Management of Diverticulitis
For patients with uncomplicated diverticulitis, outpatient management with selective antibiotic use is recommended, while complicated diverticulitis requires inpatient care with antibiotics and possible interventional procedures. 1
Classification and Diagnosis
- Uncomplicated diverticulitis is defined as localized inflammation without abscess, perforation, fistula, or obstruction 1, 2
- Complicated diverticulitis involves inflammation associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1, 2
- CT scan is the gold standard for diagnosis, showing diverticula, wall thickening, and increased density of pericolic fat 2, 3
Management of Uncomplicated Diverticulitis
Outpatient Treatment
- Outpatient management is appropriate for most patients with uncomplicated diverticulitis who can tolerate oral intake and have adequate home support 1
- Clear liquid diet during the acute phase, advancing as symptoms improve 2, 4
- Re-evaluation within 7 days; earlier if clinical deterioration occurs 1, 2
Antibiotic Use
- Antibiotics should be used selectively rather than routinely in uncomplicated diverticulitis 1, 2
- Observation with supportive care (bowel rest and hydration) is recommended for immunocompetent patients without systemic inflammatory response 1
Indications for Antibiotics in Uncomplicated Diverticulitis
- Systemic inflammatory response or signs of sepsis 1, 2
- Immunocompromised status 2, 5
- Advanced age (>80 years) 2, 3
- Significant comorbidities 1, 2
- CRP >140 mg/L or WBC >15 × 10^9/L 2, 5
- Symptoms lasting >5 days or presence of vomiting 2, 5
- Longer segment of inflammation or fluid collection on CT 2, 5
Antibiotic Selection When Indicated
- Oral antibiotics: amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 4-7 days 2, 3
- Duration: 4-7 days for immunocompetent patients; 10-14 days for immunocompromised patients 2, 5
Management of Complicated Diverticulitis
- Inpatient management with IV fluids and antibiotics 1, 6
- For small abscesses (<4-5 cm): antibiotic therapy alone for 7 days 2, 6
- For large abscesses (>4-5 cm): percutaneous drainage combined with antibiotic therapy 2, 6
- IV antibiotics with gram-negative and anaerobic coverage (ceftriaxone plus metronidazole or piperacillin-tazobactam) 5, 6
- Surgical consultation for peritonitis, large abscesses not amenable to drainage, or clinical deterioration 6, 4
Indications for Inpatient Management
- Complicated diverticulitis (abscess, perforation, fistula, obstruction, bleeding) 1, 6
- Inability to tolerate oral intake 1, 6
- Severe pain or significant comorbidities 2, 6
- Systemic inflammatory response or sepsis 1, 6
- Immunocompromised status 2, 6
Prevention of Recurrence
- Fiber-rich diet or fiber supplementation 1, 5
- Regular physical activity, particularly vigorous exercise 1, 5
- Achieving or maintaining normal body mass index 5, 3
- Avoiding smoking 5, 3
- Avoiding regular use of NSAIDs and opiates when possible 5, 3
Common Pitfalls to Avoid
- Unnecessary use of antibiotics in low-risk patients with uncomplicated diverticulitis contributes to antibiotic resistance without providing benefit 1, 2
- Failure to recognize high-risk patients who need antibiotics despite having uncomplicated disease can lead to progression to complicated diverticulitis 2, 5
- Delaying antibiotics in patients with complicated diverticulitis or high-risk factors can lead to worse outcomes 6, 3
- Restricting consumption of nuts, corn, popcorn, or small-seeded fruits is not necessary as they are not associated with increased risk of diverticulitis 1, 5
- Failing to recognize clinical deterioration requiring surgical intervention can lead to poor outcomes 6, 4