What is the management plan for diverticulitis?

Management of Diverticulitis

For patients with uncomplicated diverticulitis, management should focus on supportive care with clear liquid diet and pain control, reserving antibiotics only for select high-risk patients. 1

Classification of Diverticulitis

• Uncomplicated diverticulitis: Localized inflammation without abscess or perforation, typically confirmed by CT scan showing diverticula, wall thickening, and increased density of pericolic fat 1
• Complicated diverticulitis: Involves abscess formation, perforation, fistula, obstruction, or bleeding 1, 2

Management of Uncomplicated Diverticulitis

Outpatient Management

• Outpatient treatment is appropriate for patients with uncomplicated diverticulitis who are clinically stable, can tolerate oral intake, and have adequate social support 3
• Outpatient management is safe and effective in 94-95% of selected patients with uncomplicated diverticulitis 3, 4
• Re-evaluation should occur within 7 days; earlier if clinical condition deteriorates 3, 1

Antibiotic Use

• Antibiotics should be used selectively rather than routinely in uncomplicated diverticulitis 3, 1
• Observation without antibiotics is appropriate for immunocompetent patients with mild uncomplicated diverticulitis 3, 1

Indications for Antibiotics in Uncomplicated Diverticulitis

Antibiotics should be reserved for patients with:

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

Antibiotic Selection When Indicated

• Oral antibiotics are preferred whenever possible 3, 1
• First-line oral regimens: amoxicillin-clavulanate or ciprofloxacin plus metronidazole 2, 5
• Duration: 4-7 days for immunocompetent patients 3, 1

Management of Complicated Diverticulitis

• For small abscesses (<4-5 cm): antibiotic therapy alone for 7 days 1, 6
• For large abscesses (>4-5 cm): percutaneous drainage combined with antibiotic therapy 1, 6
• Intravenous antibiotics with gram-negative and anaerobic coverage (ceftriaxone plus metronidazole or piperacillin-tazobactam) 6, 2
• Surgical intervention for peritonitis, large abscesses not amenable to percutaneous drainage, or clinical deterioration despite medical therapy 6, 7

Indications for Inpatient Management

Patients should be hospitalized if they have:

• Complicated diverticulitis 6, 2
• Systemic inflammatory response or sepsis 3, 6
• Immunocompromised status 3, 6
• Inability to tolerate oral intake 6
• Severe pain 6
• Significant comorbidities 3, 6
• High-risk factors (symptoms >5 days, vomiting, elevated inflammatory markers) 3, 6

Prevention of Recurrence

• High-fiber diet or fiber supplementation is recommended for patients with a history of diverticulitis 3, 5
• Avoidance of seeds, nuts, and popcorn is not necessary 3
• Avoidance of non-aspirin NSAIDs when possible 3
• Regular physical activity is recommended 3
• Mesalamine, rifaximin, and probiotics are not recommended for prevention of recurrence 3

Surgical Considerations

• Elective colonic resection is not routinely recommended after an initial episode of uncomplicated diverticulitis 3
• Surgical decision should consider factors such as age, immunosuppression, operative comorbidities, and patient preference 3
• Mortality rates differ significantly between elective (0.5%) and emergency (10.6%) colonic resection 2

Common Pitfalls to Avoid

• Failing to recognize high-risk patients who need antibiotics despite having uncomplicated disease 1
• Unnecessary use of antibiotics in low-risk patients with uncomplicated diverticulitis 3, 1
• Delaying antibiotics in patients with complicated diverticulitis 6
• Failing to recognize clinical deterioration requiring surgical intervention 6
• Prolonging antibiotic therapy beyond 7 days after adequate source control 8