Treatment of Diverticulitis
For uncomplicated diverticulitis in immunocompetent patients without systemic inflammation, antibiotics are not recommended as first-line therapy, as they do not improve outcomes compared to observation alone. 1, 2
Classification and Diagnosis
- Diverticulitis is classified as either uncomplicated (localized inflammation without abscess or perforation) or complicated (with abscess, perforation, fistula, or obstruction) 2, 3
- CT scan is the gold standard for diagnosis, with findings including intestinal wall thickening, pericolonic fat inflammation, and thickening of the lateroconal fascia 2
- The annual incidence of diverticulitis in the US is approximately 180 per 100,000 people, resulting in about 200,000 hospital admissions annually 3
Treatment Approach for Uncomplicated Diverticulitis
First-line Management
- Observation with pain management (typically acetaminophen) and dietary modification with a clear liquid diet, advancing as symptoms improve 2, 3
- Outpatient management is appropriate for most patients with mild uncomplicated diverticulitis who can take fluids orally and manage themselves at home 1, 2
- Multiple studies have shown no difference in time to resolution, risk of readmission, progression to complications, or need for surgery between patients treated with or without antibiotics 1, 4, 5
When Antibiotics Are Indicated
Antibiotics should be reserved for patients with:
- Immunocompromised status 1, 2
- Systemic manifestations of infection or sepsis 1, 2
- White blood cell count >15 × 10^9 cells per liter 1, 2, 6
- CRP >140 mg/L 1, 2
- Presence of fluid collection or longer segment of inflammation on CT 1, 2
- ASA score III or IV 1
- Duration of symptoms >5 days prior to presentation 1, 2
- Presence of vomiting 1, 2
- Age >80 years 2, 3
- Pregnancy 2, 3
- Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2, 3
Antibiotic Regimens When Indicated
Outpatient setting:
Inpatient setting:
Treatment of Complicated Diverticulitis
- Antibiotics are mandatory for diverticulitis complicated by systemic inflammation, abscess, perforation, or obstruction 1
- IV antibiotics with broad-spectrum coverage of gram-negative bacilli and anaerobes 1, 3
- Duration of antibiotic therapy should be 4 days after adequate source control 1
- Percutaneous drainage for abscesses when appropriate 1, 3
- Surgical consultation for patients with generalized peritonitis 1, 3
Special Considerations
Immunocompromised Patients
- Lower threshold for CT imaging, antibiotic treatment, and surgical consultation 1, 2
- Longer duration of antibiotic treatment (10-14 days) 1, 2
- Corticosteroid use is a risk factor for diverticulitis complications including perforation 1, 2
- After recovery, consultation with a colorectal surgeon to discuss elective resection 1
Monitoring and Follow-up
- Re-evaluation within 7 days for outpatient management 1
- Earlier re-evaluation if clinical condition deteriorates 1
- Monitor for signs of progression to complicated diverticulitis, which occurs in approximately 5% of cases 1, 2
Prevention of Recurrence
- High-quality diet high in fiber from fruits, vegetables, whole grains, and legumes; low in red meat and sweets 1, 2
- Achieve or maintain normal body mass index 1, 2
- Regular physical activity 1, 2
- Avoid smoking 1, 2
- Avoid regular use of NSAIDs and opiates when possible 2
Common Pitfalls to Avoid
- Overuse of antibiotics in uncomplicated cases without risk factors 1, 2, 4
- Unnecessarily restricting consumption of nuts, corn, popcorn, or small-seeded fruits 2
- Using fiber supplements as a replacement for a high-quality diet 2
- Failing to recognize risk factors for progression to complicated diverticulitis 1, 2