What is the management plan for diverticulitis?

Management of Diverticulitis

For patients with uncomplicated diverticulitis who are immunocompetent without systemic inflammatory response, observation with supportive care without antibiotics is the recommended first-line approach. 1, 2

Classification and Diagnosis

• Diverticulitis is classified as uncomplicated (localized inflammation) or complicated (associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation) 1, 3
• CT scan is the gold standard for diagnosis, with findings including intestinal wall thickening, signs of inflammation in pericolonic fat, and thickening of lateroconal fascia 2, 4
• Annual incidence of diverticulitis in the US is approximately 180 per 100,000 people, resulting in about 200,000 hospital admissions annually 4

Management of Uncomplicated Diverticulitis

Outpatient Management

• Outpatient treatment is appropriate for patients with uncomplicated diverticulitis who are able to take fluids orally and manage themselves at home 1, 3
• Re-evaluation within 7 days is recommended, with earlier follow-up if clinical condition deteriorates 1, 2
• Outpatient management can reduce healthcare costs by 35-83% per episode compared to inpatient management 1, 5

Antibiotic Use

• Antibiotics should be used selectively rather than routinely in uncomplicated diverticulitis 1, 2
• Antibiotics are indicated for patients with:
  • Immunocompromised status 1, 2, 4
  • Systemic inflammatory response 1, 2, 3
  • Age >80 years 2, 4
  • Pregnancy 4
  • Significant comorbidities 2, 3
  • CRP >140 mg/L or WBC >15 × 10^9/L 1, 2, 3
  • Longer segment of inflammation or fluid collection on CT 1, 2
  • Symptoms lasting >5 days 1, 2
  • Presence of vomiting 1, 2

Antibiotic Selection When Indicated

• Oral options include:
  • Ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily for 7-10 days 2, 6, 5
  • Amoxicillin-clavulanate 875/125mg twice daily 2, 6, 4
• For patients requiring IV antibiotics:
  • Ceftriaxone plus metronidazole 2, 4
  • 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, 7
• For large abscesses (>4-5 cm), percutaneous drainage combined with antibiotic therapy 3, 6, 7
• After drainage of diverticular abscess, oral step-down therapy with ciprofloxacin plus metronidazole is recommended 6, 7
• Surgical intervention is indicated for peritonitis, failure of non-operative management, or after multiple recurrences 1, 7

Prevention of Recurrence

• High-fiber diet or fiber supplementation is recommended after resolution of acute diverticulitis 1, 2, 8
• Regular physical activity, particularly vigorous exercise, is recommended 2, 9
• Achieving or maintaining normal body mass index 2, 9
• Avoiding smoking 2
• Avoiding regular use of NSAIDs and opiates when possible 2, 8

Follow-up Care

• Colonoscopy is recommended after resolution of acute diverticulitis in appropriate candidates to exclude colonic neoplasm if a high-quality examination has not been recently performed 1, 7
• For chronic abdominal pain after diverticulitis with no evidence of inflammation, low to modest doses of tricyclic antidepressants may be considered 2

Common Pitfalls to Avoid

• Overuse of antibiotics in uncomplicated cases without risk factors contributes to antibiotic resistance 1, 2, 3
• Failing to recognize high-risk patients who need antibiotics despite having uncomplicated disease can lead to progression 2, 3
• Unnecessarily restricting consumption of nuts, corn, popcorn, or small-seeded fruits is not recommended 1, 2
• Prolonging antibiotic therapy beyond 7 days after adequate source control increases risk of C. difficile infection 6
• Delaying transition from IV to oral antibiotics can unnecessarily prolong hospitalization 1, 2