Diverticular disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Management of diverticulitis is determined by the presenting symptoms, clinical situation, and the presence of complications requiring further investigation and treatment, including abscess, obstruction, perforation, and fistulas. The presence of complications may be determined by the initial computed tomography scan and warrants a surgical consultation.

Patients with suspected acute complicated diverticulitis should be treated with intravenous antibiotics. Signs of sepsis should be actively sought, and acted on promptly if present. Patients with acute uncomplicated diverticulitis may require oral antibiotics if they are systemically unwell, have signs of systemic inflammation, are immunosuppressed, or have significant comorbidities.[7] If systemically well with mild symptoms, simple analgesia may be adequate treatment in uncomplicated diverticulitis.

Asymptomatic diverticulosis discovered incidentally requires no treatment, though patients should be encouraged to make dietary and lifestyle changes such as stopping smoking, and losing weight if they are overweight or obese, as these are risk factors for diverticulitis.[3]

Asymptomatic diverticulosis

Diverticulosis is the presence of diverticula without symptoms.[1] Asymptomatic diverticulosis discovered incidentally requires no treatment.[1]

There is evidence that these patients might benefit from increasing dietary fiber, including fruit and vegetables, which may reduce their risk of developing diverticulitis.[41][42][43][60][61] Patients should be advised to maintain a healthy balanced diet.[1] In patients with a low-fiber diet and constipation, it is advised to increase fiber intake gradually to minimize flatulence and bloating, and to ensure adequate fluid consumption.[1] There is no need for patients to avoid seeds, nuts, popcorn, or fruit skins.

Patients should be counseled to quit smoking, and to lose weight if they are overweight or obese, as these are risk factors for diverticulitis.[3][7]

Acute uncomplicated diverticulitis

Acute uncomplicated diverticulitis indicates acute inflammation of a diverticulum or diverticula, without abscess, phlegmon, obstruction, perforation, stricture, or fistulas.

The main goals of treatment for uncomplicated acute diverticulitis include resolution of the acute inflammation and prevention of complications. Most patients can be managed in the outpatient setting.[45]

For patients with mild symptoms, analgesia may be adequate treatment. Simple analgesia, such as acetaminophen, is recommended, with advice to return if symptoms worsen.[1] Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics should be avoided as they are associated with a risk of diverticular perforation (although opioids may be given for severe pain in a hospital setting).

Antibiotics may not be necessary if a patient with uncomplicated acute diverticulitis is systemically well.[7][43][45][62] Oral antibiotics are indicated if the patient is systemically unwell (e.g., fever), has signs of systemic inflammation (e.g., CRP >14 mg/dL [>140 mg/L] or baseline WBC count >15 x 10⁹), is immunosuppressed, or has significant comorbidities.[7][43] When selecting the class of antibiotics, follow your local protocol, or seek advice from the infectious diseases team. Examples of suitable antibiotic regimens may include amoxicillin/clavulanate, or ciprofloxacin plus metronidazole.[43][45]

Patients treated with oral antibiotics can be safely treated at home, provided they are clinically stable, and able to tolerate oral intake.[45][63][64][65][66][67] However, if symptoms persist or worsen, the patient should be admitted to the hospital and given intravenous antibiotics until clinical improvement - see Acute complicated diverticulitis section, below.[68]

Meta-analyses of studies comparing antibiotics with no antibiotic treatment have found that treating and monitoring uncomplicated diverticulitis with or without antibiotics is safe and effective, and that observational management was not statistically different from antibiotic treatment for the primary outcome of needing surgery.[69][70][71] One Cochrane review on uncomplicated diverticulitis found that the effect of antibiotics is uncertain for complications (early and long-term, emergency surgery, recurrence, and elective colon resection). [ ] One systematic review of studies comparing antibiotics with no antibiotics in patients with uncomplicated diverticulitis found no difference in risks for treatment failure, elective surgery, recurrence, and post-treatment complications.[72]

Guidelines from the American Gastroenterological Association (AGA), the American Society of Colon and Rectal Surgeons (ASCRS), the American College of Physicians (ACP), the World Society of Emergency Surgery (WSES), and the UK National Institute for Health and Care Excellence (NICE) recommend that antibiotics should be used selectively, rather than routinely, in immunocompetent patients with acute uncomplicated diverticulitis who are systemically well and otherwise healthy.[3][7][37][43][45][73][74][75]

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[76]

Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

During the acute phase of uncomplicated diverticulitis a clear liquid diet is recommended.[43] As symptoms improve diet can advance; maintaining a healthy balanced diet with whole grains, fruit, and vegetables is important to prevent the risk of recurrence.[43]

Acute complicated diverticulitis

Complications requiring further investigation and treatment include abscess, phlegmon, obstruction, perforation, stricture, and fistulas. The presence of complications may be determined by the initial computed tomography (CT) scan and warrants a surgical consult. Surgical intervention may also be considered for smoldering diverticulitis (inflammation that persists for weeks to months and can be captured on imaging) that does not respond to appropriate medical management.

