Recommendations
Key Recommendations
Give intravenous antibiotics to patients admitted to secondary care with suspected complicated acute diverticulitis.[39]
Think ‘Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[45][46][47] See Sepsis in adults.
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[46][47][49][50] Consult local guidelines for the recommended approach at your institution.
In the community: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[45]
Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
At risk of neutropenic sepsis.
In hospital: urgently consult a senior clinical decision-maker (e.g., ST3 level doctor in the UK) if you suspect sepsis.[45][46][49][51] Refer to local guidelines for the recommended approach at your institution for assessment and management of the patient with suspected sepsis.
Other complications requiring further investigation and treatment include bleeding, abscess, obstruction (see Large bowel obstruction), perforation, and fistulae. The presence of complications may be determined by the initial computed tomography scan and warrants a surgical consultation.
Initial management of bleeding, in the presence of volume depletion or shock, is to maintain haemodynamic stability by infusion of fluids and by blood transfusion.
Offer oral antibiotics to a patient with uncomplicated acute diverticulitis who is systemically unwell, is immunosuppressed, or has significant comorbidities.[39]
These patients can be safely treated at home, provided the computed tomography scan rules out complications.[63][64] If fever and leukocytosis persist after 72 hours or symptoms of acute diverticulitis or acute abdomen present, admit to hospital for intravenous antibiotics.[65]
For a patient with uncomplicated acute diverticulitis who is systemically well, offer simple analgesia and consider not using antibiotics.[39]
Management of symptomatic diverticular disease includes diet and lifestyle modification, and simple analgesia.[39]
Do not offer antibiotics to people with diverticular disease.[39]
Diverticulosis is the presence of diverticula without symptoms.[39] Asymptomatic diverticulosis discovered incidentally requires no treatment, although bulk forming laxatives may be considered for patients with constipation.[39] There is evidence to suggest that these patients might benefit from increasing dietary fibre, including fruit and vegetables.[43][44][66]
Advise a healthy balanced diet.[39] In patients with a low-fibre diet and constipation, advise increasing fibre intake gradually to minimise flatulence and bloating, and advise adequate fluid consumption.[39]
Practical tip
There is no need for people with diverticulosis to avoid seeds, nuts, popcorn, or fruit skin.[39]
Explain the benefits of exercise, weight loss, and smoking cessation, when needed, to help reduce the risk of developing acute diverticulitis or symptomatic disease.[25][39]
Diverticular disease may be defined as the presence of diverticula with mild abdominal pain or tenderness and no systemic symptoms.[39]
Give dietary and lifestyle advice to patients as for asymptomatic diverticulosis (see Asymptomatic diverticulosis above).
For patients with mild symptoms of diverticular disease advise lifelong (if tolerated) dietary modification, especially increasing fibre supplementation over weeks and increasing hydration.[39][66][67]
Consider bulk-forming laxatives if a high-fibre diet is not tolerated or the patient has persistent constipation or diarrhoea.
Consider an antispasmodic (e.g., dicycloverine) to treat abdominal cramping.[39]
Consider paracetamol for abdominal pain.[39]
Advise the patient to avoid non-steroidal anti-inflammatory drugs and opioid analgesics as they are associated with a risk of diverticular perforation (although opioids may be given for severe pain in a hospital setting).
Do not offer antibiotics to people with symptomatic diverticular disease.[39]
Consider alternative causes in a patient with persistent symptoms that do not respond to treatment.[39]
Diverticulitis indicates inflammation of a diverticulum or diverticula, and may be caused by infection. Patients with uncomplicated acute diverticulitis do not have any symptoms of an acute abdomen (i.e., severe abdominal pain, abdominal tenderness with or without guarding [suggesting peritonism], abdominal distension). The main goals of treatment of uncomplicated acute diverticulitis include elimination of the infection and prevention of complications.
