What are the treatment options for diverticulitis (inflammation of the diverticula)?

From the Guidelines

Diverticulitis treatment should be individualized based on severity, with mild cases managed at home and severe cases requiring hospitalization. For mild diverticulitis, treatment includes a clear liquid diet for 2-3 days before gradually reintroducing solid foods, and antibiotic treatment can be used selectively, rather than routinely, in immunocompetent patients with mild uncomplicated diverticulitis 1. Severe cases require hospitalization for intravenous antibiotics, possible bowel rest (nothing by mouth), and in some cases, surgical intervention. After recovery, a high-fiber diet (25-30g daily) with adequate hydration helps prevent recurrence by reducing pressure in the colon. Foods like whole grains, fruits, vegetables, and legumes are beneficial, while processed foods should be limited. Regular exercise also supports bowel health. Patients should seek immediate medical attention if they experience severe abdominal pain, fever, inability to keep liquids down, or persistent symptoms despite treatment, as complications like abscess, perforation, or obstruction may require emergency care. Some key considerations for treatment include:

• The use of computed tomography (CT) imaging for diagnosis, particularly when there is diagnostic uncertainty 1.
• The management of most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting 1.
• The initial management of select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics 1.
• The consideration of patient values and preferences in treatment decisions, including the potential benefits and harms of different management strategies 1. It's also important to note that antibiotic treatment is advised in patients with uncomplicated diverticulitis who have comorbidities or are frail, who present with refractory symptoms or vomiting, or who have a CRP >140 mg/L or baseline white blood cell count > 15 × 109 cells per liter 1. Overall, the treatment of diverticulitis should be tailored to the individual patient's needs and circumstances, taking into account the severity of the disease, the presence of comorbidities, and the patient's values and preferences.

From the Research

Treatment Options for Diverticulitis

• The management of diverticulitis can be classified into uncomplicated and complicated cases, with treatment directed accordingly 2.
• For uncomplicated diverticulitis, outpatient treatment is recommended for afebrile, clinically stable patients, and antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence 2, 3.
• Complicated diverticulitis requires non-operative management, including bowel rest and intravenous antibiotics, for small abscesses, while larger abscesses may require percutaneous drainage 2.
• Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration, and urgent surgery 2.

Role of Antibiotics in Treating Diverticulitis

• The use of antibiotics in treating uncomplicated diverticulitis is uncertain, with low-certainty evidence suggesting little or no difference between antibiotics and no antibiotics in reducing short-term complications 3.
• Antibiotics may be beneficial in selected patients with uncomplicated diverticulitis, but the evidence is limited 4.
• In complicated diverticulitis, antibiotics play a key role in management, particularly in patients with abscesses or peritonitis 2, 4.

Conservative Treatment Strategies

• Conservative treatment strategies for acute colonic diverticulitis have become more prominent, with uncomplicated patients able to be treated without antibiotics, bed rest, or dietary restrictions 5.
• Patients with isolated pericolic extraluminal air can also be treated conservatively, and selected patients can be treated as outpatients 5.
• New treatment strategies, such as mesalazine, rifaximin, and probiotics, have emerged, but their efficacy in acute diverticulitis patients is uncertain or insufficiently studied 5.

Antimicrobial Therapy

• The selection of antimicrobial agents for the treatment of acute diverticulitis is largely based on tradition, in vitro analyses, and indirect evidence from studies of complicated intra-abdominal infections 6.
• There is little evidence to support the superiority of specific antimicrobial regimens, and the optimal duration of antimicrobial therapy is unknown 6.