin allergy: Aztreonam (1-2g every 8-12 hours) 2

3. Additional Interventions:

   • Small abscesses (<4-5 cm): Antibiotic therapy alone 2
   • Large abscesses (≥4-5 cm): Percutaneous drainage plus antibiotics 2
   • Peritonitis: Immediate surgical intervention with antibiotic therapy 2

Outpatient vs. Inpatient Treatment

Multiple studies demonstrate the safety and efficacy of outpatient treatment for uncomplicated diverticulitis:

• Success rates of 92-97% for outpatient management 4, 3, 5
• Significant cost savings (approximately €1,600 per patient) 5
• Criteria for outpatient treatment:
  • Ability to tolerate oral intake
  • Absence of severe comorbidities
  • Adequate family support 3

Monitoring and Follow-up

• Reassessment at 4-7 days to confirm symptom improvement 2, 3
• Monitor for worsening symptoms including:
  • Persistent/high fever
  • Worsening abdominal pain
  • Changes in bowel movements
  • Nausea/vomiting
  • Increasing abdominal distension
  • Worsening weakness/dizziness 2
• Colonoscopy recommended 4-6 weeks after resolution of complicated diverticulitis to rule out malignancy 2

Prevention

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Avoidance of NSAIDs, opiates, and corticosteroids 2

Special Considerations

• Elderly patients often present atypically (only 50% with typical lower quadrant pain) 2
• Lower threshold for CT imaging and antibiotic therapy in elderly patients 2
• Approximately 5% of patients experience persistent abdominal pain with continued inflammation 2
• Surgical consultation should not be delayed in cases of peritonitis or hemodynamic instability 2