Diverticular Disease

NR 507 week 5 case study

Diverticular Disease

1. Compare and contrast the pathophysiology of diverticular disease (diverticulosis) and acute diverticulitis.

Diverticular disease (diverticulosis) refers to the presence of one or more diverticula within the gastrointestinal tract. Diverticula are defined as saclike mucosal outpouchings that protrude from a structure that is tubular (Nallapeta et al., 2020). According to Piscopo & Ellul (2020), they are common structural abnormalities within the GI tract and can be classified as congenital or acquired. Congenital diverticula contain all the three walls of the bowel, like in Meckel’s diverticulum. Acquired diverticula have no muscular layer, as seen in sigmoid diverticular disease.

In most cases, diverticula are symptomatic and only become detected as an incidental finding, but their clinical presentation may be sepsis or hemorrhage (Piscopo & Ellul, 2020). Diverticular disease has been associated with the refined Western diet that lacks dietary fiber. An interplay of factors accounts for the pathophysiology of diverticular disease. As the age of an individual advances, the structure of collagen is altered. Together with disordered motility and escalating intraluminal pressure, more particularly in the sigmoid colon, which is narrow, causes the mucosa to herniate through the circular muscle at regions where the bowel wall is penetrated by blood vessels (Piscopo & Ellul, 2020).

In many cases, up to 90% of them, diverticular disease is localized to the sigmoid colon, but in rare instances, it may involve the whole length of the colon. The disease does not affect the rectum since it contains a complete muscular coat and a wider lumen. Diverticulosis forms the initial stage of diverticular disease, where there is incoordination of muscles and hypertrophy that causes high levels of segmentation and intraluminal pressure (Nallapeta et al., 2020). At this phase, the diverticula are asymptomatic, but in cases of colonic segmentation, they may cause severe spasmodic pain.

Linzay & Sudha Pandit (2018) define acute diverticulitis as inflammation of an obstructed diverticulum in the presence or absence of an infection. It is the second stage of diverticular disease, where one or more diverticula becomes inflamed with accompanying peri-colitis. Acute diverticulitis is classified as complicated or uncomplicated diverticulitis. Acute uncomplicated diverticulitis is the most common presentation of acute diverticulitis accounting for 75-80% of cases. Acute complicated diverticulitis refers to the presence of a fistula, abscess, free perforation, or obstruction.

2. Identify the clinical findings from the case that supports a diagnosis of acute diverticulitis.

Clinically, acute diverticulitis presents with persistent lower abdominal pain and tenderness (Linzay & Sudha Pandit, 2018). The pain is localized to the left lower quadrant and radiates to the back and groin. The pain may be accompanied by nausea, vomiting, fever, or urinary symptoms as a consequence of irritation of the bladder (Linzay & Sudha Pandit, 2018). Patients may report blood in the stool or sometimes excessive hemorrhage. The abdomen is rigid, and a mass is felt in the left iliac fossa, which is the sigmoid. The mass is tender, immobile, resonant, and hard (Linzay & Sudha Pandit, 2018). In cases of free perforation or abscess formation, a patient may have peritoneal signs such as rebound tenderness or guarding.

In the patient above, signs and symptoms justifying acute diverticulitis include left lower quadrant (LLQ) pain associated with constipation, nausea, low-grade fever, and vomiting over one day. The LLQ is tender on light palpation, has a hyper-resonant abdomen on percussion, and the abdomen has a distended round contour. These are features of the left iliac mass, the sigmoid.

3. List 3 risk factors for acute diverticulitis.

Risk factors for acute diverticulitis include consumption of red meat on a weekly basis, obesity, smoking, alcohol, female gender, advancing age, use of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, opioids, and aspirin (Linzay & Sudha Pandit, 2018). NSAIDs cause diverticular disease by inhibiting the synthesis of prostaglandins. The diet s the main factor in acute diverticulitis since with a less fiber diet, stool takes more transit time in the GI tract, and its weight and bulkiness are reduced, leading to increased intraluminal pressure and muscle hypertrophy (Piscopo & Ellul, 2020). Excessive constipation also causes increased time of stool transit. Obstruction of a diverticulum plays a significant role in acute diverticulitis, where there is the release of intestinal bacteria when a macro or micro perforation occurs in a diverticulum triggering an inflammatory response.

4. Discuss why antibiotics and IV fluids are indicated in this case.

The pathophysiology of acute diverticulitis involves an inflammatory response triggered by the intestinal bacteria released after a macro or micro-perforation of the diverticulum (Morales-Cruz & Velázquez, 2021). Prescription of antibiotics is therefore aimed at inhibiting the bacteria that trigger an inflammatory response within the colon. The presence of low-grade fever, as manifested by the patient, is a pointer of an infectious disease secondary to pathogens such as bacteria treated with antibiotics. Also, this patient is at high risk of developing complications associated with acute diverticulitis, such as abscess formation, perforation, or fistula; therefore, with the administration of antibiotics, this progress will be prevented.

