DIVERTICULAR DISEASE

NOAH CARPENTER, MD

Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed the Bachelor of Science in chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

Abstract

Diverticulosis is a common condition in Western countries and carries the risk of serious complications. Inflammation and infection of the colon are characteristic of the complication of . Typically, ultrasound and computed tomography imaging is used in cases of of diverticulitis to help clinicians identify edematous thickening of the bowel wall and inflammatory changes. While uncomplicated diverticulitis can be treated through medical management, surgical intervention may be needed in complicated diverticulitis and without surgical intervention the prognosis may be grave. Diverticular disease and its complications including the life-threatening event of a bowel perforation are discussed.

1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology 0.5 hours (30 minutes).

Statement of Learning Need

Clinicians need to be able to recognize the symptoms of diverticular disease. Patients with diverticular disease are at risk to develop infection and bleeding. Current trends in the diagnosis and treatment of diverticular disease are essential for the clinician to understand in order to appropriately and safely manage the condition.

Course Purpose

To provide clinicians with knowledge to care for patients with diverticular disease.

2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Noah Carpenter, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

1. specifically describes

a. the presence of diverticula with symptoms. b. the presence of diverticula. c. the presence of diverticula with diverticular bleeding. d. inflammation of a .

2. Inflammation of a diverticulum, known as ______occurs when there is thinning and breakdown of the diverticular wall.

a. diverticulosis b. c. diverticulitis d. diverticular bleeding

3. A fistula is

a. a localized collection of pus. b. an abnormal tract between two areas that are not normally connected. c. a blockage of the colon. d. an infection around the abdominal organ.

4. Sepsis is defined as

a. an abnormal tract between two areas that are not normally connected. b. an infection around the abdominal organ. c. a blockage of the colon. d. an overwhelming body-wide infection.

5. Diverticular bleeding occurs when a small artery in a diverticulum

a. erodes and bleeds into the colon. b. is obstructed. c. abscesses. d. forms a fistula.

4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Introduction

Diverticulosis of the colon is a common disease in Western countries. Many of the cases reported exclude asymptomatic or uncomplicated diverticulosis. Much of the medical literature focuses on the complications of diverticulosis although the majority of cases pertain to uncomplicated diverticulosis. Complicated diverticulosis of the colon receives much attention in the health literature because it is an important cause of hospital admissions and significant economic burden of the health system in the United States. Diverticular disease consists of three main conditions that involve the development of small sacs or pockets in the wall of the colon (diverticulum) including diverticulosis, diverticular bleeding, and diverticulitis (infection). The diagnosis, complications and treatment of diverticulosis are discussed in the following sections in addition to a key focus on the effect of lifestyles factors such as diet and weight on the prevalence of diverticulosis and risk of hospitalization.

Prevalence and Etiology

Diverticular disease has been defined as clinically significant and symptomatic diverticulosis due to diverticular bleeding, diverticulitis, segmental colitis associated with diverticula, or symptomatic uncomplicated diverticular disease. In Western countries there is a higher prevalence of diverticulosis with as high as 60% of individuals over 70 years of age being affected.1 Diverticulosis has been reported to increase with age. The incidence in younger individuals (less than age 45) for acute diverticulitis is 16 percent.

Asymptomatic (diverticulosis) occurs in a majority of individuals and approximately 20% have symptomatic uncomplicated diverticular disease

5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

(SUDD) with recurring symptoms such as abdominal pain, bloating, changes in bowel patterns. SUDD may mimic symptoms of (IBS) and clinicians performing an abdominal evaluation would want to look for specific abdominal pain features that include “pain localisation, pain relief by defecation or flatulence, and pain duration…”1 Complications will occur in approximately 4% of patients, and may include acute diverticulitis, which is relatively lower an incidence as compared to the general population rate of diverticulosis.

People with diverticulitis may have many symptoms, the most common of which is pain in the lower left side of the abdomen. The pain is usually severe and comes on suddenly, though it can also be mild and then worsen over several days. The intensity of the pain can fluctuate. Diverticulitis may also cause fevers and chills, nausea or vomiting, a change in bowel habits — or , and diverticular bleeding.1

In most cases, people with diverticular bleeding suddenly have a large amount of red or maroon-colored blood in their stool. Diverticular bleeding may also cause weakness, dizziness or lightheadedness, and abdominal cramping.1

Medical researchers are not certain what causes diverticulosis and diverticular disease. For more than 50 years, the most widely accepted theory was that a low-fiber diet led to diverticulosis and diverticular disease. Diverticulosis and diverticular disease were first noticed in the United States in the early 1900s, around the time processed foods were introduced into the American diet. Consumption of processed foods greatly reduced Americans’ fiber intake.

6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Diverticulosis and diverticular disease are common in Western and industrialized countries — particularly the United States, England, and Australia — where low-fiber diets are common. The condition is rare in Asia and Africa, where most people eat high-fiber diets. Two large studies also indicate that a low-fiber diet may increase the chance of developing diverticular disease. However, a recent study found that a low-fiber diet was not associated with diverticulosis and that a high-fiber diet and more frequent bowel movements may be linked to an increased rather than decreased chance of diverticula.1

Other studies have focused on the role of decreased levels of the neurotransmitter serotonin in causing decreased relaxation and increased spasms of the colon muscle. However, more studies are needed in this area. Studies have also found links between diverticular disease and obesity, lack of exercise, smoking, and certain medications including nonsteroidal anti- inflammatory drugs, such as aspirin, and steroids.

Researchers agree that with diverticulitis, inflammation may begin when bacteria or stool get caught in a diverticulum. In the colon, inflammation also may be caused by a decrease in healthy bacteria and an increase in disease-causing bacteria. This change in the bacteria may permit chronic inflammation to develop in the colon.1

Diverticulosis

Diverticulosis merely describes the presence of diverticula. Diverticulosis is often found during a test done for other reasons, such as flexible sigmoidoscopy, colonoscopy, or barium enema. Most people with diverticulosis have no symptoms and will remain symptom free for the rest

7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

of their lives.3 A person with diverticulosis may have diverticulitis, or diverticular bleeding.

