What is the best approach to manage diverticulitis in a patient?

How to Explain Diverticulitis to a Patient

Diverticulitis is an infection or inflammation of small pouches (diverticula) that have formed in your colon wall—think of them as tiny bulges that can become inflamed and infected, causing left lower belly pain, fever, and changes in bowel habits. 1

What Are Diverticula and How Do They Cause Problems?

• Diverticula are small outpouchings that develop in the wall of your colon over time, similar to weak spots in a tire that bulge outward. 2
• Most people with these pouches (called diverticulosis) never have symptoms—in fact, about 50-66% of people over 80 have them without knowing it. 2
• Only 1-4% of people with diverticula will develop diverticulitis (the infection/inflammation) in their lifetime. 2
• When one of these pouches becomes blocked or inflamed, bacteria can multiply and cause an infection, leading to the pain and symptoms you're experiencing. 1

What Symptoms Should You Expect?

• The hallmark symptom is left lower belly pain that typically comes on gradually and may be constant or cramping. 2
• You may experience fever, chills, nausea, vomiting, and changes in bowel habits (either constipation or diarrhea). 2
• Some patients notice bloating or loss of appetite during an acute episode. 1

How Did This Happen? (Risk Factors)

• Age is the biggest factor—your risk increases significantly after age 65, though younger people can develop it too. 2
• Genetics play a surprisingly large role, accounting for about 50% of your risk, so family history matters. 1
• Certain medications increase risk, particularly NSAIDs (like ibuprofen), opioid pain medications, and steroids. 1, 2
• Lifestyle factors that increase risk include: obesity (BMI over 30), smoking, lack of physical activity, and low fiber intake. 1, 2
• Medical conditions like diabetes, high blood pressure, and connective tissue disorders also elevate your risk. 2

What Treatment Do You Need?

For Uncomplicated Diverticulitis (No Abscess or Perforation):

• Most patients with uncomplicated diverticulitis do NOT need antibiotics—observation with pain control (typically acetaminophen) and a clear liquid diet is the first-line approach. 1, 2
• You should start with clear liquids (broth, juice, gelatin) during the acute phase, then gradually advance your diet as symptoms improve. 1
• Antibiotics are reserved for specific situations: if you have persistent fever, increasing white blood cell count, are over 80 years old, pregnant, immunocompromised (on chemotherapy, high-dose steroids, or have had an organ transplant), or have serious chronic conditions like cirrhosis, kidney disease, or heart failure. 1, 2

If Antibiotics Are Needed:

• The typical outpatient regimen is amoxicillin-clavulanate (Augmentin) 875/125 mg twice daily OR ciprofloxacin 500 mg twice daily plus metronidazole 500 mg three times daily. 1, 2
• Treatment duration is 4-7 days for most patients, or 10-14 days if you're immunocompromised. 1
• You can usually be treated at home if you can keep down fluids and medications, don't have severe pain, and have someone to check on you. 1

When Hospitalization Is Needed:

• You need to be admitted if you: cannot tolerate oral intake, have severe pain requiring IV pain medication, show signs of sepsis (severe infection), have significant other medical problems, or have complications like an abscess. 1, 2
• Hospital treatment includes IV fluids, IV antibiotics (such as ceftriaxone plus metronidazole or piperacillin-tazobactam), and close monitoring. 1, 2

What About Complications?

• About 85% of diverticulitis cases are "uncomplicated" (no abscess, perforation, or fistula). 2
• If an abscess forms: Small abscesses under 4-5 cm can often be treated with antibiotics alone, while larger ones may need drainage with a needle placed through your skin under CT guidance. 1, 3
• Perforation (a hole in the colon) or widespread infection requires emergency surgery to remove the diseased segment of colon. 1, 2
• The mortality rate is very low for planned surgery (0.5%) but higher for emergency surgery (10.6%), which is why we try to avoid complications. 2

How Can You Prevent Future Episodes?

Dietary Changes (Most Important):

• Eat a high-fiber diet with at least 22 grams of fiber daily from fruits, vegetables, whole grains, and legumes—this is your best protection against recurrence. 1, 4
• Fiber from fruits appears most protective compared to other sources. 4
• Gradually increase fiber to minimize bloating, and drink plenty of water. 4
• You do NOT need to avoid nuts, seeds, popcorn, or corn—this is an outdated myth with no scientific support. 1, 4
• Reduce red meat and sweets in your diet. 1

Lifestyle Modifications:

• Exercise regularly, particularly vigorous physical activity, which significantly reduces your risk. 1, 4
• Achieve or maintain a normal body weight (BMI 18-25). 1, 4
• Stop smoking—this is a major modifiable risk factor. 1, 4
• Avoid NSAIDs (like ibuprofen) when possible—use acetaminophen for pain instead. 1, 4
• Minimize opioid pain medication use when alternatives are available. 1

What NOT to Do:

• Do NOT take mesalamine or rifaximin for prevention—these medications have been proven ineffective and may cause side effects. 1, 4
• Do NOT rely solely on fiber supplements instead of improving your overall diet. 4
• Do NOT restrict healthy foods like nuts and seeds based on outdated advice. 1, 4

What About Recurrence and Surgery?

• About 20% of patients experience a recurrence within 5 years, but most recurrences can still be managed conservatively. 1
• Surgery is NOT automatically recommended after 2 episodes—the decision should be based on how much the condition affects your quality of life, how frequent your episodes are, and your individual risk factors. 1
• Consider discussing surgery with a colorectal surgeon if: you've had 3 or more episodes within 2 years, symptoms persist for more than 3 months between episodes, you've had complicated diverticulitis (abscess, perforation), or the condition significantly impacts your daily life. 1

Follow-Up Care:

• You need a colonoscopy 4-6 weeks after your symptoms resolve to make sure there's no colon cancer mimicking diverticulitis (occurs in about 1% of cases). 1, 3
• Return immediately if you develop: fever over 101°F, severe worsening pain, persistent vomiting, inability to keep down fluids, or signs of dehydration. 1
• Follow up with your doctor within 2 weeks to ensure proper recovery. 1

Common Misconceptions to Avoid:

• Myth: "I need antibiotics every time"—Reality: Most uncomplicated cases don't require antibiotics. 1, 2
• Myth: "I can never eat seeds or nuts again"—Reality: These foods are safe and may even be beneficial due to their fiber content. 1, 4
• Myth: "I need surgery after 2 episodes"—Reality: Surgery decisions should be individualized based on quality of life impact, not episode count alone. 1
• Myth: "Fiber supplements are just as good as dietary fiber"—Reality: Whole food sources of fiber are superior and provide additional nutritional benefits. 4