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diverticular diseaseGastroenterology 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)
|Mean LOS:||14.9 days|
|Description:||SURGICAL: Major Small and Large Bowel Procedures With Major CC|
|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.
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.
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.
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.
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.
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.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Computed tomography (test of choice) and magnetic resonance imaging||No abnormalities||Diverticula, 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) scan||Normal gastric mucosa||May demonstrate diverticula||Highlights the presence of mucosal abnormalities|
|Abdominal x-rays: acute abdominal series, with flat and upright abdominal imaging||Normal abdomen||Identifies perforation in lower quadrant mass||May 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
DiagnosisAnxiety related to knowledge deficit of the disease process and treatment
OutcomesAnxiety control; Coping; Acceptance: Health status; Symptom control behavior
InterventionsAnxiety reduction; Calming technique; Coping enhancement; Presence; Distraction; Energy management; Teaching: Preoperative and procedure or treatment; Medication prescribing
Planning and implementation
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.
|Medication or Drug Class||Dosage||Description||Rationale|
|Anticholinergic drugs||Varies with drug||Diminishes colon spasms||Control pain by decreasing spasms|
|Oral antibiotics (metronidazole, ciprofloxacin, amoxicillin/clavulanate, sulfamethoxazole and trimethoprim, ceftriaxone, cefotaxime)||Varies with drug||Kills invading bacteria||Control 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.
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.
- 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)
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.
If you have any questions regarding this subject, you may consult your doctor. You may also read more here:
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?