What is the treatment for diverticulitis?

Treatment for 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

Classification and Treatment Approach

• Diverticulitis is classified as uncomplicated (absence of abscess, colon strictures, perforation, or fistula formation) or complicated based on clinical presentation and imaging findings 2
• Approximately 85% of patients with acute diverticulitis have uncomplicated disease 2
• CT scan is the recommended diagnostic test with 98-99% sensitivity and 99-100% specificity for confirming the diagnosis and assessing severity 2

Treatment of 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) 2
  • Dietary modification with a clear liquid diet 2
  • Ambulatory treatment is associated with significant cost savings compared to hospitalization 1

• Antibiotics should be reserved for specific patient populations with uncomplicated diverticulitis:

  • Patients with systemic symptoms (persistent fever or chills) 2
  • Those with increasing leukocytosis 2
  • Patients older than 80 years 2
  • Pregnant patients 2
  • Immunocompromised patients (receiving chemotherapy, high-dose steroids, or post-transplant) 2
  • Patients with chronic medical conditions (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2

• When antibiotics are indicated for uncomplicated diverticulitis:

  • First-line oral options: amoxicillin/clavulanic acid or cefalexin with metronidazole 2
  • For patients unable to tolerate oral intake: IV cefuroxime or ceftriaxone plus metronidazole or ampicillin/sulbactam 2

Treatment of Complicated Diverticulitis

Diverticulitis with Small Abscess (<4-5 cm)

• Initial trial of non-operative treatment with antibiotics alone is recommended 3, 1
• This approach has a pooled failure rate of 20% and mortality rate of 0.6% 3
• Antibiotic therapy for 7 days is typically recommended 4

Diverticulitis with Large Abscess (≥4-5 cm)

• Percutaneous drainage combined with antibiotic treatment is recommended 3, 1, 4
• When percutaneous drainage is not feasible, antibiotic therapy alone can be considered with careful clinical monitoring 3
• Surgical intervention should be considered if the patient shows worsening inflammatory signs or if the abscess doesn't respond to medical therapy 3, 4
• Antibiotic therapy for 4 days in immunocompetent patients after adequate source control 4
• Extended therapy up to 7 days may be needed for immunocompromised or critically ill patients 4

Diverticulitis with Peritonitis

• Patients require prompt fluid resuscitation, immediate antibiotic administration, and urgent surgical intervention 1, 5
• Surgical options include Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy 5
• Empiric antibiotic regimens should be based on patient's clinical condition, presumed pathogens, and risk factors for antimicrobial resistance 1
• IV antibiotics such as ceftriaxone plus metronidazole or piperacillin-tazobactam are appropriate 2

Duration of Antibiotic Therapy

• A 4-day period of postoperative antibiotic therapy is recommended if source control has been adequate in immunocompetent patients 1, 4
• Up to 7 days may be needed for immunocompromised or critically ill patients 4
• Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 4

Monitoring and Follow-up

• Elevated C-reactive protein (CRP) at presentation may predict treatment failure 3, 4
• Colonoscopy is recommended 6 weeks after CT diagnosis for all patients with complicated diverticulitis to exclude malignancy 5
• 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

Important Caveats

• The traditional recommendation for colectomy after 2 episodes of diverticulitis is no longer accepted 1
• For patients with beta-lactam allergy, alternative regimens include eravacycline or tigecycline 4
• Augmentin (amoxicillin/clavulanate) may have limited coverage against potential pathogens in complicated intra-abdominal infections 4
• Postoperative mortality varies significantly between elective (0.5%) and emergent (10.6%) colon resection 2