What is the treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis, observation with pain management and dietary modification is recommended, with antibiotics reserved only for specific patient populations including those with systemic symptoms, increasing leukocytosis, age >80 years, pregnancy, immunocompromised status, or chronic medical conditions. 1, 2

Classification and Diagnosis

Before initiating treatment, it's essential to:

1. Confirm diagnosis with CT imaging (sensitivity 98-99%, specificity 99-100%) 1, 2
2. Classify as:
   • Uncomplicated diverticulitis (85% of cases): Inflammation without abscess, strictures, perforation, or fistula
   • Complicated diverticulitis: Presence of abscess, perforation, fistula, or stricture

Treatment Algorithm

Uncomplicated Diverticulitis

1. First-line approach:

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

2. Antibiotics indicated only for:

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

3. Antibiotic regimens when indicated:

   • Oral regimens (for stable patients):
     • Amoxicillin-clavulanate OR
     • Cefalexin with metronidazole
   • IV regimens (for patients unable to tolerate oral intake):
     • Ceftriaxone plus metronidazole OR
     • Piperacillin-tazobactam 1, 2

Complicated Diverticulitis

1. Diverticulitis with abscess:

   • IV broad-spectrum antibiotics (ceftriaxone plus metronidazole or piperacillin-tazobactam)
   • Percutaneous drainage for abscesses >4 cm
   • Antibiotic therapy alone if percutaneous drainage not feasible 1, 2

2. Diverticulitis with perforation/peritonitis:

   • IV broad-spectrum antibiotics
   • Immediate surgical intervention
   • Surgical options include Hartmann's procedure or primary resection with anastomosis 1

Follow-up and Prevention

1. Post-acute episode:

   • 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

2. Prevention strategies:

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

Important Clinical Considerations

• The traditional practice of routine antibiotic use for all diverticulitis cases is no longer supported by evidence. Studies show that mild diverticulitis can be treated without antibiotics in selected patients 3
• NSAID use significantly increases 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 emergent (10.6%) colon resection for diverticulitis, highlighting the importance of appropriate timing for surgical intervention 2
• Mesalazine (alone or with antibiotics) and probiotics have shown promise in preventing recurrence of diverticulitis, though these are not yet part of standard guidelines 4

Remember that early and accurate diagnosis with appropriate imaging is crucial for determining the optimal treatment approach and avoiding unnecessary antibiotic use or delayed surgical intervention when needed.