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DIVERTICULAR

DISEASE
Rachel Ulp
Sodexo Dietetic Intern
2014
In the United States diverticulosis affects
nearly 50% of Americans by age 60 and
almost all by age 80

Diverticulosis occurs when diverticula or
pockets develop in the colon wall

Diverticulitis describes the inflammation and
subsequent complications of the pockets


THE COLON
Function is to absorb water and
electrolytes and prepare waste
for excretion

Consists of two parts:
One complete muscular layer known as inner circular layer
Outer layer of three separate longitudinal ribbons of smooth muscle (taenia coli)

Those with diverticular disease have:
Thickening of the circular muscle/shortening of the taenia coli
Narrowing of the lumen
Poor dietary fiber intake


http://www.webmd.com/digestive-disorders/picture-of-the-colon
DIVERTICULA FORMATION
Sigmoid colon has the smallest lumen and highest intraluminal pressure

Most common location of diverticula formation in Western patients

Diverticulitis occurs when diverticula
become inflamed:

Necks of diverticula become obstructed by food
particles and/or fecal matter
Causes irritation & inflammation which results in
increased mucus production allowing for bacterial
growth
http://the-medical-centre.co.uk/colonic-
hydrotherapy-treatment/
ASYMPTOMATIC
DIVERTICULOSIS
No symptoms

Detection is typically incidental, commonly found during
colonoscopy

No need for specific therapy or special follow-up unless
symptoms appear

As preventative measure MD may prescribe high-fiber, low-fat diet
and advise increasing physical activity
http://www.canandaiguamedical.com/adminpagesms/mainsitepages/pagei
nfo.asp?ci=229
SYMPTOMATIC UNCOMPLICATED
DIVERTICULITIS
Common signs include left lower quadrant pain, fever, altered bowel
habits, and mild leukocytosis

Must rule out other causes such as appendicitis, UTI, irritable bowel,
nephrolithiasis, Celiac disease, etc.

CT scan should be done, recognized as the imaging tool of choice

Treatment goals includes bowel rest, improving symptoms and
preventing reoccurrence of symptoms

In those relatively healthy, antibiotic treatment is provided on an
outpatient basis and hospital admission is not necessary
COMPLICATED DIVERTICULITIS
Caused by fistula, phlegmon, stricture abscess or free perforation

Hospitalization, intravenous antibiotics and bowel rest are
required

Elective surgery is determined on a case-by-case basis

Surgery requires resection of entire sigmoid
colon and anastomosis between descending colon and
upper rectum

Hartmanns procedure vs. laparoscopic surgery


http://www.medicinenet.com/diverticulitis_di
verticulosis_pictures_slideshow/article.htm
MEDICAL NUTRITION THERAPY
Fiber hypothesis

Fiber vs. Residue?

General
recommendations
High fiber diet, adequate fluid, physical activity

MNT during an episode of diverticulitis
http://www.tovima.gr/science/medicine-biology/article/
?aid=505098
PATIENT PROFILE:
J.D. is a 57 year old Caucasian female, 58 inches tall, 116#, BMI
24.3

Admitting Diagnosis: Acute sigmoid diverticulitis

Past medical history: Diverticulosis, hypothyroid, COPD,
bronchitis, cardiac dysrhythmia, DJD

Family history: Father had colon cancer

Denied any alcohol/illicit drug use
RECENT HISTORY
Past three years J.D. has
experienced increased amount of abdominal pain on & off

Celiac disease & IBD were ruled out after testing

Past CT and MRI were inconclusive

Gall bladder was removed due to possible biliary dyskinesia

Pain continued
http://aokemergencyroom.com/acute-abdominal-
pain/
RECENT HISTORY CONTD
April 2013 symptoms became increasingly worse,
doubled over in pain after trying to eat anything
Bowel movements were thin, occurred 12-15 times/day
Gastric emptying study done, no abnormalities found
EGD revealed distal sigmoid was fixed and tortuous
November 2013, scheduled for colonoscopy & unable
to keep down prep
Found to have blockage and scope could not progress
further
Immediately sent to the ER
DIAGNOSTIC TESTS
CT scan revealed 10 cm segment
of her sigmoid colon with wall thickening
and stranding with associated diverticula

