From the Guidelines
Management of acute diverticulitis should be based on severity, with mild cases typically treated as outpatients using oral antibiotics such as ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily for 7-10 days, while moderate to severe cases require hospitalization with IV antibiotics, bowel rest, and IV fluids. The approach to managing acute diverticulitis has evolved, with a focus on selective use of antibiotics and consideration of patient-specific factors such as comorbidities, immune status, and severity of symptoms 1.
Key Considerations
- Patients with uncomplicated diverticulitis can often be managed as outpatients without antibiotics, unless they have specific risk factors such as comorbidities, immunosuppression, or signs of systemic inflammation 1.
- Antibiotic treatment is recommended for patients with complicated diverticulitis or those with uncomplicated diverticulitis who have risk factors for progression to complicated disease, such as a high C-reactive protein level (>140 mg/L) or a baseline white blood cell count > 15 × 10^9 cells per liter 1.
- The choice of antibiotic regimen should be based on the severity of the disease, with broad-spectrum agents such as ciprofloxacin and metronidazole or amoxicillin-clavulanate commonly used in the outpatient setting, and IV antibiotics such as piperacillin-tazobactam or ceftriaxone plus metronidazole used in the inpatient setting 1.
Treatment Approach
- Patients with mild acute diverticulitis can be treated with oral antibiotics and a clear liquid diet, gradually advancing to low-fiber foods as symptoms improve.
- Patients with moderate to severe acute diverticulitis require hospitalization with IV antibiotics, bowel rest, and IV fluids, as well as pain control with acetaminophen or opioids as needed.
- Complications such as abscess formation may require percutaneous drainage, while perforation with peritonitis necessitates emergency surgery.
Follow-up and Prevention
- After recovery, patients should gradually increase dietary fiber to 25-30g daily and maintain adequate hydration to prevent recurrence.
- Follow-up colonoscopy is recommended 6-8 weeks after resolution to exclude malignancy. This approach targets the polymicrobial infection while allowing the inflamed colon to heal, with treatment decisions based on clinical presentation, laboratory findings, and imaging results 1.
From the Research
Diagnosis and Management of Acute Diverticulitis
- Acute diverticulitis is characterized by localized diverticular inflammation, and its management depends on the severity of the disease 2.
- Uncomplicated diverticulitis can be managed with or without antibiotics, as the use of antibiotics is still questionable due to the potential inflammatory nature of the condition 3.
- Patients with uncomplicated diverticulitis may present with left lower quadrant pain, tenderness, abdominal distention, and fever, and initial laboratory studies include a complete blood count, basic metabolic panel, urinalysis, and measurement of C-reactive protein 2.
Treatment Options for Complicated Diverticulitis
- Complicated diverticulitis requires hospitalization and intravenous antibiotics, and patients with a localized abscess may be candidates for computed tomography-guided percutaneous drainage 2.
- Ceftriaxone and metronidazole have been found to be non-inferior to piperacillin/tazobactam for the treatment of complicated diverticulitis, with no significant differences in 30-day readmission or all-cause mortality 4.
- Laparoscopic surgery is a viable option for patients with complicated diverticulitis, resulting in a shorter length of stay, fewer complications, and lower in-hospital mortality compared to open colectomy 2.
Outpatient Treatment of Uncomplicated Diverticulitis
- Outpatient treatment with oral antibiotics is a safe and effective option for patients with uncomplicated diverticulitis who can tolerate oral intake and have adequate family support 5.
- A study found that ambulatory treatment was completed without complication in 97% of patients with uncomplicated diverticulitis, with only 3% requiring admission due to persisting symptoms 5.
- Evidence-based treatment strategies for acute diverticulitis have evolved over time, and risk-adapted treatment strategies and operative decision-making are increasingly based on a combination of patient and disease factors 6.