Pain Management for Acute Diverticulitis
Acetaminophen is the recommended first-line analgesic for pain control in acute diverticulitis, with antibiotics reserved only for specific patient populations with complicated disease or risk factors. 1, 2
First-Line Pain Management Approach
- Acetaminophen (1g three times daily) is the primary analgesic recommended for pain control in uncomplicated diverticulitis 1, 3
- A clear liquid diet during the acute phase helps reduce pain by minimizing mechanical irritation of the inflamed colon 1
- Advance diet gradually as symptoms improve, which naturally helps reduce pain 1
Important Medication Considerations
- Avoid non-aspirin NSAIDs for pain control in patients with diverticulitis as they are associated with a moderately increased risk of diverticulitis episodes and complications 4
- Aspirin may be continued if indicated for cardiovascular protection, as the AGA suggests against routinely advising patients with diverticulitis to avoid aspirin 4
- For patients with persistent visceral hypersensitivity after the acute episode resolves, low to modest doses of tricyclic antidepressants may be considered 1, 5
Antibiotic Use in Pain Management
- Antibiotics should not be used routinely for pain control in uncomplicated diverticulitis 1, 2
- Reserve antibiotics for specific patient populations:
- Patients with systemic symptoms (persistent fever, chills) 2
- Patients with increasing leukocytosis 2
- Elderly patients (>80 years) 1, 2
- Immunocompromised patients 1, 2
- Patients with significant comorbidities (cirrhosis, chronic kidney disease, heart failure, poorly controlled diabetes) 2
- Patients with complicated diverticulitis (abscess, perforation, fistula) 1, 2
Antibiotic Selection When Indicated
- For oral therapy: amoxicillin/clavulanic acid (1g three times daily) or cefalexin with metronidazole 2, 3
- For patients unable to tolerate oral intake: intravenous antibiotics such as ceftriaxone plus metronidazole or piperacillin-tazobactam 2
Management of Complicated Diverticulitis
- Complicated diverticulitis (with abscess, peritonitis, obstruction, stricture, or fistula) requires more aggressive pain management and treatment 5, 2
- Intravenous antibiotics are necessary for complicated cases 2
- Percutaneous drainage is recommended for abscesses ≥3-4 cm 5
- Surgical intervention may be necessary for failed percutaneous drainage, generalized peritonitis, fistula formation, obstruction, or stricture 5
Common Pitfalls to Avoid
- Avoid routine use of mesalamine for pain control after acute diverticulitis, as evidence does not support its efficacy 4
- Avoid rifaximin for pain management in acute diverticulitis as evidence does not support its routine use 4
- Avoid probiotics for pain management in acute diverticulitis as evidence does not support their routine use 4
- Do not restrict physical activity; in fact, vigorous physical activity should be encouraged for patients with diverticular disease 4
Long-term Considerations
- Approximately 45% of patients report periodic abdominal pain at 1-year follow-up after an episode of acute diverticulitis 1, 5
- Consider colonoscopy 6-8 weeks after resolution of symptoms for patients with complicated diverticulitis, first episode of uncomplicated diverticulitis, or if high-quality colonoscopy was not performed within the past year 5