From the Guidelines
NSAIDs should be avoided in patients with a history of diverticulitis, as they can increase the risk of diverticular bleeding and potentially worsen inflammation. The American Gastroenterological Association (AGA) suggests advising patients with a history of diverticulitis to avoid the use of nonaspirin NSAIDs if possible, based on a conditional recommendation with very-low quality of evidence 1.
Key Considerations
- The use of nonaspirin NSAIDs has been associated with a moderately increased risk of occurrence of any episode of diverticulitis and complicated diverticulitis 1.
- Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases the risk of diverticulitis, with the risk being greater for non-aspirin NSAIDs than for aspirin 1.
- For pain management during diverticulitis, acetaminophen (Tylenol) is a safer alternative, typically dosed at 650-1000 mg every 6 hours as needed, not exceeding 4000 mg daily.
- Patients with diverticulitis should also follow a clear liquid diet initially, gradually advancing to low-fiber foods as symptoms improve, and eventually transitioning to a high-fiber diet after the acute episode resolves to help prevent recurrence.
Treatment Approach
- The standard approach for uncomplicated diverticulitis typically includes antibiotics such as amoxicillin-clavulanate (875/125 mg twice daily), or a combination of ciprofloxacin (500 mg twice daily) and metronidazole (500 mg three times daily) for 7-10 days 1.
- Antibiotic treatment is advised in patients with complicated diverticulitis or uncomplicated diverticulitis with a fluid collection or longer segment of inflammation on CT scan 1.
Lifestyle Modifications
- A prudent dietary pattern, high in fiber from fruits, vegetables, whole grains, and legumes, and low in red meat and sweets, is associated with decreased risk of incident diverticulitis 1.
- Physical activity, particularly vigorous activity, decreases the risk of diverticulitis 1.
From the Research
NSAIDs and Diverticulitis
- The use of nonsteroidal anti-inflammatory drugs (NSAIDs) has been associated with an increased risk of diverticulitis, as shown in a study published in the International journal of colorectal disease 2.
- A prospective study published in the Archives of family medicine found that regular use of NSAIDs was positively associated with the overall risk of symptomatic diverticular disease, with a relative risk of 2.24 3.
- A meta-analysis of case-control and cohort studies published in the International journal of colorectal disease found that NSAIDs and acetylsalicylic acid use were associated with an increased risk of diverticular bleeding and complicated diverticulitis, with odds ratios of 6.90 and 3.13, respectively 4.
Management of Diverticulitis
- The management of diverticulitis is undergoing a paradigm shift, with treatment moving to the outpatient setting and physicians forgoing antibiotics for uncomplicated disease 5.
- A review of the guidelines for the management of diverticulitis published in The Medical journal of Australia recommends outpatient treatment for afebrile, clinically stable patients with uncomplicated diverticulitis, and non-operative management for small abscesses 6.
- Surgical intervention is indicated for peritonitis or failure of non-operative management, with options including Hartmann procedure or primary anastomosis, with or without diverting loop ileostomy 6.
Risk Factors for Diverticulitis
- Age and NSAID use have been identified as independent determinants of diverticulitis in a study published in the International journal of colorectal disease 2.
- The use of acetaminophen has also been associated with an increased risk of symptomatic diverticular disease, particularly bleeding, in a prospective study published in the Archives of family medicine 3.
- A meta-analysis of case-control and cohort studies published in the International journal of colorectal disease found that acetylsalicylic acid use was associated with an increased risk of diverticular bleeding and complicated diverticulitis 4.