What is the recommended management for diverticulitis?

Management of Diverticulitis

For patients with acute uncomplicated left-sided colonic diverticulitis, outpatient management without antibiotics is recommended as first-line therapy, with antibiotics reserved for select patients with systemic symptoms or risk factors. 1

Diagnosis

• CT scan with IV contrast is the first-line imaging modality (sensitivity 98%, specificity 99%) 2
• Diagnosis should not be based solely on clinical signs, symptoms, and laboratory tests
• Uncomplicated diverticulitis: localized inflammation without abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1
• Complicated diverticulitis: inflammation with abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1

Management of Uncomplicated Diverticulitis

Initial Treatment

1. Outpatient management for immunocompetent patients without systemic inflammatory response, medically frail status, or requiring hospitalization 1

   • Observation with supportive care (bowel rest and hydration)
   • Pain management (typically acetaminophen) 3
   • Clear liquid diet initially, advancing as tolerated

2. Selective antibiotic use rather than routine use 1

   • Antibiotics should be reserved for patients with:
     • Systemic symptoms (persistent fever or chills)
     • Increasing leukocytosis
     • Age >80 years
     • Pregnancy
     • Immunocompromised status
     • Chronic medical conditions (cirrhosis, CKD, heart failure, poorly controlled diabetes) 3

3. Antibiotic options when indicated:

   • Oral: amoxicillin/clavulanic acid or cefalexin with metronidazole 3
   • IV (if unable to tolerate oral): cefuroxime or ceftriaxone plus metronidazole or ampicillin/sulbactam 3

Follow-up Care

• Colonoscopy 6-8 weeks after resolution to exclude colonic neoplasm if high-quality examination has not been recently performed 1, 2
• Fiber-rich diet or fiber supplementation is recommended 1
• Regular physical activity is suggested 1
• No need to avoid consumption of seeds, nuts, and popcorn 1
• Avoid use of non-aspirin NSAIDs if possible 1
• Aspirin use does not need to be restricted 1
• Not recommended: mesalamine (strong recommendation), rifaximin, or probiotics 1

Surgical Management

• Elective colonic resection is not recommended after an initial episode of acute uncomplicated diverticulitis 1
• Decision for elective prophylactic colonic resection should be individualized based on:
  • Age (younger patients have higher recurrence rates but lower operative risks)
  • Access to medical care
  • Immunosuppression status
  • Operative comorbidities
  • Patient preference 1

Management of Complicated Diverticulitis

1. Intravenous antibiotics:

   • Broad-spectrum coverage for gram-negative bacilli and anaerobes
   • Options include: piperacillin-tazobactam, ertapenem, meropenem, or combination therapy (ceftriaxone + metronidazole) 2

2. Abscess management:

   • Percutaneous drainage for abscesses >4 cm 2
   • Cultures from drainage should guide antibiotic therapy 2

3. Surgical intervention indications:

   • Distant intraperitoneal free air
   • Diffuse peritonitis
   • Failed non-operative management
   • Surgical options:
     • Stable patients: primary resection and anastomosis with/without stoma
     • Unstable/high-risk patients: Hartmann's procedure 2

Risk Factors for Disease Progression

• Symptoms lasting >5 days before presentation
• Vomiting
• Systemic comorbidity
• High C-reactive protein levels (>140 mg/L)
• CT findings of pericolic extraluminal air, fluid collection, or longer inflamed colon segment 1, 2

Prevention of Recurrence

• High-fiber diet (fruits, vegetables, whole grains, legumes)
• Regular physical activity
• Smoking cessation
• Avoid NSAIDs, opiates, and corticosteroids 2

Common Pitfalls

• Overuse of antibiotics in uncomplicated cases without systemic symptoms
• Failure to obtain appropriate imaging for diagnosis
• Unnecessary dietary restrictions (seeds, nuts, popcorn)
• Delayed colonoscopy follow-up to exclude malignancy
• Unnecessary elective surgery after a single episode of uncomplicated diverticulitis

The management of diverticulitis has evolved significantly, with recent guidelines supporting more conservative approaches for uncomplicated disease, including outpatient management and selective antibiotic use, which can reduce healthcare costs and antibiotic resistance while maintaining good outcomes.