Clinical Case Study:

Diverticulitis
By: Devin Williamson
KSC Dietetic Intern
June 7th, 2017/July 12th, 2017
 Concord Hospital

Concord, NH

9 clinical dietitians
1 per diem
8 full-time

295 licensed beds

 Diverticulosis
Diverticulum (plural: diverticula): a sac-like
protrusion or outpouching of the mucosa in the
colon.
Most common in descending and sigmoid
Mostly asymptomatic

http://news.unchealthcare.org/news/2012/january
/diets-high-in-fiber-wont-protect-against-
diverticulosis
https://www.fascrs.org/patients/disease-condition/diverticular-disease-
expanded-version-0
 Hypothetical Cause of
Diverticulosis
Hypothesis published in 1971 by two British surgeons, Painter and
Burkitt
Noted that diverticular disease was nonexistent in less economically
developed countries (observation)
Observed that fiber intake was decreasing with the industrialization of
countries
Hypothesized that a low-fiber diet causes segmentation to occur more
frequently, which results in increased intraluminal pressure
Proposed that fiber protects against high intraluminal pressure by
producing higher-volume feces
Law of LaPlace- Pressure within a cylinder equals the tension on the wall
divided by the radius.
Fiber distends the colon and increases its radius, therefore reducing pressure
 Diverticulosis: Risk
Factors
Age

Genetics

Chronic NSAID use

Obesity

Smoking

IBS

Low fiber intake

 Diverticulosis: Fiber
2104 participants, 30-80 years old

Methods:
outpatient colonoscopy
Phone interview (diet history, bowel movements, physical activity,
etc.)

Results:
Less frequent bowel movements (<7 per week) were associated with
decreased prevalence of diverticulosis
High-fiber diet was associated with higher prevalence of diverticula
Prevalence of diverticulosis increased with age

In summary, a high fiber diet may not prevent diverticulosis.

 Disease Progression
Diverticulitis
~4% of those with diverticulosis develop
diverticulitis
Diverticulitis: the inflammation and infection of a
diverticulum
Symptoms:
Nausea and vomiting
Abdominal distension
Left lower quadrant pain
Fever
Bleeding
 Diverticulitis:
Complications
Abscess

Bleeding

Perforation

Peritonitis

Fistula

Stricture
 Diverticulitis:
Diagnostic Testing
Urinalysis: abnormalities
CBC: elevated white blood cell count
CT scan: gold standard
Noninvasive
Helpful in determining diverticula, bowel
wall thickening, fistula, and abscess
Contrast enema
Not recommended for those with
perforation
Colonoscopy
Recommended 4-6 weeks after resolution
of symptoms
 Diverticulitis:
Treatment
Bowel rest, antibiotics, anti-inflammatory agents, IV fluids
Surgery for serious complications
MNT:
NPO until bleeding and diarrhea resolve
Clear liquids
Low residue nutrition therapy until inflammation and bleeding are
no longer a risk
High-fiber (6 g to 10 g beyond 20-35 g per day)/adequate fluids
after episode is resolved
Probiotics
Consumption of nuts, seeds, corn, and popcorn has not been found to
promote diverticulitis
 Mr. T.P.
Per H & P:
Arrived to the ER on 5/17
C/o (onset 5/14):
Nausea and vomiting
Abdominal pain (LLQ)
Constipation
Lower back pain
Low grade fever
Poor PO and appetite
Pain with urination
 Assessment:
Anthropometrics
Social history: Anthropometrics:
Wt: 145 lbs (66
58 YO Male
kg)
Contractor Ht: 57(170.1 cm)
BMI: 22.7
Family

Tobacco use (1 PPD >

40 years)
No h/o of colon cancer

Last colonoscopy was

7 years ago
 Assessment: History (H&P)

Medical: Surgical:
Chronic arthritis Left carpel tunnel
L4-5 decompression
Fatty liver
L2-3 discectomy
Pulmonary nodules Inguinal hernia
Asthma Repair
Osteopenia
Chronic back pain
Severe diverticulitis (?)
Hypertension
Chronic rhinitis
 Assessment:
Medications
Meloxicam- arthritis. NSAID.

Vitamin D3- osteopenia

Multivitamin

Mometasone- allergies

Omeprazole- PPI

Amlopidine- BP

Percocet- pain

Ventolin- asthma
 5/17: Day 1

CT scan: moderate sigmoid Abnormal Lab Values

diverticulitis with small WBC 14.7 (4.2-
intramural abscess
9.0)
No PO intake for 3 days Na 135 L
(mmol/L)
Diet: sips and chips
Alk Phos 125 H (45-
Plan: Bowel rest, IV fluids, IV 117 U/L)
antibiotics (Cipro and Flagyl) Ketones 15 AB
Protein 30 AB

5/19: Day
3 intake, poor PO for 7 days
Pt reports pain with
Diet: full liquid
 5/19: Day 3
Nutrition Needs

1870 kcals (~28kcal/kg)

66-79 g protein (1-1.2 g/kg)

