Acute diverticulitis is a common gastrointestinal condition characterized by the inflammation or infection of small, bulging pouches called diverticula that form in the wall of the colon. Treatment protocols depend heavily on the severity of the flare, distinguishing between uncomplicated cases that often resolve with home care and complicated presentations that require hospital intervention. Diagnosis is typically confirmed using a computed tomography (CT) scan, which helps determine the extent and severity of the disease and guides the appropriate management strategy.
Treating Uncomplicated Acute Diverticulitis
Uncomplicated acute diverticulitis is the most common presentation, involving localized inflammation without an abscess, perforation, or fistula. Healthy patients with mild symptoms who can tolerate oral intake are generally managed safely in an outpatient setting. Initial management focuses on resting the bowel and controlling symptoms, often involving a temporary clear liquid diet. As symptoms improve, usually within two to three days, the diet is gradually advanced to low-fiber foods before returning to a regular diet.
The role of oral antibiotics in mild cases is debated, with many guidelines now recommending a selective approach rather than routine use. Evidence suggests that in selected, immunocompetent patients without systemic signs of infection, observation with rest and fluids is an effective strategy. However, oral broad-spectrum antibiotics, such as ciprofloxacin and metronidazole, are still commonly prescribed for patients with underlying health issues or those who are frail. Patients managed at home must monitor their symptoms closely and seek immediate medical attention if pain worsens, fever persists, or they cannot keep down fluids.
Management of Severe and Complicated Cases
Patients presenting with severe pain, high fever, or signs of complications—such as inability to tolerate oral intake, significant comorbidities, or immunocompromised status—typically require hospitalization. Inpatient management begins with bowel rest (NPO status) and intravenous (IV) fluid resuscitation to maintain hydration. Broad-spectrum IV antibiotics are administered to target bacteria found in the colon, covering gram-negative rods and anaerobic organisms.
Complicated diverticulitis involves inflammation associated with abscess formation, perforation, fistula, or obstruction, requiring more aggressive intervention. A localized abscess may be treated initially with IV antibiotics and supportive care, particularly if it is small (less than 3 cm). Larger abscesses, or those that do not improve with antibiotics, are often drained using a CT-guided percutaneous drain. This allows the infection to be controlled without immediate surgery.
Emergency surgery is reserved for the most severe complications, such as a large-scale perforation leading to peritonitis or uncontrolled sepsis. The procedure typically involves the resection of the diseased segment of the colon. In cases of severe contamination, a Hartmann’s procedure may be performed, which removes the affected bowel and creates a temporary colostomy. For certain patients with purulent peritonitis, a resection with primary anastomosis or laparoscopic peritoneal lavage may be considered.
Recovery and Long-Term Prevention Strategies
Once the acute episode has resolved, the focus shifts to preventing future flares and promoting colon health. The diet should transition back to a normal pattern, emphasizing a high-fiber intake of 25 to 35 grams daily. Fiber helps keep stools soft and promotes regular bowel movements, which reduces the pressure within the colon that contributes to diverticula formation. Adequate hydration is necessary for the fiber to work effectively and is an important part of lifestyle changes.
Other preventive measures include maintaining a healthy body weight, engaging in regular physical exercise, and avoiding smoking, all associated with a reduced risk of recurrence. Following recovery from an acute bout of diverticulitis, a colonoscopy is generally recommended within six to eight weeks. This follow-up procedure is performed to rule out underlying conditions, such as a malignancy, which can mimic the symptoms of diverticulitis.