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

Classification and Initial Assessment

• Diverticulitis is classified as uncomplicated (absence of abscess, colon strictures, perforation, or fistula formation) or complicated based on CT findings, which guides management approach 2
• Contrast-enhanced abdominal and pelvic CT scan is the recommended diagnostic test with sensitivity of 98-99% and specificity of 99-100% 2

Treatment of Uncomplicated Diverticulitis

• Outpatient management is recommended for clinically stable, afebrile patients with uncomplicated diverticulitis, with a low failure rate of only 4.3% in meta-analyses 1
• Management consists primarily of:
  • Observation with pain management (typically acetaminophen) 2
  • Dietary modification with a clear liquid diet 2
  • Antibiotics should be reserved for specific patient populations rather than routine use 2

Antibiotic Use in Uncomplicated Diverticulitis

• Antibiotics should be initiated only for patients with:
  • Persistent fever or chills
  • Increasing leukocytosis
  • Age >80 years
  • Pregnancy
  • Immunocompromised status (receiving chemotherapy, high-dose steroids, or organ transplant recipients)
  • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2
• First-line antibiotics for outpatient treatment:
  • Oral amoxicillin/clavulanic acid or
  • Cefalexin with metronidazole 2
• For patients unable to tolerate oral intake, intravenous antibiotics are appropriate:
  • Cefuroxime or ceftriaxone plus metronidazole or
  • Ampicillin/sulbactam 2

Pericolic Gas Management

• For patients with CT findings of pericolic extraluminal gas, a trial of non-operative treatment with antibiotics is recommended 3
• Elevated CRP levels at presentation may predict treatment failure in these patients 3

Treatment of Complicated Diverticulitis

Small Abscess Management (<4-5 cm)

• For small diverticular abscesses (<4-5 cm), initial trial of non-operative treatment with antibiotics alone is recommended 3
• This approach has a pooled failure rate of 20% and mortality rate of 0.6% 3

Large Abscess Management (≥4-5 cm)

• Percutaneous drainage combined with antibiotic treatment is recommended for large abscesses 3
• When percutaneous drainage is not feasible, antibiotic therapy alone can be considered with careful clinical monitoring 3
• Surgical intervention should be performed if the patient shows worsening inflammatory signs or if the abscess does not respond to medical therapy 3

Peritonitis Management

• Patients with diffuse peritonitis require:
  • Prompt fluid resuscitation
  • Immediate antibiotic administration
  • Urgent surgical intervention 1
• Intravenous antibiotics for complicated diverticulitis include:
  • Ceftriaxone plus metronidazole or
  • Piperacillin-tazobactam 2
• A 4-day period of postoperative antibiotic therapy is recommended if source control has been adequate 1

Surgical Considerations

• Emergency surgery is considered only in patients with acute peritonitis 4
• 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
• Postoperative mortality varies significantly between elective (0.5%) and emergency (10.6%) colon resection 2

Prevention of Recurrence

• Continuous fiber intake is recommended for prevention of recurrence 5
• Some evidence suggests that mesalazine (alone or with antibiotics) and probiotics may be effective in preventing symptomatic recurrence 6
• Intermittent courses of rifaximin may improve symptoms and reduce diverticulitis recurrence 5

Follow-up Care

• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation 7
• Colonoscopy is also indicated for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who meet national bowel cancer screening criteria 7