What is the inpatient management plan for diverticulitis?

From the Guidelines

For inpatient management of diverticulitis, I recommend a comprehensive approach based on disease severity, prioritizing outpatient management for uncomplicated cases and reserving hospitalization for complicated cases or those with significant comorbidities, as suggested by the American College of Physicians guideline 1.

Key Considerations

• For uncomplicated diverticulitis, outpatient management is suggested with bowel rest, hydration, and selective use of antibiotics, considering the patient's ability to manage their condition at home and the absence of systemic inflammatory response or immunosuppression 1.
• Antibiotic treatment can be used selectively in immunocompetent patients with mild uncomplicated diverticulitis, focusing on those with signs of systemic inflammation or significant comorbidities 1.
• For complicated diverticulitis, particularly with abscess, CT-guided drainage should be considered for collections >4cm, alongside broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria 1.

Management Approach

• Bowel rest with clear liquids advancing as tolerated, and IV fluids for hydration, are initial steps in management.
• Pain control with acetaminophen and, if needed, opioids like hydromorphone, is appropriate.
• Monitor vital signs, abdominal exam findings, and inflammatory markers (WBC, CRP) daily to assess response to treatment and potential complications.
• Surgical consultation is necessary for peritonitis, perforation, obstruction, or failed medical management.
• Before discharge, transition to oral antibiotics like amoxicillin-clavulanate or ciprofloxacin plus metronidazole to complete a 10-14 day course, ensuring coverage for the polymicrobial nature of diverticular infections.

Evidence Basis

The recommendations are based on the most recent and highest quality studies, including the American College of Physicians guideline 1 and expert reviews from the World Journal of Emergency Surgery 1 and Gastroenterology 1, emphasizing a tailored approach to diverticulitis management that balances the need for effective treatment with the risks of antibiotic overuse and hospitalization.

From the Research

Inpatient Plan for Diverticulitis

• The general recommendation for inpatient management of diverticulitis includes intravenous fluid resuscitation and intravenous antibiotics 2.
• Episodes of diverticulitis severe enough to warrant hospitalization should be managed initially with intravenous antibiotics, and oral therapy can be used for outpatient treatment or when the patient's condition improves 3.
• Patients with a localized abscess may be candidates for computed tomography-guided percutaneous drainage 2.
• Fifteen to 30 percent of patients admitted with acute diverticulitis require surgical intervention during that admission, and laparoscopic surgery results in a shorter length of stay, fewer complications, and lower in-hospital mortality compared with open colectomy 2.

Antibiotic Selection

• The optimal antibiotic regimen to empirically treat complicated diverticulitis has not been well established in guidelines, but ceftriaxone and metronidazole was found to be non-inferior to piperacillin/tazobactam for the combined primary outcome of 30-day readmission or all-cause mortality 4.
• For patients with severe and complicated diverticulitis, ampicillin, gentamicin, metronidazole, piperacillin and tazobactam are the antibiotics successfully used in clinical practice 5.
• Ciprofloxacin, metronidazole and more recently, rifaximin, have been successfully used in the treatment of uncomplicated diverticular disease 5.

Treatment of Uncomplicated Diverticulitis

• The use of antibiotics for uncomplicated diverticulitis is questionable, as the condition may be inflammatory rather than infectious 6.
• The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications 6.
• There may be little or no difference between antibiotics and no antibiotics for short-term complications, and the rate of emergency surgery within 30 days may be lower with no antibiotics compared to antibiotics 6.