What is the diagnosis and treatment for diverticulitis (inflammation of the diverticula)?

From the Guidelines

Diverticulitis should be managed with a selective approach to antibiotic use, reserving antibiotics for patients with complicated disease, immunocompromised status, or high-risk features, as recommended by the American College of Physicians and supported by recent evidence from the AGA and WSES guidelines. The management of diverticulitis involves a range of strategies, from outpatient treatment with oral antibiotics for mild cases to hospitalization and surgery for more severe or complicated cases. Key considerations in the management of diverticulitis include:

• The use of abdominal CT imaging for diagnosis, particularly when there is diagnostic uncertainty, as suggested by the American College of Physicians guideline 1.
• The selective use of antibiotics, with recent guidelines suggesting that antibiotics may not be necessary for all patients with uncomplicated diverticulitis, especially those who are immunocompetent and have mild disease, as noted in the AGA clinical practice update 1 and the WSES guidelines 1.
• The importance of considering patient-specific factors, such as immunocompromised status, comorbidities, and disease severity, in determining the need for antibiotics, as emphasized in the AGA clinical practice update 1 and the WSES guidelines 1.
• The role of diet and lifestyle modifications in preventing recurrence and managing symptoms, including a high-fiber diet, adequate hydration, regular exercise, and avoidance of constipation.
• The potential benefits and risks of different treatment approaches, including the use of antibiotics, and the need for individualized decision-making based on patient-specific factors and the latest evidence. For example, the AGA clinical practice update suggests that antibiotics can be used selectively in patients with uncomplicated diverticulitis, while the WSES guidelines recommend against routine antibiotic use in immunocompetent patients with uncomplicated disease. In contrast, patients who are immunocompromised or have high-risk features may require more aggressive treatment, including antibiotics and close monitoring, as recommended by the AGA clinical practice update 1. Overall, the management of diverticulitis requires a thoughtful and individualized approach, taking into account the latest evidence and guidelines, as well as patient-specific factors and preferences.

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
• 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
• Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence, and should only be used selectively 2, 3
• Treatment without antibiotics, without bed rest, and without dietary restrictions is possible for uncomplicated diverticulitis patients 4
• A selected group of patients can be treated as outpatients 4, 5

Treatment of Complicated Diverticulitis

• Non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses 2
• 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

Role of Antibiotics in Diverticulitis Treatment

• The effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications in uncomplicated acute diverticulitis 3
• Rifaximin has demonstrated to be effective in obtaining symptoms relief at 1 year in patients with uncomplicated diverticular disease and to improve symptoms and maintain periods of remission following acute colonic diverticulitis 6
• Antibiotics seem to remain the mainstay of treatment in symptomatic uncomplicated diverticular disease and acute diverticulitis 6