Treatment of Acute Diverticulitis
The treatment of acute diverticulitis should be tailored based on disease severity, with antibiotics used selectively rather than routinely in uncomplicated cases, focusing instead on supportive care with clear liquid diet and pain control for immunocompetent patients. 1
Classification of Diverticulitis
- Uncomplicated diverticulitis: Localized diverticular inflammation without abscess or perforation, typically confirmed by CT scan showing diverticula, wall thickening, and increased density of pericolic fat 1
- Complicated diverticulitis: Involves abscess formation, perforation, fistula, or obstruction 1
Treatment Algorithm for Uncomplicated Diverticulitis
First-Line Approach
- For immunocompetent patients with uncomplicated diverticulitis, antibiotics are not recommended as first-line therapy 1, 2
- Management should focus on:
When to Use Antibiotics in Uncomplicated Diverticulitis
Antibiotics should be reserved for patients with:
- Systemic manifestations of infection 1, 2
- Immunocompromised status 1, 2
- Advanced age (>80 years) 1, 2
- Significant comorbidities 1, 2
- CRP >140 mg/L or WBC >15 × 10^9/L 1, 2
- Longer segment of inflammation or fluid collection on CT 1, 2
- ASA score III or IV 2
- Symptoms lasting >5 days 2
- Presence of vomiting 2
Antibiotic Selection When Indicated
- Oral antibiotics are preferred whenever possible 1
- Outpatient regimens:
- Duration: 4-7 days for immunocompetent patients; up to 10-14 days for immunocompromised patients 1, 2
Treatment of Complicated Diverticulitis
- For small abscesses (<4-5 cm): Antibiotic therapy alone for 7 days 1
- For large abscesses (>4-5 cm): Percutaneous drainage combined with antibiotic therapy for 4 days 1
- Inpatient antibiotic regimens with gram-negative and anaerobic coverage (options include ciprofloxacin, ceftriaxone, and piperacillin/tazobactam) 2
- Surgical intervention if clinical deterioration occurs 1
Outpatient vs. Inpatient Management
Outpatient Management Criteria
- Uncomplicated diverticulitis 1, 5
- Ability to tolerate oral intake 2, 4
- No significant comorbidities 2, 4
- Adequate family support 4
Inpatient Management Criteria
- Complicated diverticulitis 1
- Significant comorbidities 1, 2
- Inability to tolerate oral intake 1, 2
- Severe pain or systemic symptoms 1
- Lack of adequate support at home 4
Follow-up Care
- Re-evaluation within 7 days from diagnosis 2
- Earlier re-evaluation if clinical condition deteriorates 2
- Follow-up colonoscopy should be considered for patients with diverticular abscesses to rule out underlying malignancy 1
Prevention of Recurrence
- High-quality diet high in fiber from fruits, vegetables, whole grains, and legumes 2
- Regular physical activity 2
- Achieving or maintaining normal body mass index 2
- Avoiding smoking 2
- Avoiding regular use of NSAIDs and opiates when possible 2
Important Considerations and Pitfalls
- Failure to recognize high-risk patients who need antibiotics despite having uncomplicated disease can lead to progression to complicated diverticulitis 1, 3
- Unnecessary use of antibiotics in low-risk patients with uncomplicated diverticulitis provides no benefit and contributes to antibiotic resistance 1, 6
- Young patients (<50 years) and those with high pain scores (≥8/10) have increased risk for complicated or recurrent diverticulitis and should be monitored more closely 1
- The transition from IV to oral antibiotics should be made as soon as possible to facilitate earlier discharge 2
- Multiple high-quality randomized controlled trials have demonstrated that antibiotic therapy neither accelerates recovery nor prevents complications or recurrence in uncomplicated diverticulitis 3, 6