Diverticulitis Outpatient Treatment
Diverticulitis Outpatient Treatment
The classic teaching for the treatment ofdiverticulitis has included:
- Hospital admission
- Bowel rest (NPO)
- IV fluids
- Broad spectrum IV antibiotics
Early literature suggests that there is a small sub-population who fare well with outpatient treatment. (Friend et al., Ann Emerg Med, 2011)
BOTTOM LINE: Uncomplicated diverticulitis might be treated as outpatient if:
- Can tolerate POs
- No significant comorbidities
- Able to obtain antibiotics
- Have adequate pain control
- Access to followup and social support
- Prospective observational study of outpatient abx treatment for diverticulitis in Japan
- Diverticulitis diagnosis: Based on exam, blood tests, and ultrasound (no CT)
- Inclusion criteria: Age < 80 years, diverticulitis
- Exclusion criteria: “Severe” diverticulitis on ultrasound, uncontrolled DM, heart failure, renal dz, end-stage cancer, antibiotics within past 24 hrs.
- Study group: n=70 during 1997-2002 period
- Method: Day 4 and Day 7 followup
- Result: 68 of 70 (97%) were successfully treated as outpatient
- Randomized controlled trial of IV vs PO antibiotics (cipro/metronidazole combo) fordiverticulitis in Ireland. All patients admitted to hospital.
- Diverticulitis diagnosis: Purely based on clinical exam (no imaging test).
- Inclusion criteria: Left iliac fossa pain and LLQ abdominal tenderness
- Exclusion criteria: Generalized abdominal tenderness or evidence of perforation
- Study group: n=79 (41 with PO abx, 38 with IV abx)
- Result: No difference in tenderness and days-to-resolution between groups.
- Cohort study with outpatient treatment using PO antibiotics (amox/clavulanic +metronidazole combo). All patients admitted to hospital.
- Inclusion criteria: Diverticulitis diagnosis by clinical exam, labs, and CT imaging
- Exclusion criteria: Unable to tolerate POs, comorbidities (DM, renal insufficiency,heart failure, COPD, no family support)
- Study group: n=70
- Methods: Follow-up 4-7 days after initial ED visit.
- Result: 68 (97%) were successfully treated as outpatient. 2 (3%) failed outpatient tx because for increased abdominal pain (1) and vomiting (1).
- Retrospective study of outpatient diverticulitis patients
- Diverticulitis diagnosis: By clinical exam, labs, and CT
- Inclusion criteria: Outpatient diverticulitis patients
- Exclusion criteria: Prior dx of diverticulitis, colorectal cancer, inflammatory bowel dzStudy group: n=693 outpatient diverticulitis patients
- Result: 554 (94%) were successfully treated as outpatient.
- Predictors of treatment failure:
- Female: OR = 3.08 [1.31-7.28]
- Free fluid on CT: OR = 3.19 [1.45-7.05]
- WBC, perforation, abscess, phlegmon were not predictive (OR crossed 1.0)
Words of caution:
- This only provides guidelines, based on the limited evidence out there.
- Still use your common sense.
- Still consider admitting patients who are elderly (>80 years old) or have evidence of any perforation on CT.
- If on the fence,admit the patient.
- Alonso S, Pera M, Parés D, Pascual M, Gil MJ, Courtier R, Grande L. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis. 2010 Oct;12(10 Online):e278-82. doi: 10.1111/j.1463-1318.2009.02122.x. [[PubMed] PubMed]
- Etzioni DA, Chiu VY, Cannom RR, Burchette RJ, Haigh PI, Abbas MA. Outpatient treatment of acute diverticulitis: rates and predictors of failure. Dis Colon Rectum. 2010 Jun;53(6):861-5. doi: 10.1007/DCR.0b013e3181cdb243.(https://www.ncbi.nlm.nih.gov/pubmed/?term=￼￼19906059)
- Friend K, Mills AM. Is outpatient oral antibiotic therapy safe and effective for the treatment of acute uncomplicated diverticulitis? Ann Emerg Med. 2011 Jun;57(6):600-2. [PubMed]
- Mizuki A, Nagata H, Tatemichi M, Kaneda S, Tsukada N, Ishii H, Hibi T. The out-patient management of patients with acute mild-to-moderate colonic diverticulitis. Aliment Pharmacol Ther. 2005 Apr 1;21(7):889-97. [PubMed]
- Ridgway PF, Latif A, Shabbir J, Ofriokuma F, Hurley MJ, Evoy D, O'Mahony JB, Mealy K. Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis. 2009 Nov;11(9):941-6. doi: 10.1111/j.1463-1318.2008.01737.x. Epub 2008 Nov 7. [PubMed]