What is the recommended treatment for diverticulitis?

Treatment of Diverticulitis

The recommended treatment for diverticulitis depends on disease severity, with selective antibiotic use for uncomplicated diverticulitis in immunocompetent patients and more aggressive management for complicated cases. 1

Classification and Diagnosis

• Diverticulitis is classified as uncomplicated (absence of abscess, strictures, perforation, or fistula) or complicated (presence of these complications) 2
• Diagnosis typically requires CT scan, which has 98-99% sensitivity and 99-100% specificity for diverticulitis 2

Treatment of Uncomplicated Diverticulitis

Diet Management

• A clear liquid diet is recommended during the acute phase of uncomplicated diverticulitis 1
• Diet should be advanced as symptoms improve 1
• If a patient cannot advance their diet after 3-5 days, immediate follow-up is warranted 1

Antibiotic Therapy

• Antibiotics can be used selectively rather than routinely in immunocompetent patients with mild uncomplicated diverticulitis 1
• Recent evidence suggests no benefit of antibiotics in immunocompetent patients with mild uncomplicated diverticulitis regarding time to resolution, risk of readmission, progression to complications, or need for surgery 1

Indications for Antibiotics in Uncomplicated Diverticulitis

Antibiotics are indicated for uncomplicated diverticulitis in patients with:

• Comorbidities or frailty 1
• Refractory symptoms or vomiting 1
• CRP >140 mg/L or white blood cell count >15 × 10^9 cells/L 1
• Systemic symptoms (persistent fever, chills) 2
• Age >80 years 2
• Pregnancy 2
• Immunocompromised status (chemotherapy, high-dose steroids, organ transplant) 2
• Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2

Antibiotic Regimens for Uncomplicated Diverticulitis

• Oral therapy: amoxicillin-clavulanate or ciprofloxacin plus metronidazole 1, 2, 3
• Duration typically 4-7 days 1
• Oral antibiotics may be as effective as intravenous administration 1

Outpatient Management

• Patients with uncomplicated diverticulitis without significant comorbidities who can take fluids orally can be treated as outpatients 1
• Re-evaluation should occur within 7 days, or earlier if clinical condition deteriorates 1

Treatment of Complicated Diverticulitis

Medical Management

• Intravenous antibiotics with gram-negative and anaerobic coverage 1, 2
• Options include:
  • Ceftriaxone plus metronidazole 2
  • Piperacillin-tazobactam 2
  • Ampicillin, gentamicin, metronidazole 4

Abscess Management

• Small abscesses: non-operative management with bowel rest and IV antibiotics 5
• Larger abscesses (3-5 cm): percutaneous drainage plus antibiotics 2, 5

Surgical Management

• Indicated for:
  • Diffuse peritonitis 1
  • Large abscesses not amenable to percutaneous drainage 1
  • Fistulas or strictures 1
  • After 2-4 attacks of uncomplicated diverticulitis 3, 6
• Surgical options:
  • Hemodynamically stable patients without comorbidities: resection and anastomosis with or without stoma 1
  • Unstable patients or those with multiple comorbidities: Hartmann's procedure 1

Follow-up Care

• Colonoscopy is recommended 6-8 weeks after an episode of diverticulitis to exclude other pathology, unless a high-quality colonoscopy was performed within the previous year 1, 5
• For chronic symptoms after diverticulitis, both imaging and lower endoscopy should be performed to exclude ongoing inflammation, stricture, or fistula 1
• If no evidence of ongoing diverticulitis is found, visceral hypersensitivity should be considered and can be treated with a low to modest dose of a tricyclic antidepressant 1

Common Pitfalls and Caveats

• Failure to identify patients at high risk for complications who require antibiotics even with uncomplicated disease 1
• Delayed recognition of complicated diverticulitis requiring surgical intervention 1
• Overuse of antibiotics in mild uncomplicated cases where they provide no benefit 1
• Inadequate follow-up to exclude colorectal cancer, which can present similarly to diverticulitis 1, 5