What is the treatment for diverticulitis?

Treatment for Diverticulitis

The treatment for diverticulitis should be tailored based on disease severity, with uncomplicated diverticulitis managed through observation and pain control, while complicated diverticulitis requires antibiotics, possible drainage procedures, or surgery depending on the specific complications present. 1, 2

Classification and Initial Assessment

• Diverticulitis is classified as either uncomplicated (absence of abscess, strictures, perforation, or fistula) or complicated (presence of these complications) 2
• CT scan with contrast is the recommended diagnostic test with 98-99% sensitivity and 99-100% specificity for confirming the diagnosis and assessing severity 2
• Approximately 85% of patients with acute diverticulitis have uncomplicated disease 2

Treatment of Uncomplicated Diverticulitis

Outpatient Management

• Outpatient management is recommended for clinically stable, afebrile patients with uncomplicated diverticulitis 3
• This approach has shown a low failure rate of only 4.3% in meta-analyses 1
• Ambulatory treatment is associated with significant cost savings (€600-€1,900 per patient) compared to hospitalization 1

Dietary Modifications

• Initial management includes observation with pain management (typically acetaminophen) and dietary modification with a clear liquid diet 2
• Fiber supplementation is recommended once symptoms improve to reduce intraluminal pressure and prevent recurrence 4

Antibiotics for Uncomplicated Diverticulitis

• Antibiotics should be reserved for specific patient populations including:

  • Patients with systemic symptoms (persistent fever or chills)
  • Those with increasing leukocytosis
  • Patients older than 80 years
  • Pregnant women
  • Immunocompromised patients (on chemotherapy, high-dose steroids, or post-transplant)
  • Those with chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2

• When indicated, first-line antibiotics include:

  • Oral therapy: amoxicillin/clavulanic acid or cefalexin with metronidazole 2
  • Intravenous therapy (for those unable to tolerate oral intake): cefuroxime or ceftriaxone plus metronidazole, or ampicillin/sulbactam 2

Pericolic Gas Management

• For patients with CT findings of pericolic extraluminal gas (located <5cm from affected colon segment), a trial of non-operative treatment with antibiotics is recommended 1
• Studies show that non-operative treatment is suitable for patients with isolated pericolic gas, though elevated CRP levels may predict treatment failure 1

Treatment of Complicated Diverticulitis

Diverticular Abscess Management

• For small abscesses (<4-5 cm):

  • Initial trial of non-operative treatment with antibiotics alone is recommended 1
  • This approach has shown a pooled failure rate of 20% and mortality rate of 0.6% 1

• For large abscesses (>4-5 cm):

  • Percutaneous drainage combined with antibiotic treatment is recommended 1
  • When percutaneous drainage is not feasible, antibiotic therapy alone can be attempted with close clinical monitoring 1
  • Surgical intervention should be considered if the patient shows worsening inflammatory signs or if the abscess doesn't respond to medical therapy 1

Peritonitis Management

• Patients with diffuse peritonitis require:
  • Prompt fluid resuscitation
  • Immediate antibiotic administration
  • Urgent surgical intervention 3
  • Empiric antibiotic regimen should be based on the patient's clinical condition, presumed pathogens, and risk factors for antimicrobial resistance 1

Antibiotic Duration for Complicated Diverticulitis

• A 4-day period of postoperative antibiotic therapy is recommended if source control has been adequate 1
• The STOP IT trial demonstrated that outcomes after approximately 4 days of fixed-duration antibiotic therapy were similar to longer courses 1

Follow-up Care

Colonoscopy Recommendations

• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis 3
• For uncomplicated diverticulitis, colonoscopy is recommended for patients with suspicious features on CT scan or who meet national bowel cancer screening criteria 3

Prevention of Recurrence

• Continuous fiber intake and intermittent courses of rifaximin may improve symptoms and reduce diverticulitis recurrence 4
• The combination of soluble fiber (like glucomannan) and poorly absorbed antibiotics (like rifaximin) given 7-10 days every month has shown good results in preventing recurrence 4

Surgical Considerations

• The decision for elective resection after diverticulitis episodes should be made on a case-by-case basis, considering:
  • Risk factors for recurrence
  • Morbidity of surgery
  • Ongoing symptoms
  • Complexity of disease
  • Patient's comorbidities 1
• The traditional recommendation for colectomy after 2 episodes of diverticulitis is no longer accepted 1
• Emergency surgery is indicated for patients with peritonitis or when non-operative management fails 3
• Surgical mortality varies significantly: 0.5% for elective colon resection versus 10.6% for emergent colon resection 2