Are Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) safe for a patient with diverticulitis and intra-abdominal abscess formation?

NSAIDs Safety in Diverticulitis with Perforation and Intra-abdominal Abscess

NSAIDs should be avoided in this 49-year-old male with diverticulitis, perforation, and intra-abdominal abscess formation due to their association with increased risk of diverticulitis complications. 1, 2

Rationale for Avoiding NSAIDs

• The American Gastroenterological Association (AGA) suggests advising patients with a history of diverticulitis to avoid the use of nonaspirin NSAIDs if possible (conditional recommendation, very-low quality of evidence) 1
• Observational studies indicate that NSAIDs are associated with:
  • Moderately increased risk of occurrence of any episode of diverticulitis
  • Higher risk of complicated diverticulitis 1
• NSAIDs may increase the risk of diverticulitis complications by:
  • Promoting mucosal injury
  • Exacerbating underlying inflammation
  • Potentially interfering with healing processes 2, 3

Pain Management Alternatives

For this patient with diverticulitis complicated by perforation and abscess, safer pain management options include:

1. First-line option: Acetaminophen (paracetamol) 4

   • Preferred analgesic for uncomplicated diverticulitis
   • Does not carry the same risks as NSAIDs for gastrointestinal complications

2. If additional pain control is needed:

   • Low-dose tricyclic antidepressants may help manage visceral hypersensitivity 2
   • Avoid opioids when possible as they may mask symptoms and cause constipation 2

Management of Intra-abdominal Abscess

Since this patient has an intra-abdominal abscess, the following approach is recommended:

• Small abscess: Antibiotic therapy alone for 7 days 1
• Large abscess: Percutaneous drainage combined with antibiotic therapy for 4 days 1
• If percutaneous drainage not feasible:
  • In non-critically ill, immunocompetent patients: antibiotics alone
  • In critically ill or immunocompromised patients: surgical intervention 1

Antibiotic Recommendations

For diverticulitis with intra-abdominal abscess, appropriate antibiotic options include:

• First-line: Piperacillin/tazobactam 4g/0.5g q6h or 16g/2g by continuous infusion 1
• Alternative options:
  • Ertapenem 1g q24h (especially if concern for ESBL-producing organisms)
  • Eravacycline 1mg/kg q12h 1

Monitoring and Follow-up

• Monitor for resolution of symptoms and inflammation markers (WBC count, CRP, procalcitonin) 1, 2
• CT scan with IV contrast is the preferred imaging modality to assess treatment response 1, 2
• Consider colonoscopy 6-8 weeks after resolution of acute symptoms 2

Important Caveats

• While aspirin has a slightly increased risk of diverticulitis (RR 1.25), the AGA suggests not routinely advising patients to avoid aspirin due to its protective cardiovascular effects 1
• The risk of complications from NSAIDs is particularly high in patients with active inflammation and perforation, as in this case
• Patients with diverticulitis who continue to have persistent symptoms should undergo both imaging and lower endoscopy to rule out alternative diagnoses 2