 5/19: Day 3
Nutrition Diagnosis

PES: Inadequate food/beverage intake r/t

organ dysfunction AEB appetite poor and
intake poor.
 5/19: Day 3
Nutrition Intervention
Intervention: Supplements TID at meals
Breakfast: chocolate ensure frappe
Lunch & Dinner: chocolate ensure enlive

Goal:
meet nutr needs
incr intake
maintain wt
Monitor/Evaluate:
PO tolerance
wt change
N/V
bowel issues
appetite
 5/20-5/22: Day 4-6

Day 4:
N&V
Stricture?
NPO and IVF

Day 5:Abscess not amenable to IR drainage

Day 6:
Abdominal pain improving
Passing flatus, had BM
CT scan today to investigate N & V with poor PO
Results: possible colon mass in sigmoid colon. Obstructive?
Plan for colonoscopy
Considering TPN
 5/22: Day 6
Nutrition Follow-up
No PO tolerance

Acute severe malnutrition

O N
1.2% wt loss in 5 days ITI
T R
Subcutaneous fat loss: U
L N
Moderate to severe orbital A
M
Moderate to severe tricep
Muscle loss:
Moderate temporalis

Educated on TPN
 5/23: Day 7
Colonoscopy results:
Unable to pass the ClinimixE 4.25/10
scope through sigmoid lipids x3wk, trace
elements, 100 mg
Fibrotic sigmoid (25 cm)
thiamine
w/ chronic diverticulitis
1L @ 40 ml/hr
Meds: PPI/ lovenox IVF @ 60 ml/hr.
Needs: Receiving:
Diet: NPO (still not 66-79 g protein 41 g protein
tolerating PO) 1870 total kcal 704 total kcal
Initiate TPN via PICC
HIGH REFEEDING RISK
Little or no intake for
>10 days
 5/24: Day 8
TPN: Advancing to goal GI note:
ClinimixE 5/20 sigmoid resection
5/25
2 L @ 80 ml/hr
Continue
IVF @ 20 ml/hr Cipro/flagyl
Adding MVI, trace Colon mass s/p
elements, and colonoscopy
thiamine d/c lovenox

Needs: Receiving:
66-79 g protein 96 g protein
1870 total kcal 1904 total kcal
 5/25: Day 9

POD s/p sigmoid resection for stricture

Diet: sips and chips

TPN at goal
NS @ 45 ml/hr

5/26-5/28: Day 10-11

Now adding Pepcid, d/c thiamine

Protein needs adjusted for surgery:

79-99 g (1.2-1.5 g/kg)

Epidural for pain

WBC: 11.47 (5/26)9.27 (5/28)

 TPN

Day Day Day Day Day Day Day

1 2 3 4 5 6 7
BG 119 101 120 108 - 117 111
(mg/dL)

K 3.9 4.1 4.2 4.1 - 4.2 4.4

(mmol/L)

Mg 2.0 2.1 2.6 - - - 2.3

(mg/dL)

P 2.8 3.8 3.3 - - -

(mg/dL)

Is & 750 1604 1606 776 - - -20

Os 3758 2029
(net)
 5/29: Day 12
Diet advance: clear liquids w/ toast

TPN day #7
Decrease TPN by
48 g protein
1094 kcal
IVF 60 ml/hr

Calorie Count
490 kcals (26% of needs)
7 g protein (9% of needs)
 5/29: Day 12
Discharge Planning
PES: Knowledge deficit r/t altered GI function AEB
patients need for low residue diet education

Intervention: Provided low residue diet education.

Encouraged reintroduction of high fiber foods in 6-8
weeks.

I usually dont eat any of those foods anyway!

 5/30: Day 13

Discharge day

Diet: Regular (50% of breakfast and lunch)

Wt: 63.3 kg

Wt loss: 2.5 kg (4%)

Encouraged small, frequent meals

Specimens obtained during colonoscopy and

resection: negative for malignancy!
PICC line removed
 5/30: Discharge
Instructions
Low residue diet

Resume regular medications

Oxycodone added for pain management

Activity restriction: No lifting > 10 lbs.

Follow-up appointments:
Concord Surgical Associates
PCP
 Summary

Increased intake and met nutrition needs

No refeeding syndrome

Glycemic control

Provided nutrition education

Transitioned to PO!
 Resources
Academy of Nutrition and Dietetics. Nutrition Care Manual. Diverticular
Conditions. https://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&lv1=5522&lv2=33991&ncm_toc_id=33991&ncm_heading=&.
Accessed June 5th, 2017.

Peery AF, Barrett PR, Park D, et al. A high-fiber diet does not protect against
asymptomatic diverticulosis. Gastroenterology. 2012;142(2):266-72.e1.

Reinhard, T. Diverticular disease- a reexamination of the fiber hypothesis. Todays

Dietitian. 2014; 16(3): 46.

Shahedi K, Fuller G, Bolus R et al. Long-term risk of acute diverticulitis among

patients with incidental diverticulosis found during colonoscopy. Clin Gastroenterol
Hepatol. 2013;11:1609-1613.

Snyder MJ. Imaging of Colonic Diverticular Disease. Clinics in Colon and Rectal
Surgery. 2004;17(3):155-162.

Welling DR. Medical treatment of diverticular disease. Clinics in Colon and Rectal
Surgery. 2004;17(3):163-168.