Buttaro chapter 133 diverticular diseases

Consider hosptialization of a patient with diverticulitis when

-anyone w/ a temp of 101.3 or higher w/ tenderness, s/s of peritonits diabetic or immunosuppressed patient older adults chronic renal failure

What to teach for prevention of diverticulosis

30-35 g of fiber every day w/ at least 8 glasses of water introduce fiber in 5-10 increments due to increased bloating and flatulance maintain ideal body wt, daily exercise, reduced consumption of red and processed meats and aoidance of tobacco and alcohol and the routine use of nonsteroidal antiinflammatory drugs also reduce risks of development of diverticula

Epidemiology of Diverticular disease

Affects one-half of individuals > 60 Only 20% of patients with diverticulosis develop symptomatic disease Prevalence among females and males is similar, Males present at a younger age Diverticulosis is rare in underdeveloped countries, where diets include more fiber

When should a barium enema or a colonoscopy if suspected diverticular disease?

Barium enema or colonoscopy should not be performed in the acute setting because of the higher risk of perforation Barium enema or colonoscopy should be performed ~6 weeks after an attack of diverticular disease.

Goals of surgical management of diverticulitis

Controlling sepsis Eliminating complications such as fistula or obstruction Removing the diseased colonic segment Restoring intestinal continuity

Acute uncomplicated diverticulitis presents with

Fever Anorexia LLQ abdominal pain Obstipation Localized or generalized peritonitis Leukocytosis Air-fluid level in the LLQ on plain abdominal film

Increased risk for bleeding with diverticulosis if you have

Hypertension Atherosclerosis NSAIDs

Diagnosis of diverticulitis is best made on CT with the following findings:

Sigmoid diverticula Thickened colonic wall >4 mm Inflammation within the pericolic fat ± the collection of contrast material or fluid

Who should be considered for surgical management of diverticulitis?

Two attacks of diverticulitis requiring hospitalization Not rapidly improve on medical therapy

The most common cause of hematochezia in patients >60 y is

colonic diverticulum

Asymptomatic diverticular disease is best managed by

fiber-enriched diet (30 g of fiber/D) Avoid nuts and popcorn

Teaching patient regarding diverticulitis

high fiber diet when not symptomatic avoid laxatives, enemas due to increase in colonic pressure regular bowel movements

Preoperative risk factors for diverticulitis include

higher American Society of Anesthesia class and preexisting organ failure

Symptomatic diverticular disease, defined as

radiographic and hematologic confirmation of infection within the colon,

Diverticuli commonly occur in what part of the colon due to it being a high pressure zone?

sigmoid

S/S of diverticulosis

usually normal fever +- irregular bms, excessive flatulence, bloating, change in stool caliber, flattened or ribbon like to hard pellets, anorexia, n/v, and heartburn mild, colicky left lower quadrant tenderness with thickend palpable tenderness which may also be related to diverticulitis rectal bleeding is infrequent, but painless bright red bleeding or maroon colored stools suggest a diverticular bleed

The aging GI tract Begins before age 50. What happens?

Decreased pancreas size Increased incidence of cholelithiasis, decreased production of bile synthesis Decreased liver size and blood flow Decreased thirst and hunger Increased medication use Changes in the mouth Decreased esophageal motility Reduced peristalsis Diminished ability of gastric mucosa to resist damage Decreased production of intrinsic factor Reduced intestinal absorption and blood flow

If a patient is bleeding from diverticulosis, the NP understands that

Most bleeds are self-limited and stop spontaneously with bowel rest Colonoscopy, which may be both diagnostic and therapeutic in the management of mild to moderate bleeding

Differential dx for diverticulitis

Ovarian cyst Endometriosis Acute appendicitis Pelvic inflammatory disease acute appendicitis, gastroenteritis, peritonitis, cystitis, neoplasm, IBS, colitris, small bowel obstruction, testicular torsion

How is symptomatic diverticulitis managed?

Symptomatic diverticular disease should be treated initially with antibiotics and bowel rest. Clear liquids for 2-3 days, limit physical activity. DAT with a low fiber diet until s/s are gone and then increase fiber to high after s/s are gone. Trimethoprim/sulfamethoxazole(160/800 bid) or ciprofloxacin (500mg bid) or amoxicillin clavulanate (875/125) potassium(or Augmentin) with metronidazole (500 mg tid) for 7-14 days

What is diverticulosis?

True diverticulum is a saclike herniation of the entire bowel wall diverticula is a pseudodiverticulum involves only a protrusion of the mucosa through the muscularis propria of the colon (Most common type of diverticulum) Protrusion occurs at the point where vasa recti, penetrates through the muscularis propria

Intrinsic factor (IF)

also known as gastric intrinsic factor (GIF) is a glycoprotein produced by the parietal cells of the stomach. It is necessary for the absorption of vitamin B12 later on in the terminal ileum

Clinical presentation of diverticulitis

mild to moderate colicky to steady aching abdominal pain in the LLQ with a fever and leukocytosis. Hematochezia is uncommon in diverticulitis... recurrent uti or feculent faginal d/c due to fistula may be present