Treatment Plan for Diverticulitis
For uncomplicated diverticulitis, observation with supportive care (clear liquid diet and pain control) is recommended as first-line therapy, with antibiotics reserved for specific high-risk patients. 1
Classification and Initial Assessment
- Diverticulitis is classified as either uncomplicated (localized inflammation without abscess or perforation) or complicated (involving abscess, perforation, fistula, or obstruction) 1
- Diagnosis is typically confirmed by CT scan showing diverticula, wall thickening, and increased density of pericolic fat 1
- Risk factors include age >65 years, genetic factors, connective tissue diseases, obesity, use of opioids/steroids/NSAIDs, hypertension, and type 2 diabetes 2
Treatment Algorithm for Uncomplicated Diverticulitis
First-Line Management (Most Patients)
- Clear liquid diet during the acute phase, advancing as symptoms improve 1
- Pain management (typically acetaminophen) 2
- Observation without antibiotics for immunocompetent patients with mild uncomplicated diverticulitis 1
- Re-evaluation within 7 days; earlier if clinical condition deteriorates 3
When to Use Antibiotics in Uncomplicated Diverticulitis
Antibiotics should be reserved for patients with:
- Systemic manifestations of infection (persistent fever, chills) 1, 2
- Immunocompromised status (receiving chemotherapy, high-dose steroids, or post-transplant) 3, 1
- Advanced age (>80 years) 1, 2
- Significant comorbidities (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 1, 2
- Laboratory abnormalities (CRP >140 mg/L or WBC >15 × 10^9/L) 1
- Longer segment of inflammation or fluid collection on CT 1
- Pregnancy 2
Antibiotic Selection When Indicated
- Oral antibiotics are preferred whenever possible 3, 1
- Duration: 4-7 days for immunocompetent patients; 10-14 days for immunocompromised patients 3, 1
- For patients unable to tolerate oral intake: IV antibiotics (ceftriaxone plus metronidazole, ampicillin/sulbactam, or piperacillin-tazobactam) 2
Treatment of Complicated Diverticulitis
- For small abscesses (<4-5 cm): antibiotic therapy alone for 7 days 1
- For large abscesses (>4-5 cm): percutaneous drainage combined with antibiotic therapy 1
- For generalized peritonitis: emergent laparotomy with colonic resection 2
- Intravenous antibiotics such as ceftriaxone plus metronidazole or piperacillin-tazobactam 2
Outpatient vs. Inpatient Management
Outpatient Management Criteria
- Uncomplicated diverticulitis 3, 1
- Ability to tolerate oral intake 3, 1
- No significant comorbidities 3
- Adequate family support 5
- Ability to follow up within 7 days 3
Inpatient Management Criteria
- Complicated diverticulitis 1
- Significant comorbidities 1
- Inability to tolerate oral intake 1, 5
- Severe pain or systemic symptoms 1
- Inadequate home support 5
Important Considerations and Pitfalls
- Outpatient treatment has been shown to be safe and effective in 94-97% of appropriately selected patients with uncomplicated diverticulitis 4, 5
- Outpatient management can reduce healthcare costs by approximately €1,600 per patient compared to inpatient treatment 4
- Immunocompromised patients are at higher risk for progression to complicated diverticulitis and should be treated more aggressively with antibiotics and consideration for surgical consultation 3
- Short-term antibiotic therapy (4 days) has been shown to be as effective as standard therapy (7 days) for uncomplicated diverticulitis 6
- Unnecessary use of antibiotics in low-risk patients with uncomplicated diverticulitis provides no benefit and contributes to antibiotic resistance 1
- Young patients (<50 years) and those with high pain scores have increased risk for complicated or recurrent diverticulitis and should be monitored more closely 1
Prevention of Recurrence
- High-quality diet (high in fiber from fruits, vegetables, whole grains, and legumes; low in red meat and sweets) 3
- Achieve or maintain normal body mass index 3
- Regular physical activity, particularly vigorous exercise 3
- Smoking cessation 3
- Avoid regular use of NSAIDs and opioid analgesics when possible 3, 2