Consider not prescribing antibiotics if the patient with uncomplicated acute diverticulitis is systemically well.[6][39] Instead offer analgesia, such as paracetamol, and advise the patient to return if symptoms worsen.[39] Advise the patient to avoid non-steroidal anti-inflammatory drugs and opioid analgesics as they are associated with a risk of diverticular perforation (although opioids may be given for severe pain in a hospital setting).
Offer oral antibiotics if the patient with uncomplicated acute diverticulitis is systemically unwell, has signs of systemic inflammation, is immunosuppressed, or has significant comorbidities.[6][39]
When selecting antibiotics follow your local protocol or take advice from microbiology. In the UK the National Institute for Health and Care Excellence recommends for suspected or confirmed uncomplicated acute diverticulitis a 5-day course of the following oral antibiotics:[39]
Amoxicillin/clavulanate as the first-line choice
Or, if amoxicillin/clavulanate is unsuitable or the patient has a penicillin allergy:
Cefalexin (use caution in patients with a penicillin allergy) plus metronidazole; or
Trimethoprim plus metronidazole; or
Ciprofloxacin (only if switching from intravenous ciprofloxacin with specialist advice; consider safety issues - see below) plus metronidazole.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[68]
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Patients with abdominal pain, fever, or leukocytosis who have been offered oral antibiotics can be safely treated at home, provided the computed tomography scan rules out complications.[63][64]
If fever and leukocytosis persist after 72 hours or symptoms of acute diverticulitis or acute abdomen present, the patient should be admitted to hospital and given intravenous antibiotics until clinical improvement - see Acute diverticulitis (complicated) below.[65]
More info: Antibiotics in uncomplicated diverticulitis
Some investigators have questioned whether antibiotics are required in uncomplicated diverticulitis, proposing that diverticulitis may be an inflammatory rather than an infectious condition.
Meta-analyses of studies comparing antibiotics with no antibiotic treatment found that treating and monitoring uncomplicated diverticulitis without or with antibiotics is safe and effective and that observational management was not statistically different from antibiotic treatment for the primary outcome of needing surgery.[69][70][71][72][73][74]
One systematic review of studies comparing antibiotics with no antibiotics in patients with uncomplicated diverticulitis found no difference in risks for treatment failure, elective surgery, recurrence, and post-treatment complications.[75]
Results of a subsequent Cochrane review, based on limited data from five randomised clinical trials, suggested that the effect of antibiotics for uncomplicated diverticulitis is uncertain for complications (early and long-term), emergency surgery, recurrence, and elective colonic resections.[76]
[ 
]
Guidelines from the UK National Institute for Health and Care Excellence (NICE), the World Society of Emergency Surgery (WSES), the American Gastroenterological Association (AGA), the American Society of Colon and Rectal Surgeons (ASCRS), and the American College of Physicians (ACP) recommend that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis who are systemically well and otherwise healthy.[6][12][35][39][77]
Advise patients to consume a low-residue diet consisting of foodstuffs that leave a minimal residue after digestion and absorption in the gut (e.g., refined bread, cereals, white rice, vegetable and fruit juice without pulp, dairy products). The diet is low in fibres and undigested material.
Complications requiring further investigation and treatment include bleeding, abscess, obstruction, perforation, and fistulae. The presence of complications may be determined by the initial computed tomography (CT) scan and warrants a surgical consultation. Surgical intervention may also be considered for diverticular disease that does not respond to medical management.
Analgesia
Use a simple analgesic such as paracetamol. In general, analgesics that cause constipation (such as opioids) should be avoided. However, for relief of severe pain, analgesia can be escalated using tramadol and, if necessary, an opioid (e.g., morphine) in a titrated fashion.
Antibiotics
Give intravenous antibiotics to patients admitted to secondary care with suspected complicated acute diverticulitis.[39]
Review intravenous antibiotics within 48 hours, or after the CT scan if sooner, and consider stepping down to oral antibiotics.[39]
When selecting antibiotics follow your local protocol or take advice from microbiology. In the UK the National Institute for Health and Care Excellence recommends for suspected or confirmed complicated acute diverticulitis the following intravenous antibiotics first-line:[39]
Amoxicillin/clavulanate
Cefuroxime plus metronidazole
Amoxicillin plus gentamicin and metronidazole
Ciprofloxacin (only in people with allergy to penicillins and cephalosporins; consider safety issues - see below) plus metronidazole.
Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[68]
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Consult microbiology if alternative intravenous antibiotics are required.[39]
Consider any indications of sepsis in patients with complicated diverticulitis.
Practical tip
Sepsis
Think ‘Could this be sepsis?’ based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[45][46][47]
Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[46][47][49][50] Consult local guidelines for the recommended approach at your institution.
Arrange urgent review by a senior clinical decision-maker (e.g., ST3 level doctor in the UK) if you suspect sepsis:[45][51]
Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns).
A patient is also at high risk of severe illness or death from sepsis if they have a NEWS2 score below 7 and a single parameter contributes 3 points to their NEWS2 score and a medical review has confirmed that they are at high risk.
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6) or within 1 hour of any intervention for suspected sepsis (antibiotics/fluid resuscitation/oxygen) if there is no improvement in the patient’s condition.
Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[50][51]
In the community and custodial settings: refer for emergency medical care in hospital (usually by blue-light ambulance in the UK) any patient who is acutely ill with a suspected infection and is:[45]
Deemed to be at high risk of deterioration due to organ dysfunction (as measured by risk stratification)
At risk of neutropenic sepsis.
See Sepsis in adults.
A 7- to 10-day course of antibiotics is often recommended on the premise that there is background acute inflammation/infection accounting for any bleeding (when present).
Low-residue diet
It is common practice for a low-residue diet to be recommended for these patients during the acute phase until recovery, although there is no high quality evidence to date to recommend either high- or low-fibre (low-residue) diet in patients with symptomatic acute colonic diverticulitis. A low-residue diet reduces the frequency and volume of stools while prolonging intestinal transit time. It consists of foodstuffs that leave a minimal residue after digestion and absorption in the gut (e.g., refined bread, cereals, white rice, vegetable and fruit juice without pulp, dairy products). A low-residue diet is low in fibres and undigested material.
Managing bleeding
Initial management of bleeding, in the presence of volume depletion or shock, is to maintain haemodynamic stability by infusion of fluids and by blood transfusion.
The British Society of Gastroenterology guideline on the diagnosis and management of acute lower gastrointestinal bleeding recommends stratifying patients using the ‘shock index’ (the ratio of heart rate/systolic blood pressure), which is a marker of active bleeding.[56]
Stratify patients presenting with lower gastrointestinal bleeding as stable (shock index <1) or unstable (shock index >1). Stable bleeds can then be further categorised as major or minor using a risk assessment tool, such as the Oakland score.[56][78][79]
For haemodynamically unstable patients or those with a shock index of >1 after initial resuscitation, use CT angiography to locate the site of blood loss, prior to endoscopic or radiological therapy.[56]
If no source of bleeding is located, use upper gastrointestinal endoscopy to see if the bleeding is from an upper gastrointestinal source.
When catheter angiography is indicated, perform it as soon as possible after CT angiography.[56]
Isotope-labelled red blood cell nuclear scan is another option, but is rarely used in this context and should be discussed with radiology.
Admit stable patients with a major bleed to hospital for colonoscopy to identify and treat the lesion.[56]
Colonoscopy can be used for accurate diagnosis and endoscopic haemostasis can be achieved for the majority of patients. This significantly reduces the need for surgery; however, its value in prevention of subsequent bleeding is unclear.[58][80][81]
Endoscopic options for managing diverticular bleeding include injection or thermal therapies, endoscopic band ligation, or haemostatic powders.[56]
Consider only if significant bleeding continues despite attempted endoscopic and angiographic haemostasis.[56]
Patients may be stable but require red blood cell transfusion.[56]
For patients on warfarin, stop warfarin at presentation. It can be restarted at 7 days after haemorrhage in patients with low thrombotic risk.[56]
In patients with unstable haemorrhage, reverse anticoagulation with prothrombin complex concentrate and vitamin K.[56]
Abscess drainage
A localised abscess <3 cm in diameter does not warrant drainage and can be treated with antibiotics.[6][54][82]
For an abscess >3 cm in diameter, it is best to drain under CT scan or with ultrasound guidance; surgery is necessary if this cannot be accomplished.[6][39]
A CT scan of the abdomen with contrast is the imaging of choice for percutaneous drainage of abscess.