Patients with suspected complicated acute diverticulitis should be admitted to the hospital for treatment.

Antibiotics

Patients with suspected or confirmed complicated acute diverticulitis should be treated with intravenous antibiotics.[1]
Follow your local protocol or take advice from the infectious diseases team when selecting antibiotics.[7] Examples of suitable regimens include ceftriaxone plus metronidazole, or piperacillin/tazobactam.[20]
All antibiotics should be reviewed after 48 hours, and step-down to suitable oral antibiotics should be considered.[1]
Signs of sepsis should be actively sought, and acted on promptly if present. See Sepsis in adults.

Analgesia

A simple analgesic such as acetaminophen is recommended.[1] In general, opioids and NSAIDs should be avoided as they are associated with a risk of diverticular perforation.[1] However, for relief of severe pain, analgesia can be escalated using tramadol (a weak opioid) and, if necessary, a more potent opioid (e.g., morphine) in a titrated fashion.[1]

Nil per os/liquid diet

Patients with localized or generalized peritonitis should have a period of strict nil per os (NPO). This can progress to a clear liquid diet when there is adequate clinical improvement.
As symptoms improve, diet can advance; maintaining a healthy balanced diet with whole grains, fruit, and vegetables is important to prevent the risk of recurrence.[43]

Abscess drainage

An abscess >3 cm in diameter should be drained under CT scan or with ultrasound guidance; surgery is necessary if the diverticular abscess does not resolve with this.[3][5][7][77]
CT scan of the abdomen and pelvis with intravenous contrast is the imaging of choice for percutaneous drainage of abscess. Pus samples should be sent to microbiology in order to tailor antibiotic sensitivity.[77] Further imaging may be needed if the patient does not improve or deteriorates.[1]
A localized abscess <3 cm in diameter does not warrant drainage and can be treated with antibiotics only.[2][3][7][78]
In patients with an abscess >3 cm, intravenous antibiotics should be continued to complete a course of 7-10 days, depending on clinical recovery. For patients with abscesses <3 cm it may be possible to switch to oral antibiotics earlier.[1]

Managing bowel perforation or stricture/fistula

In patients with diverticular perforation with generalized peritonitis, laparoscopic lavage or colectomy should be considered.[1] The risks and benefits of each procedure should be discussed with the patient.[1]
Early laparoscopic washout can be used as a surgical strategy for acute diverticulitis (Hinchey grades I, II, and III; for details of Hinchey classification, see Etiology) and when medical treatment and percutaneous drainage have failed to contain sepsis.[79][80][81][82][83] However, there is evidence that laparoscopic lavage for Hinchey III diverticulitis does not completely control the source of infection, and is associated with an increased rate of reintervention.[84] If fecal peritonitis is identified during laparoscopy, colectomy should be carried out.[1]
For patients with severe or diffuse peritonitis, emergency colectomy, a Hartmann procedure (resection of the bowel with an end stoma), or colectomy with primary anastomosis (join in the bowel) may be necessary.[85][86] The National Institute for Health and Care Excellence in the UK recommends primary anastomosis with or without diverting stoma or Hartmann procedure.[1] For select patients (up to Hinchey IV), and depending on surgical expertise, a laparoscopic colectomy with primary anastomosis and/or a laparoscopic Hartmann procedure is safe and may improve postoperative outcomes.[87][88][89]
Treatment of diverticulitis complicated by a stricture or fistula is colectomy by an open or laparoscopic approach, as there is no role for conservative management.

Elective surgery for recurrent diverticulitis

Criteria for recommending elective colectomy for recurrent disease are not clear cut and should not be based on the number of previous attacks alone.[43] Any judgment should be made on an individual basis depending on age, frequency, and severity of recurrent symptoms, previous complications, comorbidities, and patient preferences and values.[3][43][90][91] Elective resection should usually be considered after the successful nonsurgical treatment of a diverticular abscess, or in patients with persistent symptoms due to obstruction, stricture, or fistula, or in immunocompromised patients.[3][7] Shared decision-making is recommended according to patient preferences.[59][92]

In elective settings, laparoscopic colonic resection is feasible and safe, may hasten postoperative recovery, and has fewer postoperative complications than conventional surgery, including surgical site infections.[93][94][95] Prophylactic oral antibiotic administration 1 day before surgery reduces the incidence of surgical site infection, without mechanical bowel preparation, in such patients.[96]

Aminosalicylates or antibiotics are not recommended to prevent recurrent acute diverticulitis.[65]

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