DEFINITION CAUSE SIGNS AND STATISTICS PATHOPHYSIOLOG PROGNOSIS

SYMPTOMS Y

Diverticular
Disease

COMPLICATIONS TREATMENT/ NURSING NURSING

DIAGNOSTICS PREVENTION
MEDICAL MNGMT DIAGNOSIS INTERVENTIONS
 Definition

 A diverticulum is a saclike herniation of the lining of the bowel that extends

through a defect in the muscle layer. Diverticula may occur anywhere in the
small intestine or colon but most commonly occur in the sigmoid colon.
Diverticulosis exists when multiple diverticula are present without inflammation
or symptoms. Diverticulitis results when food and bacteria retained in the
diverticulum produce infection and inflammation that can impede draining and
lead to perforation or abscess. It may occur in acute attacks or persist as a
chronic, smoldering infection.
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 Cause
i. Common in people older than 80 years.
(Diverticulosis)
ii. Younger than 40 years. (Diverticulitis)
iii. Diet high in fat and low in fiber.
iv. Sedentary lifestyle, obesity, smoking, overuse of
laxatives, and consistent use of nonsteroidal anti-
inflammatory agents

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 Pathophysiology
 The etiology of diverticular disease is relatively unknown. It appears that the
introduction of milled grains and refined sugars to the diet of Western, industrialized
nations, as well as the prevalence of low fiber intake are contributing factors for the
increased incidence of diverticular disease in the last century (Amerine, 2007).
Interestingly, incidence is low to nonexistent in Asia and rural Africa where highfiber
diets are consumed (Kelley, 2008; Lewis et al., 2011; Marrs, 2006; Porth, 2011).
Researchers at Yale University Medical School are focusing on how insufficient
dietary fiber may suppress immune responses in the colon producing an
environment that stimulates low-grade, chronic infection (Cramer, 2008). This
current hypothesis, and subsequent studies, may shed more light on this disease in
the future. The pathophysiology of diverticula formation is directly related to the
structure of, and elevated intraluminal pressure in, the colon. The colon has three
bands of longitudinal muscle called tenaie coli and these bands do not form in a
continuous pattern. Bands of circular muscle constrict the large intestines. As the
muscles contract, the lumen of the bowel is constricted. The combination of circular
muscle contraction and lack of continual longitudinal muscle layers cause the
intestine to bulge outward at weak points in the colon wall, usually where arteries
penetrate the tunica muscularis to nourish the mucosal layers.

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 Pathophysiology
The colonic mucosa then herniates through the smooth muscle layers
forming the classic pouch-like sacs. These diverticula vary in size from
0.5 to 1.0 cm in diameter (Kelley, 2008; Porth, 2011). Diverticula in the
descending colon are wide and short, whereas diverticula in the
sigmoid colon are generally long and narrow. Stool can become lodged
in these areas increasing risk for bacterial infection, perforation,
abscess, and/or fistula formation. Lumen pressure is influenced by
dietary fiber, increased peristaltic contractions, and colon structure
(Kelley, 2008; Lewis et al., 2011; Marrs, 2006; Porth, 2011).
Constipation secondary to low fiber intake is the primary cause of
increased lumen pressure (Amerine, 2007). Based on the nature of this
pathophysiology certain risk factors have been identified, which include
high fat intake, low fiber intake, sedentary lifestyle, obesity, smoking,
overuse of laxatives, and consistent use of nonsteroidal
antiinflammatory medications (Kelley, 2008; Lewis et al., 2011;
Odyssey, 2008).

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 Statistics
 The condition is common in the West. It is rare before the
age of 35, but the incidence increases with age (25% in those
over 40 years old in Western society) although it is mostly
asymptomatic. It is uncommon in countries where a high fibre
diet is consumed.
Research indicates that diverticular disease is equally
prevalent in men and women (Kelley, 2008; Lewis et al.,
2011; Marrs, 2006). Between 5% and 25% of persons over
age 50 will experience complications of diverticulitis, and up
to 200,000 patients will require hospitalization each year. It is
estimated that 50% of patients hospitalized for diverticulitis
will require surgery at some point (Kelley, 2008).

