What is the initial management for diverticulitis with contained microperforation?

Management of Diverticulitis with Contained Microperforation

Patients with diverticulitis complicated by a contained microperforation and small abscess (<4 cm) can be managed with intravenous antibiotics without immediate surgical intervention, provided they are hemodynamically stable and show no signs of sepsis. 1

Initial Assessment and Classification

• Diverticulitis with microperforation is classified as complicated diverticulitis
• Key clinical features to evaluate:
  • Hemodynamic stability
  • Presence of systemic inflammatory response
  • Size of any associated abscess
  • Extent of extraluminal air on CT imaging
  • Immunocompetence status

Management Algorithm

For Stable Patients with Contained Microperforation

1. Imaging confirmation

   • CT scan with IV contrast is preferred (sensitivity 98-99%, specificity 99%) 2, 3
   • Alternative imaging if IV contrast contraindicated: ultrasound, MRI, or non-contrast CT 2

2. Antibiotic therapy

   • Broad-spectrum antibiotics covering gram-negative bacilli and anaerobes 2
   • IV antibiotic options:
     • Piperacillin-tazobactam
     • Ceftriaxone + metronidazole
     • Ampicillin/sulbactam
     • Ertapenem 1g q24h
     • Meropenem 1g q6h (for severe cases)

3. Duration of therapy:

   • 4-7 days depending on clinical response 2
   • Consider procalcitonin monitoring to guide antibiotic discontinuation 2

4. Abscess management:

   • For abscess <4 cm: antibiotics alone are sufficient 1, 2
   • For abscess ≥4 cm: percutaneous drainage plus antibiotics 2
   • Obtain cultures from drainage to guide antibiotic therapy 2

5. Supportive care:

   • IV hydration
   • Pain control (typically acetaminophen) 3
   • Bowel rest with clear liquid diet initially 3

Monitoring and Follow-up

• Close monitoring for clinical improvement within 48-72 hours
• Watch for signs of treatment failure:
  • Persistent fever
  • Worsening abdominal pain
  • Rising inflammatory markers
  • Increasing procalcitonin levels 2
• Plan for colonic evaluation 4-6 weeks after resolution to rule out malignancy 2

Indications for Surgical Intervention

Surgery is indicated if any of the following develop:

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

Special Considerations

• Timing is critical: Delay between diagnosis and surgery >60 hours increases mortality and need for relaparotomy 1
• Distant intraperitoneal air: Large amounts of distant intraperitoneal air or distant retroperitoneal air are associated with high failure rates (57-60%) of non-operative management 1
• Immunocompromised patients have higher failure rates with standard non-operative treatment and may require more aggressive management 2

Pitfalls to Avoid

• Don't delay surgical consultation if patient fails to improve within 48-72 hours
• Don't miss signs of progressive sepsis requiring urgent intervention
• Don't confuse diverticulitis with microperforation with frank perforation and generalized peritonitis, which requires immediate surgical intervention
• Don't forget to rule out malignancy after resolution (4-6 weeks) 2