Diverticulitis

Inflammation of a diverticulum (diverticulitis) occurs when there is thinning and breakdown of the diverticular wall. This may be caused by increased pressure within the colon or by hardened particles of stool, which can become lodged within the diverticulum.

The symptoms of diverticulitis depend upon the degree of inflammation present. The most common symptom is pain in the left lower abdomen. Other symptoms can include nausea and vomiting, constipation, diarrhea, and urinary symptoms such as pain or burning when urinating or the frequent need to urinate.

Diverticulitis is divided into two basic forms: 1) simple diverticulitis, which accounts for 75 percent of cases, is not associated with complications and typically responds to medical treatment without surgery, and 2) complicated diverticulitis, which occurs in 25 percent of cases and usually requires surgery. Complications associated with diverticulitis can include the following conditions.3

● Abscess – a localized collection of pus

● Fistula – an abnormal tract between two areas that are not normally connected (e.g., bowel and bladder)

● Obstruction – a blockage of the colon

● – infection involving the space around the abdominal organ

● Sepsis – overwhelming body-wide infection that can lead to failure of multiple organs

8 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Diverticular Bleeding

Diverticular bleeding occurs when a small artery located within a diverticulum is eroded and bleeds into the colon. Diverticular bleeding usually causes painless bleeding from the . In approximately 50 percent of cases, the person will see maroon or bright red blood with bowel movements.3,4

Risk Factors For Diverticular Disease

Environmental and lifestyle factors are important risk factors for diverticular disease. In general, studies have found that red meat intake and low dietary fiber intake, lack of vigorous physical activity, obesity, and smoking are associated with increased risk of diverticular disease. A low-risk lifestyle is believed to result in a reduction in the risk of diverticular disease by approximately 50 percent and avoidance of a high risk lifestyle will effectively prevent diverticulosis and complications associated with the disease.

This section highlights the healthy lifestyle choices to prevent diverticular disease and to reduce the existing disease burden due to the lack of prevention.

Diet

Fiber

Dietary fiber in diverticular disease has been a debated topic. Fiber in the diet helps to lower the risk of complicated diverticulosis that requires hospitalization but high-fiber diet is also associated with the development of colonic diverticula.

9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

In the least, the role of fiber in the development of diverticulosis is unclear. Several early studies suggested that low dietary fiber predisposes to the development of diverticular disease but other studies have been conflicting. Fiber also does not reduce symptoms in patients with symptomatic, uncomplicated diverticular disease. However, dietary fiber and a vegetarian diet may reduce the incidence of symptomatic diverticular disease by decreasing intestinal inflammation and altering the intestinal microbiota.

Previous published data demonstrated that vegetarians and people who consume high-fiber diets may have a lower risk of diverticulitis. Individuals with diverticulosis are expected to have a lower consumption of dietary fiber. There is still a recognized trend amongst health clinicians to advise patients to avoid high-residue foods and suggesting to patients that these particles might lead to complications of diverticulum. A large prospective study (2008) by Strate LL, et al. showed that the consumption of such foods (nuts, corn, popcorn) had no effect on risks of complications and suggested patients not be recommended to avoid such foods.1

Fat and Red Meat

In one study, the risk of diverticular disease was significantly increased with diets that were low in fiber and were high in total fat or red meat as compared with diets that were low in both fiber and total fat or red meat.

Seeds and Nuts

Nut, corn, and popcorn consumption are not associated with an increase in risk of diverticulosis, diverticulitis or diverticular bleeding. In addition, no association has been found between consumption of corn and diverticulitis or between nut, popcorn, or corn consumption and diverticular bleeding or uncomplicated diverticulosis.1 10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Physical Activity

It is unclear if lack of vigorous exercise is a risk factor for diverticular disease. However, vigorous physical activity appears to reduce the risk of diverticulitis and diverticular bleeding.

Obesity

Obesity has been associated with an increase in risk of diverticulitis and diverticular bleeding.

Smoking, Caffeine and Alcohol

Current smokers appear to be at increased risk for perforated diverticulitis and a diverticular abscess as compared with nonsmokers. Caffeine and alcohol are not associated with an increased risk for symptomatic diverticular disease.

Medications

Several medications are associated with an increased risk of diverticulitis and diverticular bleeding including nonsteroidal anti-inflammatory drugs, steroids, and opiates. In contrast, statins may be associated with a decreased risk of diverticular perforation. In addition, higher levels of vitamin D have been associated with a reduced risk of hospitalization for diverticulitis.

Diagnosis of Diverticular Disease

Diverticulosis is often found during tests performed for other reasons.4 The following tests may be used to identify diverticulosis.

11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Barium Enema

The barium enema is an x-ray study that uses barium in an enema to view the outline of the lower intestinal tract. This is an older test and has been largely replaced by computed tomography (CT) scan.

Flexible Sigmoidoscopy

The flexible sigmoidoscopy is an examination of the inside of the sigmoid colon with a thin, flexible tube that contains a camera.

Colonoscopy

Colonoscopy is an examination of the inside of the entire colon using a lower endoscope.

CT Scan

A CT scan is often used to diagnose diverticulitis and its complications. If diverticulitis (not just diverticulosis) is suspected, the above three tests should not be used because of the risk of perforation.

Diverticulitis: Evaluation and Testing

Diverticulitis should be included in the differential diagnosis when a patient presents with lower abdominal pain during physical examination. In Western populations, diverticular pain is usually in the left lower quadrant at the level of the sigmoid colon. In Asian people, the pain is generally found suprapubic, right lower quadrant.