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 Signs and Symptoms
 Diverticulosis :
i. Frequently, no problematic symptoms are noted; chronic
constipation often precedes development.
ii. Bowel irregularity with intervals of diarrhea, nausea and
anorexia, and bloating or abdominal distention.
iii. Cramps, narrow stools, and increased constipation or at times
intestinal obstruction.
iv. Weakness, fatigue, and anorexia.
 Diverticulitis :
i. Acute onset of mild to severe pain in the left lower quadrant
ii. Nausea, vomiting, fever, chills, and leukocytosis
iii. If untreated, peritonitis and septicemia

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 Prognosis
 Inflammation in diverticulitis increases the risk of perforation of the
intestine. Peritonitis will develop from bacterial contamination after
perforation of a diverticula. Bleeding from the intestinal mucosa in
the area of inflammation can also occur. The presence of diverticula
and repeated periods of inflammation may allow development of
fistula formation from the diverticula to other areas within the
abdomen, such as the intestine or bladder. Patients needing surgery
may have a colostomy postoperatively. Depending on the location
of the diverticulitis and the reason for the surgery, the colostomy
may be reversible after healing has occurred.

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 Complications
 Diverticulitis:
i. Abscess
ii. Fistula (abnormal tract) formation
iii. Obstruction
iv. Perforation
v. Peritonitis
vi. Hemorrhage

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 Diagnostic
 Colonoscopy and possibly barium enema studies
 Computed tomography (CT) scan with contrast agent
 Abdominal x-ray
 Laboratory tests: complete blood cell count, revealing an elevated
white blood cell count, and elevated erythrocyte sedimentation
rate (ESR)

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 Treatment/ Medical Management
 Diverticulitis can usually be treated on an outpatient basis with diet and
medication; symptoms treated with rest, analgesics, and antispasmodics.
 The patient is instructed to ingest clear liquids until inflammation subsides,
then a high-fiber, low-fat diet. Antibiotics are prescribed for 7 to 10 days and a
bulk-forming laxative is also prescribed.
 Patients with significant symptoms and often those who are elderly,
immunocompromised, or taking corticosteroids are hospitalized. The bowel is
rested by withholding oral intake, administering IV fluids, and instituting
nasogastric suctioning.
 Broad-spectrum antibiotics and analgesics are prescribed and an opioid is
prescribed for pain relief. Oral intake is increased as symptoms subside. A low-
fiber diet may be necessary until signs of infection decrease.
 Antispasmodics such as propantheline bromide and oxyphencyclimine
(Daricon) may be prescribed.
 Normal stools can be achieved by administering bulk preparations (psyllium),
stool softeners, warm oil enemas, and evacuant suppositories.

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Treatment/ Medical Management
 Surgical Management
Surgery (resection) is usually necessary only if complications
(eg, perforation, peritonitis, hemorrhage, obstruction) occur.
Type of surgery performed varies according to the extent of
complications (one-stage resections or multistaged
procedures). In some cases fecal diversion (colostomy) may
be performed.

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 Prevention
 Consume a low-fat, high-fiber diet
 Drink six to eight glasses of water per day
 Avoid use of laxatives or enemas
 Exercise on a regular basis
 Avoid medication and foods that can cause
constipation
 Stop smoking

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 Nursing Diagnosis
 Constipation related to narrowing of the colon secondary to
thickened muscular segments and strictures.
 Acute pain related to inflammation and infection.

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
Nursing Interventions
Maintaining Normal Elimination Patterns:

i. Increase fluid intake to 2 L/day within limits of patient’s cardiac and renal reserve.

ii. Promote foods that are soft but have increased fiber content.

iii. Encourage individualized exercise program to improve abdominal muscle tone.

iv. Review patient’s routine to establish a set time for meals and defecation.

v. Encourage daily intake of bulk laxatives (eg, psyllium [Metamucil], stool softeners, or oil-retention enemas).

vi. Administer stool softeners or oil retention enemas as prescribed.

vii. Urge patients to identify food triggers (eg, nuts and popcorn) that may bring on an attack of diverticulitis and avoid
them.

 Relieving Pain:

i. Administer analgesic agents (usually opioid analgesics) for pain and antispasmodic medications.

ii. Record and monitor intensity, duration, and location of pain.

 Monitoring and Managing Potential Complications:

i. Identify patients at risk and manage their symptoms as needed.

ii. Assess for indicators of perforation: increased abdominal pain and tenderness accompanied by abdominal rigidity,
elevated white blood cell count, elevated ESR, increased temperature, tachycardia, and hypotension.

iii. Perforation is a surgical emergency: monitor vital signs and urine output, and administer IV fluids as prescribed .

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