DIVERTICULITIS
Diverticulitis: - It is the inflammation of a diverticulum(s) or a diverticular. A diverticulum is a saclike
herniation of the living in the bowel that extends through a defective muscle layer. This outpouching or
herniation occurs anywhere in the digestive truck but most commonly where a large number of blood vessels
penetrate the wall, area narrower than the others such as the sigmoid colon and where the muscle wall is
weakened. Diverticulitis results when food and bacteria retained in the diverticulum (saclike outpouching of
the lining of the bowel protruding through the muscle of the intestinal wall usually caused by high
intraluminal pressure.) produce infection and inflammation that can impede drainage and lead to perforation
or abscess formation. A congenital predisposing is suspected when disorder occurs in those younger than forty
(40) years. Diverticulitis may occur as an acute attack or may persist as a continuing, smoldering infection.
The symptoms manifested generally results from complication.
INCIDENCE
It usually affects adults above age 40. Also prevalent in Western Industrialized Nations where food processing
removes much of the roughages from foods. When it affects individuals below age 40, a genetic suspected.
CAUSES
No one knows exactly what causes the sacks or pouches of diverticulum to form. Eating a low fibre diet is one
of the most likely causes.
When body fluids, faecal matter and undigested food is trapped in the diverticulum.
When there is high intraluminal pressure.
Constipation leading to hard stool causing people to strain when passing stool. This increases the
pressure in the colon or intestines and may cause these pouches to form.
RISK FACTOR
Aging
Low fibre
Lack of exercise
Obesity
PATHOPHYSIOLOGY
Diverticular forms when the mucosa and submucosal layers of the colon herniates through the muscular wall
because of high intraluminal pressure, low volume in the colon ( [Link]-deficient contents) and decreased
muscle strength in the colon wall (i.e. muscular hypertrophy from hardened faecal masses). Bowel content
can accumulate in the diverticulum and decompose, causing inflammation and infection. The inflammation of
the weakened colonic wall of the diverticulum can cause it to perforate giving rise to irritability and spasticity
of the colon (i.e. diverticulitis). In addition abscess develop and erosion of the arterial blood vessels resulting
in bleeding. When symptoms of diverticulitis have developed, micro-perforation of the colon has occurred.
(Beitz, 2004)
CLINICAL MANIFESTATION
Change in bowel habits ( constipation, diarrhea or both)
Nausea and vomiting
Low grade fever and chills
Increase flatulence
Anorexia
Abdominal distention and tenderness
Leukocytosis
Pain which is often sudden, severe and occur in the lower left quadrant of the abdomen. Less
commonly pain will be mild at first and become worse over several days
A tender mass is felt when digital rectal examination is performed.
Urinary frequency when inflammation is in the proximity of the bladder
Mucoid stool
ASSESSMENT AND DIAGNOSTIC FINDINGS
Diverticulitis is typically diagnosed colonoscopy which permits the visualization of the extent of
diverticular disease and allows the physician to biopsy tissue to rule out other disease or
sigmoidoscopy.
Barium enema after the inflammation has subside
Computerize tomography scan (CT-Scan)
Ultrasonography
Full Blood Count (FBC) – shows elevated white blood cells)
Magnetic Resonance Imaging (MRI)
Physical examination ( Palpation of the abdomen to return)
MEDICAL MANAGEMENT
DIETARY AND PHARMACOLOGICAL MANAGEMENT
Diverticulitis can usually be treated on an outpatient basis with diet and medication. When symptoms
occur, rest, analgesics and antispasmodics are recommended. Initially a clear liquid diet is consumed
until the inflammation subsides.
Then a high fiber, low fat diet is recommended. This type of diet helps increase stool volume, decrease
colonic transit time and reduce intraluminal pressure.
Antibiotics are prescribed for 7-10 days. A bulk forming laxative is also prescribed.
In acute cases of diverticulitis with significant symptoms, hospitalization is required. Hospitalization is
often indicated for those who are elderly, immuno compromised or taking corticosteroids.
With holding oral intake, administering intravenous fluids and instituting nasogastric. Suctioning if
vomiting or distention occurs is used to test bowel.