The purpose of physical evaluation in a suspected case of acute diverticulitis is to rule out any other or co-occurring cause of abdominal pain and to proceed with diagnostic testing. As with any medical disease or 12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

complications, evaluation of the patient starts with a personal history and physical examination, including pelvic examination in women to rule out gynecological disease.3

Other possible diseases in a patient who reports acute abdominal pain include acute , colorectal cancer, inflammatory bowel disease (IBD), infectious/, and other diagnoses such as include tubo- ovarian abscess, ovarian cyst, ovarian torsion, ectopic pregnancy, cystitis, and nephrolithiasis.3 Colorectal cancer have similar features of sigmoid colon wall thickening. The distinguishing feature of acute diverticulitis found on abdominal CT scan is the existence of pericolonic and mesenteric inflammation of the colon (> 10 cm) with absence of enlarged pericolonic lymph nodes seen on abdominal CT. Distinguishing between colorectal cancer and acute diverticulitis remains difficult to arrive at in 10 to 20 percent of patients, and colonoscopy would need to be scheduled to determine the existence of a bowel cancer.3

For patients with acute appendicitis other typical symptoms besides abdominal pain to determine right diagnosis would include right lower quadrant abdominal pain, anorexia, fever, nausea, and vomiting.3 Pain could also radiate to other areas of the abdomen or groin areas. Patients with infectious colitis would require stool cultures and a good history taking to determine whether they had been traveling and exposed to a causative pathogen. In ischemic colitis the clinician would be looking for symptoms such as bloody diarrhea and dehydration, amongst other symptoms.3 Other possibilities would include irregular dietary habits and laxative use and these issues would generally be suspected during a complete history taking before further testing is required.

13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

The section below will review the laboratory tests used to diagnose diverticular disease. In the complete blood count, leukocytosis can support the diagnosis of diverticulitis. Imaging testing, specifically the computed tomography (CT) scan is considered more specific to diagnose the condition. Clinicians tend to use abdominal CT scan with oral and intravenous (IV) contrast in a suspected case of acute diverticulitis for higher sensitivity and to help exclude other causes of abdominal pain.

In general, laboratory evaluation should include a complete blood count, electrolytes, and urine analysis, and a pregnancy test for all women of childbearing age. The serum aminotransferases, alkaline phosphatase, bilirubin, amylase, and lipase levels should be obtained in patients with a suspected bowel perforation and peritonitis to determine another cause of abdominal pain other than diverticulitis. As mentioned, stool culture or other stool studies (Clostridium difficile toxin, routine stool cultures (Salmonella, Shigella, Campylobacter, Yersinia, E. coli, ova and parasites (three samples), and a Giardia stool antigen test) should be done to rule out diarrhea due to infectious cause.3

Based on symptoms and severity of illness, a person may be evaluated and diagnosed by a primary care physician, an emergency department physician, a surgeon, or a gastroenterologist. The healthcare provider will ask about the person’s health, symptoms, bowel habits, diet, and medications, and will perform a physical exam, which may include a rectal exam. A rectal exam is performed in the healthcare provider’s office. To perform the exam, the healthcare provider asks the person to bend over a table or lie on one side while holding the knees close to the chest. The healthcare provider slides a gloved, lubricated finger into the rectum. The exam is used to check for pain, bleeding, or a blockage in the intestine.

14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

The health clinician may schedule one or more of the following laboratory tests.

Blood Test

A blood test involves drawing a person’s blood at a healthcare provider’s office, a commercial facility, or a hospital and sending the sample to a lab for analysis. The hemoglobin and complete blood count (CBC) blood test can show the presence of inflammation or anemia — a condition in which red blood cells are fewer or smaller than normal, which prevents the body’s cells from getting enough oxygen.

Computerized Tomography (CT) Scan

A CT scan of the colon is the most common test used to diagnose diverticular disease. CT scans use a combination of X-rays and computer technology to create three-dimensional (3–D) images. For a CT scan, the person may be given a solution to drink and an injection of a special dye, called contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the X-rays are taken. The procedure is performed in an outpatient center or a hospital by an X-ray technician, and a radiologist interprets the images. Anesthesia is not needed. CT scans can detect diverticulosis and confirm the diagnosis of diverticulitis.

Lower Gastrointestinal (GI) Series

A lower GI series is an x-ray exam that is used to look at the . The test is performed at a hospital or an outpatient center by an x-ray technician, and a radiologist interprets the images. Anesthesia is not needed.

15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

The health clinician may provide written bowel prep instructions to follow at home before the test. The person may be asked to follow a clear liquid diet for one to three days before the procedure. A laxative or enema may be used before the test. Laxatives are medications that loosen stool and increase bowel movements. An enema involves flushing water or laxative into the rectum using a special squirt bottle. These medications cause diarrhea, so the person should stay close to a bathroom during the bowel prep.

For the test, the person will lie on a table while the radiologist inserts a flexible tube into the person’s anus. The colon is filled with barium, making signs of diverticular disease show up more clearly on X-rays.

For several days, traces of barium in the large intestine can cause stools to be white or light-colored. Enemas and repeated bowel movements may cause anal soreness. A healthcare provider will provide specific instructions about eating and drinking after the test.

Colonoscopy

This test is performed at a hospital or an outpatient center by a gastroenterologist. Before the test, the person’s healthcare provider will provide written bowel prep instructions to follow at home. The person may need to follow a clear liquid diet for one to three days before the test. The person may also need to take laxatives and enemas the evening before the test.

In most cases, light anesthesia, and possibly pain medication, will help a patient relax for the test. The patient lies on a table while the gastroenterologist inserts a flexible tube into the anus. A small camera on

16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

the tube sends a video image of the intestinal lining to a computer screen. The test can show diverticulosis and diverticular disease.

