The surgical management of acute diverticulitis has changed during the past 2 decades. Uncomplicated disease has become a nonsurgical condition once a malignant neoplasm is excluded. Surgical intervention for complicated disease is no longer mandatory given the natural history of this disease.
Antibiotic therapy has been the cornerstone of management of acute diverticulitis, with the support of multiple society guidelines. Recent evidence disputes the necessity of antibiotics in the treatment of mild diverticulitis. In a 2007 retrospective review by Hjern et al1 of 311 patients treated with or without antibiotics, similar rates of failure and recurrence were seen between groups; however, the selection of milder cases in the nonantibiotic group may have influenced this outcome. More recently, 2 randomized clinical trials, the Antibiotic Therapy of Acute Uncomplicated Colonic Diverticulitis (AVOD) trial2 and the Diverticulitis: Antibiotics or Close Observation? (DIABOLO) trial,3 found no difference in complications, need for resection, or readmission among patients with Hinchey stages Ia and Ib diverticulitis treated with and without antibiotics, with the exception of a slightly but significantly shorter length of stay in the nonantibiotic arm. Rates of recurrent or complicated diverticulitis were also similar in long-term follow-up. These findings support a nonantibiotic approach for patients with mild diverticulitis, but clinical judgment should guide this strategy, especially in a patient with fever, bacteremia, or abdominal pain.
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Wells K, Fleshman J. Nonsurgical, Minimally Invasive, and Surgical Methods in Management of Acute Diverticulitis. JAMA Surg. Published online November 21, 2018. doi:10.1001/jamasurg.2018.3112
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