From the Guidelines
Management of diverticulitis with intramural abscess requires a combination of antibiotics and possible drainage depending on abscess size, with the most recent guidelines suggesting a tailored approach based on the size of the abscess and the patient's clinical condition 1. For small intramural abscesses (< 4–5 cm), outpatient management with broad-spectrum antibiotics is appropriate, typically using a regimen such as ciprofloxacin 500 mg twice daily plus metronidazole 500 mg three times daily for 10-14 days, as suggested by the 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting 1. Some key points to consider in the management of diverticulitis with intramural abscess include:
- The size of the abscess is a critical factor in determining the treatment approach, with larger abscesses requiring more aggressive management 1.
- Percutaneous drainage guided by CT or ultrasound is indicated for abscesses larger than 4-5 cm, and may be considered for smaller abscesses that are not responding to antibiotics 1.
- Patients should maintain a clear liquid diet initially, advancing as symptoms improve, and close follow-up is essential to assess treatment response 1.
- Surgical intervention may be necessary if the patient deteriorates or if the abscess cannot be drained percutaneously, and colonoscopy is recommended 6-8 weeks later to exclude underlying malignancy as the cause of the diverticular complication 1. It's worth noting that the use of antibiotics in the management of diverticulitis is a topic of ongoing debate, with some studies suggesting that antibiotics may not be necessary in all cases of uncomplicated diverticulitis 1. However, the most recent guidelines suggest that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis, and that antibiotic treatment is advised in patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan 1.
From the Research
Management of Diverticulitis with Intramural Abscess
- The management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary 2.
- For patients with uncomplicated diverticulitis, antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 3.
- Conservative treatment with broad-spectrum antibiotics is successful in up to 70% of cases of diverticulitis with an abscess 4.
- Percutaneous drainage is recommended for larger abscesses, with different guidelines proposing different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses 5.
Treatment Options
- Endoscopic ultrasound-guided drainage with lumen apposing metal stent (LAMS) seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to the colonic wall 2.
- Amoxicillin-clavulanate may be a suitable alternative to metronidazole-with-fluoroquinolone for outpatient diverticulitis, with no differences in 1-year admission risk, 1-year urgent surgery risk, or 3-year elective surgery risk 6.
- Surgical intervention is indicated for peritonitis or in failure of non-operative management, with options including Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy 3.