Management of Diverticular Disease

Suzanne Albrecht, PharmD, MSLIS

Disclosures

US Pharmacist 

In This Article

Treatment

Outpatient Therapy

Nonoperative treatment is successful in 70% to 100% of patients with uncomplicated acute diverticulitis.[6] Patients with mild symptoms and no peritoneal signs may be managed conservatively on an outpatient basis with a clear liquid diet and broad spectrum antibiotics.[9] Antibiotics should be tailored to treat the most common bacteria found in the colon, which are gramnegative rods and anaerobic bacteria. Single-agent and multiple antibiotic agent regimens are equally effective as long as both types of bacteria (gram-negative rods and anaerobes) are susceptible.[6] (The recommended treatment regimens are detailed in Table 2 .[9]) Symptoms should improve within 48 to 72 hours.[4,9] Patients should also be placed on a low-fiber diet during this treatment phase.[10] After 3 days of treatment, the diet can be slowly advanced to normal.[4]

Inpatient Therapy

Patients who do not symptomatically improve or who cannot tolerate oral liquids need to be hospitalized.[9] Hospitalization is also indicated if the patient has a high fever, highly elevated white blood cell levels, abscess, uncontrolled pain, limited free air, partial bowel obstruction, fistula, or severe comorbid conditions, or is elderly or immunocompromised.[4,9,10] Hospitalized patients should be NPO (nothing by mouth) and on IV fluids and IV antibiotics.[7,9] The antibiotics of choice for hospitalized patients are given in Table 3 .[4,9] Symptoms should improve within 48 to 72 hours, after which the patient may be switched to oral antibiotics for 7 to 10 days. The diet may then be advanced to normal, and the patient can be discharged.[4,7]

A follow-up colonoscopy should be done 4 to 6 weeks after discharge, and a high-fiber diet should be recommended.[7] There is evidence that a high-fiber diet alleviates the symptoms of diverticular disease. Fiber intake of greater than 10 g daily (preferably 20–30 g daily) is recommended for all patients with diverticular diseases, except those suffering an acute attack of diverticulosis.[11]

Nasogastric suction is not indicated unless there is a significant ileus (intestinal obstruction).[4,7,9] An abscess larger than 4 cm in diameter should be drained.[3] CT-guided percutaneous drainage is the most appropriate way to treat patients with a large abscess.[6] For pain control, morphine should not be used because of its propensity to increase intraluminal pressure.[4,7] Meperidine (Demerol) is the drug of choice, because it has been shown to decrease colonic pressure.[4,7] NSAIDs and steroids should be avoided, because they may cause GI bleeding and perforation.[4,7] Steroids may also mask the symptoms of diverticulitis.[4]

To Operate or Not to Operate? That is the Question

Much is still not known about diverticulitis, and there does not seem to be a consensus as to when surgical intervention should be done with both acute diverticulitis and recurrent diverticulitis.[2,3,5] Approximately 1% of all patients with colonic diverticulitis will require surgery; however, that number increases to 15% to 30% for patients requiring hospitalization.[2,4] Surgery is usually not indicated after the first episode of uncomplicated diverticulitis, because only 7% to 35% of patients will have a recurrent episode.[4] When the patient is 40 years old or younger, however, surgery may be performed after the first episode, because disease in younger patients is often thought to be more aggressive and have more complications.[2] Between 2% to 30% of all cases of diverticular disease in younger patients progress to diverticulitis, and these patients are most commonly obese males. In these cases, if surgery is done, it should be to alleviate symptoms rather than prevent future complications.[2]

With patients over 40 years, surgery is usually performed after two episodes of diverticulitis.[2] With patients experiencing a second episode, there is more than a 50% probability that a third episode will occur. Medical therapy is less likely to be effective with recurrent episodes, and these episodes have a higher mortality rate.[4] Colonic resection is done to prevent future complications from diverticular disease that are likely to occur without surgery; however, 2.3% of those patients die and 14.2% require a colostomy.[2] Many of the deaths are because of anatomical leaks.[2]

Indications for immediate surgical intervention include diffuse peritonitis, massive free air, sepsis, undrainable abscess guided by CT or ultrasound, obstruction, or uncontrolled fistulas.[10] Fistulas can form by the progression of abscesses from the colon to the surrounding structures.[4] This happens in 10% to 12% of cases of diverticulitis.[3,4]

Some surgeons advocate surgery after the first episode of diverticulitis in immunocompromised patients.[3] These patients are not more likely to develop diverticulitis, but they are more likely to develop abscesses and perforation and less likely to respond to medication therapy.[2,3,6] However, they do not always present with fever and elevated white blood cell count, so it is difficult to diagnose diverticulitis in these patients. Since immunocompromised patients are more prone to perioperative mortality, caution should be exercised when deciding to perform surgery.[3]

Chronic diverticular disease may never progress to diverticulitis. Patients may present with chronic lower left quadrant pain but no fever or elevated white blood cell count. Surgery is elective and considered a safe treatment option for these patients.[2]

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