What is the management of diverticulitis of the ileum?

Management of Ileal Diverticulitis

Patients with ileal diverticulitis require prompt cross-sectional imaging, antibiotic treatment, and early surgical consultation due to the high risk of complications and recurrence. 1

Diagnosis

• CT scan with IV contrast is the gold standard for diagnosis with 98% sensitivity and 99% specificity 1
• Ileal diverticulitis is rare compared to colonic diverticulitis and can mimic acute appendicitis 2
• Unlike left-sided colonic diverticulitis, ileal diverticulitis has limited evidence for management and requires a more aggressive approach

Treatment Algorithm

Initial Management

1. For uncomplicated ileal diverticulitis:

   • Inpatient management is recommended due to higher risk of complications compared to colonic diverticulitis
   • Broad-spectrum antibiotics covering gram-negative bacilli and anaerobes 1
   • Options include:
     • Piperacillin-tazobactam
     • Ertapenem
     • Combination therapy (ceftriaxone + metronidazole or ciprofloxacin + metronidazole)
   • Bowel rest and intravenous fluids

2. For complicated ileal diverticulitis (with abscess):

   • Small abscesses (<3cm): antibiotics and close monitoring
   • Larger abscesses (≥3cm): percutaneous drainage plus antibiotics 1, 3
   • Close monitoring for signs of clinical deterioration

Surgical Management

• Indications for urgent surgery:

  • Peritonitis
  • Perforation with free intraperitoneal air
  • Failed conservative management
  • Hemodynamic instability

• Surgical options:

  • Laparoscopic or open resection of the affected ileal segment with primary anastomosis 2, 4
  • For unstable patients: damage control surgery with staged approach 1

• Timing of surgery:

  • Early surgical consultation is crucial even in seemingly mild cases 4
  • Evidence suggests high recurrence rates with conservative management alone for ileal diverticulitis 4

Special Considerations

• Unlike colonic diverticulitis, ileal diverticulitis has a higher risk of recurrence after conservative management 4
• Case reports demonstrate flare-ups occurring within short intervals (as little as 38 days) after successful antibiotic therapy 4
• Terminal ileum diverticulitis can be false diverticula with higher risk of perforation 2

Follow-up

• Colonoscopy 6-8 weeks after resolution to exclude other pathologies 1, 3
• Consider surgical resection even after successful conservative management due to high recurrence risk 4

Pitfalls and Caveats

• Do not apply the same conservative approach used for uncomplicated colonic diverticulitis to ileal diverticulitis
• Do not delay surgical consultation, as ileal diverticulitis has higher perforation and recurrence rates
• Do not discharge patients prematurely; ensure complete resolution of symptoms and inflammatory markers
• Do not miss the diagnosis by assuming right lower quadrant pain is appendicitis without appropriate imaging 2

While the American College of Physicians guidelines 5 suggest selective antibiotic use for uncomplicated colonic diverticulitis, this approach should not be applied to ileal diverticulitis due to its distinct pathophysiology and higher complication rates. The case reports of ileal diverticulitis 2, 4 demonstrate the need for more aggressive management including consideration of surgical intervention even after successful initial conservative treatment.