Acute Diverticulitis Admission Orders
Initial Assessment and Diagnostic Confirmation
For patients requiring admission with acute diverticulitis, obtain abdominal CT imaging with intravenous contrast to confirm diagnosis, assess severity, and identify complications such as abscess, perforation, or peritonitis. 1
- CT scan remains the gold standard for both diagnosis and staging, with very high sensitivity and specificity for acute diverticulitis 1
- Imaging is essential to differentiate uncomplicated from complicated disease and guide management decisions 2, 3
- Look specifically for: extraluminal air, abscess formation (note size), free fluid, pneumoperitoneum, and bowel wall thickening 4
Patient Selection for Admission
Admit patients who have complicated diverticulitis (abscess, perforation, peritonitis, obstruction, fistula, or bleeding) or uncomplicated disease with inability to tolerate oral intake, inadequate home support, immunosuppression, or signs of systemic inflammatory response. 1
Key admission criteria include:
- Age >65 years, Charlson comorbidity score ≥2, or immunosuppression/steroid use 4
- CT findings of free air, abscess, or pneumoperitoneum 4, 5
- Signs of peritonitis or sepsis requiring urgent intervention 2
- Inability to maintain oral hydration or lack of adequate outpatient follow-up 1
Inpatient Management Orders
Fluid Resuscitation and NPO Status
- Initiate intravenous fluid resuscitation immediately 6, 2
- Order bowel rest (NPO or clear liquids) for complicated diverticulitis or severe symptoms 2
Antibiotic Therapy
For complicated diverticulitis requiring admission, initiate broad-spectrum intravenous antibiotics covering gram-negative and anaerobic organisms. 6, 2
- Antibiotics are indicated for complicated disease, abscess formation, or systemic signs of infection 2, 3
- For uncomplicated diverticulitis managed inpatient, antibiotics may be used selectively based on clinical severity, though evidence shows they do not accelerate recovery or prevent complications in mild cases 1, 6
- Common regimens include: fluoroquinolone plus metronidazole, or beta-lactam/beta-lactamase inhibitor combinations 6
Laboratory Monitoring
- Order complete blood count, basic metabolic panel, and C-reactive protein at admission 6
- Monitor for leukocytosis, electrolyte abnormalities, and renal function
- Serial inflammatory markers may guide response to therapy 6
Surgical Consultation
Obtain immediate surgical consultation for patients with peritonitis, sepsis, or failure of non-operative management within 48-72 hours. 2, 3
- Surgical intervention is required in 15-30% of admitted patients 6
- Indications include: free perforation with peritonitis, clinical deterioration despite medical therapy, or large abscess (>3-5 cm) not amenable to percutaneous drainage 2
Interventional Radiology Consultation
For abscesses 3-5 cm or larger, order CT-guided percutaneous drainage 2
- Smaller abscesses (<3 cm) typically respond to antibiotics alone 2, 5
- Percutaneous drainage may avoid emergency surgery in appropriate candidates 6, 2
Common Pitfalls to Avoid
- Do not routinely admit immunocompetent patients with uncomplicated diverticulitis who can tolerate oral intake and have adequate home support – outpatient management is appropriate for most uncomplicated cases 1
- Do not reflexively prescribe antibiotics for all admitted patients with uncomplicated disease – selective use is appropriate based on severity and patient factors 1, 6
- Do not delay surgical consultation in patients with peritonitis or clinical deterioration – mortality increases with delayed intervention 2
- Do not discharge patients with CT findings of free air, significant abscess, or immunosuppression without inpatient observation 4, 5
Follow-up Planning
Order colonoscopy 4-6 weeks after resolution for all patients with complicated diverticulitis or those meeting age-appropriate screening criteria. 6, 2