From the Guidelines
Outpatient treatment for uncomplicated diverticulitis can be managed without antibiotics in select patients, with a focus on supportive care, including bowel rest, hydration, and pain management, as suggested by the American College of Physicians guideline 1. The management of diverticulitis, particularly in the outpatient setting, has evolved with recent guidelines emphasizing a more selective use of antibiotics. According to the AGA clinical practice update on medical management of colonic diverticulitis, antibiotic treatment is advised in patients with uncomplicated diverticulitis who have comorbidities, are frail, present with refractory symptoms or vomiting, or have a CRP >140 mg/L or baseline white blood cell count > 15 × 10^9 cells per liter 1. However, for immunocompetent patients with mild acute uncomplicated diverticulitis, recent evidence suggests there is no benefit in using antibiotics, with low-certainty evidence showing no difference in time to resolution or risk of readmission, progression to a complication, or need for surgery among patients treated with antibiotics compared to those not treated with antibiotics 1. Key considerations for outpatient management include:
- Selective use of antibiotics based on patient risk factors and disease severity
- Supportive care with bowel rest, hydration, and pain management
- Monitoring for signs of complications or worsening symptoms
- Dietary modifications, starting with a clear liquid diet and gradually transitioning to a low-fiber diet
- Adequate hydration and rest
- Patient education on warning signs requiring immediate medical attention, such as worsening pain, fever, or signs of complications. The American College of Physicians suggests that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting, with low-certainty evidence showing no differences in risk for elective surgery or long-term diverticulitis recurrence for outpatient compared with inpatient management 1. Overall, the approach to outpatient treatment of diverticulitis should prioritize morbidity, mortality, and quality of life, with a focus on selective antibiotic use, supportive care, and close monitoring for complications.
From the Research
Diverticulitis Treatment Outpatient
- Outpatient treatment of uncomplicated diverticulitis is a safe and effective approach, with a treatment success rate ranging from 91.5 to 100% 2.
- The overall failure rate in an outpatient setting is approximately 4.3% (95% CI 2.6%-6.3%) 3.
- Factors such as localization of diverticulitis, previous episodes of acute diverticulitis, comorbidities, pericolic air, intra-abdominal abscess, treatment according to a registered protocol, type of follow-up, type of antibiotic treatment, or diabetes do not significantly influence the rate of failure 3.
- Antibiotics play a key role in the management of both uncomplicated and complicated diverticular disease, with rifaximin demonstrating effectiveness in obtaining symptom relief and improving symptoms and maintaining periods of remission following acute colonic diverticulitis 4.
- Outpatient management is considered the best strategy in the majority of uncomplicated patients, while inpatient management and intravenous antibiotics are necessary in complicated diverticulitis 4.
- The use of mesalazine and probiotics has also been shown to be effective in the treatment of diverticulitis, with mesalazine improving symptoms and preventing symptomatic recurrence, and probiotics potentially being the future best treatment for mild-to-moderate uncomplicated attacks of acute diverticulitis 5.