Diverticulitis is a common digestive disease particularly found in the colon. Diverticulitis develops from Diverticulosis, which is caused by diverticulum. Diverticulum is saclike protrusions of the mucosa formed when the mucous membrane herniates outward through weak segments of the colon. The saclike protrusions may become infected or inflamed from food or feces being lodged inside the protrusions, which is known as diverticulitis.
Diverticulitis can occur anywhere in the colon; however about 85% occur in the sigmoid colon, where intaluminal pressures are the highest (Goldsmith, 2009). Diverticulitis can also lead to bleeding, infections, perforations or tears, or blockages in the colon. Afflicting men and women equally, the incidence of diverticular disease increases dramatically with age, affecting 5% of people under age 40, about 30% of people by age 60, and approximately 50% to 70% of people age 80 and older (Goldsmith, 2009).
Aging and insufficient dietary fiber are two of the primary risk factors for developing diverticulitis. Some other factors that influence and/or cause diverticulitis include: excess intake of refined carbohydrates, physical inactivity, obesity, smoking, use of Non-steroidal anti-inflammatory drugs (NSAIDS), decreased blood supply to the colon, inherent weakness in the colonic wall, and diseases of connective tissue.
Although, aging does play a big role in developing diverticulistis, these other factors can increase the risk of developing the disease. Most people who develop diverticulitis are asymptomatic. People who have symptoms complain of: intermittent pain in the left lower abdomen that worsens with eating and is relieved with bowel movements, mild cramping, bloating, constipation, diarrhea, and acute hemorrhage may occur without warning or pain.
For patients with more serious diverticulitis symptoms may include: acute abdominal pain (usually described as severe and present in left lower abdomen), fever and chills (associated with infection and inflammation), mild to moderate leukocytosis, tender and palpable mass in left lower quadrant, nausea, vomiting, anorexia, constipation and/or diarrhea, dysuria, urinary frequency, and occult blood in stool.
Current evidence-based guidelines recommend three steps to diagnose possible diverticulitis: the initial evaluation of the patient includes problem-specific history and physical examination, a CBC, urinalysis, and plain abdominal radiographs; secondly a CT scans with oral, IV, or rectal contrast; and thirdly a contrast enema x-ray, cystography, ultrasound, and endoscopy. The medial history taken during the physical exam includes: bowel habits, symptoms, pain, diet and medication and a digital rectal exam; which often reveals a palpable mass in the left lower quadrant.
Given that many people who develop diverticulitis do not have symptoms and do not need treatment, a high-fiber diet and mild pain medications will help relieve symptoms in most cases; while the treatment, for those people that are symptomatic, focuses on clearing up the infection and inflammation, resting the colon, and preventing or minimizing complications. Some people will experience acute attacks that will require hospitalization for treatment. If attacks are frequent or severe, the doctor may advise surgery; usually involves two operations.
The first surgery will clear the infected abdominal cavity and remove that portion of the colon. Because of infection and sometimes obstruction, the surgeon creates a temporary stoma in the abdomen; which is a colostomy, to allow normal eating and bowel movements. In the second operation, the surgeon rejoins the end of the colon. Some patients may have a permanent colostomy; usually a colostomy is performed for infection, blockage, or in rare instances, severe trauma of the colon. Ostomies can be either permanent or temporary.
A permanent ostomy is when it is impossible to reconnect two ends or when the rectum and/or anus have been removed. A temporary ostomy is for a condition that is temporary and should resolve in a period of time; the ostomy allows a bypass of stool while area is healing. Some surgically created types of ostomies are the end ostomy, loop ostomy and double barrel. The end ostomy is when the entire rectum and bowel distal to the stoma is removed. A loop ostomy is when the loop of the bowel is brought out to the abdomen (large stoma).
The double barrel ostomy forms two stomas; one stoma for mucous drainage (mucous fistula) and the other stoma for feces to expel. Not only are there different types of ostomies but there are different locations for an ostomy to be placed. Sections of the colon that can be used for an ostomy include: transverse, ascending, descending, and sigmoid. Caring for a patient with diverticulitis includes managing pain, maintaining adequate nutrition, and educating the patient and family. Educate the patient about the disease in order to prevent recurrence and possible future complications.
The patient and family need to know the importance of consuming a high-fiber diet and to know which foods contain the largest amounts of fiber. Also, adequate intake of fluids and exercise will help promote bowel hygiene. Patients with diverticulitis that need ostomy surgery need education and teaching about the surgery and what to expect, how to manage the stoma appliance and what to do with a problem arises. Building rapport with the patient will allow the patient to voice concerns and ask questions when unsure; allowing you as the nurse to assist the patient better to adjust to a new way of life.
After surgery it is important to assess for adequate blood flow to the stoma, evidenced by warm, moist, bright red appearance; if stoma appears dusky or purple and feels cool, notify the surgeon. Teaching the patient how to open and close pouch, as well as cleaning and rinsing it out. Educate patient that pouch should be replaced every three to four days, at first and as the patient become familiar with replacing the bag may be able to extend use of pouch to a week. Educate patient about the different types of pouches and adhesives that can be used.
Patient and family should be aware of the types of foods that may produce gas, such as: cabbage, broccoli, onions, beer and beans. Educate patient about keeping the skin around the stoma clean and assess for irritation from feces and adhesives. Some adverse signs that should be reported are: skin irritation, recurrent leaks around the pouch, excessive bleeding, blood in stool, change in color or consistency of stool, bulge in the skin around the stoma, and if the stoma appears to be getting larger.