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Nursing Made Incredibly Easy!:
doi: 10.1097/01.NME.0000413344.52446.97
Feature: CE Connection

Diagnosis: Diverticular disease

Kent, Vicky P. PhD, RN, CNE

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Author Information

Clinical Associate Professor • Towson University • Towson, Md.

The author has disclosed that she has no financial relationships related to this article.

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Abstract

Proper nutrition and a high-fiber diet are the keys to preventing diverticular disease, which affects at least 50% of the U.S. population older than age 60. If your patient has been diagnosed with diverticulosis, treatment focuses on lifestyle changes such as dietary modifications to prevent infection, known as diverticulitis. We deliver the goods on this prevalent condition.

Mr. F, 60, comes to your ED complaining of abdominal pain centered just below his belly button. He tells you that the pain started the previous day and it didn't diminish or vary throughout the day. However, the pain worsened at night to a 5 on a 0-to-10 pain rating scale. When he woke up, the pain still persisted and remained centered just below the belly button, which prompted him to come to the ED.

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A computed tomography (CT) scan with contrast material is completed, which definitively indicates diverticulitis with colon perforation (dye was shown going through the hole into the abdominal cavity). Mr. F is admitted to the hospital and meets with the gastrointestinal (GI) specialist. Mr. F indicates that he had a colonoscopy 4 months ago, with normal results and no unusual diverticula indicated. The healthcare provider recommends I.V. antibiotics to knock out the infection. If the infection clears, the perforation will close and surgery can be avoided.

Mr. F is discharged 4 days later infection-free. At subsequent follow-up visits, he notes that it took 6 weeks for normal bowel function to return.

In this article, you'll learn how to distinguish diverticula, diverticulosis, and diverticulitis. You'll understand how a person's age, diet, and lifestyle can have an impact on the likelihood of developing any one of these conditions, and you'll learn about their diagnosis. The treatments you'll read about range from simple diet changes to surgery, depending on the gravity of the disorder. Information about treatment and prevention focuses on the advantages of a high-fiber diet as a proactive step toward reducing your patient's risk of developing diverticular disease.

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What's in a name?

It's easy to confuse the words diverticula, diverticulosis, and diverticulitis. Here's what they mean:

* Diverticula are small pouches that form in the walls of the intestine. These intestinal sacs can occur anywhere in the GI tract, but they're often found in the sigmoid colon.

* Diverticulosis is the condition of having more than one of these bulging pouches (see Diverticulosis of the colon). As people age, especially in industrialized societies in which processed foods are consumed, they tend to develop diverticula. Data from the National Digestive Diseases Information Clearinghouse (NDDIC) indicate that America, England, and Australia are prime examples of countries in which this phenomenon happens.

* Diverticulitis occurs when the pouches become inflamed and/or infected. Pieces of food, bacteria, or fecal matter get stuck and harden in the diverticula (see Diverticulosis vs. diverticulitis).

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The older we get...

Although scientists suspect that the same people who eat a low-fiber diet are the ones who develop diverticulosis, this theory hasn't been proven. There's evidence that the likelihood of developing diverticulosis becomes greater as a person gets older. Affecting both men and women, approximately 10% of Americans over age 40 develop diverticulosis. The NDDIC reports that half of all Americans age 60 and older have some form of diverticular disease.

In countries where fast food is popularly consumed, people tend to develop diverticulosis in their left lower abdomen. Interestingly enough, in Japan, where diet and lifestyle have been increasingly westernized, individuals presenting with diverticulosis exhibit symptoms in their right lower abdomen.

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Intestinal fortitude

Figure. Diverticulos...
Figure. Diverticulos...
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If you think of the intestine as an amazing machine that handles what we eat and what we eliminate from our body, you realize that like a car, the body reacts differently to the quality and nature of the fuel we feed it. Low-fiber foods, like cheap gasoline, may muck up the machine!

Consuming too many low-fiber foods may lead to constipation and hard stools. The body strains when stools aren't adequately soft, and the colon feels pressure if a person forces a bowel movement. The pressure on the colon may result in the forming of pouches, or diverticula, in the intestinal lining. Although it's common for many people to develop diverticula, it's only a relative few who'll have the severe symptoms of inflamed and infected diverticula, requiring treatment for diverticulitis.

Bran and bran cereals, fresh fruit, whole grains, vegetables, fresh-peeled pears, peaches and apples, brown rice, carrots, cornbread, dried figs and apricots, lettuce, peas, seedless grapes, whole wheat bread, black beans, and kidney beans are all examples of high-fiber foods. When we eat high-fiber foods, the fiber isn't digestible, so it acquires a soft, gooey consistency in the intestine. Both soluble and insoluble fibers help stop constipation from happening because the fibers keep stools spongy.

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Getting down to a diagnosis

How can you tell if your patient has diverticulosis? Sometimes you can't because there may be no symptoms. Some patients may feel a ballooning and cramping in the lower abdomen. Blood on the toilet paper or in the patient's stool may be due to the presence of diverticula. Suffering may be lessened or entirely relieved by excretion or passing gas. Constipation and/or diarrhea may occur.

