What is the management plan for diverticulitis?

Management of Diverticulitis

For patients with uncomplicated diverticulitis, outpatient management without antibiotics is recommended as the first-line approach, while complicated diverticulitis requires antibiotics, possible drainage procedures, and potential surgical intervention based on severity. 1, 2

Classification and Diagnosis

• Uncomplicated diverticulitis: Localized inflammation without abscess, perforation, fistula, or obstruction 2
• Complicated diverticulitis: Inflammation with abscess, perforation, fistula, or obstruction 2
• Diagnosis typically confirmed by CT scan showing diverticula, wall thickening, and increased density of pericolic fat 2, 3

Management of Uncomplicated Diverticulitis

Outpatient Management

• Outpatient treatment is recommended for patients with uncomplicated diverticulitis who are clinically stable, can take oral fluids, and have no significant comorbidities 1
• Re-evaluation should occur within 7 days; earlier if clinical deterioration occurs 1, 2
• Outpatient management has been shown to be safe and effective in 94-95% of patients with uncomplicated diverticulitis 1, 4
• Outpatient treatment can reduce healthcare costs by approximately 35-83% per episode compared to inpatient management 1, 4

Antibiotic Use

• Antibiotics should be used selectively rather than routinely in uncomplicated diverticulitis 1, 2
• Observation with supportive care (clear liquid diet and pain control) is recommended as first-line therapy for immunocompetent patients 2, 3

Indications for Antibiotics in Uncomplicated Diverticulitis

• Systemic manifestations of infection (fever, chills) 1, 2, 3
• Immunocompromised status 1, 2, 3
• Advanced age (>80 years) 2, 3
• Significant comorbidities 1, 2
• Elevated inflammatory markers (CRP >140 mg/L, WBC >15 × 10^9/L) 1, 2
• Longer segment of inflammation or fluid collection on CT 1, 2

Antibiotic Selection When Indicated

• Oral antibiotics preferred: amoxicillin-clavulanate or fluoroquinolone plus metronidazole for 4-7 days 1, 2, 3
• For patients unable to tolerate oral intake: IV antibiotics (ceftriaxone plus metronidazole or piperacillin-tazobactam) 5, 3
• Switch from IV to oral antibiotics as soon as possible to facilitate earlier discharge 2, 5

Management of Complicated Diverticulitis

Antibiotic Therapy

• All patients with complicated diverticulitis should receive antibiotics 2, 5, 3
• IV antibiotics with gram-negative and anaerobic coverage (ceftriaxone plus metronidazole or piperacillin-tazobactam) 5, 3
• Duration: 4-7 days for immunocompetent patients; 10-14 days for immunocompromised patients 1, 5

Abscess Management

• Small abscesses (<4-5 cm): Antibiotic therapy alone for 7 days 2, 5
• Large abscesses (>4-5 cm): Percutaneous CT-guided drainage combined with antibiotic therapy 2, 5, 6

Surgical Management

• Surgical consultation for patients with peritonitis, large abscesses not amenable to percutaneous drainage, clinical deterioration despite medical therapy, or immunocompromised status 5, 6
• Emergency surgery indicated for diffuse peritonitis 3, 6
• The American Gastroenterological Association suggests against elective colonic resection after an initial episode of acute uncomplicated diverticulitis 1

Special Considerations

Immunocompromised Patients

• Lower threshold for imaging, antibiotic treatment, and surgical consultation 1, 5
• Longer duration of antibiotic therapy (10-14 days) 1, 5
• Higher risk of progression to complicated diverticulitis and/or sepsis 1

Diet and Lifestyle Recommendations

• Clear liquid diet during acute phase, advancing as symptoms improve 2
• After recovery, a fiber-rich diet or fiber supplementation is recommended 1, 7
• Regular physical activity, maintaining normal BMI, and avoiding smoking can reduce risk of recurrence 1
• No need to avoid nuts, popcorn, or seeds 1
• Avoid non-aspirin NSAIDs if possible 1

Common Pitfalls to Avoid

• Failing to recognize high-risk patients who need antibiotics despite having uncomplicated disease 2, 5
• Unnecessary use of antibiotics in low-risk patients with uncomplicated diverticulitis 1, 2
• Delaying antibiotics in patients with complicated diverticulitis or high-risk factors 5
• Failing to recognize clinical deterioration requiring surgical intervention 5
• Young patients (<50 years) and those with high pain scores (≥8/10) have increased risk for complicated or recurrent diverticulitis and should be monitored more closely 1, 2