Interactive Contact Hours
Course: Diverticulitis Return to Course Outline

Diverticulitis

An overview of presentation, diagnosis and treatment.

To view the Course Outline and take the exam online, click here.
For a printer-friendly version of the exam you can print out, complete and mail to ADVANCE, click here.



Learning Scope #450
1 contact hour
Expires Sept. 9, 2015

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70% or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).


The author has completed a disclosure form and reports no relationships relevant to the content of this article.



The goal of this continuing education offering is to provide the latest information to nurses about diverticulitis. After reading this article, you will be able to:
1. State the signs and symptoms of diverticulosis and diverticulitis.
2. Explain ways to diagnose diverticulitis and the complications associated with diverticulitis.
3. Discuss prevention and management of diverticulitis.

Diverticulitis is an inflammatory infectious condition that occurs when food or bacteria becomes trapped in the diverticula.1 Small pouches (diverticula) in the walls of the intestines become inflamed or infected.1 The exact cause of diverticulitis is not known, but many patients initially develop diverticulosis, which is caused by outpunching (diverticula) in the walls of the intestines. Diverticulosis is a noninflammatory condition that produces mild symptoms, such as abdominal pain or changes in bowel movements, or no symptoms.1

Diverticular disease in general affects various parts of the intestines and may involve the sigmoid, ascending, descending or transverse colon.1 Although the exact cause of diverticular disease is not known, it has been linked to a low-fiber diet, red meat consumption and constipation.

The most serious form of diverticular disease is diverticulitis because the diverticula become inflamed and may result in infection. Patients with diverticulitis are at risk for developing serious complications including peritonitis, bowel perforation, obstruction, bleeding and abscesses.1


Epidemiology
Diverticular disease affects 20%-60% of the U.S. population, and most cases occur in people older than 40.2 Diverticular disease is the fifth most common GI condition in this country.2 Studies of western cultures, in whom the disease has a much higher incidence, have demonstrated a link between low-fiber diets and right-sided diverticular disease.2 Right-sided diverticula disease may be found in in the ascending colon, appendix and cecum.3These studies have also linked the consumption of red meat with diverticular disease.


Manifestations
It is important to differentiate between diverticulosis and diverticulitis. As stated, diverticulosis is not an inflammatory process and its symptoms are generally less serious than those associated with diverticulitis. Common diverticulosis symptoms include the following:

  • mild to moderate abdominal pain
  • bloating
  • flatulence
  • irregular defecation.

The manifestations of diverticulitis, which are caused by micro- or macroscopic perforations in the diverticula, vary based on the part of the intestine that is affected and whether complications are present. Diverticulitis is often divided into two categories, complicated and uncomplicated.

Complicated diverticulitis, which affects 25% of patients with diverticulitis, may be due to bowel perforation, abscess, obstruction or fistula.4 These patients often require surgery. Uncomplicated diverticulitis affects approximately 75% of patients with diverticulitis and is most often treated with outpatient medical therapy (e.g., antibiotics, pain meds and liquid diet).4 However, at least 30% of these patients may require surgical intervention.5

In western countries, 70% of patients with diverticulitis complain of mild to severe left-sided lower abdominal pain that is present for several days prior to admission to a hospital.4 Other manifestations of diverticulitis include the following:6

  • nausea and vomiting

  • diarrhea
  • constipation
  • urinary problems
  • weight loss
  • anorexia
  • elevated white blood count
  • fever and chills.

Complications
The most common complications of diverticulitis are bowel perforation, peritonitis, abscesses, fistulas, GI bleeding and obstructions.1,5,6  These are medical emergencies that require immediate treatment; most cases require surgical intervention along with intravenous antibiotic therapy, anti-inflammatory agents, dietary restrictions and rest.5,6

A perforation in the intestinal tract is an opening that allows bacteria to escape from the intestine and spread through the peritoneal cavity. The most common symptom is abdominal pain over the location of the perforation. This perforation may cause peritonitis and widespread infection, and the patient is at risk for developing septic shock. Manifestations of peritonitis include a rigid, painful abdomen and absent bowel sounds.1,5-7

An abscess is a pus-filled swollen area along the intestinal wall. The patient with an intestinal abscess typically develops a fever, elevated white blood cell count and a tender, palpable mass in the affected area. Treatment includes hospitalization, IV antibiotics, possible surgery and continuous assessment for signs of peritonitis. 1,5-7 A colovesical fistula between the bowel and bladder may form, potentially causing fecal matter to enter the bladder and result in a urinary tract infection. Symptoms of a colovesical fistula include dysuria, elevated body temperature, leakage of gas or fecal material, nausea and vomiting, and abdominal pain. Treatment includes surgical repair and antibiotic therapy. 1,5-7  

Bleeding in the lower gastrointestinal tract may occur in diverticulitis as a result of inflammation that spreads through the intestinal wall. Depending on the amount and location of the bleed, patients may experience bloody stools, fatigue, fluid volume deficit, and a drop in hemoglobin and hematocrit.7 Treatment may include surgery, bowel rest, blood and fluid replacement, and prevention of hypovolemic shock.

