Management of acute colonic diverticulitis

CT: computed tomography; NPO: nil per os.

* Criteria for inpatient management (only need to meet one):

• Complicated diverticulitis
• Sepsis or systemic inflammatory response syndrome evidenced by more than one of the following: Temperature >38°C or <36°C, heart rate >90 beats per minute, respiration rate >20 respirations per minute, white blood cell count >12,000/mL or <4000/mL, C-reactive protein >15 mg/dL
• Severe abdominal pain or diffuse peritonitis, and/or failure to reduce abdominal pain in the emergency department to <5 on a visual analog scale
• Microperforation (eg, a few air bubbles outside of the colon without contrast extravasation or phlegmon)
• Age >70 years
• Significant comorbidities (eg, diabetes mellitus with organic involvement [eg, retinopathy, angiopathy, nephropathy], a recent cardiogenic event [eg, acute myocardial infarction, angina, heart failure], or recent decompensation of chronic liver disease [≥Child B] or end-stage renal disease)
• Immunosuppression (eg, poorly controlled diabetes mellitus, chronic high-dose corticosteroid use, use of other immunosuppressive agents, advanced human immunodeficiency virus infection or acquired immunodeficiency syndrome, B or T cell leukocyte deficiency, active cancer of hematologic malignancy, or organ transplant)
• Intolerance of oral intake secondary to bowel obstruction or ileus
• Noncompliance with care/unreliability for return visits/lack of support system
• Failure of outpatient treatment

¶ The choice of intravenous antibiotics depends on disease severity. Refer to UpToDate topic for details.

Δ Oral antibiotics for diverticulitis include amoxicillin-clavulanate, ciprofloxacin/metronidazole, levofloxacin/metronidazole, or trimethoprim-sulfamethoxazole/metronidazole. Refer to UpToDate topic for dosages. Assuming continued improvement, immunocompetent patients should complete a total of 4 to 7 days of antibiotic therapy (7 to 10 days for undrained abscess or phlegmon); immunocompromised patients should be treated for 10 to 14 days.