Can diverticulosis cause abdominal pain?

Can Diverticulosis Cause Abdominal Pain?

Diverticulosis itself—the mere presence of colonic diverticula—does not typically cause abdominal pain, but a subset of patients may develop nonspecific abdominal pain without inflammation, and diverticulitis (inflammation of diverticula) is a well-established cause of acute abdominal pain. 1

Understanding the Distinction

Diverticulosis vs. Diverticulitis:

• Diverticulosis refers to the structural presence of outpouchings in the colon wall and is usually asymptomatic 2, 1
• Most patients with diverticulosis remain completely asymptomatic throughout their lives 1
• Only 1-4% of patients with diverticulosis will develop acute diverticulitis in their lifetime 2
• Diverticulitis (inflammation of diverticula) presents with left lower quadrant abdominal pain, often accompanied by fever, nausea, vomiting, and leukocytosis 3, 2

When Diverticulosis May Cause Pain

A subset of patients with diverticulosis can experience abdominal pain through several mechanisms:

• Symptomatic Uncomplicated Diverticular Disease (SUDD): Some patients develop nonspecific abdominal pain (isolated or recurrent) without evidence of inflammation 1
• Segmental Colitis Associated with Diverticulosis (SCAD): A distinct entity that can cause pain in the presence of diverticula 1
• Low-grade inflammation, sensory-motor nerve damage, and dysbiosis may contribute to chronic abdominal symptoms that mimic irritable bowel syndrome 4

Post-Diverticulitis Pain (Visceral Hypersensitivity)

After an episode of acute diverticulitis, chronic abdominal pain is extremely common:

• Approximately 45% of patients report periodic abdominal pain at 1-year follow-up after uncomplicated acute diverticulitis 5, 6, 3
• Visceral hypersensitivity is the likely cause in the majority of cases after excluding ongoing inflammation 5, 6

Critical diagnostic workup before attributing pain to visceral hypersensitivity:

• Obtain CT scan of abdomen/pelvis with oral and IV contrast to exclude ongoing inflammation, stricture, fistula, or abscess 5, 6
• Perform colonoscopy 6-8 weeks after symptom resolution to exclude ischemic colitis, inflammatory bowel disease, constipation, and malignancy 5, 6

Management of visceral hypersensitivity:

• Reassure patients that ongoing symptoms are common and do not indicate ongoing infection or structural damage 6, 3
• Use low to modest doses of tricyclic antidepressants as first-line pharmacologic therapy 5, 6, 3

Common Pitfalls to Avoid

• Do not assume all abdominal pain in patients with known diverticulosis is due to the diverticula themselves—most diverticulosis is asymptomatic 1
• Do not skip imaging when evaluating acute abdominal pain—clinical symptoms alone are only 40-65% accurate in diagnosing diverticulitis 7
• Do not repeatedly treat with antibiotics if pain persists after diverticulitis, as visceral hypersensitivity is not an infectious process 6
• Do not assume symptoms will spontaneously resolve—evidence shows persistence at 1-2 years in a substantial proportion of patients 6