What is the treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis, first-line treatment consists of observation with pain management and dietary modification, with antibiotics reserved only for patients with specific risk factors; complicated diverticulitis requires intravenous antibiotics and additional interventions such as percutaneous drainage or surgery. 1, 2

Classification and Diagnosis

• Diverticulitis should be diagnosed using CT scan with IV contrast (sensitivity 98%, specificity 99%) 1
• Classification:
  • Uncomplicated: Inflammation without abscess, perforation, fistula, or stricture (85% of cases) 2
  • Complicated: Presence of abscess, perforation, fistula, or stricture 2

Treatment Algorithm

Uncomplicated Diverticulitis

1. First-line management:

   • Observation with pain management (typically acetaminophen) 2
   • Dietary modification (clear liquid diet initially) 2
   • Antibiotics are NOT routinely needed 1, 2

2. Antibiotics indicated only for:

   • Systemic symptoms (persistent fever/chills)
   • Increasing leukocytosis
   • Age >80 years
   • Pregnancy
   • Immunocompromised status (chemotherapy, high-dose steroids, organ transplant)
   • Chronic medical conditions (cirrhosis, CKD, heart failure, poorly controlled diabetes) 1, 2

3. Antibiotic options when indicated:

   • Oral regimens (for stable patients):
     • Amoxicillin-clavulanate OR
     • Cefalexin with metronidazole 1, 2
   • IV regimens (for patients unable to tolerate oral intake):
     • Ceftriaxone plus metronidazole OR
     • Piperacillin-tazobactam OR
     • Ampicillin/sulbactam 1, 2
   • Duration: Typically 7-10 days 1

Complicated Diverticulitis

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

   • Antibiotic therapy alone
   • Clinical monitoring mandatory 1

2. Large abscesses (≥4-5 cm):

   • Percutaneous drainage plus IV antibiotics 1

3. Peritonitis or sepsis:

   • Immediate surgical intervention
   • Fluid resuscitation
   • Prompt antibiotic administration 1
   • Surgical options:
     • Critically ill patients: Hartmann's procedure (preferred) 1
     • Clinically stable patients: Primary resection with anastomosis 1

4. Antibiotic selection for resistant organisms:

   • VRE risk: Consider linezolid or daptomycin
   • Invasive candidiasis risk: Echinocandins or liposomal amphotericin B
   • MDR Pseudomonas: Ceftolozane/tazobactam
   • Carbapenemase-producing Klebsiella: Ceftazidime/avibactam 1

Follow-up and Prevention

1. Monitoring:

   • Watch for treatment failure (persistent symptoms or worsening clinical condition) 1

2. Post-acute management:

   • Colonoscopy 4-6 weeks after resolution of complicated diverticulitis to rule out malignancy 1
   • Consider elective surgery 4-8 weeks after resolution for recurrent episodes 1

3. Prevention strategies:

   • High-fiber diet (fruits, vegetables, whole grains, legumes)
   • Regular physical activity
   • Smoking cessation
   • Avoid regular use of NSAIDs, opiates, and corticosteroids 1
   • The AGA suggests patients with history of diverticulitis can use aspirin but should avoid non-aspirin NSAIDs if possible 1

Clinical Pearls and Pitfalls

• Pitfall: Overuse of antibiotics in uncomplicated diverticulitis. The World Journal of Emergency Surgery suggests antibiotics can be avoided in uncomplicated cases without significant comorbidities or sepsis 1

• Pitfall: Delaying surgical intervention in patients with peritonitis. Mortality for emergency surgery (10.6%) is significantly higher than elective surgery (0.5%) 2

• Caveat: Clinical suspicion alone is correct in only 40-65% of patients, making imaging confirmation essential 1

• Pearl: Small abscesses can be successfully treated with antibiotics alone, avoiding invasive procedures 1