What is the treatment for diverticulitis?

Treatment of Diverticulitis

The treatment for 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

Uncomplicated Diverticulitis

• Outpatient management is recommended for clinically stable, afebrile patients with uncomplicated diverticulitis, with 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 patients with:
  • Systemic symptoms (persistent fever or chills)
  • Increasing leukocytosis
  • Age >80 years
  • Pregnancy
  • Immunocompromised status (receiving chemotherapy, high-dose steroids, or post-organ transplant)
  • Chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2
• When antibiotics are indicated for uncomplicated diverticulitis, first-line options include:
  • Oral amoxicillin/clavulanic acid or cefalexin with metronidazole 2
  • For patients unable to tolerate oral intake: IV antibiotics (cefuroxime or ceftriaxone plus metronidazole or ampicillin/sulbactam) 2

Complicated Diverticulitis

For Diverticulitis with Pericolic Gas

• In patients with CT findings of pericolic extraluminal gas, a trial of non-operative treatment with antibiotic therapy is recommended 3
• Elevated CRP level at presentation may predict treatment failure 3

For Diverticular Abscesses

• Small abscesses (<4-5 cm): Initial trial of non-operative treatment with antibiotics alone 3, 4

  • Systemic antibiotic therapy alone is considered safe and effective with a pooled failure rate of 20% and mortality rate of 0.6% 3
  • Antibiotic therapy alone for 7 days is recommended 4

• Large abscesses (>4-5 cm): Percutaneous drainage combined with antibiotic treatment 3, 4

  • When percutaneous drainage is not feasible, antibiotic therapy alone can be considered with careful clinical monitoring 3
  • Percutaneous drainage combined with antibiotic therapy for 4 days in immunocompetent patients 4
  • Antibiotic therapy up to 7 days in immunocompromised or critically ill patients 4

• For patients with beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 4

For Peritonitis

• Patients with diffuse peritonitis require:
  • Prompt fluid resuscitation
  • Immediate antibiotic administration
  • Urgent surgical intervention 1

Duration of Antibiotic Therapy

• 4 days of antibiotic therapy in immunocompetent and non-critically ill patients if source control is adequate 4, 1
• Up to 7 days based on clinical conditions and inflammation indices in immunocompromised or critically ill patients 4
• Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 4

Monitoring and Treatment Failure

• Surgical intervention should be considered if:
  • Patient shows worsening of inflammatory signs
  • Abscess does not reduce with medical therapy 3
• High suspicion for surgical control of the septic source should be maintained during non-operative management 3

Follow-up

• Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation 5
• Colonoscopy is also indicated for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who meet national bowel cancer screening criteria 5