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 or complicated based on CT findings, which guides treatment decisions 1
- Computed tomography (CT) scan is the recommended diagnostic test with sensitivity of 98-99% and specificity of 99-100% 2
- Risk factors include age >65 years, genetic factors, connective tissue diseases, obesity, medication use (opioids, steroids, NSAIDs), hypertension, and type 2 diabetes 2
Treatment of Uncomplicated Diverticulitis
- For uncomplicated diverticulitis (85% of cases), first-line therapy is observation and pain management (typically acetaminophen) with dietary modification (clear liquid diet) 2
- Outpatient management is recommended for clinically stable, afebrile patients with uncomplicated diverticulitis, with a low failure rate of only 4.3% 1
- Antibiotics should be reserved for specific patient populations:
- Patients with systemic symptoms (persistent fever or chills)
- Those with increasing leukocytosis
- Patients >80 years old
- Pregnant patients
- Immunocompromised patients
- Those with chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2
- When antibiotics are indicated for uncomplicated diverticulitis, first-line options include:
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
- Elevated CRP levels at presentation may predict treatment failure in these patients 1
Diverticular Abscess Management
- For small abscesses (<4-5 cm), initial trial of non-operative treatment with antibiotics alone is recommended, with 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
- When 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 1
Peritonitis Management
- Patients with diffuse peritonitis require:
- Prompt fluid resuscitation
- Immediate antibiotic administration
- Urgent surgical intervention 1
- Empiric antibiotic regimens should be based on clinical condition, presumed pathogens, and risk factors for antimicrobial resistance 1
- A 4-day period of postoperative antibiotic therapy is recommended if source control has been adequate 1
Surgical Considerations
- Surgical intervention with either Hartmann procedure or primary anastomosis (with or without diverting loop ileostomy) is indicated for peritonitis or failure of non-operative management 4
- The traditional recommendation for colectomy after 2 episodes of diverticulitis is no longer accepted 1
- Postoperative mortality varies significantly: 0.5% for elective colon resection versus 10.6% for emergent colon resection 2
- The decision for elective resection should consider risk factors for recurrence, morbidity of surgery, ongoing symptoms, complexity of disease, and patient's comorbidities 1
Follow-up Care
- Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation 4
- For patients with uncomplicated diverticulitis, colonoscopy is recommended if they have suspicious features on CT scan or meet national bowel cancer screening criteria 4
- Preventive strategies to reduce recurrence include fiber supplementation, probiotics, and possibly intermittent courses of poorly absorbed antibiotics like rifaximin 5, 6