THERAPEUTIC MANAGEMENT OF ACUTE DIVERTICULITIS

Abstract

Acute diverticulitis is the inflammatory manifestation of diverticular disease of the colon and one of the most frequent causes of acute abdomen, resulting from the perforation of a diverticulum, with potential evolution from localized inflammation to diffuse peritonitis. It is a highly prevalent condition in Western societies, where approximately 50% of individuals over 50-60 years of age have diverticulosis, and of these, 10% to 25% may develop diverticulitis during their lifetime. For diagnosis, computed tomography (CT) with intravenous contrast has become the gold standard examination, offering high sensitivity (94%) and specificity (99%), being crucial both for diagnostic confirmation and for severity stratification and therapeutic planning. The management of acute diverticulitis has undergone significant reformulation in the last two decades, driven by the guidelines of the American College of Physicians (ACP) and the World Society of Emergency Surgery (WSES). The ACP (2022) recommends that immunocompetent patients with uncomplicated and clinically stable diverticulitis can be managed on an outpatient basis. This guideline proposes the selective use of antibiotics, reserving them for cases with systemic signs, immunosuppression, or risk factors, since routine antibiotic therapy has not been shown to alter outcomes such as the need for surgery or recurrence. The ACP guideline is primarily based on clinical criteria and systemic risk. On the other hand, the WSES (2022) adopts a more stratified approach according to tomographic findings, classifying the disease into uncomplicated and complicated forms. The WSES emphasizes the central importance of CT in all elderly patients with clinical suspicion, since the presentation in this population is frequently atypical (with typical pain, fever, and leukocytosis absent in a significant proportion). Furthermore, it highlights that hospital mortality after emergency surgery increases progressively with age, reinforcing the need for individualized therapy based on comorbidities. While ACP prioritizes therapeutic rationalization, WSES structures the decision based on the radiological classification of severity, but both guidelines converge on the individualization of treatment and the abandonment of elective surgery recommendations based solely on the number of episodes. Thus, contemporary management is based on a risk-based approach, supported by high-accuracy imaging and with special attention to population particularities, especially in the elderly.