What is the management plan for diverticulitis?

Management of Diverticulitis

For immunocompetent patients with uncomplicated diverticulitis, observation without antibiotics is the recommended first-line treatment, as antibiotics do not accelerate recovery, prevent complications, or reduce recurrence rates. 1, 2, 3

Classification and Diagnosis

• Diverticulitis is defined as inflammation of diverticula (outpouchings) originating from the intestinal lumen 4
• Uncomplicated diverticulitis is localized diverticular inflammation without abscess or perforation 1, 2
• Complicated diverticulitis involves inflammation associated with abscess, phlegmon, fistula, obstruction, bleeding, or perforation 1, 3
• CT scan is the recommended diagnostic test with 98-99% sensitivity and 99-100% specificity, showing diverticula, wall thickening, and increased density of pericolic fat 4, 2

Treatment Algorithm for Uncomplicated Diverticulitis

Outpatient Management

• Outpatient management is appropriate for most patients with uncomplicated diverticulitis 2, 5
• Clear liquid diet during the acute phase, advancing as symptoms improve 2, 3
• Pain management with acetaminophen 4
• Re-evaluation within 7 days; earlier if clinical condition deteriorates 2, 3

When Antibiotics Are Indicated in Uncomplicated Diverticulitis

Antibiotics should be reserved for patients with:

• Systemic manifestations of infection or sepsis 1, 2
• Immunocompromised status 1, 2
• Advanced age (>80 years) 2, 4
• Significant comorbidities or frailty 1, 2
• Pregnancy 2, 4
• CRP >140 mg/L or WBC >15 × 10^9/L 1, 2
• Longer segment of inflammation or fluid collection on CT 1, 2
• Symptoms lasting longer than 5 days 1
• Presence of vomiting 1

Antibiotic Selection When Indicated

• Oral regimens: amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 4-7 days 2, 4
• IV regimens (for inpatients): ceftriaxone plus metronidazole or piperacillin-tazobactam 2, 4

Treatment of Complicated Diverticulitis

• Small abscesses (<4-5 cm): antibiotic therapy alone for 7 days 3
• Large abscesses (>4-5 cm): percutaneous drainage combined with antibiotic therapy for 4 days 3, 6
• For drained abscesses: ciprofloxacin 500mg orally twice daily plus metronidazole 500mg orally three times daily for 4-7 days 6
• Surgical intervention if clinical deterioration occurs or for peritonitis 3, 4
• Laparoscopic surgery is preferred over open colectomy when surgery is indicated 7

Inpatient vs. Outpatient Management

Indications for Inpatient Management

• Complicated diverticulitis 3
• Significant comorbidities 3
• Inability to tolerate oral intake 3
• Severe pain or systemic symptoms 3
• Immunocompromised status 2

Prevention of Recurrence

• High-fiber diet from fruits, vegetables, whole grains, and legumes 1, 2
• Regular physical activity, particularly vigorous exercise 1, 2
• Achieving or maintaining normal body mass index 2, 7
• Avoiding smoking 2
• Avoiding regular use of NSAIDs and opiates when possible 2
• Against routine elective colonic resection after an initial episode of acute uncomplicated diverticulitis 1

Follow-up Care

• Colonoscopy is recommended after resolution of acute diverticulitis to exclude colonic neoplasm if a high-quality examination has not been recently performed 1
• Not routinely recommended for CT-proven uncomplicated diverticulitis but should be considered for patients with diverticular abscesses 3

Common Pitfalls to Avoid

• Overuse of antibiotics in uncomplicated cases without risk factors 1, 2, 3
• Unnecessary dietary restrictions - consumption of nuts, corn, popcorn, and small-seeded fruits is not associated with increased risk 1, 2
• Assuming all patients with diverticulitis require inpatient management 2, 5
• Failing to recognize high-risk patients who need antibiotics despite having uncomplicated disease 3
• Prolonging antibiotic therapy beyond 7 days after adequate source control 6

Special Considerations

• Immunocompromised patients require a lower threshold for CT imaging, antibiotic treatment, and surgical consultation 2, 4
• Patients with corticosteroid use are at higher risk for complications, including perforation 2
• Young patients (<50 years) have increased risk for complicated or recurrent diverticulitis 3