THE TICKING BOMB IN THE ABDOMEN

DIVERTICULITISDIVERTICULOSIS

DEFINITIONS• DIVERTICULUM – SAC-LIKE PROTRUSION OF THE GUT WALL• DIVERTICULA – MEANS MORE THAN ONE

DIVERTICULUM• DIVERTICULOSIS – DESCRIBES THE PRESENCE OF

DIVERTICULUM. MAY BE SYMPTOMATIC OR ASYMPTOMATIC• DIVERTICULITIS – INFLAMMATION OF THE

DIVERTICULUM. ACUTE OR CHRONIC• COMPLICATED DIVERTICULITIS – WITH ONE OF THE FF:

BOWEL OBSTRUCTION, ABSCESS, FISTULA OR PERFORATION

• UNCOMPLICATED DIVERTICULITIS – WITHOUT ASSOCIATED SYMPTOM

DIVERTICULOSISPRESENCE OF DIVERTICULUM

DIVERTICULOSIS

ETIOLOGY AND RISK FACTORS

• LOW FIBER DIET• ADVANCED AGE (MORE THAN HALF OF PEOPLE OVER

AGE 70 HAVE THAT CONDITION)THE FOLLOWING MAY CONTRIBUTE AS WELL• HIGH FAT INTAKE• LACK OF REGULAR ACTIVITY

ANATOMY/PHYSIOLOGY

PATHOPHYSIOLOGY• DIVERTICULI DEVELOPS IN THE WEAK REGIONS OF THE COLON.• WHEN CIRCULAR MUSCLE CONTRACTIONS OCCUR IN PATIENTS WITH

SMALL AMOUNTS OF STOOL IN THE COLON, THE COLON LUMEN BECOMES OCCLUDED.

• WHEN TWO CONTRACTIONS OCCUR CLOSE TO ONE ANOTHER , THE LUMEN OF THE INTERVENING SEGMENT OF THE COLON IS ISOLATED FROM THE REST OF THE COLON AND HIGH PRESSURE IS GENERATED IN THAT SEGMENT.

• INCREASED PRESSURE RESULTS IN THE FORMATION OF DIVERTICULA BY PLACING INCREASED TENSION ON THE COLON WALL.

SIGNS AND SYMPTOMS

• NON-SPECIFIC ABDOMINAL PAIN CONSTANT OR RELIEVED BY FLATULATION OR DEFECATION

• BLOATING AND CHANGE IN BOWEL HABITS• PAINLESS HEMATOCHEZIA• SYNCOPE, LIGHTHEADEDNESS, POSTURAL DIZZINESS• WITH SEVERE BLEEDING• CHRONIC DIARRHEA

DIAGNOSTICS

• HGB: NORMAL (<24H) OR LOW (>24H)• RBC: NORMOCYTIC (ACUTE BLEED) OR MICROCYTIC (CHRONIC BLEED)• BUN: SCR: NORMAL (VS. UPPER GI BLEED)• COLONOSCOPY• RADIOGRAPHOLOGY• ENDOSCOPY: INFLAMMATION OF INTERDIVERTICULAR MUCOSA, REDDISH LESIONS,

ULCERS, EDEMA, DIFFUSE EROSIONS• HISTOLOGY: CHRONIC INFLAMMATORY CHANGES (INFLAMMATORY INFILTRATION,

GLANDULAR ARCHITECTURE CHANGES, CRYPT ABSCESSES, CRYPT HEMORRHAGE)

PHARMACOLOGIC INTERVENTION

• BROAD SPECTRUM ANTIBIOTICS IF ASYMPTOMATIC

SURGICAL INTERVENTION

• COLOSTOMY• ILIOSTOMY• RIGHT OR LEFT HEMICOLECTOMY• SUBTOTAL COLECTOMY WITH ANASTAMOSIS

DIVERTICULITISINFLAMMATION OF THE DIVERTICULUM

DEFINITION

• INFLAMMATION OF ONE OR MORE DIVERTICULA, WHICH ARE SMALL POUCHES CREATED BY HERNIATION OF MUCOSA INTO THE WALL OF THE COLON.

• CONSIDERED A DISEASE OF THE ELDERLY, BUT AS MANY AS 20% OF PATIENTS WITH DIVERTICULITIS ARE YOUNGER THAN 50 YEARS.

FISTULIZATION• A COMPLICATION OF DIVERTICULITIS• FISTULAS TO ADJACENT ORGANS AND SKIN MAY

DEVELOP, ESPECIALLY IN THE PRESENCE OF AN ABSCESS.

• COLOVESICULAR FISTULAS MOST COMMON IN MEN• IN WOMEN, THE UTERUS IS INTERPOSED BETWEEN THE

COLON AND THE BLADDER, AND THIS COMPLICATION IS ONLY SEEN FOLLOWING A HYSTERECTOMY. THE UTERUS PRECLUDES FISTULA FORMATION FROM THE SIGMOID COLON TO THE URINARY BLADDER. HOWEVER, COLOVAGINAL AND COLOCUTANEOUS FISTULAS CAN FORM BUT ARE UNCOMMON.

ETIOLOGY• HAPPENS WHEN POUCHES FORM IN THE WALL OF THE COLON.• IF THESE POUCHES GET INFLAMED OR INFECTED, IT IS CALLED

DIVERTICULITIS.• DOCTORS AREN’T SURE WHAT CAUSES DIVERTICULOSIS, BUT THEY

THINK A LOW-FIBER DIET MAY PLAY A ROLE. WITHOUT FIBER TO ADD BULK TO THE STOOL, THE COLON HAS TO WORK HARDER THAN NORMAL TO PUSH THE STOOL FORWARD. THE PRESSURE FORM THIS MAY CAUSE POUCHES TO FORM IN WEAK SPOTS ALONG THE COLON.

