Adult Medical- Adult Medical- Surgical Nursing Surgical Nursing Gastro-intestinal Module: Gastro-intestinal Module: Diverticular Disease:Diverticular Disease:

(Diverticulosis/ Diverticulitis)(Diverticulosis/ Diverticulitis)

Diverticular Disease: Diverticular Disease: Incidence and AetiologyIncidence and Aetiology

A condition of the colon, often affecting the A condition of the colon, often affecting the sigmoidsigmoid

Mostly found in the elderlyMostly found in the elderly Associated with a low fibre diet, dehydration, Associated with a low fibre diet, dehydration,

constipation and straining to defaecateconstipation and straining to defaecate The elderly often present with diverticulitis, The elderly often present with diverticulitis,

inflammation and infection of the colon inflammation and infection of the colon

Diverticular Disease: Diverticular Disease: PathophysiologyPathophysiology

With straining to defaecate, the submucosal and With straining to defaecate, the submucosal and mucosal layers of the colon herniate through the mucosal layers of the colon herniate through the muscle forming pockets (muscle forming pockets (diverticulosisdiverticulosis) )

The pockets can trap faecal matter and become The pockets can trap faecal matter and become inflamed (inflamed (diverticulitisdiverticulitis))

Local inflammation → bowel irritability/ spasticityLocal inflammation → bowel irritability/ spasticity Abscesses may form, which may:Abscesses may form, which may: Perforate → peritonitis (acute abdomen) or Perforate → peritonitis (acute abdomen) or Erode a blood vessel (haemorrhage and malaena)Erode a blood vessel (haemorrhage and malaena) Healing causes fibrosis and strictures, increasing Healing causes fibrosis and strictures, increasing

constipation and risk of sub-acute or acute obstructionconstipation and risk of sub-acute or acute obstruction

Diverticulosis: Diverticulosis: Clinical ManifestationsClinical Manifestations

Left-sided lower abdominal painLeft-sided lower abdominal pain Nausea/ anorexiaNausea/ anorexia Low grade feverLow grade fever Abdominal distensionAbdominal distension ConstipationConstipation Weight loss/ malnutritionWeight loss/ malnutrition

Diverticulitis: Diverticulitis: Clinical ManifestationsClinical Manifestations

Acute, severe pain in the left lower abdomenAcute, severe pain in the left lower abdomen Fever (may lead to septicaemia: hyperpyrexia Fever (may lead to septicaemia: hyperpyrexia

and rigors)and rigors) Constipation (may be silent bowel: no bowel Constipation (may be silent bowel: no bowel

sounds)sounds) If perforation, symptoms of peritonitis (shock)If perforation, symptoms of peritonitis (shock) Rectal bleeding and malaena Rectal bleeding and malaena

Diverticular Disease: Diverticular Disease: Medical TreatmentMedical Treatment

Rest the bowel while inflamed (clear fluids)Rest the bowel while inflamed (clear fluids) → → once settled, a high fibre, low fat dietonce settled, a high fibre, low fat diet Antibiotic courseAntibiotic course Bulk-forming laxative (Fybogel)Bulk-forming laxative (Fybogel) Anti-spasmodic (Probanthin, Buscopan)Anti-spasmodic (Probanthin, Buscopan) Pain relief (avoid codeine as constipating)Pain relief (avoid codeine as constipating) Stool-softening agent when hard, or glycerin Stool-softening agent when hard, or glycerin

suppositories suppositories

Diverticulitis: Diverticulitis: Emergency TreatmentEmergency Treatment

25% of patients with diverticulitis require 25% of patients with diverticulitis require immediate surgical intervention for an “acute immediate surgical intervention for an “acute abdomen”: perforation, abscess, peritonitis, abdomen”: perforation, abscess, peritonitis, haemorrhage, obstructionhaemorrhage, obstruction

Antibiotic coverAntibiotic cover Surgical resection with end-to-end Surgical resection with end-to-end

anastamosisanastamosis Resection with double-barrel colostomy and Resection with double-barrel colostomy and

later anastamosislater anastamosis If sub-acute, antibiotics and elective “cold” If sub-acute, antibiotics and elective “cold”

surgery may be required later surgery may be required later

Diverticular Disease: Diverticular Disease: Nursing ConsiderationsNursing Considerations

Patient teaching about diet, exercise and bowel Patient teaching about diet, exercise and bowel habithabit

If surgery required: pre- and post-operative If surgery required: pre- and post-operative nursing of a patient undergoing bowel nursing of a patient undergoing bowel resection resection

Colostomy care and patient education: Colostomy care and patient education: Observe stoma is healthy (active, red & shiny)Observe stoma is healthy (active, red & shiny) Care of colostomy and surrounding skinCare of colostomy and surrounding skin Management of diet with colostomy Management of diet with colostomy

Diverticular Disease: Bowel Diverticular Disease: Bowel Resection Pre-operative Resection Pre-operative CareCare

Emergency operation:Emergency operation: General physical check-up, chest Xray, ECGGeneral physical check-up, chest Xray, ECG Blood profile, IVI, group and cross-match (GXM)Blood profile, IVI, group and cross-match (GXM) Breathing exercises to prepare for post-opBreathing exercises to prepare for post-op Thrombo-embolism stockings/ prophylactic Thrombo-embolism stockings/ prophylactic

heparin heparin Explanation of operation and possible stoma, Explanation of operation and possible stoma,

consent and emotional supportconsent and emotional support Nil orally pre-opNil orally pre-op

Bowel Resection: Bowel Resection: Post-operative CarePost-operative Care

Regular pain reliefRegular pain relief Monitor vital signs, pulse oximetry, IV fluids, urine Monitor vital signs, pulse oximetry, IV fluids, urine

output and fluid balanceoutput and fluid balance Semi-sitting position once recoveredSemi-sitting position once recovered Breathing and leg exercises. Early ambulationBreathing and leg exercises. Early ambulation Low molecular dose heparin. IV antibioticsLow molecular dose heparin. IV antibiotics Nil by mouth (NPO) initially→ graduated intake Nil by mouth (NPO) initially→ graduated intake

(mouth care)(mouth care) Nasogastric tube aspirations, wound, drain care, Nasogastric tube aspirations, wound, drain care,

stoma care stoma care