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

From the Guidelines

Mild diverticulitis can typically be managed without antibiotics in immunocompetent patients, with a focus on rest, dietary modifications, and pain management. According to the most recent and highest quality study, antibiotics are not necessary for uncomplicated diverticulitis in immunocompetent patients without signs of systemic inflammation 1.

Key Considerations

• The definition of uncomplicated acute diverticulitis is crucial, and it is defined as localized diverticular inflammation without any abscess or perforation.
• The current consensus is that uncomplicated acute diverticulitis may be a self-limiting condition in which local host defenses can manage the inflammation without antibiotics in immunocompetent patients.
• A recent study found that antibiotic treatment for acute uncomplicated diverticulitis neither accelerated recovery nor prevented complications or recurrence 1.

Management Approach

• For uncomplicated cases, a clear liquid diet for 2-3 days, followed by a gradual transition to a low-fiber diet until symptoms resolve, is recommended.
• Pain can be managed with acetaminophen; avoid NSAIDs as they may increase complications.
• Stay well-hydrated and rest until symptoms improve.
• If you experience worsening pain, fever above 101°F, inability to tolerate fluids, or bloody stools, seek immediate medical attention as these may indicate complications requiring hospitalization.

Antibiotic Use

• Antibiotics are recommended for patients with complicated diverticulitis, those with systemic inflammation, or immunocompromised patients 1.
• When antibiotic treatment is necessary, the regimen usually includes broad-spectrum agents with gram-negative and anaerobic coverage, such as a combination of an oral fluoroquinolone and metronidazole or monotherapy with oral amoxicillin-clavulanate 1.

Prevention

• Maintaining good bowel habits with adequate fiber and hydration helps prevent future episodes of diverticulitis.
• Slowly increase fiber intake to 25-30g daily after recovery to prevent recurrence.

From the Research

Treatment of Mild Diverticulitis

• The treatment of mild diverticulitis can be managed without antibiotics in selected patients, and antibiotics should be given on indication only 2.
• Outpatient treatment with oral antibiotics is safe and effective for patients with uncomplicated acute diverticulitis, and can be applicable to most patients with tolerance to oral intake and without severe comorbidity 3.
• A study found that outpatient treatment for uncomplicated/mild complicated diverticulitis is feasible and safe, with prognostic factors of failure necessitating closer follow-up being admission/CT time, Ambrosetti score of 4, and free air around the colon 4.
• Mild diverticulitis should essentially be treated by means of hydration and adjustments in the dietary regimen, and antibiotics are not necessary when its course is uncomplicated and improvement is achieved 5.

Management and Diagnosis

• The diagnosis of diverticular disease includes clinical data, routine laboratory tests for inflammation, calprotectin in stool, coloscopy, ultrasound, CT, and magnetic resonance 5.
• The management of uncomplicated acute diverticulitis can vary among colon and rectal surgeons, especially in terms of antibiotic choice, discharge instructions, and follow-up outpatient studies 6.
• A survey found that the majority of colon and rectal surgeons choose an abdominal computed tomographic scan as the initial diagnostic test, and use a single intravenous antibiotic with second-generation cephalosporins being the most common 6.

Risk Factors and Complications

• Risk factors for diverticular disease include smoking, use of opiates and corticoids, obesity, alcoholism, hypertension, polycystosis, immunosuppression, and use of non-steroid antiflogistics 5.
• Complications of diverticular disease can be treated conservatively, and the proportion of surgeries is decreasing, with the efficiency of conservative treatment of diverticulitis increasing 5.
• Abscess should primarily be treated via non-surgical drainage, and even perforation and peritonitis can be treated via laparoscopic drainage without subsequent surgery being necessary 5.