When infections develop, an intestinal obstruction may occur as a result of intestinal wall narrowing. Partial obstructions cause abdominal pain, bloating and difficult bowel movements with thin, ribbon-like stool. Full obstructions are a medical emergency. These cause the same symptoms, except the patient is unable to have bowel movements. Bowel sounds may be high pitched initially, then absent. This condition must be treated immediately, and the patient will require NPO status, gastric decompression and most likely surgery.1,7


Diagnosis
Several diagnostic tools can help confirm a diagnosis of diverticulitis. After a thorough history and physical, a CT scan with contrast is the gold standard tool used to diagnose diverticulitis.1,7 Barium enemas are sometimes used but have an associated risk of perforation.7 Abdominal x-rays are commonly ordered to identify free air from a perforation. Blood testing can evaluate the patient for anemia, infections, inflammation, and fluid and electrolyte imbalances. In acute cases of diverticulitis, white blood cell count and erythrocyte sedimentation rate are usually elevated.6 smeltzer 2010


Collaborative Care
The treatment course for the patient with diverticulitis depends on the severity of the illness and whether complications are present. Evidence-based practices should be followed. Patient care management includes dietary changes, medications and surgical interventions. Some providers utilize the modified Hinchey system4,5,8 to classify and treat diverticulitis:

Stage 0 = mild clinical diverticulitis
Stage Ia = confined pericolic inflammation
Stage IIb = confined pericolic abscess
Stage II = pelvic or distant intra-abdominal abscess
Stage III = fecal peritonitis.

Patients with Stage 0 diverticulitis can usually be treated on an outpatient basis with pharmacologic therapy and dietary changes.8 Initially, patients may be advised to follow a liquid diet to rest the bowel. This should be followed by a low-fat, high-fiber diet. Patients whose diverticulitis is in most other stages require hospitalization. Patients in Stage Ia usually require surgery, along with select Stage Ib patients.8 The specific surgical procedure is determined based on the patient presentation and type of complication. Colon resection and colostomy may be required.3

Antibiotic therapy is usually initiated when the patient experiences an episode of complicated diverticulitis; it may not be required in cases of uncomplicated diverticulitis.1,7-9 Antibiotic therapy choice is based on the severity of the illness and the infecting organism. IV antibiotic therapy is often prescribed in the inpatient setting, and depending on the patient's response it may be changed to oral antibiotics prior to discharge. Combination antibiotic therapy is common. Intravenous combination therapy may include IV metronidazole plus an aminoglycoside, or clindamycin plus a fluoroquinolone.4 Oral antibiotic combinations may include ciproflaxin and metronidazole, or metronidazole and clindamycin. In most cases a 7- to 10-day course of therapy is adequate.4

Several small studies have examined the efficacy of probiotics and anti-inflammatory agents in the treatment of diverticulitis. Because probiotics are thought to alter the microflora in the intestines, they have been used to prevent recurrence of diverticulitis. Although this has not been well studied, there does seem to be some merit in the use of probiotics.8 Studies have also demonstrated that anti-inflammatory agents such as rifaximin and melasamine can be effective in treating symptoms and preventing recurrences. 8 Combining these two anti-inflammatories appears to have the best effects. 8 Some patients may benefit from antispasmodics such as propytheline bromide, medications for pain and bulk-forming laxatives.4,8

Another way to manage diverticulitis is with dietary changes. Adequate fiber intake (20 to 35 grams per day), adequate water consumption (2 liters per day unless contraindicated), prevention of constipation and limited red meat consumption are considered standard dietary interventions for this condition.5,7,10 When treating acute diverticulitis, a low-fiber diet (to rest the bowel) may be ordered until the infection and inflammation have been addressed. For many years, patients were told to avoid nuts, seeds and spicy food, however, no data support this recommendation. Therefore, patients should discuss this with their health care provider.


Patient Education
Patient education is an important component in the care of a patient with diverticulitis and should be focused on disease management, preventing complications and knowing when to seek medical care. An individualized teaching plan should be developed for each patient based on personal history, severity of disease, current practice guidelines and patient preferences. Patients need to understand the importance of completing their prescribed course of antibiotics and the importance of reducing red meat consumption. They should also know the types of foods that are good sources of fiber: whole grains, beans and vegetables.


Research Findings
Research about the prevention and treatment of diverticulitis is ongoing. However, many issues need further investigation. A systematic review found no significant difference between outcomes when antibiotic therapy was used or was not used to treat uncomplicated diverticulitis.7,10 It is important to note that this was based on only one randomized, controlled trial; more trials are needed before changing practice.

