Management of Diverticulitis

Introduction

Diverticulitis is a condition that requires prompt diagnosis and treatment to prevent complications, as supported by the American College of Physicians and the American Gastroenterological Association 1, 2

The sensitivity and specificity of CT scan with IV contrast for diagnosing diverticulitis are 98% and 99%, respectively, making it the recommended first-line imaging modality, as supported by the American College of Physicians 1, 3, 4
The following table summarizes the diagnostic accuracy of CT scan with IV contrast:

Modality	Sensitivity	Specificity
CT scan with IV contrast	98%	99%

Patients with suspected diverticulitis should have a low threshold for cross-sectional imaging, as recommended by the American College of Physicians 2

About 45% of patients report periodic abdominal pain at 1-year follow-up, often due to visceral hypersensitivity rather than ongoing inflammation 2
Clinical monitoring should assess for resolution of the inflammatory process within 2-3 days, and repeat imaging should be considered if there is no clinical improvement within this timeframe 5
Predictors of failure of non-operative management include small amounts of distant intraperitoneal gas, with high failure rates (57-60%) reported 1, 6

Antibiotics alone are typically sufficient for treatment of small abscesses (< 3-6 cm), according to the World Journal of Emergency Surgery guidelines 5
Large abscesses (> 3-6 cm) require percutaneous drainage plus IV antibiotics, as recommended by the World Journal of Emergency Surgery guidelines 5
Broad-spectrum antibiotic therapy covering gram-negative bacilli and anaerobes is recommended for patients with complicated diverticulitis, with options including piperacillin-tazobactam, ertapenem, and meropenem or imipenem/cilastatin, and combination therapy options including ceftriaxone + metronidazole, ciprofloxacin + metronidazole, and ampicillin + gentamicin + metronidazole 1, 3, 7
The American Gastroenterological Association recommends selective antibiotic therapy along with supportive care for patients with focal diverticulitis, with hospitalization considered for patients with concerning features such as significant leukocytosis or systemic symptoms 2

Patients with focal diverticulitis who are at higher risk and warrant more aggressive management include those with elevated white blood cell count, elevated C-reactive protein, symptoms lasting > 5 days, presence of vomiting, systemic inflammatory response, immunocompromised status, advanced age, significant comorbidities, and CT findings of pericolic extraluminal air, fluid collection, or longer inflamed colon segment 2

Surgical resection and anastomosis may be considered for stable patients, while Hartmann's procedure may be considered for unstable patients or those with multiple comorbidities, as recommended by the American College of Physicians 1
Damage control surgery with staged laparotomies may be considered for unstable patients, as supported by the American College of Surgeons 1
Patients with evidence of perforation, such as extraluminal air on CT, require close monitoring and may need surgical consultation, as supported by the American College of Physicians 1

A clear liquid diet during the acute phase, advancing diet as symptoms improve, is recommended by the American Gastroenterological Association 2
A high-fiber diet, including fruits, vegetables, whole grains, and legumes, is recommended for patients with diverticulitis, as suggested by the American Gastroenterological Association 2
Regular physical activity, smoking cessation, and avoidance of NSAIDs, opiates, and corticosteroids can help prevent recurrence and complications, as recommended by the American Gastroenterological Association 2

Colonoscopy 6-8 weeks after resolution of symptoms to exclude colonic neoplasm (if not performed within the past year) is suggested, as malignancy can be misdiagnosed as diverticulitis, with a 1.3% risk in uncomplicated diverticulitis 2
Colonoscopy 6-8 weeks after resolution is recommended to exclude colonic neoplasm if a high-quality examination has not been recently performed, as suggested by the American Gastroenterological Association 2, 8

Outpatient management is not recommended for patients with suspected complicated diverticulitis, recent antibiotic use, unstable comorbid conditions, immunosuppression, or signs of sepsis, as stated by the American College of Physicians 9
Patients with symptoms lasting longer than 5 days, vomiting, systemic comorbidity, high C-reactive protein levels, or CT findings of pericolic extraluminal air, fluid collection, or longer inflamed colon segment should be monitored closely for predictors of progression to complicated disease 9