What are the management steps for acute diverticulitis?

Management of Acute Diverticulitis

For patients with uncomplicated diverticulitis, observation with pain management and dietary modification is the first-line approach, while antibiotics should be reserved for patients with systemic symptoms, increasing leukocytosis, age >80 years, pregnancy, immunocompromise, or chronic medical conditions. 1, 2

Diagnosis

• Diagnosis requires CT imaging with IV contrast (sensitivity 98%, specificity 99%) 1
• Clinical presentation typically includes:
  • Left lower quadrant abdominal pain
  • Fever
  • Change in bowel habits
  • Nausea
  • Elevated inflammatory markers (WBC count, CRP, procalcitonin) 1

Classification and Management Algorithm

1. Uncomplicated Diverticulitis (85% of cases)

• Initial Management:

  • Outpatient treatment for clinically stable, afebrile patients 3
  • Pain control (acetaminophen preferred) 2
  • Clear liquid diet initially 2
  • Antibiotics only for specific patients:
    • Persistent fever/chills
    • Increasing leukocytosis
    • Age >80 years
    • Pregnant patients
    • Immunocompromised patients (on chemotherapy, high-dose steroids, transplant recipients)
    • Chronic medical conditions (cirrhosis, CKD, heart failure, poorly controlled diabetes) 1, 2

• Antibiotic options when indicated:

  • Oral regimens (for stable patients):
    • Amoxicillin-clavulanate
    • Cefalexin plus metronidazole (not cefalexin alone due to inadequate anaerobic coverage) 1, 2

2. Complicated Diverticulitis

• Inpatient Management Required:

  • IV fluid resuscitation 4
  • IV broad-spectrum antibiotics:
    • Ceftriaxone plus metronidazole
    • Piperacillin-tazobactam 1, 2

• Management based on complications:

  • Abscess:

    • Small abscess (<4 cm): IV antibiotics and close monitoring 1
    • Larger abscess (>4 cm): CT-guided percutaneous drainage plus IV antibiotics 1, 4

  • Perforation with peritonitis:

    • Emergent surgical intervention 2
    • Surgical options include:
      • Hartmann's procedure (resection with colostomy)
      • Primary resection with anastomosis (with or without diverting ileostomy) 1, 3
      • Laparoscopic approach preferred when feasible (shorter hospital stay, fewer complications, lower mortality) 4

Follow-up Care

• Colonoscopy recommended 4-6 weeks after resolution of symptoms for:
  • All patients with complicated diverticulitis
  • Patients with suspicious features on CT
  • Patients meeting age-appropriate screening criteria 1, 4, 3

Prevention of Recurrence

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Weight loss for patients with BMI ≥30 kg/m²
• Avoidance of NSAIDs, opiates, and corticosteroids when possible 1, 4

Important Clinical Considerations

• Mortality rates differ significantly between elective (0.5%) and emergent (10.6%) surgical management 2
• Antibiotics have not been shown to accelerate recovery, prevent complications, or prevent recurrences in mild, uncomplicated diverticulitis 4, 3
• The decision for elective surgery after recurrent episodes should be considered 4-8 weeks after resolution of the acute episode 1