In a similar study, Chabok et al concluded that antibiotic therapy was not necessary in the treatment of uncomplicated diverticulitis. 11 They found it did not prevent recurrence or improve recovery. They suggested that antibiotic therapy should only be utilized in cases of complicated diverticulitis.

Biondo et al completed a systematic review of the treatment of acute colonic diverticulitis. They examined 92 articles for information on the assessment, diagnosis and management of acute diverticulitis. They concluded that CT scans offer the best method for evaluating and staging acute diverticulitis. They also found that uncomplicated diverticulitis could be managed conservatively on an outpatient basis.2 With regard to elective surgery, the practice of recommending it after two attacks of diverticulitis should be done on an individual basis. And although laparoscopic surgery is the preferred method, it may not be possible in some cases due to the complexity of the disease. Furthermore, because each patient's presentation is so variable, an individualized treatment plan is vital to achieving positive patient outcomes.2

Issa et al completed a retrospective analysis of 96 patients who underwent surgery for acute diverticulitis. In the sample, 70.2% of the patients had no prior history of acute diverticulitis and 29.8% had a history of previous episodes of diverticulitis. Issa and colleagues found that the risk of complicated diverticulitis was not related to having multiple attacks. They also concluded that adverse outcomes and fatality rates were not related to recurrent diverticulitis and did not increase the risk for complications. They recommended continued inquiry to address the inconclusive evidence about surgical interventions, such as the recommendation to schedule elective surgery after two episodes of diverticulitis. 12

Tursi et al conducted a retrospective review of 130 patients with uncomplicated diverticulitis to determine whether endoscopic and histologic inflammation was predictive of diverticulitis recurrence. They concluded that a relationship existed and that diverticulitis should be considered a chronic condition with treatment aimed at preventing complications and recurrence.13

Treatment recommendations include the use of antibiotics and anti-inflammatory agents. Studies have demonstrated the efficacy of utilizing antibiotics and anti-inflammatory agents for treating diverticulitis, but there is no data on whether these are effective in preventing recurrence. However, clinical studies are being conducted. 13

In summary, recent research has identified CT scanning as the best choice for diagnosing diverticulitis. The use of antibiotic therapy is beneficial in complicated diverticulitis but not in uncomplicated diverticulitis. Inflammation that is present on histologic and endoscopic evaluation is related to complicated and recurring diverticulitis. Surgical interventions and other treatments should be determined on an individualized basis, and further studies are needed to identify best practices in the care of patients with diverticulitis.

Diverticulitis is a chronic condition whose presentation may be complicated or uncomplicated. Most uncomplicated cases can be treated on an outpatient basis, while complicated cases require inpatient care and possible surgical intervention. Some uncertainty exists with regard to the treatment of diverticulitis, and further research is warranted. Meanwhile, all patients should be educated about disease prevention and when to seek medical care.


References

1. Weizman AV & Nguyen GC. Diverticular disease: Epidemiology and management. Can J Gastroentero., 2011 July; 25(7): 385-389.
2. Biondo S, et al. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis. 2012;14(1):e1-e11.
3. Telem D, et al. Current recommendations on diagnosis and management of right-sided diverticulitis. Gastroenterol Res Pract.  2009: 359485. doi:  10.1155/2009/359485
4. National Digestive Diseases Information Clearinghouse. Diverticulosis and diverticulitis. http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/index.aspx
5. Young-Fadok T & Pemberton J.  Treatment of acute diverticulitis. Up to Date. http://www.uptodate.com/
6. Pemberton J & Young-Fadok T. Clinical manifestations and diagnosis of acute diverticulitis in adults. Upt to Date. http://www.uptodate.com/
7. Smelzter SC, et al. Management of patients with intestinal and  rectal disorders. In: Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 12th Edition.
Philadelphia: Lippincott, Williams, and Wilkins; 2010: 1067-1110.
8. Beckham H & Whitlow CB. The medical and nonoperative treatment of diverticulitis. Clin Colon Rectal Surg. 2009;22(3):156-160.
9. Shabanzadeh D. Antibiotics for uncomplicated diverticulitis. Cochrane Database Syst Rev. 2012;11:CD009092.
10. Smelzter SC, et al. Health care of the older adult. In: Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 12th Edition. Philadelphia: Lippincott, Williams, and Wilkins; 2010: 200-224.
11. Chabok A, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Brit J Surg. 2012;99(4):532-539.
12. Issa N, et al. Emergency surgery for complicated acute diverticulitis. Colorectal Disease. 2009;11(2):198-202.
13. Tursi A, et al. Detection of endoscopic and histological inflammation after an attack of colonic diverticulitis is associated with higher diverticulitis recurrence. J Gastrointestin Liver Dis. 2013;22(1):13-19.

Deborah Hunt is a member of the School of Nursing faculty at The College of New Rochelle in New Rochelle, N.Y. She has completed a disclosure statement and reports no relationships related to this article.