From the Guidelines
Outpatient management of mild diverticulitis is recommended for patients with uncomplicated disease who are immunocompetent, able to tolerate oral intake, and have adequate social support. This approach is supported by the American College of Physicians (ACP) guideline, which suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting 1.
Key Considerations for Outpatient Management
- Patients should be able to continue treatment at home under medical supervision with adequate family and social support and follow-up.
- Outpatient management is less intensive than inpatient management and is likely to have lower associated costs.
- Decision making should take into account individual patient circumstances, such as the availability of adequate home care.
Diagnostic Approach
- A detailed history, physical examination, and laboratory findings are the first steps in diagnosing acute colonic diverticulitis in most patients with abdominal pain or tenderness primarily in the left lower quadrant 1.
- Abdominal CT imaging can be used to complement the history, examination, and laboratory findings to establish the diagnosis of diverticulitis when there is diagnostic uncertainty.
- CT imaging is associated with very high sensitivity and specificity to make an accurate diagnosis of diverticulitis 1.
Treatment Approach
- Antibiotic treatment is not necessary for all patients with uncomplicated diverticulitis 2.
- Antibiotics are advised in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 10^9 cells per liter.
- Common antibiotic regimens include amoxicillin-clavulanate or the combination of ciprofloxacin and metronidazole.
- A clear liquid diet is advised during the acute phase of uncomplicated diverticulitis, with the goal of patient comfort, and can be advanced as symptoms improve 3.
- Pain management with acetaminophen is preferred, and NSAIDs should be avoided as they may increase the risk of complications.
Monitoring and Follow-up
- Patients should be advised to seek immediate medical attention if they develop fever >101°F, severe abdominal pain, inability to tolerate oral intake, or signs of sepsis.
- Clinical improvement is typically expected within 2-3 days, and lack of improvement warrants reassessment and possible hospitalization.
From the Research
Guidelines for Outpatient Management of Mild Diverticulitis
The guidelines for outpatient management of mild diverticulitis are as follows:
- Outpatient treatment is recommended for afebrile, clinically stable patients with uncomplicated diverticulitis 4
- Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively for patients with uncomplicated diverticulitis 4
- Treatment with amoxicillin-clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 5
- Outpatient management is safe and effective, with an overall failure rate of 4.3% (95% CI 2.6%-6.3%) 6
- Factors such as previous episodes of acute diverticulitis, comorbidities, pericolic air, intra-abdominal abscess, treatment according to a registered protocol, type of follow-up, type of antibiotic treatment, or diabetes do not influence the rate of failure 6
Selection Criteria for Outpatient Management
The selection criteria for outpatient management of mild diverticulitis include:
- Absence of severe comorbidities 7
- Ability to tolerate oral intake 8
- Presence of family or social support 8
- Absence of free air around the colon, or an Ambrosetti score of 4 7
Treatment Options
The treatment options for outpatient management of mild diverticulitis include: