Case Study of the Week: Diverticulitis

Working in the ER, I treat a lot of abdominal pain.  It seems our population lives in fear of contracting an appendicitis and seeks emergency treatment for every twitch and pang in their tummy.  Given the large number of abdominal pain related complaints I encounter on a daily basis, I have become rather adept at sorting the serious from the benign and diagnosing them appropriately.  Among my favorite diagnoses is diverticulitis. 

Along with the introduction of processed foods into the American diet in the early 1900's came diverticulitis.  Today, approximately 10% of Americans over the age of 40 have diverticula, benign out-pouchings on the colon.  Prevelance of diverticula increases with age; more than half of Americans over the age of 60 have this condition.  Of these individuals, about 25% will develop diverticulitis- inflammation and infection of the diverticula.  Diverticulitis can lead to serious complications therefore nurse practitioners must be able to diagnose and treat this condition appropriately.   

Case Presentation

A 54 year old male presents to your ED with left lower abdominal pain, diarrhea, nausea and vomiting.  He states that he has a decreased appetite along with a low grade fever and chills.  His past medical history includes a diagnosis of hypertension and obesity.  He is a smoker.  Upon arrival to the ED his vital signs are normal aside from a pule of 109 and a temperature of 100.2.  On exam you note the patient is visibly uncomfortable.  When you examen his abdomen, you note tenderness and guarding to the left lower quadrant.  Although you suspect diverticulitis, you order a CT scan of the patient's abdomen and pelvis as well as basic labs including a CBC, CMP and a urinalysis to rule out other causes of his symptoms.

The patient's labs are grossly normal aside from a WBC count of 12,400.  Results of the CT scan confirm a diagnosis of diverticulitis.  After receiving pain medication, IV fluids and nausea medication the patient feels much better.  His pulse has returned to a normal rate of 86.  You decide to discharge him home on antibiotics and pain medication.  You give strict instructions to return if his condition changes or worsens. 

Management and Outcome

Most patients with uncomplicated diverticulitis can be treated on an outpatient basis.  A clear liquid diet as well as antibiotic therapy should be prescribed, typically ciprofloxacin and metronidazole.  Both Moxifloxican and amoxicillin/clavulanic acid are also acceptable monotherapy agents.  Typically, patients see improvement in symptoms within 48 to 72 hours.  At this point, patients may try to gradually reinstate solid foods into the diet.

In severe diverticulitis, hospitalization is required.  Patients failing outpatient therapy, those who are unable to tolerate PO fluids and individuals with comorbidities may also require hospitalization.  IV fluids and antibiotics should be administered along with analgesics as needed. 

Complications of diverticulitis include abscess, perforation, peritonitis and intestinal obstruction.  Patients experiencing complications of diverticulitis may require surgical treatment such as abscess drainage or bowel resection.  Patients should be scheduled for a colonoscopy 2 to 6 weeks after the initial episode of diverticulitis to exclude other diagnoses such as malignancy and inflammatory bowel disease. 

Discussion

Researchers suspect a low-fiber diet results in formation of colon diverticula.  As the body ages, pressure also increases in the colon due to natural thickening of the intestinal wall.  This, along with straining to have a bowel movement also contributes to diverticula formation.  

As a nurse practitioner, you must encourage your patients to eat a diet high in fiber including fruits and vegetables.  This will help prevent your aging patients from contracting diverticulitis and prevent diverticula formation.