diverticular disease


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Related to diverticular disease: diverticulitis

diverticular

 [di″ver-tik´u-ler]
pertaining to or resembling a diverticulum.
diverticular disease a general term including the prediverticular state, diverticulosis, and diverticulitis.

di·ver·tic·u·lar dis·ease

symptomatic congenital or acquired diverticula of any portion of the gastrointestinal tract. Such diverticula occur in about 15% of the population but rarely cause symptoms.

diverticular disease

diverticular disease

Gastroenterology The presence of multiple diverticula–prolapsed mucosa-lined intestine through the muscularis propria of the large intestine Epidemiology DD affects 5–10% of those in developed countries > age 45; 80% of those > age 85; 20% have Sx Clinical Asymptomatic; or pain, N&V, farts Prevention DD is linked to ↑ intraluminal pressure–IP–↓ Stool bulk → ↑ GI transit time → ↑ IP → ↑ diverticulsosis; ↑ dietary fiber softens stools, ↓ IP relieves Sx. See Acute diverticulitis.

di·ver·tic·u·lar dis·ease

(dī-vĕr-tikyū-lăr di-zēz)
Symptomatic congenital or acquired diverticula of any portion of the gastrointestinal tract; found in about 15% of the population but rarely causes symptoms.

Diverticular Disease

DRG Category:329
Mean LOS:14.9 days
Description:SURGICAL: Major Small and Large Bowel Procedures With Major CC
DRG Category:391
Mean LOS:5.1 days
Description:MEDICAL: Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders With Major CC

Diverticular disease has two clinical forms, diverticulosis and diverticulitis. People with diverticulosis have multiple, noninflamed diverticula (outpouches of the intestinal mucosa through the circular smooth muscle of the bowel wall). Usually, diverticulosis is asymptomatic and does not require treatment. Diverticulitis, in contrast, occurs when the diverticula become inflamed or microperforated. Diverticular disease usually occurs in the descending and sigmoid colon and is accompanied by signs of inflammation.

Mortality and morbidity are related to complications of diverticulosis such as diverticulitis and lower gastrointestinal (GI) bleeding, which occur in 10% to 20% of patients with diverticulosis during their lifetime. The lifetime recurrence is 30% after the first episode of diverticulitis and more than 50% after a second episode.

Causes

Patients generally have increased muscular contractions in the sigmoid colon that produce muscular thickness and increased intraluminal pressure. This increased pressure, accompanied by a weakness in the colon wall, causes diverticular formations. In addition, diet may be a contributing factor. A diet with insufficient fiber reduces fecal residue, narrows the bowel lumen, and leads to higher intra-abdominal pressure during defecation. Diverticulitis is caused when stool and bacteria are retained in the diverticular outpouches, leading to the formation of a hardened mass called a fecalith. The fecalith obstructs blood supply to the diverticular area, leading to inflammation, edema of tissues, and possible bowel perforation and peritonitis.

Genetic considerations

Diverticula can occur as a feature of several genetic disorders, including type IV Ehlers-Danlos syndrome and autosomal dominant polycystic kidney disease. Genetic contributions to isolated diverticula are suggested by the ethnic distribution.

Gender, ethnic/racial, and life span considerations

Diverticular disease is rare in those under 40 years of age. When the disorder does occur before age 40, it can usually be attributed to a congenital predisposition. From 30% to 60% of people with diverticular disease are between ages 60 and 80. As people age, structural changes in both genders occur in the muscular layers of the colon, which places the elderly at risk for the disease. By the age of 85, two-thirds of the population has the condition. The male-to-female ratio is equal. Ethnicity and race have no known effects on the risk for diverticular disease except for people with Asian ancestry (see Global Health Considerations).

Global health considerations

Diverticular disease is a disease of industrialized Western countries, probably because diet may influence the prevalence and data are not always recorded in developing countries. For unknown reasons, Asian populations have a tendency toward right-sided diverticula as compared to non-Asians, who have more left-sided disease. Globally, most experts suggest that the incidence likely parallels that in the United States, which is 6% to 22% of the population. In recent years, the prevalence has increased in Japan, possibly because of changes in diet and lifestyle.

Assessment

History

Patients with diverticulosis are generally asymptomatic but may report cramping abdominal pain in the left lower quadrant of the abdomen that is relieved with episodes of flatulence and a bowel movement. Occasional rectal bleeding may also be noted. Patients with diverticulitis usually report cramping in the left lower quadrant with abdominal pain that radiates to the back. Other complaints frequently reported are episodes of constipation and diarrhea, low-grade fever, chills, weakness, fatigue, abdominal distention, flatulence, and anorexia. Patients may report that symptoms often follow and are accentuated by the ingestion of foods such as popcorn, celery, fresh vegetables, whole grains, and nuts. Symptoms are also aggravated during stressful times.

