What is the recommended treatment for diverticulitis?

Treatment for Diverticulitis

For uncomplicated diverticulitis, observation with pain management and dietary modification is the recommended first-line treatment, with antibiotics reserved for specific patient populations with risk factors. 1, 2

Diagnosis

• CT scan with IV contrast is the recommended diagnostic test for suspected diverticulitis (sensitivity 98-99%, specificity 99%) 1, 2
• Alternative imaging options when CT with contrast is contraindicated:
  • Ultrasound
  • MRI
  • CT scan without IV contrast 3

Treatment Based on Classification

Uncomplicated Diverticulitis (WSES stage 0)

• Conservative management:

  • Observation with pain management (typically acetaminophen)
  • Dietary modification (clear liquid diet initially)
  • Antibiotics should be avoided in immunocompetent patients without sepsis 3, 1

• 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, CKD, heart failure, poorly controlled diabetes) 1, 2

• Antibiotic regimens when indicated:

  • Oral: Amoxicillin-clavulanate or cefalexin with metronidazole for 5-7 days
  • IV (if unable to tolerate oral): Ceftriaxone plus metronidazole or piperacillin-tazobactam 1, 2

Complicated Diverticulitis

Localized complications (WSES stage 1a - pericolic air bubbles/small fluid)

• Broad-spectrum antibiotic therapy 3

Abscess (WSES stage 1b-2a)

• Broad-spectrum antibiotic therapy
• Percutaneous drainage for abscesses >4 cm 3, 1
• Cultures from drainage to guide antibiotic therapy

Distant intraperitoneal free air (WSES stage 2b)

• Surgical intervention recommended 3

Diffuse peritonitis (WSES stage 3-4)

• Prompt surgical source control strongly recommended 3
• Surgical options:
  • Primary resection with anastomosis (with/without diverting stoma) for stable patients
  • Hartmann's procedure for unstable or high-risk patients 1

Follow-up and Prevention

Post-treatment monitoring

• Expect pain resolution within 2-3 days of appropriate management
• Consider colonoscopy 4-6 weeks after resolution of complicated diverticulitis to rule out malignancy 1

Elective surgery considerations

• Not recommended after conservatively treated episode in asymptomatic patients without complications 3
• Consider in:
  • Immunocompromised patients (if fit for surgery)
  • Patients with stenosis, fistulae, or recurrent diverticular bleeding
  • Patients with very symptomatic disease affecting quality of life 3, 1

Prevention strategies

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

Common Pitfalls and Caveats

• Avoid routine antibiotics in uncomplicated cases as they don't reduce duration or prevent recurrence 4
• Don't delay surgical intervention in patients with peritonitis or sepsis 4
• Recognize that outpatient treatment is appropriate for most uncomplicated cases with failure rates significantly lower (10%) compared to inpatient treatment (32%) 1
• Postoperative mortality differs significantly between elective (0.5%) and emergent (10.6%) colon resection, highlighting the importance of appropriate patient selection and timing 2