Diverticulitis Management: A Hospitalist's Guide to Imaging, Antibiotics, and Surgery

Understanding Diverticulitis

• 💡 Diverticulitis is the inflammation of pre-existing outpouchings in the intestine called diverticula.
• 🎯 Uncomplicated diverticulitis involves localized inflammation confined to the colon wall and surrounding fat.
• ⚠️ Complicated diverticulitis occurs when there is anatomical disruption, such as abscess formation, perforation, stricture, or fistula.

Diagnosis and Assessment

• 🔍 Differentiating complicated from uncomplicated diverticulitis based on history and physical exam alone can be challenging.
• 📈 While elevated white blood cell counts and C-reactive protein can be indicative, their degree of abnormality may raise suspicion rather than confirm complications.
• 🏥 CT imaging is the gold standard for diagnosing diverticulitis and assessing for complications like abscesses or perforations.

Treatment Strategies: Antibiotics and Disposition

• 💊 Antibiotic use in uncomplicated diverticulitis is selective, not routine, with immune-competent patients without signs of sepsis potentially managed without antibiotics.
• 🎯 For patients requiring antibiotics, regimens should cover enteric gram-negative and anaerobic bacteria, with common options including amoxicillin-clavulanate or ciprofloxacin plus metronidazole.
• 🏥 Admission is recommended for complicated diverticulitis, while uncomplicated cases with no signs of sepsis and good follow-up may be candidates for outpatient management.

Managing Complicated Diverticulitis

• 🎯 Abscesses larger than 3 cm typically warrant drainage via interventional radiology (IR), with careful consideration for location to avoid fistula formation.
• 💉 For admitted patients with complicated disease, IV antibiotics are standard, often starting with broad coverage like ceftriaxone and metronidazole, with potential for step-down to oral therapy.
• ⏱️ Following source control (like IR drainage), a shorter antibiotic course of approximately 4-5 days is often adequate, based on trials like STOP-IT.

Surgical Considerations and Follow-Up

• ⚠️ Patients with complicated diverticulitis, especially those with abscesses, should have a surgical consultation for follow-up planning.
• 🏥 Elective surgery for diverticulitis is a shared decision, focusing on the burden of disease on the patient's life rather than solely the number of episodes.
• 🔍 Colonoscopies are recommended after diverticulitis, particularly complicated cases, to rule out underlying colon cancer, with a low but present risk (up to 5-10%).
• 🚫 There is no data to support avoiding seeds and nuts; patients should avoid foods that cause them discomfort.