Pain Management for Diverticulitis

Introduction to Pain Management

The American Gastroenterological Association recommends acetaminophen as the primary analgesic for pain control in uncomplicated diverticulitis, with antibiotics reserved for specific patient populations or complicated cases 1
A clear liquid diet during the acute phase helps reduce pain by minimizing mechanical irritation of the inflamed colon, as suggested by the Gastroenterology guidelines 1, 2

Advance diet as symptoms improve, which naturally helps reduce pain, according to the Gastroenterology guidelines 2
For persistent pain after the acute episode resolves, low to modest doses of tricyclic antidepressants may be considered for visceral hypersensitivity, as recommended by the Gastroenterology guidelines 1

Antibiotics should be added selectively rather than routinely, specifically for patients with comorbidities or frailty, as suggested by the Gastroenterology guidelines 1, 3
The World Society of Emergency Surgery guidelines recommend selective use of antibiotics based on specific patient factors, such as refractory symptoms or vomiting, and elevated CRP or WBC levels 4, 1
Complicated diverticulitis, such as abscess, perforation, or fistula, requires antibiotic treatment, according to the Gastroenterology guidelines 3

Approximately 45% of patients report periodic abdominal pain at 1-year follow-up after an episode of acute diverticulitis, likely due to visceral hypersensitivity, as reported in the Gastroenterology guidelines 1
Visceral hypersensitivity can be treated with tricyclic antidepressants, as recommended by the Gastroenterology guidelines 1
The American Gastroenterological Association clinical practice update provides guidance on excluding ongoing inflammation with imaging and lower endoscopy before attributing symptoms to visceral hypersensitivity 1, 5

The 2020 World Society of Emergency Surgery guidelines and 2021 American Gastroenterological Association clinical practice update provide the strongest evidence for pain management in diverticulitis, recommending acetaminophen as the primary analgesic and selective use of antibiotics 4, 1
Multiple randomized controlled trials, including the DIABOLO trial, have shown that antibiotics can be safely omitted in uncomplicated diverticulitis without affecting recovery time or complication rates, as reported in the World Journal of Emergency Surgery 4, 6, 7

The American Gastroenterological Association suggests avoiding non-aspirin NSAIDs for pain control in patients with diverticulitis as they are associated with a moderately increased risk of diverticulitis episodes and complications 8, 9, 10
Aspirin may be continued if indicated for cardiovascular protection, as the American Gastroenterological Association suggests against routinely advising patients with diverticulitis to avoid aspirin 8, 9

The American Gastroenterological Association recommends against routine use of mesalamine for pain control after acute diverticulitis, as evidence does not support its efficacy 8, 10
The American Gastroenterological Association recommends against rifaximin for pain management in acute diverticulitis as evidence does not support its routine use 8, 10
The American Gastroenterological Association recommends against probiotics for pain management in acute diverticulitis as evidence does not support their routine use 8, 10
Patients with diverticular disease should be encouraged to engage in vigorous physical activity 10

The American Gastroenterological Association advises patients with diverticulitis to avoid non-aspirin NSAIDs if possible (conditional recommendation, very-low quality evidence) 11, 12, 13
Non-aspirin NSAIDs are associated with a moderately increased risk of both incident diverticulitis episodes and complicated diverticulitis 11, 12, 13
Observational studies demonstrate that non-aspirin NSAIDs show a moderately increased risk of occurrence of any episode of diverticulitis AND complicated diverticulitis 11, 12, 13

This risk is greater for non-aspirin NSAIDs than for aspirin, making ketorolac (Toradol) particularly concerning 14

Unlike other NSAIDs, aspirin may be continued if indicated for cardiovascular protection, as the AGA suggests against routinely advising patients to avoid aspirin (the risk increase is slight: RR 1.25, 95% CI 0.61-2.10) 11, 12, 13
The modest protective effects of aspirin on overall mortality and nonfatal myocardial infarction outweigh the slight diverticulitis risk in patients with cardiovascular indications 11, 12, 13