What is the treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis, first-line treatment is observation with pain management (typically acetaminophen) and dietary modification, with antibiotics reserved only for patients with specific risk factors or complications. 1, 2

Diagnosis and Classification

Before initiating treatment, accurate diagnosis is essential:

• CT scan with IV contrast is the recommended diagnostic test (sensitivity 98-99%, specificity 99%) 1, 2
• Clinical presentation typically includes left lower quadrant pain, fever, change in bowel habits, and elevated inflammatory markers 1
• Classification into uncomplicated or complicated diverticulitis guides treatment approach

Treatment Algorithm for Diverticulitis

Uncomplicated Diverticulitis (85% of cases)

1. Initial Management:

   • Observation with pain management (acetaminophen preferred)
   • Clear liquid diet initially, advancing as tolerated
   • Outpatient management for most patients 1, 2, 3

2. Antibiotics only for patients with:

   • 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)
   • Signs of sepsis 1, 2

3. Antibiotic options when indicated:

   • Oral regimens (for stable patients):

     • Amoxicillin-clavulanate
     • Cephalexin plus metronidazole (cephalexin alone is inadequate due to poor anaerobic coverage)

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

     • Ceftriaxone plus metronidazole
     • Piperacillin-tazobactam 1, 2

Complicated Diverticulitis

1. Management approach:

   • Inpatient treatment with IV broad-spectrum antibiotics
   • NPO (nothing by mouth) status initially
   • Close clinical monitoring 1, 2

2. For diverticulitis with abscess:

   • Antibiotics plus percutaneous drainage for abscesses >4cm
   • Antibiotics alone for smaller abscesses 1

3. Surgical intervention required for:

   • Generalized peritonitis
   • Hemodynamic instability
   • Failure of non-operative management
   • Options include Hartmann's procedure or primary resection with anastomosis 1

Prevention of Recurrence

After resolution of acute episode:

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Avoidance of NSAIDs, opiates, and corticosteroids when possible 1

Follow-up Recommendations

• Colonoscopy 4-6 weeks after resolution of complicated diverticulitis to rule out malignancy 1
• Consider elective surgery 4-8 weeks after resolution of acute episode in selected cases 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Recent evidence supports observation without antibiotics for uncomplicated diverticulitis in immunocompetent patients without systemic symptoms 1, 2, 4

2. Inadequate anaerobic coverage: When antibiotics are indicated, ensure coverage includes gram-positive, gram-negative, and anaerobic bacteria 1

3. Delayed intervention for complicated cases: Prompt surgical consultation is essential for patients with peritonitis or hemodynamic instability 1

4. Insufficient follow-up: Failure to recommend colonoscopy after complicated diverticulitis may miss underlying malignancy 1

5. Neglecting lifestyle modifications: Long-term management should emphasize dietary changes and physical activity to reduce recurrence risk 1