The Curbsiders Internal Medicine Podcast

Episode 510: Diverticulitis for the Hospitalist
Release Date: January 5, 2026

Episode Overview

This episode of The Curbsiders dives deep into inpatient management of diverticulitis, focusing on practical approaches for hospitalists. Hosts Drs. Moni Amin, Meredith Trubitt, and R.J. Blackburn interview Dr. Robert Hollis (colorectal surgeon) and Dr. Andrew Webster (infectious disease physician) to clarify diagnosis, classification, antibiotic choices, nutrition, when to consult surgery or IR, and management of complicated cases. The episode closes with case-based pearls and modern updates in diverticulitis care.

Meet the Guests

• Dr. Robert Hollis: Colorectal surgeon, Cleveland Clinic-trained, focus on colorectal cancer, hereditary syndromes, diverticulitis, and care transitions after ostomy.
• Dr. Andrew Webster: Infectious diseases physician, antimicrobial stewardship lead at Atlanta VA, expertise in diagnostic stewardship and medical education.

Notable Quotes & Moments

• “One of the best advice is to know when to go fast and when to go slow... it applies not only in the operating room but around everything else you do.” –Dr. Hollis (04:09)
• “Diverticulitis is really just inflammation of these pre-existing out-pouchings... It’s worth mentioning... you don’t necessarily always need antibiotics.” –Dr. Webster (10:44)
• “If you eat it and you hurt afterwards, don’t eat it. But there is no data to support avoiding seeds and nuts. Total myth.” –Dr. Hollis on seeds/nuts (69:25)
• “Never hesitate to reach out to ID… we’re people people, so we like to talk to you about your cases…” –Dr. Webster (71:11)

Key Discussion Points

1. Case-Based Clinical Reasoning

Case 1 (09:12–48:53):

58-year-old man with mild LLQ pain, subjective fevers, elevated WBC, and uncomplicated diverticulitis on CT.

• Definition

  • Diverticulitis = inflammation of diverticula. Not always infection. (10:44)
  • Uncomplicated = confined to colon wall/local fat; no anatomic disruptions.
  • Complicated = abscess, phlegmon, perforation, fistula, obstruction, stricture.

• Diagnosis

  • History/exam: LLQ tenderness, severity of symptoms, systemic signs (fever persistence, tachycardia, peritonitis).
  • Labs: WBC, CRP (thresholds help but non-specific); lactate if considering severe disease (15:37)
  • Gold standard: CT abdomen/pelvis with IV contrast (17:11)

• Disposition

  • Admit if: complicated disease, sepsis, severe comorbidities, unreliable follow-up (21:08)
  • Outpatient: reliable, immunocompetent, mild, no concerning features.

• Antibiotics

  • Antibiotics NOT always required for mild uncomplicated cases if immune-competent, reliable, and no systemic illness. (22:54)
  • If antibiotics are warranted:
    • Amoxicillin/clavulanate monotherapy is preferred (ease, safety profile).
    • OR Ciprofloxacin + metronidazole (QT risk, C diff risk, more pills).
    • TMP/SMX + metronidazole: reserve for allergy or second-line.
    • Duration: 5-7 days, never over 7, ideally closer to 5 (28:02)
    • Consider local resistance patterns (antibiogram).
    • DYNAMO trial – no difference in recurrence or emergency surgery with/without antibiotics in select patients (28:02)
    • BID (twice daily) dosing of metronidazole is increasingly accepted for tolerability (42:59).

• Complicated Cases

  • IV antibiotics (ceftriaxone + metronidazole for community-acquired; broader if risk factors for resistance). (31:02)
  • Admit all complicated cases for monitoring and further intervention (29:28).

2. Complicated Diverticulitis: Abscess and Perforation

Case 2 (49:00–62:58):

67-year-old woman with 4 cm pericolic abscess.

• Interventional Radiology (IR) vs. Surgery

  • 3cm abscesses: IR drainage is preferred if safely accessible (50:38).

  • Surgical consult should be involved early for complicated anatomy, long-term follow-up, or if IR impossible.
  • Transrectal IR drains generally avoided—risk of fistula; transgluteal sometimes used (50:44).

• Antibiotic Approach

  • IV empiric therapy (ceftriaxone + metronidazole), same as complicated cases without abscess (52:35).
  • If abscess is drained, culture data may allow for antibiotic narrowing.
  • Duration after source control: Typically 4 days after drainage per STOP-IT trial; total therapy may be longer if undrained (extend to 10–14 days; sometimes longer with follow-up imaging).

• Follow-up Imaging

  • Only repeat imaging if lack of clinical improvement or for procedural planning (57:13).
  • Imaging intervals: ~4 weeks outpatient unless clinically worsening. In the hospital, only scan earlier if worsening.

• Surgical Indications & Shared Decision-Making

  • Elective surgery: case-by-case for complicated disease, especially with recurrent/severe abscess, impact on life, or high risk of recurrence (60:44).
  • No set episode threshold for surgery. For uncomplicated, shared decision; for complicated, ASCRS guidelines recommend consideration after hospitalization.

