Diverticulosis
Diverticulosis
• A diverticulum is a
saclike out pouching of
the lining of the bowel
that extends through a
defect in the muscle
layer.
• Diverticulosis exists
when multiple
diverticula are present
without inflammation or
symptoms
• Diverticulitis results when food and bacteria
retained in a diverticulum produce infection
and inflammation that can impede drainage
and lead to perforation or abscess formation.
• Diverticulitis is most common (95%) in the
sigmoid colon
Predisposing factors
• A congenital predisposition is suspected
• (When the disorder occurs in those younger
than 40 years of age)
• A low intake of dietary fiber is considered a
predisposing factor.
• Diverticulitis may occur in acute attacks or
may persist as a continuing, smoldering
infection.
Pathophysiology
High Decreased muscle
intraluminal low volume in the colon strength in the
pressure colon wall
The mucosa and sub mucosal layers
of
the colon herniate through the
muscular wall
Contents can accumulate
in the diverticulum and
decompose,
Abscesses develop and may
eventually perforate,
Leads to peritonitis and erosion
of the blood vessels (arterial)
with bleeding
Clinical features
• Bowel irregularity and intervals of diarrhea
• Abrupt onset of crampy pain in the left lower quadrant
of the abdomen
• Low-grade fever.
• Nausea and anorexia, and some bloating or abdominal
distention may occur.
• With repeated local inflammation of the diverticula, the
large bowel may narrow with fibrotic strictures, leading
to cramps, narrow stools, and increased constipation.
• Weakness, fatigue, and anorexia.
• Mild to severe pain in the lower left quadrant.
• The condition, if untreated, can lead to septicemia
Assessment and Diagnostic Findings
• A CT scan is the procedure of choice and can reveal
abscesses
• Abdominal x-ray findings may demonstrate free air
under the diaphragm if a perforation has occurred from
the diverticulitis
• Barium enema, which shows narrowing of the colon and
thickened muscle layers.
• (If there are symptoms of peritoneal irritation and
when the diagnosis is diverticulitis, barium enema is
contraindicated because of the potential for
perforation.)
• A colonoscopy may be performed if there is
no acute diverticulitis or after resolution of an
acute episode to visualize the colon,
determine the extent of the disease, and rule
out other conditions.
• Laboratory tests: Complete blood cell count
revealing elevated TLC & ESR
Complications
• Peritonitis(Abdominal pain, a rigid board like
abdomen, loss of bowel sounds)
• Abscess formation.( If an abscess develops,
the associated findings are tenderness, a
palpable mass, fever, and leukocytosis)
• Inflamed diverticula may erode areas adjacent
to arterial branches, causing massive rectal
bleeding.
Medical Management
• Dietary And Medication Management
• Diet is clear liquid until the inflammation
subsides; then, a high-fiber, low-fat diet is
recommended.
• This type of diet helps to increase stool
volume, decrease colonic transit time, and
reduce intraluminal pressure
Symptomatic Management:
• Rest, analgesics, and antispasmodics are
recommended.
• Bowel rest:
• Withholding oral intake,
• Administering intravenous fluids
• Nasogastric suctioning if vomiting or
distention occurs
• (Oral intake is increased as symptoms subside)
Drugs therapy
• A bulk forming laxative is prescribed (Metamucil)
• Stool softeners (Colace), by instilling warm oil into the
rectum, or by inserting an evacuant suppository
(Dulcolax).
• Broad-spectrum antibiotics are prescribed for 7 to 10
days.
• An opioid is prescribed for pain relief( morphine is not
used because it increases segmentation and intraluminal
pressures.)
• Antispasmodics such as propantheline bromide (Pro-
Banthine) and oxyphencyclimine (Daricon) may be
prescribed.
Surgical Management
• One-stage resection in which the inflamed
area is removed and a primary end-to-end
anastomosis is completed
Continued..
• Multiple-staged procedures for complications such
as obstruction or perforation
• A two-stage resection may be performed in which
the diseased colon is resected (as in a one-stage
procedure) but no anastomosis is performed;
• The end of the bowel are brought out onto the
abdomen as stoma.
• The remaining rectum is sealed, creating what is
known as Hartmann’s pouch/ Rectal stamp
• This “double-barrel” colostomy is then re
anastomosed in a later procedure
The Hartmann procedure
Nursing Assessment
Health history:
• Onset and duration of pain
• Past and present elimination patterns.
• Dietary habits to determine fiber intake and
straining at stool
• History of constipation with periods of
diarrhea, tenesmus (i.e, spasms of the anal
sphincter with pain and persistent urge to
defecate),
• Abdominal bloating, and distention.
Continued..
Assessment
• Auscultation for the presence and character of
bowel sounds
• Palpation for lower left quadrant pain,
tenderness, or firm mass.
• The stool is inspected for pus, mucus, or
blood.
• It is important to monitor temperature, pulse,
and blood pressure for abnormal variation
Nursing Diagnosis
• Constipation related to narrowing of the colon
from thickened muscular segments and
strictures
• Acute pain related to inflammation and
infection
Maintaining normal elimination patterns
• Fluid intake of 2 L per day (within limits of the patient’s cardiac
and renal reserve)
• Foods that are soft but have increased fiber to increase the bulk
of the stool and facilitate peristalsis
• An individualized exercise program is encouraged to improve
abdominal muscle tone.
• Review the patient’s daily routine to establish a schedule for
meals and a set time for defecation and to assist in identifying
habits that may have suppressed the urge to defecate.
• Encourage daily intake of bulk laxatives such as Metamucil, which
helps to propel feces through the colon.
• Stool softeners are administered as prescribed to decrease
straining at stool, which decreases intestinal pressure.
• Oil retention enemas may be prescribed to soften the stool,
making it easier to pass.
RELIEVING PAIN
• Records the intensity, duration, and location of
pain to determine if the inflammatory process
worsens or subsides.
• Analgesics (eg, meperidine) to relieve the pain
of diverticulitis and antispasmodic agents to
decrease intestinal spasm are administered as
prescribed.
•
Monitoring and managing
potential complications
The nurse assesses for the following signs
of perforation:
• Increased abdominal pain and tenderness
accompanied by abdominal rigidity
• Elevated white blood cell count
• Elevated sedimentation rate
• Increased temperature
• Tachycardia
• Hypotension
