What is the recommended treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis, conservative treatment without antibiotics is recommended for immunocompetent patients without signs of sepsis, focusing on observation, pain control, and dietary modification. 1

Classification and Initial Management

Uncomplicated Diverticulitis

• Outpatient Management:

  • Appropriate for patients who:
    • Have no systemic inflammatory response
    • Can continue treatment at home under medical supervision
    • Have adequate family and social support 1
  • Treatment includes:
    • Observation
    • Pain control (typically acetaminophen)
    • Dietary modification with clear liquid diet 2

• When to Use Antibiotics:

  • Antibiotics should be reserved for specific patients:
    • Those with persistent fever or chills
    • Increasing leukocytosis
    • Age >80 years
    • Pregnant patients
    • Immunocompromised patients
    • Those with chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2

• Antibiotic Options (when indicated):

  • Oral: Amoxicillin/clavulanic acid or cefalexin with metronidazole 2
  • IV (if unable to tolerate oral intake): Cefuroxime or ceftriaxone plus metronidazole, or ampicillin/sulbactam 2

Complicated Diverticulitis

• Inpatient Management with:

  • IV antibiotics covering gram-negative bacilli and anaerobes for 4-7 days 1
    • Single-agent options: Piperacillin-tazobactam, ertapenem, meropenem or imipenem/cilastatin
    • Combination therapy: Ceftriaxone + metronidazole, ciprofloxacin + metronidazole, ampicillin + gentamicin + metronidazole

• Surgical Intervention Indications:

  • Diffuse peritonitis
  • Persistent symptoms despite percutaneous drainage
  • Failure of medical therapy with worsening inflammatory signs 1
  • Generalized peritonitis requiring emergent laparotomy 2

Diagnostic Approach

• First-line imaging: CT scan with IV contrast (sensitivity 98-99%, specificity 99%) 1, 2
• Alternative imaging options:
  • Ultrasound or MRI (if CT with contrast is contraindicated)
  • CT without IV contrast (for patients with kidney concerns) 1

Follow-up and Prevention

• Follow-up:

  • Early colonoscopy (4-6 weeks) after conservative treatment to rule out malignancy 1

• Prevention strategies:

  • High-fiber diet (fruits, vegetables, whole grains, legumes)
  • Regular physical activity
  • Smoking cessation
  • Avoidance of NSAIDs, opiates, and corticosteroids 1
  • Consider fiber supplementation and possibly rifaximin for symptomatic uncomplicated diverticular disease 1

Important Considerations

• Risk factors for progression to complicated disease:

  • Symptoms lasting >5 days before presentation
  • Vomiting
  • Systemic comorbidity
  • High C-reactive protein levels
  • CT findings of pericolic extraluminal air, fluid collection, or longer inflamed colon segment 1

• Surgical considerations:

  • Primary resection and anastomosis for stable patients
  • Hartmann's procedure for unstable or high-risk patients
  • Damage control procedure for severe hemodynamic instability 1
  • Elective colectomy is not advised for immunocompetent patients with uncomplicated diverticulosis or recurrent uncomplicated diverticulitis 1

• Mortality rates:

  • 0.5% for elective colon resection
  • 10.6% for emergent colon resection 2

• Caution: Delay between diagnosis and surgery >60 hours increases mortality and need for relaparotomy 1