Case 3 (63:01–69:49):

72-year-old man, diffuse peritonitis, sepsis, perforated diverticulitis with free air/fluid.

• Imaging for Perforation

  • CT: free air, free fluid, diffuse peritonitis.
  • Recognize spectrum: small sealed leaks to diffuse contamination.

• Operative Management

  • Requires urgent surgery—source control (64:37).
  • Surgery options:
    • Hartmann’s procedure (end colostomy)
    • Resection with primary anastomosis + diverting ileostomy
    • Loop colostomy for diversion in extreme cases
  • Ostomy reversal: varies by type (Hartmann’s often >3–6 months, ileostomy as early as 8–12 weeks) (68:26).
  • Patient recovery and decision-making addressed in follow-up; importance of counseling about ostomy and reversal timeline.

3. Other Management Considerations

• Nutrition (46:05)

  • Start with clear liquids, “spoon diet”, advance with clinical improvement—no solid evidence about fiber restriction.
  • Parenteral/enteral nutrition rarely needed unless profound complications.
  • Fiber: no need to strictly avoid except during acute illness; resume normal diet as tolerated.

• Pain Control (48:07)

  • Minimize opioids; if required, only short course for transition home.
  • Persistent pain needing opiates = consider ongoing disease or complications.

• Colonoscopy After Diverticulitis (34:54, 35:18)

  • Uncomplicated cases: routine colonoscopy low-yield (risk ~2%); may defer unless they’re due for age-appropriate screening.
  • Complicated cases: colonoscopy typically recommended after recovery (risk 5–10%), especially if atypical CT findings or concerning symptoms (weight loss, bleeding).

• Hereditary/Gene Factors (36:37)

  • Recurrent or young-onset diverticulitis—consider family history/genetics, but routine testing not yet warranted.

• Mythbusting: Seeds and Nuts (69:25)

  • Patients do not need to avoid these; restriction is not evidence-based.

Segment Timestamps (MM:SS)

• Guest introductions / lightning round: 01:46–08:08
• Case 1: Definition, diagnosis, disposition: 09:12–31:02
• Case 1: Antibiotic regimens, resistance, pill burden: 22:54–31:02
• Nutrition and pain management: 46:05–48:53
• Case 2: Abscess management (IR vs. surgery) and antibiotics: 49:00–56:51
• Source control and antibiotics duration: 52:35–56:51
• Complicated cases, follow-up, elective surgery: 60:44–62:58
• Case 3: Perforation, surgery, ostomies: 63:01–68:26
• Colonoscopy, seeds/nuts, counseling: 34:54, 69:25
• Guest take-home points: 70:06–72:08

Top Take-Home Pearls

1. Uncomplicated diverticulitis does not always require antibiotics. Select immune-competent, reliable outpatients can be monitored with supportive care only.
2. Preferred oral regimen: Amoxicillin/clavulanate monotherapy; alternative ciprofloxacin + metronidazole (metronidazole can be given BID).
3. Complicated diverticulitis = admit, IV antibiotics, early surgical/IR involvement.
4. Abscesses >3 cm: IR drainage if feasible; consult surgery for inaccessible or complex cases.
5. Perforation with diffuse peritonitis: Emergent surgery—expect ostomy, need for careful counseling, and staged recovery.
6. Colonoscopy: Not universally needed after uncomplicated cases; must be age-appropriate or if complicated features/recurrent symptoms.
7. Seeds and nuts: No need for restriction post-diverticulitis.

Memorable Moments

• RJ and Meredith's revelation about bid metronidazole dosing:
  “I’m the only person on this podcast that knew you could use metronidazole bid.” –Dr. Blackburn (43:54)
• Dr. Hollis' take on nutrition:
  “I treat them sort of like my child with gastroenteritis: spoon diet, clear liquids, and if they’re progressing, advance as their pain resolves.” (46:05)
• Co-host’s summary of modern care trends:
  “We don’t count the number of episodes anymore… it’s more about the burden upon their life.” –Dr. Hollis on surgery indication (60:44)
• Classic myth-busting:
  “If it hurts when you do it, stop doing it... there is no data to support avoiding seeds and nuts.” –Dr. Hollis (69:25)

Final Takeaways (70:06–72:08)

• Dr. Webster:

  • Not every diverticulitis needs antibiotics; tailor based on risk.
  • Choose reliable outpatient regimens.
  • Complicated cases and those failing therapy must be admitted and may need procedural/radiologic/surgical management.
  • Consult ID as needed!

• Dr. Hollis:

  • Abscess >3 cm: IR drainage, surgical follow-up.
  • Many with complicated disease may need resection or colonoscopy down the line.
  • Sick/perforated patients—urgent surgery.
  • Counseling and shared decision-making essential.

For medical professionals, this episode provides a concise, case-based road map to modern inpatient diverticulitis management, delivered with Curbsiders’ signature humor and high-yield practicality.