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CE Home > Gastroenterology > NW0170 Diverticular Disease: Proper diet may help prevent common colon condition
Advanced Practice Course
NW0170c · 1.0 hr
Diverticular Disease: Proper diet may help prevent common colon condition
Author: Connie Goldsmith, RN, MPA

Course Objectives

The purpose of this program is to provide nurses with information about the prevalence and causes of diverticular disease, as well as the symptoms of diverticulitis. The diagnosis and treatment of common complications will be discussed, as will nursing implications for people with the disorder. After studying the information presented here, you will be able to -

1. Identify the two primary risk factors for diverticulosis.

2. Describe five symptoms of diverticulitis.

3. Discuss three serious complications of diverticulitis.

 

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Your patient has constipation, or maybe diarrhea. Mild abdominal pain. Severe abdominal pain. No pain. She is bloated and flatulent – or not. His stool tests positive (or negative) for blood. What do these vague and sometimes conflicting symptoms mean? Colon cancer? Irritable bowel syndrome? Ulcerative colitis? While it could be any of these, it's more likely that your patient has diverticular disease, the most common colon disease in the Western world.1

 

Afflicting men and women equally, the incidence of diverticular disease increases dramatically with age, affecting 5% of those under age 40, about 30% at age 60, and over 50% at age 80 and older.2 It most commonly occurs in North America, Australia, and Europe, where diets typically are high in processed foods and low in fiber.3 It's less common in Asia and Africa, where diets usually contain larger amounts of vegetable fiber.3

 

This module will review the pathophysiology of diverticular disease and explain the difference between diverticulosis and diverticulitis. It will identify the risk factors and causes for diverticular disease, as well as its diagnosis and treatment. Serious complications can occur with diverticulitis, such as bowel obstruction, perforation, sepsis, and peritonitis. Interventions to address these problems will be included.

 

Etiology

 

Diverticular disease includes asymptomatic diverticulosis as well as the more serious and symptomatic diverticulitis. While aging (decrease in strength of colon musculature) and insufficient dietary fiber (leading to decreased fecal bulk) are the two primary risk factors for diverticular disease, other factors include compromised vascular supply to the colon, inherent weakness in the colonic wall, and diseases of connective tissue, such as those present with scleroderma, Marfan’s syndrome, and Ehlers-Danlos syndrome.1,2  

 

The lower gastrointestinal system is composed of several layers of tissue that surround the intestinal lumen: the innermost mucosal layer, a submucosal connective tissue layer, layers of circular and longitudinal muscles, and the outermost peritoneum.

 

Diverticula (plural for diverticulum) are saclike protrusions of the mucosa formed when the mucous membrane herniates outward through vulnerable segments of the circular muscle fibers in areas weakened by muscular hypertrophy, rigidity, or fibrosis. They often occur in two or four parallel rows at sites where small arteries that supply the colonic mucosa penetrate the muscle. The prolonged transit time typical of low bulk stools causes chronic contractions of the circular musculature, resulting in increased intraluminal pressure. The movement of small, hard stools through the colon requires extra muscular effort, further increasing pressure on the colon wall and the chance for diverticula to develop.

 

Diverticulosis is the presence of diverticula. Typically, diverticula measure 5 to 10 mm, but can exceed 2 cm; they may vary in number from one to dozens.2,5 About 85% occur in the sigmoid colon, where intraluminal pressures are highest.2 They rarely occur in the stomach, but have been found in the duodenum in up to 25% of patients, according to some studies.6 A congenital anomaly called Meckel's diverticulum, located at the ileocecal valve, is found in about 3% of the population.6 Occasionally, diverticula may be located in the small bowel and rarely, in the mid or distal esophagus.7 One study of patients with self-described dysphagia and "food-sticking" who underwent office-based transnasal esophagoscopy revealed undiagnosed esophageal diverticular disease as the etiology of the symptoms.7

 

Most people with diverticulosis are unaware of their condition. Instead, the diagnosis is made when diverticula are noted during procedures such as colonoscopy, barium enema, or sigmoidoscopy are performed for other reasons. Only about 15% to 20% of patients with diverticulosis ever experience symptoms.5 Of those who develop symptomatic diverticulitis, about a third will suffer recurrent episodes.4

 

Symptoms

 

Diverticula themselves are not harmful, and most patients with uncomplicated diverticulosis will not experience symptoms. Some people may experience vague signs such as intermittent pain in the left lower abdomen that worsens with eating and is relieved with bowel movements or passing gas. Mild cramping may be present. Bloating, constipation or diarrhea may occur. Because these symptoms are mild and often spontaneously resolve, diverticulosis often goes undiagnosed.

