Can a patient with constipation and diverticulitis use an enema?

Enema Use in Diverticulitis: Not Recommended

Enemas should NOT be used in patients with acute diverticulitis due to the significant risk of colonic perforation, regardless of constipation severity. 1, 2

Why Enemas Are Contraindicated in Diverticulitis

Mechanism of Harm

• Colonic distention from enemas increases transmural pressure and directly raises perforation risk in inflamed diverticular tissue, which is already weakened by the extramucosal inflammatory process 1
• The American College of Radiology explicitly states that colonic distention (whether by colonoscopy or air-contrast enema technique) increases the risk of colonic perforation in acute diverticulitis 1
• Diverticulitis impairs the tensile strength of the bowel wall, making it particularly vulnerable to rupture from the mechanical pressure and distention caused by enema administration 3

Absolute Contraindications Apply

The American Society of Clinical Oncology identifies multiple contraindications that are directly relevant to diverticulitis patients 2:

• Severe colitis, inflammation, or infection of the abdomen (which diverticulitis represents) can be exacerbated by enemas, increasing perforation risk
• Undiagnosed abdominal pain should preclude enema use, as it may mask underlying serious conditions or worsen them
• Any patient with suspected intestinal complications should undergo proper diagnostic evaluation with CT imaging before any intervention 2

Proper Management of Constipation in Diverticulitis

First-Line Approach

Oral laxatives are the appropriate treatment for constipation in diverticulitis patients, not enemas 1, 4:

• Osmotic laxatives: Polyethylene glycol (PEG) 17g with 8 oz water twice daily, lactulose, or magnesium salts 1, 4
• Stimulant laxatives: Senna, bisacodyl, or sodium picosulfate 1, 4
• Maintain adequate fluid intake throughout treatment 1

Escalation Strategy When Oral Laxatives Fail

If constipation persists despite oral laxatives 1:

1. Rule out bowel obstruction with imaging (CT scan is preferred) before any further intervention 2
2. Assess for hypercalcemia and review other constipating medications 1
3. Consider adding magnesium-based products or increasing osmotic laxative doses 1
4. Only after excluding obstruction and complications, and only if absolutely necessary, consider suppositories (NOT enemas) 1

Critical Caveat About Timing

• Colonoscopy and invasive bowel procedures should be deferred 4-6 weeks after resolution of acute diverticulitis symptoms 5
• This same principle applies to enemas—the inflamed tissue needs time to heal before any mechanical intervention 1, 3

When Diverticulitis Complications Are Present

Complicated Diverticulitis Requires Different Management

If the patient has 6:

• Abscess formation
• Perforation
• Fistula
• Obstruction
• Peritonitis

Management consists of 6:

• Intravenous antibiotics (ceftriaxone plus metronidazole or piperacillin-tazobactam)
• Percutaneous drainage for localized abscesses
• Surgical consultation for emergent laparotomy if generalized peritonitis is present
• Enemas remain absolutely contraindicated in all these scenarios 2

Alternative Strategies for Severe Constipation

If Oral Route Fails and No Obstruction Present

Small-volume rectal suppositories (bisacodyl) may be considered as a safer alternative to enemas, but only after 1, 2:

• CT imaging confirms no obstruction, perforation, or abscess
• The acute inflammatory phase has resolved
• Digital rectal examination confirms fecal impaction requiring local intervention

Special Populations

Avoid ALL rectal interventions (including suppositories and enemas) in patients with 1, 2:

• Neutropenia or thrombocytopenia (increased bleeding/infection risk)
• Recent pelvic radiotherapy (tissue fragility)
• Recent colorectal surgery (anastomotic disruption risk)

Bottom Line Algorithm

1. Patient with diverticulitis + constipation → Start oral osmotic laxatives (PEG) + stimulant laxatives (senna) 1, 4
2. If constipation persists → Obtain CT abdomen/pelvis to rule out obstruction/complications 2, 6
3. If imaging shows uncomplicated diverticulitis → Escalate oral laxative doses, add magnesium products 1
4. If imaging shows complicated diverticulitis → IV antibiotics, surgical consultation, NO enemas 6
5. Enemas are never appropriate in the acute or subacute phase of diverticulitis 1, 2