Diverticulitis used to be thought of as a progressive disease with increasing risk of complications with a greater number of episodes. That general concept drove guidelines for aggressive management, specifically generous antibiotic administration, and surgical interventions.
More recent data suggests we can be less aggressive with our treatment in the correct patient population.
Epidemiology
· The incidence of diverticulitis in the United States is 180/100,000 persons per year
· Diverticulitis is most common in older adults
· Large increase in cases with younger adults. The incidence of diverticulitis in individuals 40–49 years old increased by 132% from 1980 through 2007 alone
Uncomplicated Diverticulitis vs Complicated Diverticulitis
· Uncomplicated diverticulitis: thickening of the colon wall and peri-colonic inflammatory changes.
· Complicated diverticulitis: abscess, peritonitis, obstruction, stricture, and/or fistula.
· Small percentage of cases will be complicated
· Most common complication: abscess or phlegmon
· Most people recover from, 5% will go on to develop smoldering diverticulitis.
When to Image
· CT should be performed to confirm diagnosis in previously unimaged patients
· Severe presentations
· Failure of outpatient therapy
· Immunocompromised
· Surgical preparation
Immunosuppressed Patients
· They can present with MILDER symptoms
· Present with severe or complicated disease
· Low threshold to image, consult colorectal surgery, and treat with antibiotics
· Corticosteroid use is a risk factor for diverticulitis and can contribute to complications, including perforation and death.
· Higher risk to develop complicated diverticulitis from uncomplicated diverticulitis
· Antibiotics: broad-spectrum agents with gram-negative and anaerobic coverage
· Longer duration of treatment (10–14 days).
Antibiotics
· Antibiotic treatment can be used SELECTIVELY, in immunocompetent patients with mild uncomplicated diverticulitis
· No difference in time to resolution or risk of readmission, progression to a complication, or need for surgery in those treated vs no antibiotics
· Give antibiotics with uncomplicated diverticulitis who have comorbidities, frail, refractory symptoms, or vomiting
· Symptoms longer than 5 days
· CRP >140 mg/L
· WBC count > 15 x 109 cells/L
Outpatient Antibiotics
· Regimen includes broad-spectrum agents with gram-negative and anaerobic coverage.
· Oral fluoroquinolone and metronidazole
· Or monotherapy with oral amoxicillin/clavulanate.
· The duration of treatment is usually 4–7 days but can be longer at physicians discretion
Inpatient Antibiotics
· Ceftriaxone (1 gram IV every 24 hours) + metronidazole (500mg IV every 8 hours)
· Levofloxacin (500mg IV every 24 hours) + metronidazole (500mg IV every 8 hours)
· Piperacillin-Tazobactam (3.375 – 4.5g IV every 6 hours)
· Imipenem-Cilastatin (500mg IV every 6 hours)
Colonoscopy
· After an episode of complicated diverticulitis and after the first episode of uncomplicated diverticulitis
· Can defer if within a year colonoscopy was performed
· Must wait 6–8 weeks or until resolution of symptoms, whichever is longer. Obtain sooner if alarm symptoms
· Risk of colon cancer complicated diverticulitis (7.9%) vs uncomplicated diverticulitis (1.3%)
When to Admit
· All complicated diverticulitis
· Intractable nausea/vomiting
· Comorbid disease
· High WBC, fever, elderly, immunocompromised
· Failed outpatient therapy
· Large Abscess >3-4cm
When to Discharge
· Can tolerate PO
· No significant comorbidities
· Able to obtain outpatient antibiotics if needed
· Adequate pain control
· Uncomplicated disease
· All newly diagnosed should follow up colonoscopy in 6-8 weeks
· Surgical referral for all patients with 3rd or 4th episode of diverticulitis
References
https://www.giboardreview.com/wp-content/uploads/2021/12/Guidelines-AGA-diverticulitis-2021.pdf
https://coreem.net/core/diverticular-disease/
http://www.emdocs.net/em3am-diverticulitis/
www.emdocs.net