What is the treatment for worsening diverticulitis?

Treatment for Worsening Diverticulitis

For worsening diverticulitis, escalate treatment based on clinical severity, with antibiotics, percutaneous drainage for abscesses larger than 4-5 cm, and surgical intervention for those with persistent symptoms, diffuse peritonitis, or failed conservative management. 1, 2

Assessment and Diagnosis

• Diagnostic confirmation: CT scan with IV contrast is the gold standard (sensitivity 98-99%, specificity 99%) 2
• Laboratory markers: Elevated white blood cell count, leukocyte shift to left (>75%), elevated C-reactive protein, and procalcitonin 2
• Clinical indicators of worsening: Persistent fever, increasing leukocytosis, signs of peritonitis, hemodynamic instability, or lack of improvement with initial therapy 3

Treatment Algorithm for Worsening Diverticulitis

1. Uncomplicated Diverticulitis with Worsening Symptoms

• Initial management:
  • Transition from observation to antibiotic therapy if symptoms worsen 2, 3
  • Intravenous antibiotics for patients unable to tolerate oral intake:
    • First-line options: Ceftriaxone + metronidazole, piperacillin-tazobactam, or ampicillin/sulbactam 2, 3
  • Bowel rest with clear liquid diet initially 2
  • Pain management (typically acetaminophen) 3

2. Complicated Diverticulitis with Abscess

• For abscesses <4-5 cm:

  • IV antibiotics alone with close monitoring 1

• For abscesses ≥4-5 cm:

  • Percutaneous drainage under CT guidance plus IV antibiotics 1
  • Catheter removal when drainage output has ceased or decreased substantially 1
  • If no resolution occurs, consider catheter repositioning or surgical intervention 1

3. Diverticulitis with Diffuse Peritonitis or Failed Conservative Management

• Surgical intervention is indicated for:

  • Diffuse peritonitis
  • Persistent symptoms despite percutaneous drainage
  • Failure of medical therapy with worsening inflammatory signs 1, 2

• Surgical options:

  • Stable patients: Primary resection and anastomosis (with/without diverting stoma) 2
  • Unstable or high-risk patients: Hartmann's procedure 2
  • Damage control procedure for severe hemodynamic instability 2

Special Considerations

• Immunocompromised patients:

  • More aggressive management required due to higher failure rates with standard non-operative treatment 2
  • Lower threshold for surgical intervention 2, 4

• Duration of antibiotic therapy:

  • Initial IV therapy for 3-5 days after adequate source control
  • Total course of 5-7 days if good clinical response
  • Extended therapy if ongoing signs of peritonitis or systemic illness beyond 7 days 2

• Follow-up:

  • Plan early colonic evaluation (4-6 weeks) for patients with diverticular abscesses treated non-operatively to rule out malignancy 1
  • Routine colonoscopy is not recommended for uncomplicated diverticulitis treated non-operatively 1, 2

Prevention of Recurrence

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Avoidance of NSAIDs, opiates, and corticosteroids 2
• Consider fiber supplementation with poorly absorbed antibiotics like rifaximin for symptomatic patients 2, 5

Monitoring Response

• Reassess within 48-72 hours of initiating treatment
• Lack of improvement should prompt investigation for inadequate source control or resistant organisms
• Expect pain resolution within 2-3 days of appropriate management 2

Pitfalls to Avoid

• Delayed escalation of care: Failure to recognize when medical therapy is inadequate can lead to increased morbidity and mortality
• Inadequate source control: Abscesses ≥4-5 cm generally require drainage, not just antibiotics 1
• Missing underlying malignancy: Consider colonoscopy after resolution of complicated diverticulitis to rule out cancer 1, 2
• Underestimating severity in immunocompromised patients: These patients require more aggressive management and earlier surgical consultation 2, 4