Diverticular Disease

Hmm I feel like talking about intestinal disorders. Actually, I'm doing this for my state board review which is due around January of next year. Wish me luck guys. A diverticulum is a sac-like outpouching of the lining of the bowel that extends through a defective muscle layer. It may occur anywhere along the GI tact. Multiple diverticular disease of the colon is called diverticulosis. Diverticulitis results when retention of food and bacteria happens causing infection and inflammation. A congenital predisposition is suspected when the disorder occurs in those younger than 40 years old. An intake of low dietary fiber predisposes the disease but the exact cause is unknown. It forms when the mucosa and submucosal layers of the colon herniate through the muscular wall due to high intraluminal pressure, low volume in the colon wall. Content accumulate in the diverticulum and eventually decompose, causing inflammation and infection. Obstruction can happen while inflammation aggravates the obstruction more. The inflammation tends to spread to the surrounding bowel wall, giving rise to irritability and spascitiy of the colon.

Complications

• Bowel Perforation
• Peritonitis
• Blood vessel erosion
• Bleeding
• Abscess
• Septicemia

Clinical Manifestations

• May be asymptomatic
• Chronic constipation
• Diarrhea
• Abdominal cramps left lower quadrant
• Low-grade fever
• Nausea & anorexia
• Bloating
• Abdominal distention
• Weakness
• Fatigue

Lab Tests and Findings (click here for normal lab values)

• Complete blood cell count
• Elevated leukocyte
• Elevated sedimentation rate
• Fecalysis
  

Diagnostics (click here for diagnostic procedures)

• CT Scan
• Abdominal X-Ray
• Barium enema (contraindicated with peritoneal irritation, potential perforation)
• Colonoscopy

Impression: Abscesses (CT scan), free air under the diaphragm indicates perforation (x-ray), narrowing of colon (barium enema)


Medical Management
Dietary & Medication Regimen:

• Analgesics
• Antispasmodics
• Clear liquid diet until inflammation subsided THEN high-fiber, low fat diet to increase stool volume decrease colonic transit time and intraluminal pressure
• Low-fiber diet until signs of infection decrease
• Antibiotics
• Bulk-forming laxative
• Opioids prescribed but NO MORPHINE

Antispasmodics:

• Propantheline bromide (Pro-Banthine)
• Oxyphencyclimine (Daricon)

Other medications:

• Metamucil
• Colace
• Dulcolax

Nursing Management
Assess:

• Health history
• Onset and duration of pain
• Past and present elimination patterns (include constipations, diarrhea, tenesmus)
• Fiber intake
• Auscultate bowel sounds
• Stool inspected for pus, mucous or blood
• Monitor vital signs

Diagnosis:

• Constipation R/T narrowing of the colon from thickened muscular segments and strictures
• Acute pain R/T inflammation and infection

Planning & Goals:

• Attainment and maintenance of normal elimination patter
• Relief from pain
• No complications

Nursing Interventions

• Recommend a fluid intake of 2 L per day (within the limits of patient's cardiac & renal reserve)
• Suggest fiber-rich soft foods that can increase the bulk of the stool to facilitate peristalsis
• Exercise program to improve abdominal muscle tne
• Adherence to medication regimen
• Analgesics for pain
• Record intensity, duration and location of pain
• Assess for signs of perforation:

-Increased pain and tenderness with abdominal rigidity
-Elevated WBC count
-Elevated sedimentation rate
-Increased temp.
-Tachycardia
-Hypotension

• Be ready for surgical emergency when perforation symptoms persist

Image taken: http://apps.uwhealth.org/health/adam/graphics/images/en/15810.jpg