Diverticulitis Treatment & Management

The approach to the treatment of diverticulitis can be broadly classified into either uncomplicated disease or complicated disease, with a few other special considerations to take into account. Acute uncomplicated diverticulitis is successfully treated in 70-100% of patients with conservative management.^{[2, 3]}

• Acute diverticulitis tends to be more severe in very elderly people and in patients who are immunocompromised or who have debilitating comorbid conditions, such as diabetes and renal failure.
• Patients with mild diverticulitis, typically with Hinchey stage I disease, can be started on an outpatient treatment regimen. This consists of a clear liquid diet and 7-10 days of oral broad-spectrum antimicrobial therapy, which covers anaerobic microorganisms, such as Bacteroides fragilis and Peptostreptococcus and Clostridium organisms , as well as aerobic microorganisms, such as Escherichia coli and Klebsiella, Proteus, Streptococcus, and Enterobacter organisms. Single and multiple antibiotic regimens are equally effective as long as both groups of organisms are covered. According to the World Gastroenterology Organisation (WGO) 2007 practice guidelines for diverticular disease, such a regimen should result in improvement within 48-72 hours.^[4]

  • One typical oral antibiotic regimen is a combination of ciprofloxacin (or trimethoprim-sulfamethoxazole) and metronidazole. Moxifloxacin is appropriate monotherapy for outpatient treatment of uncomplicated diverticulitis. Amoxicillin/clavulanic acid monotherapy is acceptable as well.
  • Patients should be instructed to be on a clear liquid diet only and can advance the diet slowly as tolerated after clinical improvement, which usually occurs within 2-3 days.
• Hospitalization is required with evidence of severe diverticulitis, such as systemic signs of infection or peritonitis. Patients who are unable to tolerate oral hydration, who fail outpatient therapy (ie, persistent or increasing fever, pain, or leukocytosis after 2-3 d), who are immunocompromised, or who have comorbidities may also require hospitalization. Pain may be severe enough to require parenteral narcotic analgesia.

  • Initiate bowel rest and intravenous fluid hydration. Start broad-spectrum intravenous antibiotic coverage until culture results, if obtained, are available.
  • Monotherapy with beta-lactamase inhibiting antibiotics or carbapenems provides broad antibacterial coverage and is appropriate for patients who are moderately ill and require admission. Such antibiotics include the following: piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid, imipenem, or meropenem.
  • Multiple drug regimens are also appropriate options in the hospital setting and may consist of metronidazole and a third-generation cephalosporin or a fluoroquinolone. Such antibiotics include the following: ceftriaxone, cefotaxime, ciprofloxacin, or levofloxacin. Previously, gentamicin was recommended as part of a multiple drug regimen. Although it is still a reasonable choice, substitution with a third-generation cephalosporin or a fluoroquinolone has been advocated to avoid the risk of aminoglycoside nephrotoxicity.
  • When severe penicillin allergy is a concern, tigecycline is a good choice for monotherapy.
  • For patients who are immunocompromised, imipenem or meropenem may be preferred over ertapenem for better enterococcal and pseudomonal coverage.
  • Pain management is important. Morphine is acceptable for pain control and is preferable over meperidine given the adverse effects associated with meperidine. Although early recommendations for pain management favored meperidine based on a theoretical risk of affecting bowel tone and sphincters, randomized prospective studies comparing the narcotic options are not available. Use of nonsteroidal anti-inflammatory drugs and corticosteroids have been associated with a greater risk of colon perforation and should be avoided whenever possible.
  • Within 2-3 days of hospitalization, the patient's fever, pain, and leukocytosis should begin to resolve. The patient can then be started on a clear liquid diet and advanced as tolerated. If tolerating oral intake and clinically stable, the patient can be discharged to complete a 7- to 10-day course of oral antibiotic therapy.
  • If fever and leukocytosis do not resolve after 2-3 days of treatment or if serial examinations reveal worsening signs or new peritoneal findings, a repeat CT scan of the abdomen is advisable to rule out an abdominal abscess or other complications. The WGO 2007 guidelines state that a lack of improvement should prompt clinical suspicion and an investigation for a phlegmon or an abscess.^[4]
  • If a patient is found to have a peridiverticular abscess that measures more than 4 cm in diameter (Hinchey stage II disease), a CT–guided percutaneous drainage is indicated. This usually leads to a prompt (< 72 h) reduction in pain, fever, and leukocytosis. Percutaneous drainage is also beneficial in that it may allow for elective surgery rather than emergency surgery and increase the likelihood of a successful 1-stage procedure.
  • For abscess cavities containing gross fecal material or when there is perforation, early surgical intervention is required.
• Once the acute episode has resolved, the patient may advance diet as tolerated and then maintain a lifelong high-fiber diet. Colonoscopy or, alternatively, barium enema with flexible sigmoidoscopy should be done after resolution of an initial episode (typically 2-6 wk after recovery) to exclude other diagnoses, such as cancer, ischemia, and inflammatory bowel disease.

