1. Diverticulitis A Clinical Review
Kathy Freeman RN
Primary Care I SUNYIT
Dr. Jennifer Klimmick Yingling

2. Diverticulitis Definition: “Diverticulosis is
characterized by asymptomatic sac-like
protrusions (diverticula)in the colonic
wall that form when the mucosa
herniates at weak points in the
muscularis propria”(Reddy,V.,& Longo,W. 2013).

3. Diverticulitis Definition continued:
The condition of having many asymptomatic diverticula is called diverticulosis. When the retained food and bacteria occlude the opening of the diverticula inflammation ensues often causing complications of abcess, fistula, and sometimes perforation. This inflammatory process is referred to as the condition of diverticulitis( Dunphy,L., Brown-Winland,J.,Porter,B.&Thomas,D., 2011).

4. Pathophysiology “The diverticula form at weak points in the
colon wall, usually where arteries penetrate
the turnica muscularis to nourish the mucosal
layer. Abnormal colonic motility along with
Intraluminal hypertension also maybe
contributing factors. The colonic mucosa
herniates through the smooth muscle layer”
(McCance,K., Huether,S., Brashers,V., &
Rote,N.,2010).

5. Etiology Factors associated with etiology: Motility
Colon wall resistance
Low fiber diet
High fat/high carb (western diet)
Increased intraluminal pressure
Genetics – monozygomatic twins twice as
likely as dizygomatic twins to develop
diverticulosis (Wilkins,T., Embry,K., &
George,R., 2013).

6. Incidence Common in Western industrialized countries
Occurs in 5-10% of persons older than 45 years of age
80% of those older than 85 years of age
Rising numbers of hospitalizations of those younger than 50 from 18-34%
2.4 Billion dollars spent and estimated 3400 deaths (Wilkins,T.,Embry,K., &George,R.,2013).

7. Screening/Risk Factors
Diverticulosis often found incidental on CT Scans, Radiologic Studies and Colonoscopies.
Risk factors for developing Diverticulosis include:
Smoking
Obesity
Lack of physical activity
High consumption of red meat and fats
Low fiber diets
Constipation
NSAIDS
ETOH Consumption in younger age groups (Jacobs,D., 2013).

8. Clinical Manifestations/Presentation
Vary with extent of disease process
Uncomplicated diverticulosis – no symptoms
Acute uncomplicated diverticular cases report obstipation, abdominal pain that localizes to the left lower quadrant
Fever/Leukocytosis
Stool guiac may be positive
Symptoms classified Uncomplicated of Complicated
Both sets can manifest with nausea vomiting or abdominal guarding( Marrs, J., 2006).

9. Clinical Manifestation/Presentation
Complicated cases of Diverticulitis could involve sepsis , bowel abscess, fistula, obstruction or peritonitis, and on physical exam a mass maybe palpated(Marr,J., 2006).
Patients with acute abdominal pain that spreads suddenly and rapidly should be considered to have a perforation into the peritoneum involving the whole abdomen especially if their abdomen is rigid and should be considered for emergency surgical intervention( Jacobs,D., 2013).

10. Differential Diagnosis
Appendicitis
Bowel obstruction
Colorectal cancer
Ectopic Pregnancy
Inflammatory bowel disease
colitis
Inguinal hernia
Ovarian tortion, malignancy or abcess
UTI
Nephrolithiasis
Pancreatitis
Gastroenteritis

11. Diagnostics Continued
Severity of Diverticulitis often graded with Hinchey Criteria- distinguishes 4 stages of perforated disease
Current Classification
I. Pericolic abcess or phlegmon
II. Pelvic intraabdominal or retroperitoneal abcess
III. Generalized purulent peritonitis
IV. General fecal peritonitis this is asscoiated with 43 % risk of death(Klarenbeek,B., Korte, N., Peet, D& Cuesta,M., 2011).

12. Diagnostics
US/MRI and CT Scan are all utilized for radiological studies but CT Scan is the test of choice because has high sensitivity % approaching 100% for specificity of the diagnosis of diverticulitis and allows for the specific extent of disease process(Jacobs,D., 2013).
Colonoscopy and Sigmoidoscopy are typically avoided in acute cases of diverticulitis because of increased risk of colon perforation but are helpful in diagnosing non symptomatic diverticulosis, or when acute diverticulitis has resolved to check for other inflammatory bowel diseases and cancers(Jacobs, D., 2013).