 

Serious and potentially life-threatening problems begin when undigested food, fecal matter, and bacteria become trapped in the saclike diverticula, forming a hard mass called a fecalith. The inflamed diverticula result in acute diverticulitis. Symptoms may include:2,4,8

  • Abdominal pain usually described as severe and colicky; will be in left lower quadrant 93% to 100 % of the time
  • Fever (57-100% of the time) and chills, as infection begins in inflamed diverticula
  • Mild to moderate leukocytosis in about two-thirds of the patients
  • A tender, palpable mass in left lower quadrant
  • Nausea, vomiting, and anorexia
  • Constipation and/or diarrhea
  • Dysuria, urinary frequency
  • Occult blood in stool

Complications of acute diverticulitis may include:2,4,8

  • Complete or partial bowel obstruction caused by strictures, adhesions, scarring, or inflammation
  • Abscess formation in colon
  • Obstruction of left ureter by diseased sigmoid colon
  • Fistulas between diseased colon and bladder, vagina, uterus, ureter, abdominal wall, or another part of the bowel
  • Perforation of an abscess, a fistula or a diverticulum, sending fecal matter into the peritoneum or bloodstream, causing sepsis or peritonitis.

Diagnosis

 

The differential diagnoses for diverticulitis are extensive and include acute appendicitis, Crohn's disease, colon cancer, irritable bowel syndrome, cholecystitis, ulcerative colitis, pyelonephritis, gastroenteritis and gynecological problems such as pelvic inflammatory disease, ovarian cyst, and ectopic pregnancy.2,4,8

 

Upon physical examination, the abdomen may be distended or tympanic. Guarding and rebound tenderness may be present. Bowel sounds may be hyperactive, normal or absent. A rectal exam often reveals a palpable mass in the left lower quadrant. About 25% of patients will have occult blood on examination.4 A blood count may show an elevated white count, with leukocytosis and a shift to the left. Hemoglobin and hematocrit can be low because of acute or chronic bleeding.

 

Flat and upright abdominal films should be performed on most patients with abdominal pain.6 They may demonstrate ileus, dilation of the large or small bowel, bowel obstruction, abscesses, and pneumoperitoneum (air in the peritoneal cavity), signifying bowel perforation. While perforation is an uncommon complication of diverticulitis, it is a surgical emergency requiring prompt intervention because of its high mortality rate.

 

CT scan with intravenous contrast is the initial procedure of choice for diagnosing diverticulitis, especially in the presence of severe disease.8,9 It can show abscesses, fistulas, and thickening of the colonic wall, as well as the presence or absence of other intra-abdominal pathology.2,9 While studies have shown CT to be highly sensitive and highly specific, a negative scan does not completely exclude the possibility of diverticulitis.2,4 Ultrasonography may be useful in selected patients, especially in women of childbearing age to exclude gynecological pathology.10

 

Additional studies may be indicated in stable patients without acute symptoms. Flexible sigmoidoscopy and colonoscopy can reveal strictures, colon cancer, polyps, and may help determine the source of bleeding, if any. Barium enema and/or water-soluble enema can be performed after regional inflammation has resolved, and can readily identify the number and location of diverticula. The need for invasive procedures must be weighed against the risk of bowel perforation by either the instrument or the insufflation of pressurized air.2,10,11

 

Treatment

 

More than two-thirds of patients with an incidental finding of diverticulosis have no symptoms and do not need treatment.2 Patients who present with vague, nonspecific complaints such as bloating, constipation, diarrhea, or mild abdominal pain may require studies to determine if diverticulosis is the cause of their symptoms. However, if diverticula are present, they should not be assumed to be the cause of the symptoms until other serious conditions such as cancer are ruled out.