Cramping or bloating may occur during the first hour after the test. Driving is not permitted for 24 hours after the test to give the anesthesia time to wear off. Before the appointment, a patient should make plans for a ride home. Full recovery is expected by the next day, and people should be able to go back to their normal diet.1

Complications of Diverticular Disease

The complications of diverticular disease tend to be variable and potentially confusing to diagnose. If diverticulitis is an underlying cause of severe complications, such as perforation of diverticulum, abscess, and bleeding, among other serious conditions, prompt diagnosis and intensive treatment need to occur, and affected patients often require hospitalization to prevent further medical complications or death.2

Diverticulitis is reportedly one of the most frequent bowel emergencies. In acute diverticulitis, abdominal pain generally is severe enough to send a patient to the emergency department. Approximately 10 % – 25 % of patients diagnosed with colonic diverticulosis develop diverticulitis. The condition is diagnosed using an ultrasonography (US), which is generally the first choice for diagnostic imaging because US allows good visualization of inflamed diverticulum, appearing as “a noncompressible outpouching of a bowel wall with thickened and hypoechoic wall often containing an obstructive fecalith at the ostium… adjacent bowel wall edema and thickening with edematous hyperechoic mesentery can be visualized on US”.2 During the US procedure, an amount of US transducer compression generally elicits abdominal discomfort and pain. Computed tomography is

17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

the preferred imaging technique in cases of suspected acute diverticulitis and resulting complications. “Severity of inflammation, involvement of bowel segment and local and distant complications of diverticulitis can be assessed with CT”.2

People with acute diverticulitis may develop complications that include: 1) an abscess, which occurs when pus collects in the pouch, 2) a perforation, a small tear or hole in the diverticula, 3) a blockage in the colon or caused by scarring, 4) an abnormal passageway (fistula) between sections of bowel or the bowel and bladder, or 5) peritonitis, a medical emergency that requires immediate care, which can occur if the infected or inflamed pouch ruptures, spilling intestinal contents into the abdominal cavity.2

Abscess, Perforation, and Peritonitis

Antibiotic treatment of diverticulitis usually prevents or treats an abscess. If the abscess is large or does not clear up with antibiotics, it may need to be drained. After giving the person numbing medication, a radiologist inserts a needle through the skin to the abscess and then drains the fluid through a catheter. An abdominal ultrasound or a CT scan usually is done prior to deciding the procedure.

A person with a perforation usually needs surgery to repair the tear or hole. Sometimes, a person needs surgery to remove a small part of the intestine if the perforation cannot be repaired. A person with peritonitis may be extremely ill, with nausea, vomiting, fever, and severe abdominal tenderness.

18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

A colonic perforation requires immediate surgery to clean the abdominal cavity and possibly a colon resection at a later date after a course of antibiotics. Blood transfusion may be needed if the person has lost a significant amount of blood. Without prompt treatment, peritonitis can be fatal.1 Perforation of the colon is discussed in more depth in a later section.

Fistula

Diverticulitis-related infection may lead to one or more fistulas. Fistulas usually form between the colon and the bladder, small intestine, or skin. The most common type of fistula occurs between the colon and the bladder. Fistulas can be corrected with a colon resection and removal of the fistula.

Intestinal Obstruction

Diverticulitis-related inflammation or scarring caused by past inflammation may lead to intestinal obstruction. If the intestine is completely blocked, emergency surgery is necessary, with possible colon resection. Partial blockage is not an emergency, so the surgery or other procedures to correct it can be scheduled.

When urgent surgery with colon resection is necessary for diverticulitis, two procedures may be needed because it is not safe to rejoin the colon right away. During the colon resection, the surgeon performs a temporary colostomy, creating an opening, or stoma, in the abdomen. The end of the colon is connected to the opening to allow normal eating while healing occurs. Stool is collected in a pouch attached to the stoma on the abdominal wall. In the second surgery, several months later, the surgeon rejoins the ends of the colon and closes the stoma.1

Treatment of Diverticular Disease 19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Individuals with diverticulosis who do not have symptoms do not require treatment. However, most clinicians recommend increasing fiber in the diet, which can help to bulk the stools and possibly prevent the development of new diverticula, diverticulitis, or diverticular bleeding. Fiber is not proven to prevent these conditions in all patients but may help to control recurrent episodes in some.3,4

Fiber Diet

Increased fiber is recommended in the treatment of diverticular disease. Fruits and vegetables are a good source of fiber.

Seeds and Nuts

Patients with diverticular disease have historically been advised to avoid whole pieces of fiber (such as seeds, corn, and nuts) because of concern that these foods could cause an episode of diverticulitis; however, this concern is unproven. Current recommendations do not suggest that patients with diverticulosis avoid seeds, corn, or nuts.

Medications

A number of studies suggest the medication mesalazine (Asacol), given either continuously or in cycles, may be effective at reducing abdominal pain and gastrointestinal symptoms of diverticulosis. Research has also shown that combining mesalazine with the antibiotic rifaximin (Xifaxan) can be significantly more effective than using rifaximin alone to improve a person’s symptoms and maintain periods of remission.1

20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Probiotics

Although more research is needed, probiotics may help treat the symptoms of diverticulosis, prevent the onset of diverticulitis, and reduce the chance of recurrent symptoms. Probiotics are live bacteria, like those normally found in the GI tract. Probiotics can be found in dietary supplements — in capsules, tablets, and powders — and in some foods, such as yogurt.1

Diverticulitis and Complications

As mentioned, diverticulosis may give rise to diverticulitis and runs the risk of complications that may include conditions of , abscess, fistula, or perforation.3 The treatment of diverticulitis will depend on symptom severity. A mild case of diverticulitis involves symptoms of mild abdominal pain (usually left lower abdomen) and is generally managed in a person’s home with oral antibiotics and clear liquid diet. Worrisome signs or symptoms that would require medical attention include a temperature greater than 100.1°F (38°C), increased or severe abdominal pain, and an intolerance of fluid intake.

Hospitalization is generally needed when symptoms increase to a moderate to severe level of pain and may require hospitalization to support treatment. Patients will be required to go on restricted intake (nothing to eat or drink) and intravenous fluids and antibiotics will be started. Colon abscesses that develop will require drainage, which involves an abdominal surgical procedure to place the drainage tube.

Diverticular Bleeding

Diverticular bleeding is rare. Bleeding can be severe; however, it may stop by itself and not require treatment. A person who has bleeding from the

21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

rectum, even a small amount, should be immediately medically evaluated. To treat the bleeding, a colonoscopy may be performed to identify the location of and stop the bleeding. A CT scan or angiogram also may be used to identify the site of the bleeding.

