What is the management plan for diverticulitis?

Management of Diverticulitis

For patients with uncomplicated diverticulitis, outpatient management with supportive care and without antibiotics is recommended as first-line therapy, while complicated diverticulitis requires antibiotics, possible drainage procedures, and potential surgical intervention. 1

Classification of Diverticulitis

• Uncomplicated diverticulitis: localized inflammation without abscess, perforation, fistula, or obstruction 1
• Complicated diverticulitis: inflammation associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1, 2

Diagnosis

• CT scan is the gold standard for diagnosis with 98-99% sensitivity and 99-100% specificity 3
• Findings include intestinal wall thickening, pericolonic fat inflammation, and thickening of lateroconal fascia 4
• Laboratory studies should include complete blood count, basic metabolic panel, C-reactive protein, and urinalysis 5

Management of Uncomplicated Diverticulitis

Outpatient Management

• Outpatient management is recommended for patients with uncomplicated diverticulitis who have no significant comorbidities and can tolerate oral intake 1
• Re-evaluation within 7 days; earlier if clinical condition deteriorates 1
• Outpatient management is safe with a failure rate of only 4.3% and reduces healthcare costs by approximately 35-83% per episode 1

Antibiotic Use

• For select immunocompetent patients with uncomplicated diverticulitis, initial management without antibiotics is recommended, focusing instead on supportive care 1, 2
• Supportive care includes clear liquid diet during the acute phase, advancing as symptoms improve, and pain control (typically acetaminophen) 2, 3

When Antibiotics Are Indicated

• Antibiotics should be used in uncomplicated diverticulitis for patients with:
  • Systemic inflammatory response 1, 4
  • Immunocompromised status 1
  • Advanced age (>80 years) 4, 3
  • Significant comorbidities 1, 4
  • CRP >140 mg/L or WBC >15 × 10^9/L 2, 4
  • Symptoms lasting >5 days or high pain scores (≥8/10) 1, 4
  • Vomiting 1, 4
  • Fluid collection or longer segment of inflammation on CT 2, 4

Antibiotic Regimens When Indicated

• Oral options: amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 4-7 days 1, 4, 3
• Transition from IV to oral antibiotics should be made as soon as possible 1

Management of Complicated Diverticulitis

• Inpatient management with IV antibiotics is necessary 1, 6
• IV antibiotic options include ceftriaxone plus metronidazole or piperacillin-tazobactam 4, 6, 3
• For small abscesses (<4-5 cm): antibiotic therapy alone for 7 days 2, 6
• For large abscesses (>4-5 cm): percutaneous CT-guided drainage combined with antibiotic therapy 2, 6
• Surgical consultation for peritonitis, large abscesses not amenable to drainage, or clinical deterioration 6
• Duration: 4 days for immunocompetent patients with adequate source control; up to 7 days for immunocompromised or critically ill patients 4, 6

Special Considerations

Immunocompromised Patients

• Lower threshold for CT imaging, antibiotic treatment, and surgical consultation 1, 6
• Longer duration of antibiotic treatment (10-14 days) 1, 4
• More likely to present with severe or complicated disease 1

Prevention of Recurrence

• High-quality diet high in fiber from fruits, vegetables, whole grains, and legumes 1, 4
• Regular physical activity, particularly vigorous exercise 1, 4
• Achieve or maintain normal body mass index 1, 4
• Avoid smoking 1, 4
• Avoid regular use of NSAIDs and opiates when possible 1, 4

Common Pitfalls to Avoid

• Unnecessary use of antibiotics in low-risk patients with uncomplicated diverticulitis contributes to antibiotic resistance without providing benefit 1, 2
• Failing to recognize high-risk patients who need antibiotics despite having uncomplicated disease 2
• Delaying antibiotics in patients with complicated diverticulitis or high-risk factors 6
• Failing to recognize clinical deterioration requiring surgical intervention 6
• Restricting consumption of nuts, corn, popcorn, or small-seeded fruits unnecessarily 4