Send pus samples to microbiology in order to tailor antibiotic sensitivity.[39]
Continue on intravenous antibiotics, completing a course of up to 14 days in people with CT-confirmed diverticular abscess. Switch to oral antibiotics if possible for patients with abscesses <3 cm.[39]
Consider further imaging if the patient does not improve or deteriorates.[39]
Managing bowel perforations
Consider diagnostic laparoscopy prior to exploratory laparotomy if the primary diagnosis is uncertain.
Offer laparoscopic lavage or resectional surgery to patients with diverticular perforation with generalised peritonitis.[39] Discuss the risks and benefits of each procedure with the patient.[39]
Early laparoscopic washout is increasingly adopted as a surgical strategy for acute diverticulitis (Hinchey grades I, II, and III; see Aetiology for details of Hinchey classification) and when medical treatment and percutaneous drainage have failed to contain sepsis.[81][83][84][85][86][87][88] However, there is evidence that laparoscopic lavage for Hinchey III diverticulitis does not completely control the source of infection, and is associated with an increased rate of re-intervention.[89]
If faecal peritonitis is identified during laparoscopy, resectional surgery should be carried out.[39]
For patients with severe or diffuse peritonitis, emergency colectomy, a Hartmann's procedure (resection of the bowel with an end stoma), or colectomy with primary anastomosis (join in the bowel) may be necessary.[90][91] The National Institute for Health and Care Excellence in the UK recommends primary anastomosis with or without diverting stoma or Hartmann’s procedure based on patient characteristics, available expertise, and case-by-case basis.[39][92]
For select patients (Hinchey I, II, and III), and pending surgical expertise, a laparoscopic colectomy with primary anastomosis and/or a laparoscopic Hartmann's procedure is safe and may improve postoperative outcomes. [
]
[Evidence C]
Management of clinically stable, localised perforated diverticular disease has changed in recent years with a move towards fewer surgical interventions and non-operative management strategies in highly selected cohorts of patients.[93][94] This is not universally accepted, and not yet included in existing guidelines with strong evidence, so these approaches should only be carefully selected on a case-by-case basis with close clinical supervision.
Consider elective open or laparoscopic resection for patients who have recovered from complicated acute diverticulitis but have continuing symptoms (such as stricture or fistula).[39]
Criteria for recommending elective colectomy for recurrent disease are not clear cut and should not be based on the number of previous attacks alone. Make judgements on an individual basis depending on age, frequency, and severity of recurrent symptoms; previous complications; presence of comorbidities; and patient preferences and values.[12][35][95][96] In elective settings, laparoscopic colonic resection is feasible and safe, may hasten postoperative recovery, and has fewer postoperative complications than conventional surgery, including surgical site infections.[97][98][99]
Prophylactic oral antibiotic administration one day before surgery reduces the incidence of surgical-site infection, without mechanical bowel preparation, in such patients.[100]
Mesalazine, probiotics, or rifaximin are not recommended for the prevention of recurrent diverticulitis.[12][101] Evidence shows that mesalazine does not reduce the risk of recurrence.[102]
[ ]
There is insufficient evidence for the use of rifaximin, mesalazine plus rifaximin in combination, balsalazide plus probiotics in combination, or burdock tea.[101][102]
Do not offer an aminosalicylate or antibiotics to prevent recurrent acute diverticulitis.[39]
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