What is the treatment for diverticulitis?

Treatment for Diverticulitis

The treatment for diverticulitis should be stratified based on disease severity, with uncomplicated diverticulitis managed through observation and pain control, while reserving antibiotics for patients with systemic symptoms, immunocompromise, advanced age, or complicated disease. 1, 2

Diagnosis Confirmation

• CT scan with IV contrast is the gold standard diagnostic test (sensitivity 98%, specificity 99%) 1, 2
• Laboratory markers to assess: white blood cell count, C-reactive protein, procalcitonin 1

Treatment Algorithm

Uncomplicated Diverticulitis (85% of cases)

1. First-line approach:

   • Observation with pain management (typically acetaminophen)
   • Clear liquid diet initially, advancing as tolerated
   • No antibiotics needed for most patients 1, 2

2. Antibiotics indicated only for patients with:

   • Persistent fever or chills
   • Increasing leukocytosis
   • Age >80 years
   • Pregnancy
   • Immunocompromised status (chemotherapy, high-dose steroids, organ transplant)
   • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 1, 2

3. Antibiotic options when indicated:

   • Oral regimens (for stable patients):

     • Amoxicillin-clavulanate
     • Cefalexin plus metronidazole (cefalexin alone is inadequate due to poor anaerobic coverage) 1, 2

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

     • Ceftriaxone plus metronidazole
     • Piperacillin-tazobactam 1, 2

Complicated Diverticulitis

1. Management approach:

   • Intravenous broad-spectrum antibiotics (ceftriaxone plus metronidazole or piperacillin-tazobactam)
   • Close clinical monitoring
   • NPO (nothing by mouth) status 1, 2

2. For diverticulitis with abscess:

   • Antibiotics plus percutaneous drainage for abscesses >4 cm
   • Antibiotics alone if percutaneous drainage not feasible 1

3. Surgical intervention required for:

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

Prevention of Recurrence

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

Follow-up

• Colonoscopy recommended 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

Important Caveats

• The older approach of treating all diverticulitis with antibiotics has been challenged by recent evidence showing observation alone is sufficient for uncomplicated cases 1, 2, 3
• NSAIDs increase the risk of recurrence (odds ratio 7.25) and should be avoided when possible 1, 3
• Mortality rates differ significantly between elective (0.5%) and emergency (10.6%) surgical management, emphasizing the importance of appropriate timing for surgical intervention 2