What is the recommended treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis, first-line therapy is observation with pain management (typically acetaminophen) and dietary modification with a clear liquid diet, while antibiotics should be reserved for patients with specific risk factors or systemic symptoms. 1, 2

Diagnosis

• CT scan with IV contrast is the recommended first-line imaging modality with 98-99% sensitivity and 99-100% specificity 1, 2
• Patients with abdominal guarding or lower left abdominal pain should undergo imaging regardless of laboratory values 1

Treatment Algorithm for Diverticulitis

Uncomplicated Diverticulitis (85% of cases)

1. Conservative management:

   • Observation with pain control (acetaminophen preferred)
   • Dietary modification (clear liquid diet initially)
   • Avoid NSAIDs, opiates, and corticosteroids 1

2. Selective antibiotic use - reserve for patients with:

   • Systemic symptoms (persistent fever or chills)
   • Increasing leukocytosis
   • Age >80 years
   • Pregnancy
   • Immunocompromised status (chemotherapy, high-dose steroids, organ transplant)
   • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 1, 2

3. Antibiotic options for uncomplicated cases:

   • Oral: amoxicillin/clavulanic acid or cefalexin with metronidazole
   • IV (if unable to tolerate oral): cefuroxime or ceftriaxone plus metronidazole or ampicillin/sulbactam 2

Complicated Diverticulitis

1. Intravenous antibiotics:

   • Piperacillin-tazobactam, ertapenem, meropenem, or imipenem/cilastatin
   • Combination therapy: ceftriaxone + metronidazole, ciprofloxacin + metronidazole, or ampicillin + gentamicin + metronidazole 1, 2

2. Abscess management:

   • <4 cm: antibiotics alone

   • 4 cm: percutaneous drainage plus antibiotics 1

   • Cultures from drainage should guide antibiotic therapy

3. Surgical intervention indications:

   • Distant intraperitoneal free air
   • Diffuse peritonitis
   • Failed non-operative management
   • Large amounts of distant intraperitoneal/retroperitoneal air (high failure rates of 57-60% with non-operative management) 1

4. Surgical options:

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

Follow-up and Prevention

• Colonoscopy 6-8 weeks after acute episode to rule out malignancy 1
• Preventive measures:
  • High-fiber diet (fruits, vegetables, whole grains, legumes)
  • Regular physical activity
  • Smoking cessation
  • Fiber supplementation 1

Important Considerations

• Delay between diagnosis and surgery >60 hours increases mortality and need for relaparotomy 1
• Postoperative mortality varies significantly: 0.5% for elective colon resection vs. 10.6% for emergent colon resection 2
• Risk factors for progression to complicated disease include:
  • Symptoms >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

Special Populations

• Patients under 50 years of age or immunocompromised patients may benefit from early surgical intervention after first episode, particularly with radiological signs of severe diverticulitis 3
• Emerging therapies being investigated include mesalazine (alone or with antibiotics) and probiotics, which may help prevent recurrence, though evidence is still limited 4, 5