What is the management approach for diverticulitis?

Management of Diverticulitis

For immunocompetent patients with uncomplicated diverticulitis, initial management without antibiotics is recommended, focusing on supportive care with clear liquid diet and pain control. 1, 2, 3

Classification of Diverticulitis

• Uncomplicated diverticulitis: localized inflammation without abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1, 3
• Complicated diverticulitis: inflammation associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1

Diagnostic Approach

• CT scan is the gold standard for diagnosis with 98-99% sensitivity and 99-100% specificity 2, 4
• Findings include diverticula, wall thickening, and increased density of pericolic fat 3
• Laboratory studies should include complete blood count, basic metabolic panel, and C-reactive protein 5

Treatment Algorithm for Uncomplicated Diverticulitis

Outpatient Management

• Outpatient management is recommended for patients with uncomplicated diverticulitis who have no significant comorbidities, can take fluids orally, and can manage themselves at home 1
• Re-evaluation within 7 days; earlier if clinical condition deteriorates 1, 3
• Clear liquid diet during the acute phase, advancing as symptoms improve 2, 3
• Pain management (typically acetaminophen) 4

When to Use Antibiotics

Antibiotics should be reserved for patients with:

• Immunocompromised status 1, 2, 3
• Systemic inflammatory response or signs of sepsis 1, 3
• Advanced age (>80 years) 2, 4
• Significant comorbidities 1, 3
• CRP >140 mg/L or WBC >15 × 10^9/L 1, 2
• Longer segment of inflammation or fluid collection on CT 1, 2
• Symptoms lasting >5 days or presence of vomiting 1

Antibiotic Selection When Indicated

• Oral antibiotics are preferred whenever possible 2, 6
• Outpatient regimen: oral amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 4-7 days 2, 4
• Inpatient regimen: IV antibiotics with gram-negative and anaerobic coverage (ceftriaxone plus metronidazole or piperacillin-tazobactam) 2, 4
• Duration: 4-7 days for immunocompetent patients; 10-14 days for immunocompromised patients 2, 3

Management 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
• Surgical intervention if clinical deterioration occurs 3

Indications for Hospitalization

Patients should be hospitalized if they have:

• Complicated diverticulitis 1, 3
• Significant comorbidities or inability to take fluids orally 1, 3
• Severe pain or systemic symptoms 3
• Immunocompromised status 1, 2
• Signs of peritonitis 5

Prevention of Recurrence

• High-quality diet high in fiber from fruits, vegetables, whole grains, and legumes; low in red meat and sweets 1, 2
• Regular physical activity and achieving/maintaining normal body mass index 1, 2
• Avoiding smoking and limiting NSAID use (except aspirin for cardiovascular prevention) 1, 2

Important Considerations and Pitfalls

• Overuse of antibiotics in uncomplicated cases without risk factors provides no benefit and contributes to antibiotic resistance 1, 3
• Failure to recognize high-risk patients who need antibiotics despite having uncomplicated disease can lead to progression to complicated diverticulitis 3
• Unnecessary restriction of nuts, corn, popcorn, or small-seeded fruits is not recommended as they are not associated with increased risk 2
• The risk of complicated diverticulitis is highest with the first presentation 1
• Outpatient management has been shown to be cost-effective, with healthcare cost savings of approximately 35-83% per episode compared to inpatient management 1, 7
• Oral antibiotics have been shown to be equally effective as intravenous antibiotics for patients who require antibiotic treatment 1, 6, 8