What is the initial management for diverticulitis?

Initial Management of Diverticulitis

For patients with acute uncomplicated left-sided colonic diverticulitis, outpatient management with observation and supportive care (bowel rest and hydration) without antibiotics is the recommended initial approach for select patients. 1

Classification and Diagnosis

• Diverticulitis is classified as either uncomplicated (localized inflammation) or complicated (associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation) 1, 2
• Diagnosis is typically confirmed with contrast-enhanced abdominal and pelvic CT scan, which has a sensitivity of 98-99% and specificity of 99-100% 3
• Implementation of treatment does not require a CT-confirmed diagnosis, but imaging should be obtained when signs and symptoms suggest perforation, bleeding, obstruction, or abscess 1

Management Algorithm for Acute Diverticulitis

Step 1: Determine if uncomplicated or complicated

• Uncomplicated: Localized inflammation without abscess, perforation, fistula, or obstruction 1, 2
• Complicated: Inflammation with abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1, 2

Step 2: For Uncomplicated Diverticulitis

• Outpatient management is recommended for most patients with uncomplicated diverticulitis 1

• Supportive care includes:

  • Bowel rest (clear liquid diet initially) 3
  • Adequate hydration 1
  • Pain management (typically acetaminophen) 3
  • Close follow-up within 4-7 days to confirm improvement 4

• Antibiotics should be used selectively rather than routinely 1, 2

• Antibiotics are indicated for patients with:

  • Systemic inflammatory response 1
  • Immunosuppression 1
  • Persistent fever or chills 3
  • Increasing leukocytosis 3
  • Age >80 years 3
  • Pregnancy 3
  • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 3

• When antibiotics are needed:

  • Oral options: amoxicillin/clavulanic acid or cefalexin with metronidazole 3
  • IV options (if unable to tolerate oral intake): cefuroxime or ceftriaxone plus metronidazole or ampicillin/sulbactam 3

Step 3: For Complicated Diverticulitis

• Inpatient management with IV antibiotics (ceftriaxone plus metronidazole or piperacillin-tazobactam) 3
• Additional interventions as indicated:
  • Percutaneous drainage for abscesses 3
  • Surgical intervention for peritonitis 3

Clinical Considerations and Cautions

• Outpatient management is not appropriate for patients with:

  • Suspected complicated diverticulitis 1
  • Recent antibiotic use 1
  • Unstable comorbid conditions 1
  • Immunosuppression 1
  • Signs of sepsis 1
  • Inadequate home care support 1

• Risk factors for progression to complicated disease include:

  • Symptoms lasting >5 days 1
  • Initial pain score >7 1
  • Vomiting 1
  • Systemic comorbidity 1
  • Leukocyte count >13.5 × 10^9 cells/L 1
  • C-reactive protein >140 mg/L 1
  • CT findings of pericolic extraluminal air or fluid collection 1

• Outpatient management has been shown to be safe and effective with success rates of 97% in appropriate patients 4, 5

• Outpatient treatment is associated with lower costs (35-83% savings per episode) and fewer hospital-associated complications 1, 6

• Initial management without antibiotics should include watchful waiting and continued monitoring of patient status 1

• Colonoscopy is recommended after resolution of acute diverticulitis to exclude colonic neoplasm if a high-quality examination has not been recently performed 1, 2

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