Asymptomatic and mildly symptomatic patients may be encouraged to increase their intake of dietary fiber unless advised otherwise by their health care provider. Increasing fiber may decrease the likelihood of future complications such as diverticulitis.2 Some researchers have postulated that diverticular disease, like scurvy, is due to a dietary deficiency and can largely be prevented by an adequate intake of dietary fiber.5

 

 Patients with abdominal symptoms that do not include inflammation or infection also may be treated with anticholinergic and antispasmodic medications, for example, dicyclomine (Bentyl) or propantheline bromide (Pro-Banthine), to decrease spasticity in the colon.4

 

When symptoms of diverticulitis are present (defined as inflammation or infection associated with diverticula), broad-spectrum antibiotics are indicated. Selected patients with milder disease (fever lower than 101° Fahrenheit, WBC 13,000 to 15,000) and strong support systems at home may be treated as outpatients with a liquid or low residue diet, and broad-spectrum oral antibiotics with anaerobic activity.2,4,8

 

Patients who do not begin to improve within three days, and those with more severe illness or comorbid conditions should be hospitalized.2 Once admitted, they may be kept NPO and a nasogastric tube inserted to allow for bowel rest. Intravenous fluids and intravenous antibiotics will be administered. Symptoms should start to improve within a few days, at which time the diet may be slowly advanced. Antibiotic treatment may be continued for seven to 10 days.2

 

Patients with complications will usually require hospitalization. About 20-30% of patients with diverticulitis will require surgery for their complications.2 Common complications can include:


Abscess, perforation and peritonitis: An abscess – an inflamed, infected diverticulum – should be suspected if the patient fails to improve within a few days. While small abscesses may be treated conservatively with antibiotics and bowel rest, larger ones are at danger of perforating into other organs or the abdominal cavity, leading to life-threatening peritonitis. Large, well-contained abscesses may be drained percutaneously using CT guidance. Complex or inaccessible abscesses, or those that have perforated, may require laparoscopic resection, open bowel resection, and sometimes temporary colostomy.

 

Fistula: A fistula is an abnormal passage from one organ or cavity to another. Fistulas occur with diverticulitis when an abscess extends or ruptures into an adjacent organ. The most common type of fistula goes from the colon to the bladder.5 Symptoms include air or fecal material in the urine. A fistula can also occur from the colon to the vagina, or from the colon to the uterus. Surgery is necessary to correct these conditions.

 

Bowel obstruction: Diverticulitis can cause partial or complete bowel obstruction that may spontaneously resolve or require surgical intervention. Partial obstruction is more common and can occur because of narrowing of the intestinal lumen due to scarring, inflammation or compression from abscesses. If the obstruction does not resolve with intestinal decompression, bowel rest, and antibiotics, surgical resection of the affected area of the colon is necessary.

 

Bleeding: Gastrointestinal bleeding occasionally occurs with acute diverticulitis, but it is much more common with otherwise asymptomatic diverticular disease. A dozen different conditions can cause lower GI bleeding, including colon cancer, polyps, inflammatory bowel disease, Crohn’s disease, hemorrhoids, and fissures. While only 5% of patients with diverticulosis experience hemorrhage, about 50% of all cases of acute lower gastrointestinal bleeding are due to diverticulosis.2

 

Diverticular hemorrhage is most often arterial in nature and caused by the erosion or perforation of blood vessels by ruptured inner colonic mucous membranes. This can lead to mild, moderate, or severe bleeding which is generally painless. It stops on its own in about 85% of patients.2 In the case of massive or continued bleeding, blood transfusions and management of fluid and electrolytes will be needed. Nurses should carefully monitor vital signs and serial hematocrit and hemoglobin in any patient with lower GI bleeding.

 

The patient with uncontrolled GI bleeding will require studies to identify the exact site of bleeding. Sigmoidoscopy, colonoscopy, angiography, or nuclear scans can be used. In the case of the latter, a small amount of radioactive technetium is infused. A scan easily locates the site of bleeding in the abdomen where the radioactive blood accumulates. This method is especially effective if bleeding is slow or comes from the small intestine where a colonoscopy cannot visualize it. Because most bleeding occurs in the colon, an urgent colonoscopy, performed after administration of a rapid, high-volume colonic lavage solution, can identify the source of bleeding up to 85% of the time.2

 

Once located, diverticular bleeding may be treated by local irrigation with epinephrine solutions or bipolar coagulation through a colonoscope, decreasing the need for surgery.5,11 When medical, endoscopic, and angiographic therapies fail, then resection, subtotal colectomy or hemicolectomy (with or without temporary colostomy depending on the circumstances) may be required. Bleeding recurs in about 25% of patients.2

 

  
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