In the case of more serious symptoms, the patient may feel sudden, acute pain, or the pain might appear over a few days. Non-Asians tend to feel tenderness on the left lower side. Swelling, gas, fever, chills, nausea, vomiting, not feeling hungry, and not eating may all be symptoms of diverticulitis. The abdomen may feel harder or stiffer than usual. Diarrhea and constipation may alternate.

When a patient presents with severe pain that indicates diverticular disease, preliminary lab tests such as a white blood cell count, a urinalysis, and guaiac testing of the stool may be ordered. Additional tests include abdominal X-rays, ultrasound, and CT scan of the abdomen. The most effective diagnostic tool is the abdominal CT scan with contrast material. Using appropriate diagnostic tests in conjunction with the patient's clinical picture is needed to ensure proper treatment. A delay in care or unnecessary procedures could create more problems for your patient.

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Treatments that can't be beat

Figure. Diverticulos...
Figure. Diverticulos...
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Patients with mild-to-moderate symptoms respond well to outpatient treatment protocols. For most cases of diverticulosis, a high-fiber diet and pain medications help resolve the problem. Healthcare providers may prescribe bed rest, oral antibiotics, and/or a liquid diet for a set period of time. Anticholinergics may be recommended. If this combination works, the healthcare provider may then recommend a gradual introduction of high-fiber foods into the patient's diet.

When diverticula become infected and/or inflamed, treatment centers on resolving the infection, helping the colon get some rest, and avoiding or reducing any complications that might arise from diverticulitis. Broad-spectrum oral antibiotics, including ciprofloxacin, metronidazole, cephalexin, and doxycycline, are commonly used to treat mild infections associated with diverticulitis. Antibiotics are usually taken for a period of 7 to 10 days. Anticholinergic drugs such as chlordiazepoxide and dicyclomine relieve muscle spasms in the area of the diverticula and reduce pain. Patients who don't improve within 24 to 48 hours may require additional treatment.

If the patient presents with severe symptoms of diverticulitis, the healthcare provider may recommend a hospital stay. In this situation, the patient may need I.V. antibiotics and/or surgery (see Complications of diverticulitis).

Surgery is called for when nonsurgical treatment hasn't been enough to fight the infection and inflammation, pain, and complications resulting from diverticulitis. In a colon resection, the surgeon removes the damaged piece of the colon and connects the remaining parts of the colon to help stop further complications and future acute occurrences of the disease. The patient may require a temporary colostomy, especially if there are gross abnormalities of the colon.

Perforations, abscesses, peritonitis, complete intestinal obstruction, and severe bleeding may require two surgeries. The first surgery entails treating the abscesses by cleaning the infected section of the colon and removing the damaged piece. The surgeon performs a temporary colostomy, which allows the colon to rest and the inflammation associated with the diverticulitis to heal. After the problem resolves, the bowel is reconnected and the stoma is closed. Patients who require a temporary colostomy need additional emotional support and education about colostomy care.

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Keep it soft!

Adding fiber can help control diverticulosis. It's recommended that patients consume 20 to 35 g of fiber daily, and healthcare providers may prescribe high-fiber products to enrich a patient's diet. These fiber supplements should always be swallowed with 8 ounces of water.

The common wisdom recommends avoiding nuts, seeds, and foods that might pass into, aggravate, or even obstruct diverticula, but researchers don't agree on the extent to which this advice should be followed. Many agree that some beans, peas, coarse grains, popcorn, corn, fruits and vegetables with skins, coffee, tea, and alcohol are products to be avoided. Some healthcare providers urge patients to stay away from any food with seeds, such as strawberries, tomatoes, cucumbers, pomegranates, and pickles.

There's a difference of opinion in the most recent research as to how restricted a patient's diet needs to be to keep diverticulosis under control. Another variable is that each of us reacts somewhat differently to what we eat and drink based on a number of variables, including our genetic makeup and the characteristics of each person's body. Keeping a food diary can help your patient understand what works and what exacerbates the problem.

When a patient with diverticulosis experiences cramps, bloating, or constipation, the healthcare provider may recommend pain medications. One drawback to some pain medications is that the patient may suffer from constipation as an adverse reaction.

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Be a prevention sensation

Teach your patient to understand diverticular disease and the importance of a high-fiber diet to help control diverticulosis. If the patient starts to exhibit symptoms of diverticulosis, recommend altering the intake to a bland diet. Encourage your patient to drink lots of fluids to discourage constipation and an inflamed bowel.

For a patient hospitalized with diverticulitis, it's important to assess vital signs and monitor intake and output. An increase in pulse or respirations may be an early sign of a fluid volume deficit. An elevated temperature could mean infection. Examine stools for color and consistency. Assess visually and for occult blood. Administer antibiotics and other medications as prescribed. If surgery becomes necessary, it will be just as important with diverticulitis as with any disease to follow proper preoperative and postoperative practices.

Use the mnemonic HIGH FIBER to remember key nursing interventions for a patient with diverticular disease:

* Help your patient by assessing the problem, recording and reporting signs and symptoms, monitoring progress, administering necessary medications, and teaching your patient about necessary lifestyle and diet changes.

