What is the treatment for diverticulitis?

Treatment for Diverticulitis

For uncomplicated diverticulitis, observation with pain management and dietary modification is recommended, with antibiotics reserved for specific patient populations including those with systemic symptoms, increasing leukocytosis, age >80 years, pregnancy, immunocompromised status, or chronic medical conditions. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• CT imaging with IV contrast is the gold standard (sensitivity 98%, specificity 99%) 1, 2
• Alternative imaging options include MRI or unenhanced CT when contrast is contraindicated 1
• Laboratory markers include elevated white blood cell count, leukocyte shift to left, elevated C-reactive protein, and procalcitonin 1

Treatment Algorithm

1. Uncomplicated Diverticulitis (85% of cases)

• First-line therapy:

  • Observation with pain management (typically acetaminophen)
  • Dietary modification with clear liquid diet
  • No routine antibiotics 1, 2, 3

• Antibiotics indicated 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, chronic kidney disease, heart failure, poorly controlled diabetes) 1, 2

• Antibiotic regimens for outpatient treatment:

  • Oral: amoxicillin-clavulanate or cefalexin with metronidazole 1, 2
  • Duration: typically 7-10 days 1, 4

2. Complicated Diverticulitis

• Pericolic air bubbles or small pericolic fluid without abscess:

  • Antibiotic therapy recommended 1

• Diverticulitis with abscess:

  • Intravenous broad-spectrum antibiotics
  • Percutaneous drainage for abscesses larger than 4 cm
  • Antibiotic therapy alone if percutaneous drainage not feasible 1, 2

• IV antibiotic options:

  • Ceftriaxone plus metronidazole
  • Piperacillin-tazobactam 1, 2

• Indications for immediate surgical intervention:

  • Hemodynamic instability
  • Generalized peritonitis
  • Failure of non-operative management 1

Treatment Setting

• Outpatient treatment is viable for most uncomplicated cases (95% success rate) 5
• Inpatient treatment required for:
  • Complicated diverticulitis
  • Inability to tolerate oral intake
  • Severe pain requiring parenteral analgesia
  • Significant comorbidities 1, 2

Prevention of Recurrence

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Avoidance of NSAIDs, opiates, and corticosteroids 1
• Colonoscopy recommended 4-6 weeks after resolution of complicated diverticulitis to rule out malignancy 1

Follow-up

• Elective surgery consideration 4-8 weeks after resolution of acute episode in selected cases 1
• Mortality rates differ significantly between elective (0.5%) and emergency (10.6%) colon resection 2

Important Considerations

• Recent evidence suggests uncomplicated diverticulitis may be inflammatory rather than infectious, questioning the routine use of antibiotics 3
• The Cochrane review indicates uncertainty about the effect of antibiotics for complications, emergency surgery, and recurrence in uncomplicated diverticulitis 3
• Outpatient treatment has demonstrated similar safety and efficacy to inpatient treatment with significant cost savings (approximately €1,600 per patient) 5