Treatment for Sigmoid Diverticulitis with Fistula, Abscess, and Possible Bowel Obstruction

Assessment and Initial Management

• The World Journal of Emergency Surgery recommends initiating broad-spectrum intravenous antibiotics immediately while preparing for definitive treatment, with options including Meropenem, Piperacillin/tazobactam, or Eravacycline for patients with sepsis or septic shock 1

Management of Abscess Component

• For large abscesses (>4-5cm), percutaneous drainage should be performed in conjunction with antibiotic therapy when technically feasible, with cultures guiding subsequent antibiotic therapy 2, 3, 4

Surgical Management

• Prompt and effective source control surgery is strongly recommended for complicated diverticulitis with fistula formation and possible bowel obstruction, with options including primary resection with anastomosis, Hartmann's procedure, or damage control surgery 4, 5, 6

Duration of Antibiotic Therapy

• Antibiotics should be continued for 4 days in immunocompetent and non-critically ill patients, and up to 7 days in immunocompromised or critically ill patients undergoing source control procedures 1

Post-Treatment Follow-up

• Early colonic evaluation (colonoscopy) should be planned within 4-6 weeks after resolution of the acute episode to rule out underlying malignancy, particularly in cases with abscess or fistula 4, 7

Pitfalls and Caveats

• Non-operative management is not recommended for diverticulitis with fistula, abscess, and possible bowel obstruction due to high failure rates and risk of septic complications, and delaying surgical intervention can lead to increased morbidity and mortality 4, 5