What is the treatment for diverticulitis?

Treatment of Diverticulitis

The treatment of diverticulitis should be tailored based on disease severity, with uncomplicated diverticulitis managed through observation and pain control, while complicated diverticulitis requires antibiotics, possible drainage procedures, or surgery depending on the specific complications present. 1

Classification and Initial Assessment

• Diagnosis of first occurrence of diverticulitis requires radiological evidence of inflammation, typically using contrast-enhanced abdominal and pelvic CT scan, which has a sensitivity of 98-99% and specificity of 99-100% 2
• Treatment approach is determined by classifying diverticulitis as uncomplicated (absence of abscess, strictures, perforation, or fistula) or complicated (presence of these features) 1, 3

Treatment of Uncomplicated Diverticulitis

• Outpatient management is recommended for clinically stable, afebrile patients with uncomplicated diverticulitis, with studies showing a low failure rate of only 4.3% 1
• Management consists primarily of observation with pain management (typically acetaminophen) and dietary modification with a clear liquid diet 2
• Antibiotics should be reserved for specific patient populations:
  • Patients with systemic symptoms (persistent fever or chills)
  • Those with increasing leukocytosis
  • Patients older than 80 years
  • Pregnant patients
  • Immunocompromised patients
  • Those with chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2
• First-line antibiotics for uncomplicated diverticulitis when indicated include oral amoxicillin/clavulanic acid or cefalexin with metronidazole 2
• For patients with CT findings of pericolic extraluminal gas, a trial of non-operative treatment with antibiotics is recommended, though elevated CRP levels may predict treatment failure 4, 1

Treatment of Complicated Diverticulitis with Abscess

• For small abscesses (<4-5 cm), an initial trial of non-operative treatment with antibiotics alone is recommended 4, 5
• For large abscesses (>4-5 cm), percutaneous drainage combined with antibiotic treatment is recommended 4, 5
• When percutaneous drainage is not feasible, antibiotic therapy alone can be considered with careful clinical monitoring 4
• Surgical intervention should be performed if the patient shows worsening of inflammatory signs or if the abscess does not reduce with medical therapy 4

Antibiotic Regimens for Diverticular Disease

• For patients requiring IV antibiotics: ceftriaxone plus metronidazole, ampicillin/sulbactam, or piperacillin-tazobactam 2
• For patients with beta-lactam allergy: eravacycline 1 mg/kg q12h or tigecycline 100 mg loading dose then 50 mg q12h 5
• Duration of antibiotic therapy:
  • 4 days in immunocompetent and non-critically ill patients if source control is adequate 5, 1
  • Up to 7 days for immunocompromised or critically ill patients 5
  • Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 5

Management of Severe Complicated Diverticulitis

• Patients with diffuse peritonitis require:
  • Prompt fluid resuscitation
  • Immediate antibiotic administration
  • Urgent surgical intervention 1
• Surgical options include Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy 3
• Postoperative mortality varies significantly: 0.5% for elective colon resection versus 10.6% for emergent colon resection 2

Follow-up Care

• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation 3
• For prevention of recurrence, continuous fiber intake is recommended 6, 7
• The decision for elective resection after diverticulitis episodes should be made on a case-by-case basis, considering risk factors for recurrence, morbidity of surgery, ongoing symptoms, and patient's comorbidities 1