A traditional angiogram is a special kind of X-ray in which a thin, flexible tube called a catheter is threaded through a large artery, often from the groin, to the area of bleeding. Contrast medium is injected through the catheter so the artery shows up more clearly on the X-ray. The procedure is performed in a hospital or an outpatient center by an X-ray technician, and a radiologist interprets the images. Anesthesia is not needed, though a sedative may be given to lessen anxiety during the procedure. If the bleeding does not stop, abdominal surgery with a colon resection may be necessary. In a colon resection, the surgeon removes the affected part of the colon and joins the remaining ends of the colon together; general anesthesia is used. A blood transfusion may be needed if the person has lost a significant amount of blood.3,4

Surgery

When emergency surgery is needed in a case of acute abdominal infection, this generally involves a two-part operation. The first operation involves removal of the diseased colon and creation of a colostomy. A colostomy is an opening between the colon and the skin, where a bag is attached to collect waste from the intestine. The lower end of the colon is temporarily sewed closed to allow it to heal. Approximately three to six months later, a second operation is performed to reconnect the two parts of the colon and close the opening in the skin. The patient will then be able to empty the bowel through the rectum.

22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Patients may require up to a year to recover from the first operation, depending on how sick they were. In non-emergency situations, the diseased area of the colon can be removed and the two ends of the colon can be reconnected in one operation, without the need for a colostomy.

An operation to remove the diseased area of the colon may not be necessary if the patient improves with medical therapy. In most individuals (70 to 100 percent) acute diverticulitis can be managed without surgery. A randomized trial of 132 patients treated with a first dose of intravenous antibiotics in the emergency department and followed as an out- and inpatient basis had similar failure rates and quality of life.4 However, acute complicated diverticulitis generally requires treatment of both inflammation of the colon (diverticulitis) and resulting complications which usually involves hospitalization and possibly surgery.

In the past, patients diagnosed with two or more uncomplicated attacks of diverticulitis were recommended to proceed with surgery however such recommendations are currently discouraged, and the 2014 Practice Parameters of the American Society of Colon and Rectal Surgeons called for “an individualized approach to recommending elective sigmoid colectomy after recovery from uncomplicated diverticulitis.”4 It was reported that the complications and colostomy rates associated with surgery were no higher following four episodes of diverticulitis than if there was only one episode. More episodes of diverticulitis were also not associated with a higher rate of moving on to open surgery from a laparoscopic procedure.4

Recurrent diverticulitis does not recur in the majority of patients, approximately 58 to 84 percent. In two large cohort studies patients were followed for four years after an initial episode of acute diverticulitis and

23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

researchers documented low rates of hospital readmission and surgery. Also, in another study of over 65,000 patients in England that were managed nonoperatively for a first episode of diverticulitis, the rate for readmission for recurrent diverticulitis was 11.2 percent after a minimum 4-year follow-up, and only 0.9 and 0.75 percent of study participants required emergency and elective colectomy. Factors affecting recurrence of diverticulitis and readmission with emergency surgery included gender (female), young age, smoking, obesity, and a history of complicated initial disease.4 A Canadian study of over 14,000 patients during an approximate four year period showed that the readmission rate was 9 percent, and that 1.9 and 1.7 percent of the study participants required emergency and elective colectomy. A risk factor for both readmission and emergency surgery was complicated initial disease, and for individuals age < 50 there was the risk for readmission but not for emergency surgery.4 Other studies have shown that “recurrence diverticulitis is usually not more severe, or "virulent," than the initial episode”:4 Patients with > 2 prior episodes of diverticulitis have been found to have similar morbidity and mortality rates compared with patients with less prior episodes.

Overall, surgery may be needed when recurrent diverticulitis occurs in patients with symptoms. Systematic reviews have shown that 20 to 35 percent of patients with nonsurgical management of diverticulitis episodes ended up having chronic abdominal pain as compared with 5 to 25 percent of patients who underwent surgery. A reported approximate 15 percent of patients diagnosed with acute diverticulitis will eventually end up having a surgical procedure. Some health clinicians recommend surgery after the first attack of diverticulitis in people who are less than 40 to 50 years. The reason for this is that the disease may be more severe in this age group and there may be an increased risk of recurrent disease that will ultimately

24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

require surgery. Thus, having surgery at a young age could potentially eliminate the chances of developing worsened disease.4

In many cases, an elective operation can be performed laparoscopically, using small incisions, rather than the typical vertical abdominal incision. Laparoscopic surgery usually allows for a faster recovery and a shorter hospital stay.

Prognosis of Diverticular Disease

The usual signs and symptoms of diverticular disease has been stated above, however over the course of the disease there are multiple complications that may occur. Complications may include conditions such as pylephlebitis, perforation, intestinal obstruction, abscess and fistula formation amongst others, which affect overall morbidity and mortality rates. CT and US imaging help clinicians to early diagnose diverticular disease and to avoid severe complications and successful treatment requires a multidisciplinary treatment approach.2

When the complication of perforation occurs secondary to severe colonic wall inflammation and necrosis the prognosis varies depending on whether the perforation is small and self-limited or non-contained. Perforation from colonic diverticulitis is generally seen on the left side of the colon. The clinical signs tend to be insidious and silent, resulting in delayed diagnosis and a poorer prognosis.2

The more serious non-contained perforations occur in 1 %–2 % of acute diverticulitis cases and may lead to local abscess and fistula formation. The presence of free air in the abdomen in a well-contained perforation will be detected locally whereas intra-abdominal free air that is diffuse or

25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

widespread is typically detected in large non-contained perforations. This signs of an intraperitoneal perforation would be acute abdominal pain, nausea and vomiting; however, perforation of second and third portions of , posterior aspect of the ascending, descending and sigmoid colon segments will lead to retroperitoneal free air.2

In a case of perforated diverticulitis, subdiaphragmatic free air can be seen on an upright abdominal X-ray. Sonographic testing helps to improve visualization of colonic wall thickening and edema, however may be difficult to detect perforated diverticulitis. CT remains the best detection of abdominal free air (success rate of 85 %).2 CT images can detect small air bubbles between bowel segments and endovascular air bubbles can be seen in mesenteric veins and portal vein in advanced cases.2 Patients with perforated diverticulitis in poor health, using steroid treatment and experiencing a first diverticulitis attack are reported to be more prone to bowel perforation and peritonitis with guarded prognosis.

