Treatment of Chronic Diverticulitis
For chronic diverticulitis, treatment should focus on dietary modifications, lifestyle changes, selective antibiotic use, and pain management, with surgery reserved for specific cases with persistent symptoms despite conservative management. 1
Diagnosis and Assessment
- Imaging: CT scan with IV contrast is the preferred initial imaging modality to differentiate between uncomplicated diverticulosis and diverticulitis 1
- Laboratory tests: Complete blood count to check for leukocytosis, C-reactive protein (CRP) levels, and procalcitonin in select cases 1
- Colonoscopy: Recommended 6-8 weeks after resolution of acute symptoms if not performed within the past year 1
- Earlier colonoscopy if alarm symptoms are present (change in stool caliber, iron deficiency anemia, blood in stool, weight loss)
Medical Management
Antibiotic Therapy
- Selective use: Antibiotics should be used selectively rather than routinely in uncomplicated cases 2, 1
- Indications for antibiotics:
- Immunocompromised patients
- Patients with systemic symptoms (persistent fever, chills)
- Increasing leukocytosis
- Age >80 years
- Pregnancy
- Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 3
- First-line antibiotics:
- Oral: Amoxicillin/clavulanic acid or cefalexin with metronidazole
- IV (if unable to tolerate oral): Ceftriaxone plus metronidazole or piperacillin-tazobactam 3
Pain Management
- Avoid: NSAIDs (may increase risk of complications) and anticholinergics like dicyclomine 1
- Preferred: Acetaminophen for pain control 3
- For visceral hypersensitivity: Low to modest doses of tricyclic antidepressants 1
Dietary and Lifestyle Modifications
Dietary Management
- Acute phase: Clear liquid diet during flare-ups, advancing to regular diet within 3-5 days as symptoms improve 1
- Maintenance phase:
Lifestyle Modifications
- Exercise: Regular vigorous physical activity to maintain bowel regularity 1
- Weight management: Maintain normal BMI as obesity is a risk factor 1
- Smoking cessation: Avoid smoking as it increases diverticulitis risk 1
- Medication management: Limit use of non-aspirin NSAIDs and opioid analgesics 1
Constipation Management
- First-line: Osmotic laxatives such as polyethylene glycol (17g daily) or milk of magnesia 1
- Second-line: Add stimulant laxatives (bisacodyl or glycerol suppositories) if inadequate response 1
- Refractory cases: Consider newer agents such as lubiprostone or linaclotide 1
Surgical Management
Surgery should not be advised based solely on the number of episodes 2. Instead, surgical decisions should be personalized based on:
- Severity of disease
- Patient preferences and values
- Risks and benefits 2
The World Journal of Emergency Surgery guidelines suggest that patients with CT findings of distant free gas without diffuse intra-abdominal fluid may be treated non-operatively only if close follow-up can be performed 2.
Patient Education
- Inform patients that the risk of complicated diverticulitis is highest with the first presentation 2
- Explain that genetic factors contribute to diverticulitis risk, but modifiable lifestyle factors can reduce recurrence 2, 1
- The long-term risk of serious complications and death is low with conservative management 4
Follow-up Care
- Monitor for symptom resolution
- Assess for chronic symptoms that may indicate alternative diagnoses
- Consider both imaging and lower endoscopy in patients with history of diverticulitis and persistent symptoms 2
By following this comprehensive approach to chronic diverticulitis management, patients can experience symptom relief and reduced risk of recurrence while avoiding unnecessary interventions.