What is the best treatment for diverticulitis?

Treatment of Diverticulitis

For most patients with acute uncomplicated left-sided colonic diverticulitis, outpatient management without antibiotics is the recommended initial approach. 1

Classification and Initial Assessment

Diverticulitis is classified into two main categories:

1. Uncomplicated diverticulitis (85% of cases): Inflammation without abscess, strictures, perforation, or fistula formation
2. Complicated diverticulitis: Presence of abscess, colon strictures, perforation, or fistula formation

Diagnostic Approach

• CT scan with IV contrast is the recommended diagnostic test (sensitivity 98-99%, specificity 99%) 1, 2
• Alternative imaging options for contraindications to IV contrast: ultrasound, MRI, or non-contrast CT 1
• Laboratory markers: increased WBC count, leukocyte shift to left, elevated CRP, procalcitonin 1

Treatment Algorithm for Diverticulitis

1. Uncomplicated Diverticulitis

• First-line therapy: Observation with pain management (typically acetaminophen) and dietary modification (clear liquid diet) 1, 2
• Antibiotics should be reserved 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 regimens (5-7 days):
  • Amoxicillin-clavulanate OR
  • Cefalexin with metronidazole 1, 2
• IV regimens (for patients unable to tolerate oral intake):
  • Cefuroxime or ceftriaxone plus metronidazole OR
  • Ampicillin/sulbactam 2

2. Complicated Diverticulitis

• Intravenous antibiotics:
  • Ceftriaxone plus metronidazole OR
  • Piperacillin-tazobactam 2
• Additional interventions as indicated:
  • Percutaneous drainage of intra-abdominal abscess
  • Surgical intervention for complications 1, 2

Surgical Management

Indications for Immediate Surgery:

• Generalized peritonitis
• Failure of conservative management
• Hemodynamic instability 1

Surgical Options:

• Stable patients: Primary resection and anastomosis (with/without diverting stoma)
• Unstable/high-risk patients: Hartmann's procedure
• Severe hemodynamic instability: Damage control procedure 1

Note: Postoperative mortality varies significantly: 0.5% for elective colon resection vs. 10.6% for emergent colon resection 2

Prevention of Recurrence

• High-fiber diet: Fruits, vegetables, whole grains, legumes 1
• Regular physical activity
• Smoking cessation
• Avoid: NSAIDs, opiates, and corticosteroids 1
• Consider: Fiber supplementation (particularly soluble fiber like glucomannan) 3

Follow-up

• 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

Common Pitfalls to Avoid

1. Overuse of antibiotics in uncomplicated cases without risk factors
2. Delaying surgical consultation for immunocompromised patients or those with complications
3. Failure to recognize when outpatient management is inappropriate (sepsis, inability to tolerate oral intake, inadequate social support)
4. Neglecting preventive measures after resolution of acute episode