From the Guidelines
The workup for a 33-year-old patient with suspected diverticulitis should begin with a detailed history, physical examination, and laboratory findings, followed by abdominal CT imaging when there is diagnostic uncertainty, as recommended by the American College of Physicians 1. The initial evaluation should focus on assessing the severity of symptoms, including abdominal pain, fever, and changes in bowel habits. Laboratory tests such as a complete blood count, C-reactive protein, and basic metabolic panel can help identify signs of inflammation and infection. Urinalysis is also essential to rule out urinary tract pathology.
- Key considerations in the workup include:
- Assessing for predictors of progression to complicated diverticulitis, such as symptom duration longer than 5 days, vomiting, systemic comorbidity, and high C-reactive protein levels 1
- Evaluating the need for imaging, with CT scan being the preferred modality for its high sensitivity and specificity in diagnosing diverticulitis 1
- Considering alternative diagnoses, such as cancer, gynecologic or renal causes of acute abdomen, or inflammatory bowel disease, especially in patients without a history of diverticulitis or with atypical symptoms 1 Abdominal CT imaging is associated with very high sensitivity and specificity for diagnosing diverticulitis, and its use can help establish the diagnosis and guide management decisions 1. In patients with suspected diverticulitis, the use of CT imaging can help identify complications such as abscess formation, perforation, or obstruction, which may require urgent surgical intervention.
- The management of diverticulitis should be individualized based on the severity of symptoms, patient comorbidities, and the presence of complications.
- For patients with uncomplicated diverticulitis, outpatient management with supportive care and selective use of antibiotics may be appropriate, as suggested by the American College of Physicians 1 and the American Gastroenterological Association 2. Outpatient management without antibiotics can be considered for select patients with acute uncomplicated left-sided colonic diverticulitis, as it may not be associated with significant differences in diverticulitis-related complications or quality of life 1. However, the decision to use antibiotics should be based on individual patient factors, including the severity of symptoms, presence of comorbidities, and risk of complications.
- Follow-up colonoscopy is typically recommended 6-8 weeks after resolution of symptoms to exclude other pathologies, particularly in patients with their first episode of diverticulitis or those with concerning features 2. Overall, the workup and management of diverticulitis should prioritize a patient-centered approach, taking into account individual patient factors, symptoms, and preferences, as well as the latest evidence-based guidelines 1, 2.
From the Research
Diagnostic Approach
- For a 33-year-old patient with suspected diverticulitis, radiological evidence of inflammation using computed tomography (CT) is needed to diagnose the first occurrence of diverticulitis 3.
- CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred 3.
Classification and Management
- Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms, and patient history; this classification is used to direct management 3.
- Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis 3.
- For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 3, 4.
Antibiotic Treatment
- The use of antibiotics in uncomplicated diverticulitis is uncertain, with some studies suggesting no difference in outcomes between antibiotic and no antibiotic treatment 4.
- For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses 3.
- The choice of antibiotic regimen is not well established, but antibiotics with activity against common gram-negative and anaerobic pathogens are recommended 5.
- Amoxicillin-clavulanate may be a suitable alternative to metronidazole-with-fluoroquinolone for outpatient diverticulitis, with potentially reduced risk of fluoroquinolone-related harms 6.
Follow-up and Colonoscopy
- Colonoscopy is recommended for all patients with complicated diverticulitis 6 weeks after CT diagnosis of inflammation, and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 3.