Diverticulitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Mohamed Moubarak, M.D. [3]

Medical Therapy

Overview

An initial episode of acute diverticulitis is usually treated with conservative medical management, including bowel rest (ie, nothing by mouth), IV fluid resuscitation, and broad-spectrum antibiotics which cover anaerobic bacteria and gram-negative rods. However, recurring acute attacks or complications, such as peritonitis, abscess, or fistula may require surgery, either immediately or on an elective basis.

Upon discharge, patients may be placed on a low residue diet. This low-fiber diet gives the colon adequate time to heal without needing to be overworked. Later, patients are placed on a high-fiber diet. There is some evidence this lowers the recurrence rate.

Uncomplicated Diverticulitis

A 7-10 days of oral broad-spectrum antibiotic therapy is tried for acute uncomplicated diverticulitis. The most common agents used in uncomplicated diverticulitis are:

• Quinolone-metronidazole or
• Amoxicillin-clavulanic acid or
• Trimethoprim-sulfamethoxazole with metronidazole

Admission to the hospital is indicated in all patients who are elderly, those with compromised immune systems, other comorbidities, cannot tolerate oral hydration, or fails to improve despite appropriate antibiotic therapy. The aim of hospital admission is bowel rest, nasogastric tube placement, and parenteral antibiotics.

Outpatients should be advised to use diet consist of liquids only for 2-3 days, after which the diet can be resumed slowly. hospitalized patients can be treated with either liquids, or NPO with intravenous hydration depending on the severity.

There is no scientific evidence that suggests the avoidance of nuts and seeds prevents the progression of diverticulosis to an acute case of diverticulitis. Further, in a survey of fellows of The American Society of Colon and Rectal Surgeons, although the majority of the surgeons responding to the survey favored adherence to a low residue diet, half of them still belief that there is no value in specifically avoiding seeds and nuts.

Routine colonoscopy is recommended after the resolution of the attack, to exclude colonic neoplasia, or any other possible cause.

Complicated Diverticulitis

Surgical intervention is required for complicated acute diverticulitis which include:

• Peritonitis
• Failed percutaneous drainage of an abscess
• Enterocutaneous fistula formation
• Bowel obstruction

Empirical intravenous antibiotics that covers gram-negative and anaerobic pathogens are used.

Antibiotics Used in Complicated Diverticulitis Preferred Regimen ▸ Ampicillin sulbactam 3 g IV/6 hours OR ▸Piperacillin-tazobactam 3.375 or 4.5 g IV every 6 hours OR ▸Ticarcillin clavulanate 3.1 g IV every 4 hours OR ▸ Ceftriaxone 1 g IV every 24 hours PLUS ▸Metronidazole 500 mg IV every 8 hours Alternative Regimen ▸ Ciprofloxacin 400 mg IV every 12 hours OR ▸Levofloxacin 500 or 750 mg IV once daily PLUS ▸Metronidazole 500 mg IV every eight hours OR ▸ Imipenem cilastatin 500 mg IV every six hours OR ▸Meropenem 1 g IV every eight hours OR ▸Doripenem 500 mg IV every eight hours OR ▸Ertapenem 1 g IV once daily

In some cases surgery may be required to remove the area of the colon with the diverticula. Patients suffering their first attack of diverticulitis are typically not encouraged to undergo the surgery, unless the case is severe. Patients suffering repeated episodes may benefit from the surgery. In such cases the risks of complications from the diverticulitis outweigh the risks of complications from surgery.