What is the management of diverticulitis?

Management of Diverticulitis

The management of diverticulitis should be guided by classification as uncomplicated or complicated disease, with selective use of antibiotics only for patients with systemic manifestations, immunocompromise, or significant comorbidities in uncomplicated cases. 1, 2, 3

Classification and Diagnosis

• Diverticulitis is classified as uncomplicated (localized inflammation) or complicated (inflammation with abscess, phlegmon, fistula, obstruction, bleeding, or perforation) 2, 4
• CT scan is the preferred diagnostic test with 98-99% sensitivity and 99-100% specificity, showing diverticula, wall thickening, and increased density of pericolic fat in uncomplicated cases 4, 5
• Laboratory studies should include complete blood count, basic metabolic panel, urinalysis, and C-reactive protein measurement 6, 7

Management of Uncomplicated Diverticulitis

• Outpatient management is appropriate for clinically stable, afebrile patients with uncomplicated diverticulitis 2, 3
• Antibiotics should be used selectively rather than routinely in uncomplicated diverticulitis 1, 3
• Supportive care includes bowel rest with clear liquid diet and adequate hydration 2, 8
• Pain management typically with acetaminophen is recommended 4

When to Use Antibiotics in Uncomplicated Diverticulitis

Antibiotics should be considered in patients with:

• Systemic manifestations of infection or sepsis 3, 8
• Immunocompromised status 8, 4
• Advanced age (>80 years) 8, 4
• Significant comorbidities (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 8, 4
• Elevated inflammatory markers (CRP >140 mg/L or WBC >15 × 10^9/L) 8
• Symptoms lasting longer than 5 days 2, 3

Antibiotic Selection When Indicated

• First-line oral antibiotics: amoxicillin/clavulanic acid or cefalexin with metronidazole 4
• For patients unable to tolerate oral intake: IV antibiotics (ceftriaxone plus metronidazole or piperacillin-tazobactam) 4
• Duration: 4-7 days for immunocompetent patients; up to 7 days for immunocompromised or critically ill patients 8

Management of Complicated Diverticulitis

• For small abscesses (<4-5 cm): antibiotic therapy alone for 7 days 3, 8
• For large abscesses (≥4-5 cm): percutaneous drainage combined with antibiotic therapy 3, 8, 5
• Surgical intervention is indicated for peritonitis, failure of non-operative management, or clinical deterioration 8, 5
• Laparoscopic surgery is preferred over open colectomy when surgery is required 6

Follow-up Care

• Colonoscopy is recommended 4-6 weeks after resolution of symptoms for patients with complicated diverticulitis or who have not had a high-quality colonoscopy in the past year 1, 3
• The optimal timing is typically 6-8 weeks after resolution of acute diverticulitis 1

Prevention Strategies

• A fiber-rich diet or fiber supplementation is recommended for patients with a history of diverticulitis 1, 3
• Regular physical activity should be encouraged 1, 3
• Avoid non-aspirin NSAIDs when possible 1, 3
• Achieve or maintain healthy body weight (BMI 18-25 kg/m²) 6, 7
• Avoid tobacco use 6, 7

Common Pitfalls to Avoid

• Overuse of antibiotics in uncomplicated diverticulitis without systemic manifestations contributes to antibiotic resistance without clinical benefit 3, 8
• Failure to recognize high-risk patients who need antibiotics despite having uncomplicated disease 8
• Failure to identify predictors of progression to complicated disease (symptoms >5 days, vomiting, high CRP levels, high pain scores) 2, 3
• Performing colonoscopy during an acute flare rather than waiting 4-6 weeks after resolution 7
• Recommending elective colonic resection after an initial episode of uncomplicated diverticulitis 1