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, drainage procedures, or surgery depending on the specific complications present. 1

Classification and Initial Assessment

• Diverticulitis is classified as uncomplicated (absence of abscess, strictures, perforation, or fistula) or complicated based on CT findings, which guides appropriate management 1, 2
• CT scan is the recommended diagnostic test with 98-99% sensitivity and 99-100% specificity for diagnosing diverticulitis 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% 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 select patients with uncomplicated diverticulitis who have:
  • Systemic symptoms (persistent fever or chills) 2
  • Increasing leukocytosis 2
  • Age >80 years 2
  • Pregnancy 2
  • Immunocompromised status (receiving chemotherapy, high-dose steroids, or post-transplant) 2
  • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2
• First-line oral antibiotics for uncomplicated diverticulitis include:
  • Amoxicillin/clavulanic acid or 2
  • Cefalexin with metronidazole 2

Treatment of Complicated Diverticulitis

Diverticulitis with Pericolic Gas

• For patients with CT findings of pericolic extraluminal gas, a trial of non-operative treatment with antibiotic therapy is recommended 3
• Careful monitoring is essential as elevated CRP levels at presentation may predict treatment failure 3

Diverticular Abscess Management

• For small 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
• For large abscesses (≥4-5 cm):
  • Percutaneous drainage combined with antibiotic treatment is recommended 3
  • If percutaneous drainage is not feasible, antibiotic therapy alone can be considered with careful clinical monitoring 3
  • Surgical intervention is required if the patient shows worsening inflammatory signs or if the abscess doesn't respond to medical therapy 3

Diverticulitis with Peritonitis

• Patients with diffuse peritonitis require:
  • Prompt fluid resuscitation 1
  • Immediate antibiotic administration 1
  • Urgent surgical intervention 1, 4
• Intravenous antibiotic options include:
  • Ceftriaxone plus metronidazole 2
  • Piperacillin-tazobactam 2
  • For patients unable to take oral medications: cefuroxime or ceftriaxone plus metronidazole or ampicillin/sulbactam 2

Important Considerations and Pitfalls

• Mortality risk varies significantly based on management approach: 0.5% for elective colon resection versus 10.6% for emergent colon resection 2
• A 4-day period of postoperative antibiotic therapy is sufficient if source control has been adequate 1
• The traditional recommendation for colectomy after 2 episodes of diverticulitis is no longer accepted; decisions for elective resection should be individualized 1
• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation to rule out malignancy 4
• Fiber supplementation is recommended for both asymptomatic and symptomatic diverticulosis to reduce intraluminal pressure and potentially prevent acute diverticulitis 5

Prevention of Recurrence

• Continuous fiber intake and intermittent courses of antibiotics may improve symptoms and reduce diverticulitis recurrence 5
• Recent evidence suggests that mesalazine (alone or with antibiotics) and probiotics may be effective in preventing recurrence of diverticulitis 6