Another complication of diverticular disease with a guarded prognosis is severe intestinal obstruction. Although the condition is rare, diverticulitis and partial obstruction secondary to wall edema and peripheral inflammation or abscess formation may occur. Risks that lead to a bowel obstruction include presence of an intramuscular fibrosis and bowel rigidity often found in chronic diverticulitis. Bowel obstruction may result in 10–20 % of the cases.2 An obstructive malignant mass may exist in the colon and will need to be ruled out. Long colonic segment (>10 cm) involvement generally suggests diverticulitis, however clinicians should remember that a short segment obstruction may involve neoplasm and acute diverticulitis. Colon cancer cannot be excluded with confidence based on the level of bowel obstruction

26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

since diverticulosis without active inflammation is common in the general population.2

Surgery generally is not needed in the majority of people affected by diverticular disease and the majority of people with uncomplicated diverticulitis will respond to medical treatment. After successful treatment for a first attack of diverticulitis, approximately one-third of patients will remain asymptomatic, have episodic cramps without diverticulitis, and a second attack of diverticulitis is not a common event. The prognosis tends to remain similar following a second attack of diverticulitis. Subsequent attacks tend to be of similar severity, not increasing in severity as previously believed.4

Diverticulosis may cause no problem or it may cause episodes of bleeding and/or diverticulitis over a period of time. Acute diverticulitis clinical presentation will vary based on inflammation severity and symptoms associated complications. For patients with acute diverticulitis, an approximate 25 percent of them will have associated acute or chronic complications.4

Prevention of Diverticular Disease

To prevent diverticular disease or reduce the complications from it, it is important to maintain good bowel habits. This includes having regular bowel movements and avoiding constipation and straining. Eating appropriate amounts of the right types of fiber and drinking plenty of water and exercising regularly will help keep bowels regulated.

The American Dietetic Association recommends 20 to 35 grams of fiber a day. Every person, regardless of the presence of diverticula, should try to

27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

consume 20 to 35 grams of fiber every day. Fiber is the indigestible part of plant foods. High-fiber foods include whole grain breads, cereals, and crackers, berries, fruit, vegetables (such as broccoli, cabbage, spinach, carrots, asparagus, squash, and beans), brown rice, bran products, and cooked dried peas and beans, among other foods. Drinking eight 8-ounce glasses of water a day, monitoring changes in bowel movements (from constipation to diarrhea) and getting enough rest and sleep, are other ways to prevent diverticular disease.5,7

Because of the lack of evidence surrounding prior dietary claims that foods such as nuts, seeds and corn should be avoided and some of the known health benefits, patients should not be asked to restrict these foods. Additionally, while a correlation exists between a low-fibre diet and diverticular disease and its complications, there is no conclusive evidence of a causal link. Patients are generally recommended to maintain a high-fibre diet despite inconclusive evidence because of a widespread belief in the health benefits.

Case Study

The following case study was published in BMC Gastroenterology (2018).6 A 56-year-old female was evaluated for a change in bowel habit over a six month period that included stool frequency, elimination of mucous and rectal bleeding. During evaluation the patient reported an absence of abdominal pain and stable weight. In the patient’s history she reported bladder exstrophy (a rare birth defect with bladder development outside the fetus) with multiple surgeries, eventually leading to cystectomy and ileal conduit formation at the age of five. Her childhood and adult medical history included multiple urinary tract infection (UTI) and no other major

28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

comorbidities or risk factors for colorectal malignancy. Her family history was negative for colorectal disease.

The patient underwent a colonoscopy that revealed sigmoid colon sessile polyps (approximately 3 cm in size) located in the same area of the sigmoid colon; and the polyps were positioned adjacent to a “diverticulum-like structure”.5 Tissue samples of the polyps were obtained and sent for histological study, which indicated adenomatous polyps with both low and high grade dysplasia but with no submucosal invasion. The colonic mucosa around the diverticulum appeared atypical as well however did not appear adenomatous. Diverticular disease or polyps were not found in other areas of the colon during the rest of the colonoscopy.

Although polyps are generally resected endoscopically, surgery was preferred because of the potential difficulties of polyp removal through an endoscopic in this case. Radiological imaging had been done that showed sigmoid thickening, which was suggestive of invasive disease. Therefore, high anterior resection through an open approach was the preferred surgical method due to a history of extensive pelvic surgery and anticipated intra- abdominal adhesions typically associated with pelvic surgery. There were adhesions discovered during laparotomy involving the right fallopian tube (adhered to the sigmoid colon) and there were other potential pathological findings around the colon. An end colostomy was presented as an option, which the patient preferred during pre-operative discussion and planning because of continuous suffering due to erratic bowel patterns. The authors reported that the patient had an uneventful recovery and her quality of life was good after surgery.

29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Discussion

The authors reported that all forms of urinary diversion, which this patient had reported, have been connected to an increased risk of intestinal malignancy following a long latent period. Further, the authors reported the shortest and longest reported latencies of intestinal malignancy as 3 and 53 years, respectively. Smoking and tobacco-derived urinary carcinogens have a suggested role following bladder cancer resection.

The pathogenesis of these tumors is unclear and multifactorial in nature, and there are suggested theories. Experimental data has been conflicting however it has been suggested carcinogenesis in bowel segments exposed to the urinary stream can occur. Ureterosigmoidostomy (US) during the 1950s had been the primary method of urinary diversion and “many patients encountered hyperchloremic acidosis and troublesome diarrheas, sometimes with fecal incontinence”.5 There was increased medical concern of higher rates of colorectal cancer in patients with US, and the authors reported such patients appeared to have increased risk of developing sigmoid tumors with latencies, even in cases of exposure to the urinary stream at six months or less. It is currently recommended ureters implanted into the sigmoid should be excised.