• BACTERIA CAN GROW IN THE POUCHES, AND LEAD TO INFLAMMATION AND INFECTION.

RISK FACTORS

• “DISEASE OF THE WESTERN CIVILIZATION”• LOW FIBER CONSTIPATION• OBESITY, LACK OF PHYSICAL ACTIVITY• NSAIDS• SMOKING

ANATOMY/PHYSIOLOGY• PSEUDODIVERTICULA –

HERNIATIONS OF MUCOSA AND SUBMUCOSA BY SEROSA WHERE VASA RECTAE PENETRATE THE CIRCULAR MUSCULAR LAYER

• BETWEEN EACH SIDE OF THE MESENTERIC TAENIA , AND ON ONEA SIDE OF THE ANTIMESENTERIC TAENIAE

PATHOPHYSIOLOGY• MICRO OR MACROSCOPIC PERFORATION

OF THE DIVERTICULUM SUBCLINICAL INFLAMMATION DUE TO GENERALIZED PERITONITIS

• PREVIOUSLY THOUGHT TO BE DUE TO FECALITHS CAUSING INCREASED DIVERTICULAR PRESSURE (RARE)

• EROSION OF DIVERTICULAR WALL FROM INCREASED INTRAUMINAL PRESSURE INFLAMMATION FOCAL NECROSIS PERFORATION

• USUALLY INFLAMMATION IS MILD AND MICROPERFORATIOIS WALLED OFF BY PERICOLONIC FAT AND MESENTERY

SIGNS AND SYMPTOMS

• MOST COMMON SYMPTOM: BELLY PAIN, USUALLY IN THE LOWER LEFT SIDE THAT IS SOMETIMES WORSE WHEN YOU MOVE

• FEVER AND CHILLS• BLOATING AND GAS• DIARRHEA OR CONSTIPATION• NAUSEA AND SOMETIMES VOMITING• NOT FEELING LIKE EATING

DIAGNOSTIC

• CBC: (OFTEN SEE LEUKOCYTOSIS)• ELECTROLYTES• R/O UA• R/O PREGNANCY TEST (WOMEN)• SERUM AMINOTRANSFERASES• ALKALINE PHOSPHATE

• BILIRUBIN• AMYLASE• LIPASE• CULTURES: ONLY TO PATIENTS WITH

DIARRHEA• R,O INFECTIOUS PROCESS• CT SCAN • ULTRASOUND

PHARMACOLOGIC INTERVENTION• ANTIBIOTICS TO TREAT INFECTION (MONOTHERAPY:

PIPERACILLIN/TAZOBACTAM, AMPICILLIN, SULBACTAM, TICARCILLIN/CLAVULANIC ACID, IMIPENEM/MEROPENEM) (MULTIPLE DRUG REGIMENS: METRONIDAZOLE WITH CEPHALOSPORIN, CEFOTAXIME, CEFTOLOZANETAZOBACTAM, CIPROFLOXACIN

• MORPHINE : ACCEPTABLE FOR PAIN CONTROL• OVER-THE-COUNTER PAIN RELIEVER SUCH AS ACETAMINOPHEN

(TYLENOL) (HAS BEEN ASSOCIATED WITH A GREATER RISK FOR COLON PERFORATION AND SHOULD BE AVOIDED WHENEVER POSSIBLE

• INTRAVENOUS ANTIBIOTICS (FOR COMPLICATED DIVERTICULITIS

MEDICAL INTERVENTION

• INSERTION OF A TUBE TO DRAIN AN ABSCESS, IF ONE HAS FORMED

SURGICAL INTERVENTION

NEEDED IF YOU HAVE A COMPLICATION SUCH AS PERFORATION, ABSCESS, FISTULA, OR BOWEL OBSTRUCTION PRIMARY BOWEL RESECTION – THE SURGEON REMOVES THE DISEASED

SEGMENTS OF YOUR INTESTINE AND THEN RECONNECTS THE HEALTHY SEGMENTS (ANASTOMOSIS) THIS ALLOWS YOU TO HAVE NORMAL BOWEL MOVEMENTS. DEPENDING ON THE AMOUNT OF INFLAMMATION, YOU MAY HAVE OPEN SURGERY OR A MINIMALLY INVASIVE (LAPAROSCOPIC) PROCEDURE.

BOWEL RESECTION WITH COLOSTOMY: IF THERE IS SO MUCH INFLAMMATION IT IS NOT POSSIBLE TO REJOIN THE COLON AND RECTUM, A COLOSTOMY WILL BE PERFORMED.

NURSING CONSIDERATIONS• ADMINISTER ANTIBIOTICS, STOOL SOFTENERS, AND ANTI-SPASMODICS • MAINTAIN BED REST (ACUTE DIVERTICULITIS)• MAINTAIN LIQUID DIET DURING THE ACUTE ATTACK• WHEN ADMINISTERING MEDICATIONS, MONITOR FOR SIGNS. WATCH FOR

TEMPERATURE ELEVATION, INCREASING ABDOMINAL PAIN, BLOOD IN STOOLS AND LEUKOCYTOSIS.

• IF PATIENT HAS HAD ANGIOGRAPHY, INSPECT INSERTION SITE FOR BLEEDING.