What is the treatment for diverticulitis?

Treatment of Diverticulitis

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

Diagnostic Approach

• CT scan with IV contrast is the gold standard diagnostic test (sensitivity 98-99%, specificity 99%) 1
• Alternative imaging when CT with contrast is contraindicated:
  • Ultrasound
  • MRI (sensitivity 98%, specificity 70-78%)
  • CT without contrast 1
• Laboratory markers: elevated WBC count, leukocyte shift to left (>75%), elevated CRP, procalcitonin 1

Treatment Algorithm

Uncomplicated Diverticulitis (85% of cases)

1. Conservative Management:

   • Observation with pain management (typically acetaminophen)
   • Dietary modification (clear liquid diet initially)
   • Outpatient treatment appropriate for most patients who can tolerate oral intake, have adequate family support, and don't have severe comorbidities 1, 2

2. Antibiotic Therapy (reserved for specific patients):

   • Indications for antibiotics:

     • Persistent fever or 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

   • Oral regimens (5-7 days):

     • Amoxicillin-clavulanate OR
     • Cefalexin with metronidazole 1, 2

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

     • Ceftriaxone plus metronidazole OR
     • Piperacillin-tazobactam 1, 2

Complicated Diverticulitis

1. Medical Management:

   • IV broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria:
     • Ceftriaxone plus metronidazole OR
     • Piperacillin-tazobactam 1, 2

2. Interventional Management:

   • Percutaneous drainage for abscesses 2
   • Surgical intervention for:
     • Generalized peritonitis (emergent laparotomy with colonic resection)
     • Persistent or recurrent abscesses
     • Fistula formation
     • Obstruction 1, 2

3. Surgical Options:

   • Primary resection with anastomosis (with/without diverting stoma) for stable patients
   • Hartmann's procedure for unstable or high-risk patients
   • Damage control procedure for severe hemodynamic instability 1

Post-Treatment Care

• Expect pain resolution within 2-3 days of appropriate management 1
• Consider colonoscopy 4-6 weeks after resolution of complicated diverticulitis to rule out malignancy 1
• High-fiber diet recommended for prevention of recurrence 1
• Regular physical activity, smoking cessation, and avoidance of NSAIDs, opiates, and corticosteroids help prevent recurrence 1

Important Caveats and Pitfalls

• Overuse of antibiotics: Recent evidence suggests antibiotics may not be necessary for all cases of uncomplicated diverticulitis 1, 3
• Surgical timing: Elective surgery should be considered 4-8 weeks after resolution of acute episode if indicated 1
• Mortality risk: Postoperative mortality is significantly higher for emergent colon resection (10.6%) compared to elective resection (0.5%) 2
• Outpatient management failure: While outpatient treatment has lower failure rates (10%) compared to inpatient treatment (32%), careful patient selection is crucial 1

Emerging Treatments

• Mesalazine (alone or with antibiotics) and probiotics have shown promise in preventing recurrence of diverticulitis, though evidence is still developing 4, 5