The latent period between US and colonic tumors is typically long and US is usually performed during childhood so that there is time for bowel cancer screening to start. Long-term annual surveillance should be started in patients who have undergone US. The patient in this case report would have needed bowel cancer screening because she was found to have intact US sites later in life that had not been excised at the time of revisional surgery.

30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Summary

Diverticular disease has been defined as clinically significant and symptomatic diverticulosis due to diverticular bleeding, diverticulitis, segmental colitis associated with diverticula, or symptomatic uncomplicated diverticular disease. In Western countries there is a higher prevalence of diverticulosis with as high as 60% of individuals over 70 years of age being affected. Diverticulosis has been reported to increase with age. The incidence in younger individuals (less than age 45) for acute diverticulitis is 16 percent.

The incidence and prevalence of diverticulosis has increased to become a significant health cost. Researchers are studying the pathogenesis and treatment of diverticular disease. There is widespread concern that diverticular disease can develop into a chronic condition for some patients, and that often it may go undiagnosed. Existing studies currently support a more conservative approach to prophylactic surgery in patients with recurrent disease or chronic symptoms.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement. 31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

1. Diverticulosis specifically describes

a. the presence of diverticula with symptoms. b. the presence of diverticula. c. the presence of diverticula with diverticular bleeding. d. inflammation of a diverticulum.

2. Inflammation of a diverticulum, known as ______occurs when there is thinning and breakdown of the diverticular wall.

a. diverticulosis b. colitis c. diverticulitis d. diverticular bleeding

3. A fistula is

a. a localized collection of pus. b. an abnormal tract between two areas that are not normally connected. c. a blockage of the colon. d. an infection around the abdominal organ.

4. Sepsis is defined as

a. an abnormal tract between two areas that are not normally connected. b. an infection around the abdominal organ. c. a blockage of the colon. d. an overwhelming body-wide infection.

5. Diverticular bleeding occurs when a small artery in a diverticulum

a. erodes and bleeds into the colon. b. is obstructed. c. abscesses. d. forms a fistula.

6. True or False: A low-fiber diet is associated with diverticulosis and an increased chance of diverticula.

a. True b. False

32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

7. In the colon, inflammation may be caused by

a. a decrease in healthy bacteria. b. a decrease in disease-causing bacteria. c. an increase in disease-causing bacteria. d. Both a., and c.

8. ______has been associated with an increased risk of both diverticulitis and diverticular bleeding.

a. A low-fiber diet b. Lack of exercise c. Obesity d. Corn or popcorn consumption

9. ______appears to increase the risk for perforated diverticulitis and a diverticular abscess.

a. Smoking b. Consuming caffeine c. Alcohol consumption d. Inactivity

10. In testing for diverticular disease, a blood test may be ordered by the healthcare provider to determine

a. the presence of diverticula. b. the level of healthy bacteria. c. the presence of inflammation or anemia. d. levels of blood-alcohol.

11. Which of the following tests is used as a diagnostic tool if diverticulitis is suspected?

a. Flexible sigmoidoscopy b. Computerized tomography (“CT”) scan of the colon c. Lower gastrointestinal (“GI”) series d. Colonoscopy

33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

12. After an enema, a patient’s stools may be white or light-colored for several days because of ______in the large intestine.

a. statins b. bacteria c. water d. barium

13. ______is/are associated with an increased risk of diverticulitis and diverticular bleeding.

a. Statins b. Higher levels of vitamin D c. Alcohol consumption d. Steroids

14. One complication of acute diverticulitis may be ______, which involves spilling intestinal contents into the abdominal cavity.

a. peritonitis b. sepsis c. a fistula d. colitis

15. The usual treatment for a patient with diverticulitis who develops an abscess is

a. to drain the abscess. b. to surgically remove the abscess. c. to remove a small part of the intestine. d. to treat the patient with antibiotics.

16. Which of the following is true of diverticular bleeding?

a. It is common for patients with diverticulitis. b. It may stop by itself and not require treatment. c. Bleeding is never severe. d. A patient need only see a healthcare provider if the bleeding is severe.

34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

17. The American Dietetic Association recommends ______grams of fiber a day.

a. more than 50 b. 20 to 35 c. 10 d. 40 to 50

18. ______uses small incisions, rather than the typical vertical abdominal incision, to treat diverticulitis.

a. Revisional surgery b. Flexible sigmoidoscopy c. Laparoscopic surgery d. A colostomy

19. Diverticular disease involves the presence of ______in the wall of the colon.

a. disease-causing bacteria b. bleeding c. small sacs or pockets d. an abscess

20. True or False: When treating diverticulosis, combining mesalazine with the antibiotic rifaximin (Xifaxan) can be significantly more effective than using rifaximin alone.

a. True b. False

35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

CORRECT ANSWERS:

1. Diverticulosis specifically describes

b. the presence of diverticula.

“Diverticulosis merely describes the presence of diverticula.”

2. Inflammation of a diverticulum, known as ______occurs when there is thinning and breakdown of the diverticular wall.

c. diverticulitis

“Inflammation of a diverticulum (diverticulitis) occurs when there is thinning and breakdown of the diverticular wall.”

3. A fistula is

b. an abnormal tract between two areas that are not normally connected.

“Fistula - an abnormal tract between two areas that are not normally connected (e.g., bowel and bladder).”

4. Sepsis is defined as

d. an overwhelming body-wide infection.

“Sepsis – overwhelming body-wide infection that can lead to failure of multiple organs.”

5. Diverticular bleeding occurs when a small artery in a diverticulum

a. erodes and bleeds into the colon.

“Diverticular bleeding occurs when a small artery located within a diverticulum is eroded and bleeds into the colon.”

