Diverticular Disease.pptx

DEFINITION

CAUSE

SIGNS AND SYMPTOMS

STATISTICS PATHOPHYSIOLOG Y

PROGNOSIS

Diverticular Disease

COMPLICATIONS

TREATMENT/ DIAGNOSTICS MEDICAL MNGMT

PREVENTION

NURSING DIAGNOSIS

NURSING 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 antiinflammatory 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 lowfiber 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. HOM E

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.  i. ii.  i.

Urge patients to identify food triggers (eg, nuts and popcorn) that may bring on an attack of diverticulitis and avoid them. Relieving Pain: Administer analgesic agents (usually opioid analgesics) for pain and antispasmodic medications. Record and monitor intensity, duration, and location of pain. Monitoring and Managing Potential Complications: 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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