What is the initial management for a 45-year-old female with a computed tomography (CT) diagnosis of diverticulitis?

Management of Diverticulitis in a 45-Year-Old Female

For a 45-year-old female with CT-confirmed uncomplicated diverticulitis, outpatient management without antibiotics is recommended as the initial approach, focusing on supportive care including bowel rest and hydration. 1, 2

Classification and Initial Assessment

• Diverticulitis is classified as either uncomplicated (localized inflammation) or complicated (associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation) 1
• CT scan findings help determine the severity and guide management decisions 1, 3
• Uncomplicated diverticulitis (WSES stage 0) shows diverticula, wall thickening, and increased density of pericolic fat without evidence of abscess or perforation 2
• Complicated diverticulitis may show pericolic air bubbles (WSES stage 1a), abscess (WSES stages 1b-2a), distant free air (WSES stage 2b), or diffuse peritonitis (WSES stages 3-4) 1

Management of Uncomplicated Diverticulitis

• Outpatient management is appropriate for patients who are afebrile, clinically stable, and can follow up as outpatients under medical supervision 1, 3
• Antibiotics should be avoided in immunocompetent patients with uncomplicated diverticulitis without systemic manifestations of infection 1, 2
• Multiple high-quality randomized controlled trials (AVOD and DIABOLO) have demonstrated that antibiotics neither accelerate recovery nor prevent complications or recurrence in uncomplicated diverticulitis 1
• Supportive care includes:
  • Bowel rest (clear liquid diet initially) 3
  • Adequate hydration 1
  • Pain management (typically acetaminophen) 3

When to Consider Antibiotics

• Antibiotics should be considered in patients with:
  • Complicated diverticulitis (abscess, perforation, fistula) 1, 3
  • Systemic inflammatory response or sepsis 1
  • Immunocompromised status (chemotherapy, high-dose steroids, post-transplant) 2, 3
  • Advanced age (>80 years) 3
  • Significant comorbidities 1, 3
  • Symptoms lasting longer than 5 days 1
  • High C-reactive protein levels (>140 mg/L) 1

Management of Complicated Diverticulitis

• For localized complicated diverticulitis with pericolic air bubbles (WSES stage 1a):
  • Antibiotic therapy is recommended 1
• For diverticulitis with small abscess (<4-5 cm):
  • Initial trial of antibiotics alone 1
• For diverticulitis with large abscess (>4-5 cm):
  • Percutaneous drainage combined with antibiotics 1
• For diverticulitis with distant free air without diffuse fluid:
  • Non-operative management only in highly selected patients with close monitoring 1
• For diverticulitis with diffuse peritonitis:
  • Surgical intervention is required 1

Monitoring and Follow-up

• Close clinical monitoring is essential, especially when managing without antibiotics 1, 2
• If symptoms worsen or fail to improve within 2-3 days, reassessment with repeat imaging is warranted 4, 5
• Predictors of progression to complicated disease include:
  • Symptoms lasting >5 days 1
  • Initial pain score >7 1
  • Vomiting 1
  • Leukocyte count >13.5 × 10^9 cells/L 1
  • High C-reactive protein levels (>140 mg/L) 1
• Colonoscopy is recommended 4-6 weeks after resolution of symptoms to exclude other pathology 5, 6

Common Pitfalls to Avoid

• Overuse of antibiotics in uncomplicated cases, which contributes to antibiotic resistance without clinical benefit 1, 2
• Failure to recognize high-risk patients who would benefit from antibiotics despite mild presentation 2, 3
• Inadequate follow-up to ensure resolution of symptoms 2, 5
• Missing signs of progression to complicated diverticulitis 1