Diverticulitis Treatment & Management: Approach Considerations, Medical Care, Surgical Care

broad spectrum diet, diverticulitis treatment

Diverticulitis Treatment & Management

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Approach Cons >

The management of patients with diverticulitis depends on their presentation severity, presence of complications, and comorbid conditions. Therefore, there is no standard treatment in the medical management of diverticular disease, including diverticulitis. [4]

The initial approach involves determining whether the patient has complicated or uncomplicated disease. [2] Uncomplicated diverticulitis is defined as localized diverticular inflammation without complication, whereas complicated diverticulitis consists of inflammation associated with a complication such as abscess, fistula, obstruction, bleeding, or perforation). [30] Computed tomography (CT) imaging can confirm the diagnosis of diverticulitis and distinguish between both disease processes.

Uncomplicated diverticulitis can be managed medically and in an ambulatory setting, whereas complicated disease requires a more aggressive approach that can often require urgent or elective surgery, and treatments that are specific to the complication itself (eg, abscess drainage). [2] A gastroenterology consultation may be helpful, as can further assistance with surgical and interventional radiology consultations.The modified Hinchey classification is based on CT scan findings and is used to categorize diverticulitis as well as help to guide appropriate interventions. [3]

Emergency colectomy is performed when severe complications arise or when the patient’s condition does not respond to medical treatment. Complications requiring surgical intervention include the following: purulent peritonitis, uncontrolled sepsis, fistula, and obstruction. In a retrospective study of over 3000 patients, about 20% of patients admitted for acute diverticulitis required emergency colectomy.

Elective resection of the involved bowel segment after three episodes of uncomplicated diverticulitis to prevent further attacks is generally recommended by consensus guidelines. In addition, earlier resection for younger patients with diverticulitis as well as for patients who are immunocompromised has been proposed. As most complicated diverticulitis occurs on the first presentation and data for elective resection have come from small retrospective studies, this recommendation remains controversial.

Successful percutaneous drainage of a diverticular abscess has not been associated with greater recurrence or more severe disease and does not necessitate elective colectomy.

Antibiotics are known to be the mainstay of therapy for most patients with acute diverticulitis, but recent studies have questioned their necessity, especially in mild, uncomplicated disease. [4, 31] It appears that antimicrobial use in acute uncomplicated diverticulitis increases patients’ stay in the hospital without lowering the overall or individual complication rates. [32]

A 2012 Cochrane review showed no significant benefit of antibiotic therapy in the treatment of uncomplicated diverticulitis, however these data were based mostly on one well-done randomized controlled trial. [33] The 2015 American Gastroenterological Association (AGA) guidelines stated that clinicians must be selective in using antibiotics in patients in this subgroup of patients. [5]

Patients who have been successfully treated for acute diverticulitis should be reassessed in 6-8 weeks. Those who are symptom free at that time should undergo colonoscopy to rule out malignancy, if they have not had a recent, high-quality colonic examination. [5]

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