Oral Antibiotic Therapy for Acute Uncomplicated Diverticulitis

Diverticula are small outpouchings that develop at weak points along the wall of the colon (large bowel), probably because of high pressures associated with muscle contractions during the passage of stool. When these sacs become obstructed and/or inflamed (most frequently in middle-aged or elderly individuals), they enlarge and create pain and fever. Usually, the left lower quadrant is involved, because diverticula tend to form in the left-side portion of the colon (descending colon) more frequently than in the right-side portion (ascending colon) or horizontal connecting section (transverse colon). A ruptured diverticulum can cause a clinical picture much like that of a ruptured appendix, with pain in the left side of the abdomen instead of the right side. The victim should seek medical attention, and his diet be limited to clear fluids. Antibiotics (metronidazole, metronidazole combined with doxycycline, amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, cefixime, ciprofloxacin, or cefpodoxime) should be administered if help is more than 24 hours away. 

As the population ages, diverticulitis is expected to become more prevalent. In a recent article entitled “Is Outpatient Oral Antibiotic Therapy Safe and Effective for the Treatment of Acute Uncomplicated Diverticulitis” (Annals of Emergency Medicine 2011;57[6]:600-602) by Kerri Friend, MD and Angela Mills, MD from the University of Pennsylvania, the authors used a technique of reviewing the medical literature to identify research articles related to the search terms “uncomplicated diverticulitis” and “treatment.” They found four related articles. Uncomplicated diverticulitis is diverticulitis that responds to medical (i.e., non-surgical) treatment. In reviewing the articles identified by the search, the authors concluded that outpatient (i.e., hospitalization not required) treatment of acute uncomplicated diverticulitis might be reasonable for the following types of patients: persons who can tolerate oral intake (e.g., can keep fluids down without vomiting or excessive pain), have access to oral antibiotics, have adequate pain control, do not have significant and simultaneous medical problems (e.g., diabetes, heart failure, kidney disease, or end-stage cancer) and have access to adequate follow-up and social support. Of note is the fact that the patients chosen for outpatient therapy were the beneficiaries of computed tomography (CT) or ultrasound to exclude manifestations of complicated diverticulitis, such as the presence of an abscess.

What is the application of this approach to patients who may be suffering from diverticulitis in the outdoors when they are away from a prompt urban medical evaluation? It is that uncomplicated acute diverticulitis can likely be treated with outpatient therapy (oral rehydration, relative bowel rest [i.e., avoiding solid foods for the first few days if possible], physical rest and avoidance of overexertion, and oral antibiotics and pain medications). If diverticulitis is suspected and therapy initiated, the sufferer should still be brought to medical attention as soon as possible.