Broad Spectrum Antibiotics are prescribed for 7-10 days.
An opioids (e.g. meperidine (Demerol) ) is prescribed for pain relieve. Morphine is contraindicated
because it can increase intraluminal pressure in the colon, exacerbating symptoms.
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 oxyphenyclimine (Daricon) may be prescribed.
Normal stool can be achieved by supplementing dietary fiber by using bulk preparations (psyllium) or
stool softeners (docusate) by instilling warm oil into the rectum or by inserting an evacuant
suppository (bisacodyl)
SURGICAL MANAGEMENT
Although acute diverticulitis usually subsides with medical management, immediate surgical intervention is
necessary if complications occur (e.g. perforation, peritonitis, hemorrhage and obstruction)
CT guided percutaneous drainage may be performed to drain the abscess and IV antibiotics are administered.
After the abscess is drained and the acute episode of inflammation has subsided (after approximately 6 weeks)
Surgery may be recommended to prevent repeated episode.
Two types of surgery typically considered are:
One-stage resection in which the inflamed area is removed and primary end to end anastomosis is
completed.
Multiple stage procedure for complications such as obstruction or perforation. The type of surgery
performed depends on the extent of complications found during surgery.
PRE-OPERATIVE NURSING MANAGEMENT
Reassure patient to allay his fear and anxiety
Re-inform patient about the surgery and obtain informed consent form
Explain the informed consent form to the patient and ensure that he signs it
Monitor vital i.e. temperature, pulse, respiration, blood pressure (B.P) and pain level and record and
report any deviation from the normal
Ensure all requested investigations are done such as x-ray and laboratory investigations and results are
available
Teach patients on post-operative deep breathing
Teach patient on diet modification for post operative management
Assess patient manifestation of perforation such as pyrexia, increased abdominal pain and tenderness
accompanied by abdominal rigidity
Monitor bowel sounds
Observe patients urine and stool, record and report bowel habits
Encourage patient to lie on the affected part to relieve pain
Maintain nil-per-os to rest the bowel
Pass NG-tube to decompress the stomach
Prepare the site for surgery such as shaving and bathing etc.
Administer IV fluids as prescribed
Administer antibiotics as prescribed (prophylaxis)
Weigh patient to serve as base line data
Measure patients abdominal girth (place on the umbilicus)
POST-OPERATIVE NURSING MANAGEMENT
Monitor vital signs and compare with base line data
Position patient comfortably in the supine position
Monitor patients bowel sounds and bowel habits
Administer IV fluids as prescribed
Begin patients diet with fluids diets, the semi-solid and then solid food high in fiber when bowel
returns
Encourage intake of fluids and fruits
Encourage patient to perform icy, deep breathing and coughing exercise
Administer analgesics and antibiotics as prescribed
Monitor intake and output
Observe incision site for bleeding
Dress incisional site as ordered and observe for signs of bleeding and infection
Perform colostomy care if colostomy is in place and observe for stoma redness
Teach patients about how he will maintain care cope with colostomy
NURSING MANAGEMENT
Ensure adequate bed rest
Prescribed antibiotics (IV) are given
Anti-colinergics are also given to reduce gastric hyper motility
Nil-per-os
IV fluids such as dextrose saline, ringers lactate and normal saline are given etc
Pass NG-tube and suctioning
Maintain the patient diet
Keep patient in semi-fowlers position
Monitor and record vital signs
Assess abdominal distension
Allay the patients anxiety
Ensure oral care
REHABILITATION
Identify ways to decrease constipation by intake of foods that are soft but have increased fiber such as
prepared cereals or soft cooked vegetables to increase bulk of stool and facilitate peristalsis thereby
promoting defecation
An individual exercise is encouraged
Some people with diverticulitis may have food triggers such as nuts, popcorn that brings on an attack
of diverticulitis. Patient should be urged to identify these triggers and avoid them
Monitor stool for bleeding
COMPLICATIONS
Bowel perforation
Peritonitis
Abscess
Fistula
Hemorrhage
Stricture
NURSING DIAGNOSIS
Constipation related to narrowing of the colon from thickened muscular segments and strictures
Acute pain related to inflammation and infection