About 15-25% of patients presenting with a first episode of acute diverticulitis have complicated disease that requires surgery. According to the WGO 2007 guidelines, 15-30% of patients admitted for management of diverticulitis will need surgery during their admission, with an 18% surgical mortality rate.^[4]

• The classic surgical indications include some features characteristic of Hinchey stage III or IV disease and are as follows:

  • Free-air perforation with fecal peritonitis
  • Suppurative peritonitis secondary to a ruptured abscess
  • Uncontrolled sepsis
  • Abdominal or pelvic abscess (unless CT-guided aspiration is possible)
  • Fistula formation
  • Inability to rule out carcinoma
  • Intestinal obstruction
  • Failing medical therapy
  • Immunocompromised status
  • Extremes of age
• Recurrent episodes of acute diverticulitis: Elective surgery was previously recommended in any patient who had 2 or more episodes of diverticulitis that were successfully treated medically; data have since called this practice into question when the patient is otherwise healthy.
• Preoperative preparation with antibiotics should be given in all patients. Single and multiple drug regimens, as discussed in Medical Care, are appropriate choices. However, for patients with more extensive contamination, a single drug regimen (with either imipenem/cilastin or piperacillin/tazobactam) or a multiple drug regimen (with ampicillin, gentamicin, and metronidazole) may be warranted for peritonitis. Bowel preparation is usually possible for nonemergent situations.
• Guidelines from the American Society of Colon and Rectal Surgeons (2006) recommend emergency surgery for patients with diffuse peritonitis and for those who fail nonoperative management. Also, patients who are immunosuppressed or immunocompromised are at an increased risk of failing medical therapy or perforation and should be approached with a lower threshold.^[5]
• A 2-stage surgical approach is the most common surgical procedure performed today for the emergency treatment of acute diverticulitis.

  • A traditional Hartmann procedure is commonly performed, which involves resection of the diseased segment of bowel, an end-colostomy, and closure of the rectal stump. Typically, 3 months later, a second procedure can be performed to close the rectal stump; however, this second operation can be technically difficult and is not performed in many patients. This is the preferred approach in patients with fecal peritonitis and in most cases of purulent peritonitis.^{[6, 7]}
  • An alternative to the Hartmann procedure includes resection of the diseased colon, primary anastomosis (with or without intraoperative colonic lavage), and proximal diverting stoma, either colostomy or ileostomy. The second procedure in this course would be to close the stoma. This approach is primarily used when there are relative contraindications to primary anastomosis but no purulent or feculent peritonitis and there is nonedematous bowel. The advantage is that it avoids the technically difficult second stage used in the Hartmann procedure.
  • Extensive and unnecessary dissections, which open up tissue planes to infection and increase blood loss, have no role.
  • Examining data from patients who had undergone the Hartmann procedure for acute diverticulitis and then (after a median 7-month period) had undergone reversal surgery, Fleming and Gillen investigated the rate of and risk factors for complications linked to the reversal procedure.^[7] The authors found that out of 76 reversal patients, 18 of them (25%) had post-reversal complications.
  • Fleming and Gillen also found in the above study that risk factors for reversal complications included being a current smoker, having a low preoperative albumin level, and allowing a prolonged period of time to pass between the Hartmann and reversal procedures. The authors concluded that despite the reversal surgery's significant complication rate, offering the operation to appropriately selected patients is acceptable. They also suggested that preoperative identification of modifiable of risk factors may benefit patients.
• The decision to proceed with elective surgery, typically at least 6 weeks after recovery from acute diverticulitis, should be made on a case-by-case basis. As recommended by the 2007 WGO guidelines, this decision should consider age and medical condition of the patient, frequency and severity of attacks, and the presence of any persistent symptoms after the acute episode. Other appropriate indications for elective colectomy include inability to exclude carcinoma, after an episode of complicated diverticulitis treated nonoperatively, or after percutaneous drainage of a diverticular abscess.^[4]