Physical examination

The most common symptoms are left lower quadrant pain, cramping, and change in bowel habits. Because diverticular disease is a chronic disorder that generally alters a patient’s nutritional intake, inspect for malnutrition symptoms such as weight loss, lethargy, brittle nails, and hair loss. Assess vital signs because temperature and pulse elevations are common. Palpate the patient’s abdominal area for pain or tenderness over the left lower quadrant. Palpate for a mass in this area, which may indicate diverticular inflammation.

Psychosocial

Because emotional tension and stress commonly precipitate episodes of diverticulitis, determine the patient’s current stressors and his or her coping mechanisms and what type of support system is available.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Computed tomography (test of choice) and magnetic resonance imagingNo abnormalitiesDiverticula, localized colonic wall thickening (> 5 mm)Abnormalities such as diverticula, abscesses, fistulas, and pericolic fat inflammation can be located; excludes other pathologies
Technetium-99m sodium pertechnetate (gastric or Meckel’s) scanNormal gastric mucosaMay demonstrate diverticulaHighlights the presence of mucosal abnormalities
Abdominal x-rays: acute abdominal series, with flat and upright abdominal imagingNormal abdomenIdentifies perforation in lower quadrant massMay show signs of free air if the GI tract has perforated; identifies signs of intestinal irritation (ileus), volvulus, bowel obstruction

Other Tests: Stool specimen, angiography if bleeding is occurring, and complete blood count. Barium enema usually fails to identify diverticulum. Lipase/amylase and liver function tests, ultrasound, sigmoidoscopy, and double-contrast enema.

Primary nursing diagnosis

Diagnosis

Anxiety related to knowledge deficit of the disease process and treatment

Outcomes

Anxiety control; Coping; Acceptance: Health status; Symptom control behavior

Interventions

Anxiety reduction; Calming technique; Coping enhancement; Presence; Distraction; Energy management; Teaching: Preoperative and procedure or treatment; Medication prescribing

Planning and implementation

Collaborative

medical.
For uncomplicated diverticulosis, a diet high in vegetable fiber is recommended. If constipation is a problem, bulk-forming laxatives and stool softeners are often prescribed to decrease stool transit time and minimize intraluminal pressure. For diverticulitis, care centers on resting the bowel until the inflammatory process subsides. Bedrest is recommended to decrease intestinal motility, and oral intake is restricted, with supplemental intravenous fluid administration followed by a liquid diet and, eventually, a bland, low-residue diet. After the inflammatory episode resolves, the patient is advanced to a high-fiber diet to prevent future acute inflammatory attacks.

surgical.
Surgical intervention may be required if the diverticular disease becomes symptomatic and is not relieved with conservative treatment. Surgery is mandatory if complications develop, such as hemorrhage, bowel obstruction, abscess, or bowel perforation. A colon resection with temporary colostomy placement may be necessary until the bowel heals.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
Anticholinergic drugsVaries with drugDiminishes colon spasmsControl pain by decreasing spasms
Oral antibiotics (metronidazole, ciprofloxacin, amoxicillin/clavulanate, sulfamethoxazole and trimethoprim, ceftriaxone, cefotaxime)Varies with drugKills invading bacteriaControl the spread of infection when a fever is present

Other Drugs: Analgesics may also be ordered. Generally, meperidine (Demerol) is preferred, because morphine increases intracolonic pressure, thus creating more discomfort and possibly intestinal perforation.

Independent

For uncomplicated diverticulosis, nursing interventions focus on teaching measures to prevent acute inflammatory episodes. Explain the disease process and the strong connection between dietary intake and diverticular disease. Instruct the patient that a diet high in fiber—such as whole grains and cereals, fresh fruits, fresh vegetables, and potatoes—should be followed. Caution the patient to avoid foods with seeds or nuts, which may lodge in the diverticula and cause inflammation.

Teach the patient about prescribed medications. In addition, discuss measures to prevent constipation. Instruct the patient to avoid activities that increase intra-abdominal pressure, such as lifting, bending, coughing, and straining with bowel movements. Instruct the patient about relaxation techniques. Discuss symptoms that indicate an acute inflammation, which would require prompt medical attention.

For patients with diverticulitis, provide supportive care to promote bowel recovery and provide comfort. As the inflammation subsides, teach the patient measures to prevent inflammatory recurrences. Instruct the patient about the purpose of any diagnostic procedures ordered. Should surgery be required, instruct the patient preoperatively about the procedure and postoperative care, leg exercises, deep-breathing exercises, and ostomy care when appropriate. Postoperatively, meticulous wound care must be provided to prevent infection.