According to Morales-Cruz & Velázquez (2021), the choice of intravenous antibiotics is based on the severity of the illness in the patient, older age, the risk of having adverse outcomes, and immunosuppression. The patient is 84, and her age justifies using intravenous antibiotics once she is hospitalized. Older age is associated with poor immunity, and her risk of having adverse outcomes of acute diverticulitis is high. Upon treatment with intravenous antibiotics, there is an improvement in her course of illness.

The patient, upon examination, has features that point toward dehydration. The presence of a pale mucosa, poor skin turgor, blood pressure of 90/60mmHg indicative of mild hypertension, and a tachycardia of 101 are indicators that the patient is dehydrated and therefore requires intravenous fluids for volume resuscitation.

References

Linzay, C. D., & Sudha Pandit. (2018, November 18). Acute Diverticulitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459316/

Morales-Cruz, M., & Velázquez, P. M. (2021). The Use of Antibiotics in Diverticulitis: An Update in Non-operative Management. In www.intechopen.com. IntechOpen. https://www.intechopen.com/chapters/79124

Nallapeta, N. S., Farooq, U., & Patel, K. (2020). Diverticulosis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430771/

Piscopo, N., & Ellul, P. (2020). Diverticular Disease: A Review on Pathophysiology and Recent Evidence. The Ulster Medical Journal, 89(2), 83–88. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576390/

Strate, L. L., & Morris, A. M. (2019). Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology, 156(5), 1282–1298. https://doi.org/10.1053/j.gastro.2018.12.033

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Purpose

The purpose of the graded collaborative discussions is to engage faculty and students in an interactive dialogue to assist the student in organizing, integrating, applying, and critically appraising knowledge regarding advanced nursing practice. Scholarly information obtained from credible sources as well as professional communication are required. Application of information to professional experiences promotes the analysis and use of principles, knowledge, and information learned and related to real-life professional situations. Meaningful dialogue among faculty and students fosters the development of a learning community as ideas, perspectives, and knowledge are shared.

Activity Learning Outcomes

Through this discussion, the student will demonstrate the ability to:

Compare and contrast the pathophysiology of diverticular disease (diverticulosis) and acute diverticulitis. (CO1)

Identify risk factors for acute diverticulitis and the clinical signs and symptoms associated with the disease. (CO3)

Explain the significance of physical exam and diagnostic findings in the diagnosis of diverticular disease. (CO4)

Due Date

Initial post is due on Wednesday by 11:59 p.m. MT. All posts are due by Sunday, 11:59 p.m. MT

A 10% late penalty will be imposed for discussions posted after the deadline on Wednesday, regardless of the number of days late. NOTHING will be accepted after 11:59pm MT on Sunday (i.e. student will receive an automatic 0). Week 8 discussion closes on Saturday at 11:59pm MT.

Total Points Possible: 100

Preparing the Assignment

Requirements:

Read the case study below.

In your initial discussion post, answer the questions related to the case scenario and support your response with at least one evidence-based reference by Wed., 11:59 pm MT.

Provides a minimum of two responses weekly on separate days; e.g., replies to a post from a peer; AND faculty member’s question; OR two peers if no faculty question using appropriate resources, before Sun., 11:59 pm MT.

Case Scenario:

An 84- year-old -female who has a history of diverticular disease presents to the clinic with left lower quadrant (LLQ) pain of the abdomen that is accompanied by with constipation, nausea, vomiting and a low-grade fever (100.20 F) for 1 day.

On physical exam the patient appears unwell. She has signs of dehydration (pale mucosa, poor skin turgor with mild hypotension [90/60 mm Hg] and tachycardia [101 bpm]). The remainder of her exam is normal except for her abdomen where the NP notes a distended, round contour. Bowel sounds a faint and very hypoactive. She is tender to light palpation of the LLQ but without rebound tenderness. There is hyper-resonance of her abdomen to percussion.  

The following diagnostics reveal:  

Stool for occult blood is positive.

Flat plate abdominal x-ray demonstrates a bowel-gas pattern consistent with an ileus. 

Abdominal CT scan with contrast shows no evidence of a mass or abscess. Small bowel in distended. 

Based on the clinical presentation, physical exam and diagnostic findings, the patient is diagnosed with acute diverticulitis and she is admitted to the hospital. She is prescribed intravenous antibiotics and fluids (IVF). Her symptoms improved and she could tolerate a regular diet before she was discharged to home.   

Discussion Questions:

Compare and contrast the pathophysiology between diverticular disease (diverticulosis) and diverticulitis.

Identify the clinical findings from the case that supports a diagnosis of acute diverticulitis.  

List 3 risk factors for acute diverticulitis.

Discuss why antibiotics and IV fluids are indicated in this case.