Diverticular disease is a condition characterized by the formation of diverticula, which are small pouch-like protrusions that form along the walls of a hollow structure, most commonly, the large intestine. Having multiple diverticula in the colon is called diverticulosis. And if one or more of these diverticula become inflamed, that’s called diverticulitis.
Now, let’s zoom into the wall of the intestine, which is made up of four layers. The outermost layer is called serosa or adventitia. Next is the muscular layer, which contracts to move food through the bowel. After that is the submucosa, which consists of a dense layer of tissue that contains blood vessels, lymphatics, and nerves. And finally, there’s the inner lining of the intestine called the mucosa; which surrounds the lumen of the gastrointestinal tract and comes into direct contact with digested food.
Now, there isn’t a single cause of diverticular disease, but rather it’s a multifactorial disease, meaning that there’s a combination of genetic predisposition and environmental risk factors. These include age over 40 years old, consuming a diet low in fiber and high in fatty foods or red meat, being obese, and having a sedentary lifestyle. Other risk factors include smoking, alcohol use, and taking certain medications, like NSAIDs.
All right, now, regardless of the cause, there’s an increase in the pressure inside the colon. This pressure pushes on the mucosa and submucosa until they bubble out through weak spots along the wall, like where a blood vessel penetrates the muscle layer of the intestine. These blood vessels can get weaker and rupture, leading to gastrointestinal bleeding. In addition, bacteria and undigested food may get stuck inside these protrusions, and cause infection within the intestinal wall.
Diverticulitis can in turn lead to serious complications, including bowel obstruction, as well as the formation of an abscess, which is a pocket of infected pus. Some clients may develop fistulae, which are abnormal connections with an adjacent organ or structure. In other cases, if the diverticula becomes distended enough, it may rupture and cause peritonitis.
Now, the clinical manifestations of diverticular disease will depend on the severity of the disease. Most of the time, clients won’t even know they have diverticulosis until the diverticula become inflamed, leading to an acute episode of diverticulitis. At this point, they may present with abdominal pain, which typically localizes in the lower left quadrant of the abdomen; fever, along with nausea and vomiting; a change in bowel habits, like alternating constipation and diarrhea; as well as painless hematochezia, which means bright red or maroon blood passing from the rectum. Moreover, if the acute episode of diverticulitis does not completely resolve, it may become chronic.
Diagnosis of diverticulosis is typically made incidentally during a routine colonoscopy or a CT scan that might be done for another reason entirely. On the other hand, the diagnosis of diverticulitis starts with history and physical assessment, followed by a CT scan of the abdomen and pelvis. A complete blood count might also be performed, typically showing leukocytosis, along with elevated inflammatory markers like CRP.
Although there’s no cure for diverticular disease, certain treatment options can be used to help mitigate some of the symptoms, improve the client’s quality of life, and prevent complications. This involves lifestyle modifications, like maintaining a balanced, high fiber diet, and increasing fluid intake. In severe cases of gastrointestinal bleeding, surgical intervention might be required, like coagulation therapy and surgical clips, which are applied to the bleeding artery in order to seal it.
Now, clients with mild diverticulitis that isn't associated with systemic signs like fever, are typically managed with analgesics, or oral antibiotics. On the other hand, for severe diverticulitis with systemic signs like fever, as well as for clients that are immunocompromised, intravenous fluids and intravenous antibiotics might be administered. Finally, surgical intervention is required for clients who develop serious complications.
All right, now let’s look at the nursing care you’ll be providing for a client with diverticular disease. Priority goals of care are to improve gastrointestinal function, monitor for complications, and provide supportive care.
Begin by placing your client on bed rest, instituting NPO status, and administering the ordered IV fluids, antibiotics, and analgesics. If your client has nausea and vomiting and is diagnosed with a bowel obstruction, insert a nasogastric tube attached to low suction. Next, review their most recent laboratory test results and assess their vital signs.
Immediately report signs of severe diverticular bleeding to the healthcare provider, such as decreased hematocrit or hemoglobin, or tachycardia, or hypotension. Then, send blood to the lab for type and crossmatch in the event their hemoglobin drops below 7g/dL and they need a blood transfusion; and prepare your client for a diagnostic colonoscopy, as ordered.