Underlying mass could not be
excluded

Complete blood count

Comprehensive metabolic panel

Urinalysis
http://www.meddean.luc.edu/lumen/MedEd/Radio/curric
ulum/Surgery/diveriticulitis2.htm
MEDICATIONS
Cipro
MVI
Protonix
Synthroid
KCL
Flagyl
Zofran
Entereg
Lovenox
Apresonline
Rocephin
Percocet
http://www.garden-city-pharmacy-
online.com/medication-identification-and-interaction.html
SURGICAL COURSE
GI consult placed, sigmoid resection necessary

Sigmoid stricture likely due to previous diverticulitis event

J.D. had a laparoscopic left colectomy with take down of splenic
flexure and small bowel resection

No complications, however, a portion of the small bowel was
resectioned due to involvement in inflammatory process



http://www.mymeditrip.com/medical-
procedure/general-surgery/colectomy.html
NUTRITION THERAPY
Altered GI function related to sigmoid stricture likely
due to prior diverticulitis as evidenced by CT scan and
H&P note.
Inadequate oral intake related to inability to tolerate
solid foods, abdominal pain, n/v as evidenced by
patients self-report.
1100-1320 kcal (25-30 kcal/kg)
35-44 g Protein (0.8-1 g Pro/kg)
1320 mL (30 mL/kg)
NUTRITION THERAPY S/P
SURGERY
Monitoring & Evaluation
GI profile for return of bowel function
Mealtime behavior for tolerance
Total Energy Intake for adequacy
Electrolyte/Renal profile for improved Phosphorous & BUN levels

RD Recommendation:
Advance diet as tolerated to clear liquid, light, then low fiber diet. Initiate
Resource Breeze supplement x3/day and provide MVI.

Upon discharge, follow low fiber diet for two weeks and gradually introduce
fiber gradually. Continue to follow high fiber diet.
QUESTIONS?
REFERENCES
Feldman, Friedman, and Lawrence J. Brandt. Sleisenger and Fordtrans Gastrointestinal and Liver Disease:
Pathophysiology/Diagnosis/Management. Philadelphia: Saunders, 2010.
Diverticular Disease. American Society of Colon & Rectal Surgeons. Accessed March 23, 2014.
http://www.fascrs.org/patients/conditions/diverticular_disease/.
Touzios, John G., and Eric J. Dozois. "Diverticulosis and acute diverticulitis."Gastroenterology Clinics of North
America 38, no. 3 (2009): 513-525.
Matrana, Marc R., and David A. Margolin. "Epidemiology and pathophysiology of diverticular disease." Clinics in colon
and rectal surgery 22, no. 3 (2009): 141.
MacGregor, Ruth L. "Robotic-assisted laparoscopic bowel resection for diverticular disease." OR Nurse 2013 6, no. 6
(2012): 16-24.
Tursi, A., and S. Papagrigoriadis. "Review article: the current and evolving treatment of colonic diverticular
disease." Alimentary pharmacology & therapeutics 30, no. 6 (2009): 532-546.
Manwaring, Mark, and Bradley Champagne. "Diverticular disease: Genetic, geographic, and environmental aspects."
In Seminars in Colon and Rectal Surgery, vol. 22, no. 3, pp. 148-153. WB Saunders, 2011.

Yeo, Charles J. Shackelfords Surgery of the Alimentary Tract. Philadelphia: Saunders, 2013.

Stocchi, Luca. "Current indications and role of surgery in the management of sigmoid diverticulitis." World journal of
gastroenterology: WJG 16, no. 7 (2010): 804.
Marx, Hockberger, and Ron M. Walls. Rosens Emergency Medicine, Eighth Edition. Philadelphia: Saunders, 2014.
Tarleton, Sherry, and John K. DiBaise. "Low-Residue Diet in Diverticular Disease Putting an End to a Myth." Nutrition in
Clinical Practice 26, no. 2 (2011): 137-142.
Burgell, Rebecca E., Jane G. Muir, and Peter R. Gibson. "Pathogenesis of Colonic Diverticulosis: Repainting the
Picture." Clinical Gastroenterology and Hepatology 11, no. 12 (2013): 1628-1630.