Diverticulitis

A Clinical Review

Kathy Freeman RNPrimary Care I SUNYIT Dr. Jennifer Klimmick Yingling

Diverticulitis

• Definition: “Diverticulosis is characterized by asymptomatic sac-like protrusions (diverticula)in the colonic wall that form when the mucosa herniates at weak points in the muscularis propria”(Reddy,V.,& Longo,W. 2013).

Diverticulitis• Definition continued: The condition of having many asymptomatic diverticula is called diverticulosis. When the retained food and bacteria occlude the opening of the diverticula inflammation ensues often causing complications of abcess, fistula, and sometimes perforation. This inflammatory process is referred to as the condition of diverticulitis( Dunphy,L., Brown-Winland,J.,Porter,B.&Thomas,D., 2011).

Pathophysiology• “The diverticula form at weak points in the colon wall, usually where arteries penetrate the turnica muscularis to nourish the mucosal layer. Abnormal colonic motility along with Intraluminal hypertension also maybe contributing factors. The colonic mucosa herniates through the smooth muscle layer”(McCance,K., Huether,S., Brashers,V., & Rote,N.,2010).

EtiologyFactors associated with etiology:• Motility• Colon wall resistance• Low fiber diet• High fat/high carb (western diet)• Increased intraluminal pressure• Genetics – monozygomatic twins twice as likely as dizygomatic twins to develop diverticulosis (Wilkins,T., Embry,K., & George,R., 2013).

Incidence

• Common in Western industrialized countries

• Occurs in 5-10% of persons older than 45 years of age

• 80% of those older than 85 years of age• Rising numbers of hospitalizations of those

younger than 50 from 18-34% • 2.4 Billion dollars spent and estimated 3400

deaths 1998-2005 (Wilkins,T.,Embry,K., &George,R.,2013).

Screening/Risk Factors• Diverticulosis often found incidental on CT Scans,

Radiologic Studies and Colonoscopies.• Risk factors for developing Diverticulosis include:• Smoking• Obesity• Lack of physical activity• High consumption of red meat and fats• Low fiber diets • Constipation• NSAIDS• ETOH Consumption in younger age groups

(Jacobs,D., 2013).

Clinical Manifestations/Presentation• Vary with extent of disease process • Uncomplicated diverticulosis – no symptoms• Acute uncomplicated diverticular cases

report obstipation, abdominal pain that localizes to the left lower quadrant

• Fever/Leukocytosis• Stool guiac may be positive• Symptoms classified Uncomplicated of

Complicated • Both sets can manifest with nausea vomiting

or abdominal guarding( Marrs, J., 2006).

Clinical Manifestation/Presentation• Complicated cases of Diverticulitis could

involve sepsis , bowel abscess, fistula, obstruction or peritonitis, and on physical exam a mass maybe palpated(Marr,J., 2006).

• Patients with acute abdominal pain that spreads suddenly and rapidly should be considered to have a perforation into the peritoneum involving the whole abdomen especially if their abdomen is rigid and should be considered for emergency surgical intervention( Jacobs,D., 2013).

Differential Diagnosis• Appendicitis• Bowel obstruction• Colorectal cancer• Ectopic Pregnancy• Inflammatory bowel disease• colitis• Inguinal hernia • Ovarian tortion, malignancy or abcess• UTI• Nephrolithiasis• Pancreatitis• Gastroenteritis

Diagnostics Continued• Severity of Diverticulitis often graded with

Hinchey Criteria- distinguishes 4 stages of perforated disease

• Current Classification I. Pericolic abcess or phlegmon II. Pelvic intraabdominal or retroperitoneal abcess III. Generalized purulent peritonitis IV. General fecal peritonitis this is asscoiated with 43 % risk of death(Klarenbeek,B., Korte, N., Peet, D& Cuesta,M., 2011).

Diagnostics• US/MRI and CT Scan are all utilized for radiological

studies but CT Scan is the test of choice because has high sensitivity 93-97 % approaching 100% for specificity of the diagnosis of diverticulitis and allows for the specific extent of disease process(Jacobs,D., 2013).