  • Regarding frequency, after one attack, about one third of patients will have a later second attack of acute diverticulitis. After a second episode, a further one third will have yet another attack. According to the 2007 WGO guidelines, a repeat episode requires immediate surgery if complications occur, such as free perforation, obstruction, abscess that is not resolved by percutaneous drainage, fistulas, and failure to respond to treatment.^[4]
  • Regarding severity, most patients who present with complicated diverticulitis do so at the time of their first episode. Therefore, once a patient's initial presentation has been determined to be uncomplicated or complicated, the patient's future episodes are likely to follow a similar course.
  • A 1-stage surgical approach with resection and primary anastomosis is often possible in elective settings since the disease is well localized and/or significantly resolved. The bowel must be well vascularized, nonedematous, tension free, and well prepared. The proximal margin should be an area of pliable colon without hypertrophy or inflammation. The distal margin should extend to the upper third of the rectum where the taenia coalesces. Not all of the diverticula-bearing colon must be removed, since diverticula proximal to the descending or sigmoid colon are unlikely to result in further symptoms.
  • Patients with Hinchey stage I or II disease can usually have preoperative bowel preparation.
• The classic 3-stage surgical approach is now rarely indicated because of high associated morbidity and mortality and is considered only in critical situations in which resection cannot safely be performed.

  • In this approach, the initial operation is simply drainage of the diseased segment and creation of a proximal diversion colostomy, without resection.
  • The second operation is performed 2-8 weeks later to resect the diseased bowel and perform a primary anastomosis.
  • A third operation, performed 2-4 weeks after the second operation, closes the stoma.
• Increasing experience with laparoscopic techniques for colon resection suggests that some of its advantages include less pain, a smaller scar, and shorter recovery time.^[8] There is no change in early or late complications and cost and outcome are comparable to open procedures. This approach is best suited for patients in whom the episode of acute diverticulitis has resolved and in patients with Hinchey stage I or II disease.
• Special considerations exist for some forms of complicated diverticulitis.

  • For diffuse peritonitis, an appropriate initial empiric antibiotic regimen must include either single agent therapy with imipenem/cilastin or piperacillin/tazobactam or multiple drug therapy with ampicillin, gentamicin, and metronidazole.
  • Obstruction needs to be differentiated from carcinoma, and, even if biopsy results are negative, resection may be necessary to exclude carcinoma if there is enough suspicion based upon appearance alone.
  • Abscesses without peritonitis may be amenable to percutaneous drainage with an elective single-stage operation after the episode has resolved. Drainage is usually through the anterior abdominal wall but may be done transgluteally or through the rectum or the vagina, depending on the location of the abscess. Catheter drainage may be helpful in patients who cannot undergo surgery and should be left in place until drainage is less than 10 mL in 24 hours. Catheter sinograms can be performed periodically to monitor the resolution of the abscess cavity before the catheter is removed.
  • Fistulas generally do not close spontaneously, but they may be managed with an elective 1-stage procedure in most cases. Also, in the absence of urinary tract obstruction, observation appears safe in patients with contraindications to surgery.
  • Patients who are immunosuppressed are at an increased risk of perforation, and surgery is necessary in almost all patients who are either already immunosuppressed or are about to start immunosuppressive therapy.

• Surgical consultation
• Gastroenterologic consultation

• In mild episodes, a clear liquid diet is advised. Clinical improvement should occur within 2-3 days, and the diet can then be advanced as tolerated.
• Administer nothing by mouth in episodes of moderate-to-severe acute diverticulitis.
• Studies imply a high-fiber diet will prevent progression of diverticulosis. However, after patients have become symptomatic, the benefit of fiber supplementation is less clear. Recommending to patients to avoid seeds and nuts is currently less common, since it is now thought that seeds and nuts may not play a significant role in the development of diverticulitis, as believed in the past.
• Long-term management probably includes a high-fiber, low-fat diet.

Normal activity is possible after resolution of the acute episode.