Diverticular disease
Diverticular disease: Excerpt from Professional Guide to Diseases (Eighth Edition)
In diverticular disease, bulging pouches (diverticula) in the GI wall push the mucosal lining through the surrounding muscle. The most common site for diverticula is in the sigmoid colon, but they may develop anywhere, from the proximal end of the pharynx to the anus. Other typical sites are the duodenum, near the pancreatic border or the ampulla of Vater, and the jejunum. Diverticular disease of the stomach is rare and is usually a precursor of peptic or neoplastic disease. Diverticular disease of the ileum (Meckel’s diverticulum) is the most common congenital anomaly of the GI tract. (See Meckel’s diverticulum.)
Diverticular disease has two clinical forms. In diverticulosis, diverticula are pres-ent but don’t cause symptoms. In diverticulitis, diverticula are inflamed and may cause potentially fatal obstruction, infection, or hemorrhage.
Causes and incidence
In diverticulitis, retained undigested food mixed with bacteria accumulates in the diverticular sac, forming a hard mass (fecalith). This substance cuts off the blood supply to the thin walls of the sac, making them more susceptible to attack by colonic bacteria. Inflammation follows, possibly leading to perforation, abscess, peritonitis, obstruction, or hemorrhage. Occasionally, the inflamed colon segment may produce a fistula by adhering to the bladder or other organs.
Diverticula probably result from high intraluminal pressure on areas of weakness in the GI wall, where blood vessels enter. Diet may also be a contributing factor because insufficient fiber reduces fecal residue, narrows the bowel lumen, and leads to higher intra-abdominal pressure during defecation. The prevalence of diverticulosis in Western industrialized nations, where processing removes much of the roughage from foods, supports this theory. Diverticular disease is most prevalent in those older than age 40.
The incidence of diverticular disease increases with age, but 20% of patients are younger than age 50. Right-sided diverticulitis is most common in Asians, accounting for 75% of cases in that ethnic group. Left-sided diverticulitis is more common in Western countries, where it accounts for 70% of cases.
ELDER TIP About 50% of older adults develop diverticulosis. In elderly patients, a rare complication of diverticulosis (without diverticulitis) is hemorrhage from colonic diverticula. Such hemorrhage is usually mild to moderate and easily controlled, but may occasionally be massive and life-threatening.
Signs and symptoms
Diverticulosis usually produces no symptoms, but may cause recurrent left lower quadrant pain, which is commonly accompanied by alternating constipation and diarrhea and is relieved by defecation or the passage of flatus. Symptoms resemble irritable bowel syndrome (IBS) and suggest that both disorders may coexist.
Mild diverticulitis produces moderate left lower abdominal pain, mild nausea, gas, irregular bowel habits, low-grade fever, and leukocytosis. In severe diverticulitis, the diverticula can rupture and produce abscesses or peritonitis, which occurs in up to 20% of such patients. Symptoms of rupture include abdominal rigidity and left lower quadrant pain. Peritonitis follows release of fecal material from the rupture site and causes signs of sepsis and shock (high fever, chills, and hypotension). Rupture of the diverticulum near a vessel may cause microscopic or massive hemorrhage, depending on the vessel’s size.
Chronic diverticulitis may cause fibrosis and adhesions that narrow the bowel’s lumen and lead to bowel obstruction. Symptoms of incomplete obstruction are constipation, ribbonlike stools, intermittent diarrhea, and abdominal distention. Increasing obstruction causes abdominal rigidity and pain, diminishing or absent bowel sounds, nausea, and vomiting.
Diagnosis
In many cases, diverticular disease produces no symptoms and is found during an upper GI series performed as part of a differential diagnosis.
CONFIRMING DIAGNOSIS Tests showing diverticular disease include computed tomography (reveals areas of inflammation), colonoscopy, sigmoidos-copy, and barium enema.
Barium-filled diverticula can be single, multiple, or clustered and may have a wide or narrow mouth. Barium outlines — but doesn’t fill — diverticula blocked by impacted feces. In patients with acute diverticulitis, a barium enema may rupture the bowel, so this procedure requires caution. If IBS accompanies diverticular disease, X-rays may reveal colonic spasm.
Biopsy rules out cancer; however, a colonoscopic biopsy isn’t recommended during acute diverticular disease because of the strenuous bowel preparation it requires. Blood studies may show an elevated erythrocyte sedimentation rate in diverticulitis, especially if the diverticula are infected.
Treatment
Diverticulosis that doesn’t produce symptoms generally doesn’t necessitate treatment. Intestinal diverticulosis with pain, mild GI distress, constipation, or difficult defecation may respond to a liquid or bland diet, stool softeners, and occasional doses of mineral oil. These measures relieve symptoms, minimize irritation, and lessen the risk of progression to diverticulitis. After pain subsides, patients also benefit from a high-residue diet and bulk medication such as psyllium.
Treatment of mild diverticulitis without signs of perforation must prevent constipation and combat infection. It may include bed rest, a liquid diet, stool softeners, and a broad-spectrum antibiotic.
If diverticulitis is refractory to medical treatment, a colon resection is necessary to remove the involved segment. Perforation, peritonitis, obstruction, or fistula that accompanies diverticulitis may require a temporary colostomy to drain abscesses and rest the colon, followed by later reanastomosis 6 weeks to 3 months after initial surgery.
Special considerations
Management of uncomplicated diverticulosis chiefly involves thorough patient education about fiber and dietary habits.
❑ Make sure that the patient understands the importance of dietary fiber and the harmful effects of constipation and straining during defecation. Encourage increased intake of foods high in indigestible fiber, including fresh fruits and vegetables, whole grain bread, and wheat or bran cereals. Warn that a high-fiber diet may temporarily cause flatulence and discomfort. Advise the patient to relieve constipation with stool softeners or bulk-forming cathartics. However, caution the patient against taking bulk-forming cathartics without plenty of water; if swallowed dry, they may absorb enough moisture in the mouth and throat to swell and obstruct the esophagus or trachea.
❑ If the patient with diverticular disease is hospitalized, observe his stools carefully for frequency, color, and consistency, and keep accurate pulse and temperature charts because changes may signal developing inflammation or complications.
After surgery to resect the colon:
❑ Watch for signs of infection.
❑ Provide meticulous wound care because perforation may already have infected the area.
❑ Check drain sites frequently for signs of infection (purulent drainage or foul odor) or fecal drainage.
❑ Change dressings as necessary.
❑ Encourage coughing and deep breathing to prevent atelectasis.
❑ Watch for signs of postoperative bleeding (hypotension and decreased hemoglobin level and hematocrit).
❑ Record intake and output accurately.
❑ Keep the nasogastric tube patent.
❑ Teach ostomy care as needed.
❑ Arrange for a visit by an enterostomal therapist.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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