What is the diagnosis and treatment for cecal diverticulitis (inflammation of a diverticulum in the cecum)?

From the Guidelines

Cecal diverticulitis should be diagnosed using abdominal CT imaging when there is diagnostic uncertainty, as it provides high sensitivity and specificity for an accurate diagnosis 1. When diagnosing cecal diverticulitis, a detailed history, physical examination, and laboratory findings are the first steps, but abdominal CT imaging can be used to complement these findings when diagnostic uncertainty remains.

• The use of CT imaging is supported by moderate-certainty evidence, which shows that it is associated with very high sensitivity and specificity for diagnosing diverticulitis 1.
• However, the clinical significance of detecting incidental findings with CT imaging is unclear, and potential harms include radiation exposure, side effects of contrast agents, and out-of-pocket costs 1.
• In patients with suspected cecal diverticulitis, clinicians should err on the side of imaging if there are predictors of progression to complicated diverticulitis, such as symptoms lasting longer than 5 days or signs of perforation, bleeding, obstruction, or abscess 1.

For patients with acute uncomplicated cecal diverticulitis, outpatient management is suggested, as it may have a lower risk of potential harms associated with hospitalization and lower costs 1. Outpatient management can be considered for immunocompetent patients with acute uncomplicated cecal diverticulitis who have no evidence of systemic inflammatory response and can continue treatment at home under medical supervision.

• Low-certainty evidence shows that there may be no differences in risk for elective surgery or long-term diverticulitis recurrence between outpatient and inpatient management 1.
• However, decision-making should take into account individual patient circumstances, such as the availability of adequate home care, and predictors of progression to complicated disease, such as symptoms lasting longer than 5 days or vomiting 1.

For select patients with acute uncomplicated cecal diverticulitis, initial management without antibiotics may be considered, as low-certainty evidence shows that there may be no differences in diverticulitis-related complications or quality of life between those receiving and those not receiving antibiotics 1. Initial management without antibiotics can be considered for immunocompetent patients with uncomplicated cecal diverticulitis who have no systemic inflammatory response or immunosuppression and can follow up as an outpatient under medical supervision.

• However, antibiotic treatment may slightly decrease treatment failure rates, and the use of antibiotics without evidence of important benefit to the patient may incur potential harms, such as increased costs and contribution to antibiotic resistance 1.
• Predictors of progression to complicated disease among patients with uncomplicated acute diverticulitis include symptoms lasting longer than 5 days, an initial pain score greater than 7, vomiting, systemic comorbidity, and high C-reactive protein levels 1.

From the Research

Definition and Classification of Cecal Diverticulitis

• Cecal diverticulitis is a condition where there is inflammation of a diverticulum in the cecum, which is the first part of the large intestine 2.
• The etiology of cecal diverticulitis remains unclear, but it is thought to be related to the same degenerative process that causes left-sided diverticulosis 2.
• Diverticulitis can be classified as uncomplicated or complicated, based on the presence of complications such as abscesses, perforation, or peritonitis 3, 4.

Clinical Presentation and Diagnosis

• Patients with cecal diverticulitis may present with symptoms such as abdominal pain, tenderness, fever, nausea, and vomiting, which can be similar to those of acute appendicitis 2, 5.
• The diagnosis of cecal diverticulitis is often made using computed tomography (CT) scans, which can show evidence of inflammation and complications such as abscesses or perforation 3, 4.
• Laboratory studies such as complete blood count, basic metabolic panel, and urinalysis may also be used to support the diagnosis 3.

Treatment and Management

• The treatment of cecal diverticulitis depends on the severity of the condition and the presence of complications 3, 4.
• Uncomplicated diverticulitis can be treated with outpatient management, including bowel rest and selective use of antibiotics 3, 4.
• Complicated diverticulitis may require non-operative management, including bowel rest and intravenous antibiotics, or surgical intervention, such as Hartmann procedure or primary anastomosis 3, 4.
• Surgical approach to cecal diverticulitis may include right hemicolectomy, diverticulectomy, or appendectomy with drainage of intraabdominal abscess 5.

Prevention and Recurrence

• Prevention of recurrences of diverticulitis may include increased intake of dietary fiber, exercise, cessation of smoking, and weight loss in obese individuals 3.
• The use of antibiotics such as amoxicillin-clavulanate may reduce the risk of fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 6.
• Colonoscopy is recommended for all patients with complicated diverticulitis and for patients with uncomplicated diverticulitis who have suspicious features on CT scan or who otherwise meet national bowel cancer screening criteria 4.