What is the treatment approach for a diverticulitis flare?

Treatment Approach for Diverticulitis Flare

For diverticulitis flares, treatment 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 of Diverticulitis

• Diverticulitis should be classified as uncomplicated (localized inflammation) or complicated (inflammation with abscess, phlegmon, fistula, obstruction, bleeding, or perforation) to guide appropriate management 2
• Computed tomography (CT) with intravenous contrast is the preferred imaging modality to confirm diagnosis and assess for complications 3

Management 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, 2
• For uncomplicated diverticulitis, antibiotics should be used selectively rather than routinely, with supportive care (bowel rest and hydration) as the initial approach 2
• Antibiotics should be reserved for patients with:
  • Systemic symptoms such as persistent fever or chills
  • Increasing leukocytosis
  • Age >80 years
  • Pregnancy
  • Immunocompromised status (receiving chemotherapy, high-dose steroids, or post-transplant)
  • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 4
• For patients with CT findings of pericolic extraluminal gas, a trial of non-operative treatment with antibiotics is recommended, though elevated CRP levels may predict treatment failure 5

Management of Complicated Diverticulitis with Abscess

• 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% 5, 6
• For large abscesses (≥4-5 cm), percutaneous drainage combined with antibiotic treatment is recommended 5, 6, 2
• When percutaneous drainage is not feasible, antibiotic therapy alone can be considered with careful clinical monitoring 5
• Surgical intervention should be performed if the patient shows worsening of inflammatory signs or if the abscess does not respond to medical therapy 5, 6

Antibiotic Regimens

• First-line oral antibiotics for uncomplicated diverticulitis when indicated:
  • Amoxicillin/clavulanic acid or
  • Cefalexin with metronidazole 4
• For patients requiring intravenous antibiotics:
  • Ceftriaxone plus metronidazole
  • Piperacillin-tazobactam
  • Ampicillin/sulbactam 4
• For patients with beta-lactam allergy:
  • Eravacycline 1 mg/kg q12h or
  • Tigecycline 100 mg loading dose then 50 mg q12h 6

Duration of Antibiotic Therapy

• 4 days of antibiotic therapy in immunocompetent and non-critically ill patients if source control is adequate 6, 1
• Up to 7 days based on clinical conditions and inflammation indices in immunocompromised or critically ill patients 6
• Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 6

Monitoring and Treatment Failure

• Elevated C-reactive protein (CRP) at presentation may be a predictor for treatment failure 6
• A high suspicion for surgical control of the septic source should be maintained if the patient shows worsening of inflammatory signs 5

Follow-up Care

• Colonoscopy is recommended 6 weeks after resolution of symptoms for patients with complicated diverticulitis or who have not had a high-quality colonoscopy in the past year 2, 7

Prevention Strategies

• A fiber-rich diet or fiber supplementation is recommended for patients with a history of diverticulitis 2
• Regular physical activity should be encouraged, and non-aspirin NSAIDs should be avoided when possible 2

Common Pitfalls to Avoid

• Overuse of antibiotics in uncomplicated diverticulitis can contribute to antibiotic resistance without providing significant clinical benefit 2
• Failure to recognize predictors of progression to complicated disease, such as symptoms lasting >5 days, vomiting, systemic comorbidity, high CRP levels, and certain CT findings 2
• Performing colonoscopy during the acute flare-up rather than waiting until 6 weeks after resolution of symptoms 3