* Increase patient comfort and rest.

* Get relief and/or diminish discomfort for your patient.

* Handle patient anxiety with psychological support.

* Encourage Fluid intake.

* Instruct your patient about the disease and the benefits of a high-fiber diet and proper nutrition.

* Be proactive in all treatment procedures, including follow-up.

* Evaluate patient progress and look for evidence of no abnormalities.

* Record and report signs and symptoms.

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High fiber and fancy-free

Diverticulosis is a treatable condition, and diverticulitis is preventable when the patient follows a healthy diet and maintains proper bowel hygiene. Many people have diverticulosis and never experience any symptoms. Treatment varies according to the severity of the signs and symptoms, and most patients are managed successfully as outpatients. The keys to successful resolution of the immediate symptoms and prevention of complications are bowel rest and a pharmacologic treatment regimen that includes antibiotics and appropriate pain medications.

A patient's age, eating habits, and lifestyle are key factors for the nurse to consider when caring for patients diagnosed with diverticular disease. Now that you know the difference between diverticula, diverticulosis, and diverticulitis, teach your patients. They should know the signs and symptoms of these conditions and when to contact their healthcare provider. Help your patients understand that simple lifestyle and dietary changes can reduce the risk of recurrent problems. Educating your patients about a high-fiber diet may be the most important thing you can do to help prevent further and more serious complications of diverticular disease.

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Complications of diverticulitis

Your patient may have one of the following serious complications that require surgery:

* Fistula. An abnormal uniting of tissue between an organ and the skin or between two organs may develop. Sometimes during infection, damaged tissue will heal connected to something it touched; with diverticulitis, the bladder, the small intestine, or the skin may adhere to the damaged tissue. Very commonly in men with a fistula, the bladder and colon may connect. This linking may cause an ongoing urinary tract infection that only surgery can repair.

* Partial intestinal obstruction. A restriction of the intestinal path.

* Perforation. A tear in the intestinal wall, sometimes a result of a weakened area.

* Abscess. A sac filled with pus or infection.

* Peritonitis. A critical or chronic swelling of the tissue that lines the abdominal cavity, which sustains and encases the organs in the abdominal cavity.

* Complete intestinal obstruction. A total blockage of the intestine.

* Severe bleeding.

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memory jogger

To remember nursing interventions for a patient with diverticular disease, think HIGH FIBER:

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* Help your patient by assessing the problem, recording and reporting signs and symptoms, monitoring progress, administering necessary medications, and teaching your patient about necessary lifestyle and diet changes.

* Increase patient comfort and rest.

* Get relief and/or diminish discomfort for your patient.

* Handle patient anxiety with psychological support.

* Encourage Fluid intake.

* Instruct your patient about the disease and the benefits of a high-fiber diet and proper nutrition.

* Be proactive in all treatment procedures, including follow-up.

* Evaluate patient progress and look for evidence of no abnormalities.

* Record and report signs and symptoms.

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On the web

* International Foundation for Functional Gastrointestinal Disorders: http://www.iffgd.org/library?topicGroup=adultTopicGroup&adultTopicGroup=9&kidTopicGroup=&generalTopicGroup=32&sortBy=id&bfa=all&perPage=10&x=22&y=8

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* Mayo Clinic: http://www.mayoclinic.com/health/diverticulitis-diet/MY00736

* MedlinePlus: http://www.nlm.nih.gov/medlineplus/diverticulosisanddiverticulitis.html

* National Digestive Diseases Information Clearinghouse: http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/index.aspx

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Learn more about it

Carlson DS, Pfadt E. Perforated diverticulitis. Nursing. 2009;39(2):72.

Harvard Women's Health Watch. Diverticular disease prevention and treatment. Harvard Health Publications. February 2011:4–5.

McCafferty MH, Roth L, Jorden J. Current management of diverticulitis. Am Sur. 2008;74(11):1041–1049.

Mizuki A, Nagata H, Tatemichi M, et al. The out-patient management of patients with acute mild-to-moderate colonic diverticulitis. Aliment Pharmacol Ther. 2005;21(7):889–897.

Nguyen MCT, Chudasama YN, Dea SK, Cooperman A. Diverticulitis. http://emedicine.medscape.com/article/173388-overview.

Ruschman K. Care of patients with inflammatory intestinal disorders. In: Ignatavicius DD, Workman ML, eds. Medical Surgical Nursing: Patient-Centered Collaborative Care. 6th ed. St Louis, MO: Elsevier Saunders; 2010.

Salem TA, Molloy RG, O'Dwyer PJ. Prospective study on the management of patients with complicated diverticular disease. Colorectal Dis. 2006;8(3):173–176.

Toorenvliet BR, Bakker RF, Breslau PJ, Merkus JW, Hamming JF. Colonoic diverticulitis: a prospective analysis of diagnostic and clinical decision-making. Colorectal Dis. 2010;12(3):179–186.

© 2012 Lippincott Williams & Wilkins, Inc.

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