Management and Treatment of Diverticulitis
Initial Diagnostic Approach
For patients with suspected acute diverticulitis, obtain a CT scan with oral and intravenous contrast to confirm diagnosis and assess for complications. 1, 2
- CT imaging has 98-99% sensitivity and 99-100% specificity for diagnosing acute diverticulitis 3
- CT findings help classify disease as uncomplicated (localized inflammation only) versus complicated (abscess, perforation, fistula, obstruction, or bleeding) 1, 4
- Laboratory studies should include complete blood count, C-reactive protein, and basic metabolic panel 5
- High-risk features predicting progression to complicated disease include: symptoms >5 days, CRP >140 mg/L, WBC >15 × 10⁹ cells/L, pericolic extraluminal air on CT, fluid collection, or longer inflamed colon segment 1, 2
Treatment of Uncomplicated Diverticulitis
First-Line Management: Observation Without Antibiotics
Most immunocompetent patients with uncomplicated diverticulitis should be managed with observation and supportive care alone, without antibiotics. 2, 4
- Multiple high-quality randomized trials (including the DIABOLO trial with 528 patients) demonstrate that antibiotics neither accelerate recovery nor prevent complications or recurrence in uncomplicated cases 2, 6
- Supportive care consists of: clear liquid diet during acute phase, advancing as tolerated; pain control with acetaminophen only; and bowel rest 2, 4
- Re-evaluation within 7 days is mandatory, with earlier assessment if symptoms worsen 2, 4
When to Use Antibiotics in Uncomplicated Diverticulitis
Reserve antibiotics for patients with specific high-risk features: 2, 4
- Immunocompromised status (chemotherapy, high-dose steroids, organ transplant, corticosteroid use) 2, 3
- Age >80 years 2, 3
- Pregnancy 2, 3
- Persistent fever or chills despite supportive care 2, 3
- Increasing leukocytosis or elevated inflammatory markers (CRP >140 mg/L or WBC >15 × 10⁹ cells/L) 2, 3
- Refractory symptoms or vomiting 2, 4
- Inability to maintain oral hydration 2, 4
- Significant comorbidities (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2, 3
- CT findings of fluid collection, longer segment of inflammation, or pericolic extraluminal air 1, 2
- ASA score III or IV 1, 2
Antibiotic Regimens When Indicated
Outpatient oral regimens (4-7 days for immunocompetent patients): 2, 6
- First-line: Ciprofloxacin 500 mg orally twice daily PLUS metronidazole 500 mg orally three times daily 2, 6
- Alternative: Amoxicillin-clavulanate 875/125 mg orally twice daily 2, 6
Inpatient IV regimens (transition to oral as soon as tolerated): 2, 6
Outpatient vs. Inpatient Management
Outpatient management is appropriate for patients who meet ALL criteria: 1, 2
- Able to tolerate oral fluids and medications 1, 2
- Temperature <100.4°F (38°C) 2
- Pain controlled with acetaminophen alone (pain score <4/10) 2
- No significant comorbidities or frailty 1, 2
- Adequate home and social support 1, 2
- No signs of systemic inflammatory response or sepsis 1, 2
Hospitalization is required for: 1, 2
- Complicated diverticulitis 1, 2
- Inability to tolerate oral intake 1, 2
- Severe pain or systemic symptoms 1, 2
- Signs of peritonitis or sepsis 1, 2
- Significant comorbidities or immunocompromised status 1, 2
Treatment of Complicated Diverticulitis
All patients with complicated diverticulitis require hospitalization, IV antibiotics, and surgical consultation. 2, 4
Abscess Management
- Small abscesses (<4-5 cm): IV antibiotics alone for 7 days 2, 4
- Large abscesses (≥4-5 cm): Percutaneous CT-guided drainage PLUS IV antibiotics for 4 days 2, 4
- After adequate drainage, antibiotic duration is 4 days for immunocompetent patients with adequate source control 2, 6
Surgical Indications
Emergent surgery is indicated for: 2, 3
- Generalized peritonitis 2, 3
- Sepsis or septic shock 2, 3
- Failed medical management 2, 3
- Inability to drain abscess percutaneously 2, 3
Surgical options include: 3, 7
- Primary resection with anastomosis (preferred in stable patients) 7
- Hartmann procedure (for critically ill patients with diffuse peritonitis) 7
- Laparoscopic approach results in shorter hospital stay, fewer complications, and lower mortality compared to open surgery 5
Post-Acute Management and Prevention
Follow-Up Colonoscopy
Colonoscopy should be performed 4-6 weeks after symptom resolution for: 2, 7
- All patients with complicated diverticulitis (7.9% risk of colon cancer) 2
- Patients with first episode of uncomplicated diverticulitis who haven't had colonoscopy in past year 2
- Patients >50 years requiring routine screening 2
- Patients with suspicious CT findings 7
Lifestyle Modifications to Prevent Recurrence
Evidence-based interventions to reduce recurrence risk: 2
- High-quality diet: High in fiber from fruits, vegetables, whole grains, legumes (>22.1 g/day); low in red meat and sweets 2
- Regular vigorous physical activity 2
- Achieve or maintain normal BMI (18-25 kg/m²) 2
- Smoking cessation 2
- Avoid regular use of NSAIDs and opioids when possible 2, 3
Do NOT restrict: Nuts, corn, popcorn, or small-seeded fruits (no evidence of increased risk) 2
Do NOT prescribe: Mesalamine or rifaximin for prevention (strong evidence against efficacy) 2
Elective Surgery Considerations
Elective sigmoidectomy should be individualized based on: 2
The traditional "two-episode rule" is no longer accepted - decision should not be based solely on number of episodes 2
- The DIRECT trial demonstrated significantly better quality of life at 6 months with elective sigmoidectomy versus conservative management in patients with recurrent/persistent symptoms 2
- Postoperative mortality: 0.5% for elective resection vs. 10.6% for emergent resection 3
Critical Pitfalls to Avoid
- Overusing antibiotics in uncomplicated diverticulitis without risk factors - contributes to antibiotic resistance without clinical benefit 1, 2
- Failing to recognize high-risk features that predict progression to complicated disease 1, 2
- Assuming all patients require hospitalization when most can be safely managed outpatient with 35-83% cost savings 1, 2
- Applying "no antibiotics" approach to complicated diverticulitis - evidence for observation excludes patients with abscesses and higher Hinchey stages 2
- Delaying surgical consultation in patients with frequent recurrence affecting quality of life 2
- Stopping antibiotics early even if symptoms improve when antibiotics are indicated 2
- Unnecessarily restricting diet (avoiding nuts, seeds, popcorn) - not evidence-based 2