Evidence-Based Practice and Health Policy

Strate, L.L., Erichsen, R., Horvath-Puho, E., Pedersen, L., Baron, J.A., & Sorensen, H.T. (2013). Diverticular disease is associated with increased risk of subsequent arterial and venous thromboembolic events. Clinical Gastroenterology and Hepatology. Advanced online publication. doi 10.1016/j.cgh.2013.11.026

  • Inflammatory processes, such as those associated with diverticular disease, may also be associated with an increased risk for cardiovascular complications.
  • Investigators examined cardiovascular risk in a population of 77,065 patients with no previous history of cardiovascular disease who were diagnosed with diverticular disease and found significantly increased risks when compared to an age- and sex-matched population cohort of 302,572 individuals.
  • Patients diagnosed with diverticular disease had an increased relative risk (IRR) of experiencing acute myocardial infarction (IRR, 1.11; 95% CI, 1.07 to 1.14), stroke (IRR, 1.11; 95% CI, 1.08 to 1.15), venous thromboembolism (IRR, 1.36; 95% CI, 1.3 to 1.43), and subarachnoid hemorrhage (IRR, 1.27; 95% CI, 1.09 to 1.48). The relative risks were highest during the first year after diagnosis.

Documentation guidelines

  • Presence of abdominal pain, nausea and vomiting, and diarrhea or constipation
  • Patient’s ability to cope with the stoma
  • Appearance of abdominal wound and stoma
  • Ability to manage a colostomy, if appropriate

Discharge and home healthcare guidelines

Be sure the patient understands any prescribed medications, including purpose, dosage, route, and side effects. Explain the need to keep the wound clean and dry. Teach the patient any special care needed for the wound. Review stoma care with the patient. Teach the patient to observe the wound and report any increased swelling, redness, drainage, odor, separation of the wound edges, or duskiness of the stoma. Review with the patient measures for preventing inflammatory recurrences. Discuss the signs of diverticular inflammation, such as fever, acute abdominal pain, a change in bowel pattern, and rectal bleeding. Explain that such symptoms require prompt medical attention.

di·ver·tic·u·lar dis·ease

(dī-vĕr-tikyū-lăr di-zēz)
Symptomatic congenital or acquired diverticula of any portion of gastrointestinal tract.

Patient discussion about diverticular disease

Q. What corn based products can I eat. I have diverticular disease. I love corn tortillas, corn bread, corn dogs.

A. The dietary recommendations for people with diverticular disease of the colon are usually to add fibers-rich foods (fruits, vegetables etc.). As far as I know corn isn't especially rich in dietary fibers, so I don't know about any recommended corn-based foods, although I don't know about any recommendations to refrain from eating corn-based foods.

If you have any questions regarding this subject, you may consult your doctor. You may also read more here:
http://www.nlm.nih.gov/medlineplus/dietaryfiber.html

Q. How to prevent diverticulitis? I am a 43 year old man. I just had colonoscopy and my Doctor said I have diverticulosis and am at risk in developing diverticulitis. How can I prevent developing diverticulitis?

A. You have Diverticulosis, which means you have diverticulas (small pouches) on your digestive system. These diverticula are permanent and will not go away. No treatment has been found to prevent complications of diverticular disease. Diet high in fiber increases stool bulk and prevents constipation, and theoretically may help prevent further diverticular formation or worsening of the diverticular condition. Some doctors recommend avoiding nuts, corn, and seeds which can plug diverticular openings and cause diverticulitis. Whether avoidance of such foods is beneficial is unclear. If you develop unexplained fever, chills or abdominal pain, you should notify your doctor immediately since it could be a complication of diverticulitis.

More discussions about diverticular disease
References in periodicals archive ?
During the literature review, we came across a few population-based studies on the prevalence and incidence of complications in diverticular disease from South Asian countries,3,13 but did not find any such study from Pakistan.
On the other hand, dietary fibre supplementation, though often recommended for patients with symptomatic diverticular disease, is probably more useful as a preventive rather than a therapeutic intervention.
That's what doctors told patients with symptoms of diverticular disease until 2008.
The distribution is predominantly descending colon and sigmoid, in the region of diverticular disease.
Despite this, there is a substantial healthcare burden inflicted by diverticular disease and within the United States alone it accounts for 312,000 hospital admissions, 1.
Vegetarians were found to be a third less likely to get diverticular disease, a condition thought to be caused by eating too little fibre.
Mr Common says that age is a risk factor with some forms of cancer, including gastro-intestinal cancer, while deprivation can contribute to stomach cancer and a poor diet can pre-dispose people to develop inflammatory bowel disease, diverticular disease and gastro-intestinal cancers.
The overall incidence of diverticular disease is 30% in patients above the age of 60 years.
CT scan of the abdomen and pelvis demonstrated a small intra-pelvic collection, probably secondary to diverticular disease of the sigmoid colon (Fig.
A 2006 Family Physicians Inquiries Network Clinical Inquiry on diverticulosis found inconsistent evidence that fiber decreases the risk of symptomatic diverticular disease (SOR: C, case control studies and a large prospective cohort study).
The aetiology of diverticular disease, despite being an ancient malady, remains poorly characterised, and management continues to be taxing.
High fiber diets are associated with a number of health benefits, including lowering blood cholesterol levels, lowering blood sugar levels, relieving constipation and preventing development of diverticular disease, which affects the colon.