From the Guidelines
Diverticulitis should be managed with a selective approach to antibiotic treatment, reserving antibiotics for immunocompromised patients or those with complicated disease, while emphasizing lifestyle modifications to reduce recurrence risk, as recommended by the most recent guidelines 1.
Key Considerations
- The management of diverticulitis depends on the severity of the disease, with mild cases potentially being managed without antibiotics in immunocompetent patients 1.
- Antibiotic treatment should be used selectively, rather than routinely, in immunocompetent patients with mild acute uncomplicated diverticulitis 1.
- Patients with a history of diverticulitis and chronic symptoms should undergo evaluation to exclude alternative diagnoses, using both imaging and lower endoscopy 1.
- Lifestyle modifications, including a high-quality diet, normal body mass index, regular physical activity, smoking cessation, and avoidance of nonsteroidal anti-inflammatory drugs (except for aspirin prescribed for cardiovascular disease prevention), are crucial in reducing the risk of recurrence 1.
Treatment Approach
- For mild cases, a clear liquid diet for 2-3 days, followed by a gradual transition to low-fiber foods, and eventually a high-fiber diet (25-30g daily) once symptoms resolve, can be recommended.
- Pain management with acetaminophen is preferred, avoiding NSAIDs which may irritate the digestive tract.
- Severe cases require hospitalization for IV antibiotics, bowel rest, and possibly surgery.
Prevention
- Maintaining a high-fiber diet, drinking plenty of water, exercising regularly, and avoiding constipation are key preventive measures.
- Smoking cessation and weight management also play a significant role in preventing recurrence.
- Patients should be educated about the risk of complicated diverticulitis, particularly with the first presentation, and the importance of genetic factors in diverticulitis risk 1.
From the Research
Diagnosis and Classification of Diverticulitis
- Radiological evidence of inflammation, using computed tomography (CT), is needed to diagnose the first occurrence of diverticulitis 2
- CT is also warranted when the severity of symptoms suggests that perforation or abscesses have occurred 2
- Diverticulitis is classified as complicated or uncomplicated based on CT scan, severity of symptoms and patient history; this classification is used to direct management 2
Treatment of Uncomplicated Diverticulitis
- Outpatient treatment is recommended in afebrile, clinically stable patients with uncomplicated diverticulitis 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 2, 3
- Ambulatory treatment of uncomplicated acute diverticulitis is safe, effective and applicable to most patients with tolerance to oral intake and without severe comorbidity and having appropriate family support 4
Treatment of Complicated Diverticulitis
- Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses; larger abscesses of 3-5 cm should be drained percutaneously 2
- Patients with peritonitis and sepsis should receive fluid resuscitation, rapid antibiotic administration and urgent surgery 2
- Surgical intervention with either Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy, is indicated for peritonitis or in failure of non-operative management 2
Antibiotic Treatment
- The effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications in uncomplicated acute diverticulitis 3
- A ceftriaxone treatment ≥4 days led to a higher incidence of intra-abdominal Enterococcus faecium 5
- Treating diverticulitis in the outpatient setting with amoxicillin-clavulanate may reduce the risk for fluoroquinolone-related harms without adversely affecting diverticulitis-specific outcomes 6