What is the recommended treatment for diverticulitis?

Treatment of Diverticulitis

The recommended treatment for diverticulitis depends on disease severity, with uncomplicated diverticulitis managed conservatively without antibiotics in immunocompetent patients, while complicated diverticulitis requires antibiotics, possible drainage procedures, or surgery depending on the specific complications. 1

Classification and Initial Assessment

Diverticulitis is classified as:

1. Uncomplicated diverticulitis: Inflammation without abscess, perforation, fistula, or stricture
2. Complicated diverticulitis: Presence of abscess, perforation, peritonitis, fistula, or stricture

Diagnostic Approach

• CT scan with IV contrast is the preferred diagnostic test (sensitivity 98-99%, specificity 99%) 1, 2
• Alternative imaging: ultrasound or MRI when CT with contrast is contraindicated 1

Treatment Algorithm

Uncomplicated Diverticulitis

• Conservative management without antibiotics is recommended for immunocompetent patients without signs of sepsis 1

• Dietary management:

  • Clear liquid diet during acute phase 1
  • Advance diet as symptoms improve (typically 3-5 days) 1
  • Transition to high-fiber diet after recovery 1

• Antibiotics indicated only for:

  • Immunocompromised patients
  • Systemic symptoms (persistent fever/chills)
  • Increasing leukocytosis
  • Patients >80 years old
  • Pregnant patients
  • Patients with chronic medical conditions (cirrhosis, CKD, heart failure, poorly controlled diabetes) 1, 2

• Antibiotic options when indicated:

  • Oral: amoxicillin/clavulanic acid or cefalexin with metronidazole 2
  • IV (if unable to tolerate oral): ceftriaxone + metronidazole, ciprofloxacin + metronidazole, or ampicillin/sulbactam 1, 2

Complicated Diverticulitis

Small Abscess (<4-5 cm)

• Initial trial of antibiotics alone 3
• Monitor closely for clinical improvement

Large Abscess (>4-5 cm)

• Percutaneous drainage combined with antibiotics 3
• IV antibiotics: piperacillin-tazobactam, ertapenem, meropenem, or combination therapy (ceftriaxone + metronidazole) 1

Peritonitis

• Hemodynamically stable patients: Surgical resection and anastomosis with/without stoma 3
• Unstable patients or those with multiple comorbidities: Hartmann's procedure 3
• Severe hemodynamic instability: Consider damage control procedure 1

Follow-up Care

• Colonoscopy 6-8 weeks after acute episode to rule out malignancy 1
• Pain management for ongoing discomfort: acetaminophen or low-dose tricyclic antidepressants 1, 2

Prevention of Recurrence

• High-fiber diet including fruits, vegetables, whole grains, and legumes 1
• Regular physical activity
• Smoking cessation
• Avoid: NSAIDs, opiates, and corticosteroids 1

Important Caveats

• Elective colectomy is not recommended for immunocompetent patients with uncomplicated diverticulosis or recurrent uncomplicated diverticulitis 1

• Surgical intervention is indicated for:

  • Diffuse peritonitis
  • Persistent symptoms despite percutaneous drainage
  • Failure of medical therapy with worsening inflammatory signs 1
  • Immunocompromised patients
  • Diverticulitis with stenosis, fistulas, or recurrent bleeding 1

• Warning signs requiring closer monitoring:

  • Symptoms lasting >5 days before presentation
  • Vomiting
  • High C-reactive protein levels
  • CT findings of pericolic extraluminal air or fluid collection 1
  • Large amounts of distant intraperitoneal air (associated with 57-60% failure rate of non-operative management) 3