Diverticulitis management

Diverticulitis management

Diverticulitis occurs when retained fecal material and bacteria within a diverticulum lead to fecalith formation and obstruction. This may compromise the diverticular blood supply, resulting in infection, inflammation, and perforation.

Classification

Uncomplicated diverticulitis

• Microperforation resulting in localized inflammation and infection

Complicated diverticulitis

• Macroperforation resulting in:

  • Abscess formation

  • Peritonitis

  • Fistula formation

  • Intestinal obstruction

Clinical presentation

Symptoms

• Left lower quadrant (LLQ) abdominal pain

• Fever

• Nausea

• Vomiting

• Constipation

• Diarrhea

Physical findings

• LLQ abdominal tenderness

• Palpable abdominal mass

• Peritoneal signs

• Septic shock in severe disease

Differential diagnosis

• Inflammatory bowel disease (IBD)

• Infectious colitis

• Pelvic inflammatory disease (PID)

• Ectopic pregnancy

• Cystitis

• Colorectal cancer

Investigations

Imaging

• Plain abdominal radiographs to exclude:

  • Free intraperitoneal air

  • Ileus

  • Intestinal obstruction

• Contrast-enhanced CT scan of the abdomen to assess:

  • Abscess formation

  • Fistula formation

  • Other complications

Endoscopy

• Colonoscopy is contraindicated during the acute phase due to increased risk of perforation.

• Colonoscopy should be performed 6–8 weeks after recovery to exclude underlying neoplasia.

Pharmacological treatment

Mild uncomplicated diverticulitis (outpatient management)

Suitable for patients with minimal comorbidities and who can tolerate oral intake.

First-line regimen

Amoxicillin + clavulanate

• Amoxicillin + clavulanate (FDC) (PO) 625 mg 12 hourly for 7–10 days

AND

Metronidazole

• Metronidazole (PO) 400 mg 8 hourly for 7–10 days

AND

• Liquid diet until clinical improvement

Alternative regimen

Ciprofloxacin

• Ciprofloxacin (PO) 500 mg 12 hourly for 7–10 days

AND

Metronidazole

• Metronidazole (PO) 400 mg 8 hourly for 7–10 days

AND

• Liquid diet until clinical improvement

Severe or complicated diverticulitis

Intravenous antibiotic therapy

Ceftriaxone

• Ceftriaxone (IV) 1–2 g 24 hourly for 7–10 days

OR

Piperacillin + tazobactam

• Piperacillin + tazobactam (FDC) (IV) 4.5 g 6–8 hourly for 7–10 days

OR

Meropenem

• Meropenem (IV) 1 g 8 hourly for 7–10 days

AND

Metronidazole

• Metronidazole (IV) 500 mg 8 hourly for 7–10 days

Management of complications

Abscess

• Abscesses >4 cm should be drained percutaneously or surgically.

Surgical intervention

Indications include:

• Progression despite medical treatment

• Undrainable abscess

• Free perforation

• Generalized peritonitis

• Obstruction

• Fistula formation

Follow-up

• After adequate source control, a shorter antibiotic course of approximately 4 days may be sufficient.

• Surgical resection for recurrent diverticulitis should be considered on a case-by-case basis.