• Colonoscopy and Sigmoidoscopy are typically avoided in acute cases of diverticulitis because of increased risk of colon perforation but are helpful in diagnosing non symptomatic diverticulosis, or when acute diverticulitis has resolved to check for other inflammatory bowel diseases and cancers(Jacobs, D., 2013).

Diagnostics Continued• CBC- Leukocytosis 55% of patients • C- Reactive Protein• Urinalysis to rule out UTI • Pregnancy test in females • Fecal occult blood testing • CMP – assess metabolic and renal function• ESR- inflammation marker• Contrast Enema- rarely used anymore• CXR-30-50% of patients have non specific abnormalities on

CXR• Discussion as previous re: colonoscopy in acute cases if

suspected inflammatory bowel disease or cancer should wait 6-8 weeks.

Treatment/Managment• Treatment will depend on severity of case• First step to determine severity• If suspected perforation/ guarding/ rigidity high fever,

sepsis treat emergently ER for probable surgical intervention.

• CT scan will determine severity along with labs and whole picture , patients with complicated diverticulitis at risk for colonic perforation can undergo CT guided percutaneous drainage of abcess.

• 15-30 % of patients admitted with acute diverticulitis require surgical intervention(Wilkin,T., Embry,K., and George,R.,2013).

Treatment/Management Cont.• Non Pharmacological treatment:First stage of treatment

for mild symptoms may be a low residue diet or liquid diet in attempt to rest the bowel(Tursi, A., 2012).

• Pharmocological treatment outpatient: Antibiotics are the treatment for diverticulitis and because of the many different types of bacteria the treatment usually consists of a combination of drugs. A common practice is to use Flagyl or Metranidazole along with Cipro or Bacrtrim.

• Pharmacological: If opiate analgesics are required Morphine is not recommended because of risk of hypersegmentation and possible increased intralumenal pressure of colon( Tursi, A., 2012).

Treatment/ Management Cont.• Treatment and management inpatient will

vary inpatient as opposed to outpatient.• Inpatient –IV antibiotic options• Invanz, Zosyn,Timentin, Primaxin, Merrem,

Doribax• Laproscopic Surgery for drainage , washout

and resection result in shorter length of stay, fewer complications, and lower in hospital mortality compared with open colectomy

(Wilkins,T.,Embry,K., & George,R.,2013).

Diverticulitis • Complications• Perforation• Peritonitis• Bowel obstruction• Colon rupture• Hemorrhage• Death

• Referrals• Surgical consults• Gastroenterology• Nutrition• Wound Care• VNA

• Follow up • Patient’s being followed in the

outpatient setting should be seen in close follow up and advised to call and be seen sooner with fever or increased symptoms to suggest possible need for hospitalization.

• Discharged inpatients should be seen outpatient setting in 7-10 days depending if surgical procedures were performed

Counseling• Patients that have been previously diagnosed with

and treated with diverticulitis should be educated on ;

• High fiber diet 35 g daily from whole grains, vegetables, legumes. Fiber should be increased on a gradual basis to prevent side effects of gas and bloating, recommend increasing by 5 g per week

• Smoking cessation counseling as it has been proven that smoking is associated with

complicated diverticulitis(Wilkins,T.,Embry,K.,& George,R.,2013).

Counseling Continued• Increasing exercise as there is a direct

correlation between diverticulitis and inactivity, obesity and constipation which can all be helped with exercise routines.

• In addition to high fiber , low carb, low fat diets are helpful in helping to prevent obesity which is a risk factor for diverticulitis especially in younger male patients(Pisanu,A.,Vacca,V.,Reccia,I.,Podda & Uccheddu,A.,2013).

Take Home Points Diverticulitis• Still affects 65% of people over age 80 but

increasingly becoming more prevalent in people younger than 50, recent data supports trend related to childhood and young adult increased obesity rates and decreased exercise habits(Pisanu,A.,Vacca,V.,Reccia,I.,Podda & Uccheddu,A.,2013).

• CT Scan – Gold Standard Test for diagnosing• Myth – Nuts, Popcorns and maybe harmful.• Treatments- trials have been tested with

Xifaxan and 5 ASA, Robotic assisted surgery.

References