Pain Management for Diverticulitis
Primary Pain Management Approach
For patients with diverticulitis, acetaminophen is the first-line analgesic, while NSAIDs and opioids should be avoided as they increase the risk of complications and disease progression. 1, 2
Recommended Analgesic Strategy
Acetaminophen (paracetamol) is the preferred pain medication for both uncomplicated and complicated diverticulitis, as it provides adequate pain control without increasing the risk of perforation or disease progression 1, 2, 3
Pain should be controlled to a score <4/10 on a visual analogue scale using acetaminophen alone before considering outpatient management 1
For patients requiring hospitalization, acetaminophen remains the primary analgesic during the acute phase 1
Medications to Avoid for Pain Control
NSAIDs (nonsteroidal anti-inflammatory drugs) should be avoided during acute diverticulitis and for long-term management, as they are associated with increased risk of diverticulitis flares, complications, and perforation 1, 4, 2, 5
Opioids should be avoided when possible, as they increase the risk of diverticulitis development and may worsen outcomes 1, 4, 2
Aspirin does not need to be routinely avoided and can be continued if indicated for cardiovascular protection 1, 4
Pain Management in Special Populations
Chronic Post-Diverticulitis Pain
For patients with chronic abdominal pain after diverticulitis resolution with no evidence of ongoing inflammation on imaging and endoscopy, low to modest doses of tricyclic antidepressants may be considered to address visceral hypersensitivity 1
Approximately 45% of patients report ongoing abdominal pain at 1-year follow-up, usually due to visceral hypersensitivity rather than active inflammation 1
Both imaging and lower endoscopy are required before attributing chronic symptoms to post-diverticulitis pain, to exclude inflammatory bowel disease, ischemic colitis, or malignancy 1
High Pain Scores as Risk Stratification
Initial pain score ≥8/10 at presentation is a risk factor for progression to complicated disease and should prompt consideration for hospitalization and closer monitoring 6, 1
Patients with severe pain despite acetaminophen may require inpatient management for closer observation, even if other criteria for outpatient management are met 1
Dietary Modifications During Acute Pain Phase
Clear liquid diet is advised during the acute phase of diverticulitis when pain is most severe, advancing to regular diet as symptoms improve 1
Bowel rest with clear liquids helps reduce colonic stimulation and may improve pain control during the initial 24-48 hours 2, 3
Critical Pitfalls to Avoid
Never prescribe NSAIDs for pain control in diverticulitis, as this significantly increases the risk of perforation and complicated disease 1, 4, 2
Do not assume that severe pain automatically requires opioid analgesia—adequate pain control can usually be achieved with acetaminophen and supportive care 1, 2
Avoid attributing chronic abdominal pain to recurrent diverticulitis without repeat imaging and endoscopy to exclude alternative diagnoses 1
Do not delay surgical consultation in patients with recurrent episodes causing significant quality of life impairment, as the DIRECT trial demonstrated that elective sigmoidectomy results in better quality of life than continued conservative management 1, 7