What is the recommended treatment for diverticulitis?

Treatment of Diverticulitis

For uncomplicated diverticulitis in immunocompetent patients without signs of systemic inflammation, antibiotics are not recommended as first-line therapy, and management should focus on supportive care with clear liquid diet and pain control. 1, 2, 3

Classification and Diagnosis

• Diverticulitis is classified as either uncomplicated (localized inflammation without abscess or perforation) or complicated (involving abscess, perforation, fistula, or obstruction) 1, 3
• CT scan is the gold standard for diagnosis, with findings including diverticula, wall thickening, and increased density of pericolic fat 2, 3
• Uncomplicated diverticulitis typically presents with left lower quadrant pain, nausea, vomiting, fever, and leukocytosis 4

Treatment Algorithm for Uncomplicated Diverticulitis

• Initial management:

  • Clear liquid diet during the acute phase, advancing as symptoms improve 2, 3
  • Pain management (typically acetaminophen) 4
  • Observation without antibiotics for immunocompetent patients 1
  • Re-evaluation within 7 days; earlier if clinical deterioration occurs 3

• When to use antibiotics in uncomplicated diverticulitis:

  • Presence of systemic manifestations of infection 2, 3
  • Immunocompromised status 1, 2
  • Advanced age (>80 years) 3, 4
  • Significant comorbidities 2, 3
  • CRP >140 mg/L or WBC >15 × 10^9/L 2, 3
  • Longer segment of inflammation or fluid collection on CT 2, 3

• Antibiotic selection when indicated:

  • Oral antibiotics are preferred whenever possible 1
  • Outpatient: Ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily for 7-10 days 2, 5
  • Alternative outpatient: Amoxicillin-clavulanate 6, 4
  • Duration: 4-7 days for immunocompetent patients; 7-10 days for immunocompromised patients 2, 3

Treatment of Complicated Diverticulitis

• For small abscesses (<4-5 cm), antibiotic therapy alone for 7 days 3
• For large abscesses (>4-5 cm), percutaneous drainage combined with antibiotic therapy 3, 6
• IV antibiotics with gram-negative and anaerobic coverage for inpatient settings, with options including:
  • Ciprofloxacin plus metronidazole 2, 5
  • Ceftriaxone plus metronidazole 4
  • Piperacillin/tazobactam 2, 4
• Surgical intervention if clinical deterioration occurs 3, 4

Outpatient vs. Inpatient Management

• Outpatient management is suitable for uncomplicated diverticulitis without risk factors 3, 5
• Inpatient management is necessary for:
  • Complicated diverticulitis 3
  • Significant comorbidities 3
  • Inability to tolerate oral intake 3, 5
  • Severe pain or systemic symptoms 3
  • Immunocompromised patients 1, 2

Prevention of Recurrence

• High-quality diet (high in fiber from fruits, vegetables, whole grains, legumes; low in red meat and sweets) 2
• Regular physical activity and maintaining normal body mass index 2
• Avoiding smoking and regular use of NSAIDs and opiates 2, 4

Important Considerations and Pitfalls

• Failure to recognize high-risk patients who need antibiotics despite having uncomplicated disease can lead to progression to complicated diverticulitis 3
• Unnecessary use of antibiotics in low-risk patients with uncomplicated diverticulitis provides no benefit and contributes to antibiotic resistance 1, 3
• The transition from IV to oral antibiotics should be made as soon as possible to facilitate earlier discharge 3, 5
• Young patients (<50 years) and those with high pain scores have increased risk for complicated or recurrent diverticulitis and should be monitored more closely 3
• Immunocompromised patients are at increased risk for failure of standard, non-operative treatment and may require urgent surgical intervention 1