13. Diagnostics Continued
CBC- Leukocytosis 55% of patients
C- Reactive Protein
Urinalysis to rule out UTI
Pregnancy test in females
Fecal occult blood testing
CMP – assess metabolic and renal function
ESR- inflammation marker
Contrast Enema- rarely used anymore
CXR-30-50% of patients have non specific abnormalities on CXR
Discussion as previous re: colonoscopy in acute cases if suspected inflammatory bowel disease or cancer should wait 6-8 weeks.

14. Treatment/Managment Treatment will depend on severity of case
First step to determine severity
If suspected perforation/ guarding/ rigidity high fever, sepsis treat emergently ER for probable surgical intervention.
CT scan will determine severity along with labs and whole picture , patients with complicated diverticulitis at risk for colonic perforation can undergo CT guided percutaneous drainage of abcess.
15-30 % of patients admitted with acute diverticulitis require surgical intervention(Wilkin,T., Embry,K., and George,R.,2013).

15. Treatment/Management Cont.
Non Pharmacological treatment:First stage of treatment for mild symptoms may be a low residue diet or liquid diet in attempt to rest the bowel(Tursi, A., 2012).
Pharmocological treatment outpatient: Antibiotics are the treatment for diverticulitis and because of the many different types of bacteria the treatment usually consists of a combination of drugs. A common practice is to use Flagyl or Metranidazole along with Cipro or Bacrtrim.
Pharmacological: If opiate analgesics are required Morphine is not recommended because of risk of hypersegmentation and possible increased intralumenal pressure of colon( Tursi, A., 2012).

16. Treatment/ Management Cont.
Treatment and management inpatient will vary inpatient as opposed to outpatient.
Inpatient –IV antibiotic options
Invanz, Zosyn,Timentin, Primaxin, Merrem, Doribax
Laproscopic Surgery for drainage , washout and resection result in shorter length of stay, fewer complications, and lower in hospital mortality compared with open colectomy
(Wilkins,T.,Embry,K., & George,R.,2013).

17. Diverticulitis Complications Perforation Peritonitis Bowel obstruction
Colon rupture
Hemorrhage
Death
Referrals
Surgical consults
Gastroenterology
Nutrition
Wound Care
VNA
Follow up
Patient’s being followed in the outpatient setting should be seen in close follow up and advised to call and be seen sooner with fever or increased symptoms to suggest possible need for hospitalization.
Discharged inpatients should be seen outpatient setting in 7-10 days depending if surgical procedures were performed

18. Counseling
Patients that have been previously diagnosed with and treated with diverticulitis should be educated on ;
High fiber diet 35 g daily from whole grains, vegetables, legumes. Fiber should be increased on a gradual basis to prevent side effects of gas and bloating, recommend increasing by 5 g per week
Smoking cessation counseling as it has been proven that smoking is associated with
complicated diverticulitis(Wilkins,T.,Embry,K.,&
George,R.,2013).

19. Counseling Continued
Increasing exercise as there is a direct correlation between diverticulitis and inactivity, obesity and constipation which can all be helped with exercise routines.
In addition to high fiber , low carb, low fat diets are helpful in helping to prevent obesity which is a risk factor for diverticulitis especially in younger male patients(Pisanu,A.,Vacca,V.,Reccia,I.,Podda & Uccheddu,A.,2013).

20. Take Home Points Diverticulitis
Still affects 65% of people over age 80 but increasingly becoming more prevalent in people younger than 50, recent data supports trend related to childhood and young adult increased obesity rates and decreased exercise habits(Pisanu,A.,Vacca,V.,Reccia,I.,Podda & Uccheddu,A.,2013).
CT Scan – Gold Standard Test for diagnosing
Myth – Nuts, Popcorns and maybe harmful.
Treatments- trials have been tested with Xifaxan and 5 ASA, Robotic assisted surgery.

21. References