36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

6. True or False: A low-fiber diet is associated with diverticulosis and an increased chance of diverticula.

b. False

“Medical researchers are not certain what causes diverticulosis and diverticular disease. For more than 50 years, the most widely accepted theory was that a low-fiber diet led to diverticulosis and diverticular disease…. Two large studies also indicate that a low-fiber diet may increase the chance of developing diverticular disease. However, a recent study found that a low-fiber diet was not associated with diverticulosis and that a high- fiber diet and more frequent bowel movements may be linked to an increased rather than decreased chance of diverticula.”

7. In the colon, inflammation may be caused by a. a decrease in healthy bacteria. b. a decrease in disease-causing bacteria. c. an increase in disease-causing bacteria. d. Both a., and c. [correct answer]

“In the colon, inflammation also may be caused by a decrease in healthy bacteria and an increase in disease-causing bacteria. This change in the bacteria may permit chronic inflammation to develop in the colon.”

8. ______has been associated with an increased risk of both diverticulitis and diverticular bleeding.

c. Obesity

“Obesity has been associated with an increase in risk of diverticulitis and diverticular bleeding.”

9. ______appears to increase the risk for perforated diverticulitis and a diverticular abscess.

a. Smoking

“Current smokers appear to be at increased risk for perforated diverticulitis and a diverticular abscess as compared with nonsmokers. Caffeine and alcohol are not associated with an increased risk for symptomatic diverticular disease.” 37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

10. In testing for diverticular disease, a blood test may be ordered by the healthcare provider to determine

c. the presence of inflammation or anemia.

“The hemoglobin and complete blood count (CBC) blood test can show the presence of inflammation or anemia — a condition in which red blood cells are fewer or smaller than normal, which prevents the body’s cells from getting enough oxygen.”

11. Which of the following tests is used as a diagnostic tool if diverticulitis is suspected?

b. Computerized tomography (“CT”) scan of the colon

“A CT scan is often used to diagnose diverticulitis and its complications. If diverticulitis (not just diverticulosis) is suspected, the above three tests should not be used because of the risk of perforation.”

12. After an enema, a patient’s stools may be white or light-colored for several days because of ______in the large intestine after an enema.

d. barium

“An enema involves flushing water or laxative into the rectum using a special squirt bottle…. For several days, traces of barium in the large intestine can cause stools to be white or light-colored.”

38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

13. ______is/are associated with an increased risk of diverticulitis and diverticular bleeding.

d. Steroids

“Several medications are associated with an increased risk of diverticulitis and diverticular bleeding including nonsteroidal anti-inflammatory drugs, steroids, and opiates.”

14. One complication of acute diverticulitis may be ______, which involves spilling intestinal contents into the abdominal cavity.

a. peritonitis

“People with acute diverticulitis may develop complications that include: … or 5) peritonitis, a medical emergency that requires immediate care, which can occur if the infected or inflamed pouch ruptures, spilling intestinal contents into the abdominal cavity.”

15. The usual treatment for a patient with diverticulitis who develops an abscess is

d. to treat the patient with antibiotics.

“Antibiotic treatment of diverticulitis usually prevents or treats an abscess. If the abscess is large or does not clear up with antibiotics, it may need to be drained.”

16. Which of the following is true of diverticular bleeding?

b. It may stop by itself and not require treatment.

“Diverticular bleeding is rare. Bleeding can be severe; however, it may stop by itself and not require treatment.” 39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

17. The American Dietetic Association recommends ______grams of fiber a day.

b. 20 to 35

“The American Dietetic Association recommends 20 to 35 grams of fiber a day. Every person, regardless of the presence of diverticula, should try to consume 20 to 35 grams of fiber every day.”

18. ______uses small incisions, rather than the typical vertical abdominal incision, to treat diverticulitis.

c. Laparoscopic surgery

“In many cases, an elective operation can be performed laparoscopically, using small incisions, rather than the typical vertical abdominal incision.”

19. Diverticular disease involves the presence of ______in the wall of the colon.

c. small sacs or pockets

“Diverticular disease consists of three main conditions that involve the development of small sacs or pockets in the wall of the colon (diverticulum) including diverticulosis, diverticular bleeding, and diverticulitis (infection).”

20. True or False: When treating diverticulosis, combining mesalazine with the antibiotic rifaximin (Xifaxan) can be significantly more effective than using rifaximin alone.

a. True

“Research has also shown that combining mesalazine with the antibiotic rifaximin (Xifaxan) can be significantly more effective than using rifaximin alone to improve a person’s symptoms and maintain periods of remission.”

40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

Reference Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. Carabotti, M., et al (2018). Demographic and clinical features distinguish subgroups of diverticular disease patients: Results from an Italian nationwide registry. United European Gastroenterol J. 2018 Jul; 6(6): 926–934. 2. Ruhi Onur, M., et al (2016). Diverticulitis: a comprehensive review with usual and unusual complications. Insights Imaging; 2017 8(1): 19–27. 3. Pemberton, J. (2018). Clinical manifestations and diagnosis of acute diverticulitis in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-and- diagnosis-of-acute-diverticulitis-in- adults?search=diverticulosis&source=search_result&selectedTitle=5~9 4&usage_type=default&display_rank=5 4. Pemberton, J. (2018). Acute colonic diverticulitis: Medical management. UpToDate. Retrieved from https://www.uptodate.com/contents/acute-colonic-diverticulitis- medical- management?search=diverticulitis&source=search_result&selectedTitle =1~40&usage_type=default&display_rank=1. 5. National Institute of Diabetes and Digestive and Kidney Diseases (2016). Eating, Diet, & Nutrition for Diverticular Disease. NIDDK. Retrieved from https://www.niddk.nih.gov/health- information/digestive-diseases/diverticulosis-diverticulitis/eating-diet- nutrition. 6. Schembri, J, et al (2018). An unusual diverticulum adjacent to two large colonic polyps; a case report. BMC Gastroenterol. 18(1):83. 7. Po-Hong, L, et al (2017). Adherence to a Healthy Lifestyle is Associated with a Lower Risk of Diverticulitis among Men. Am J Gastroenterol. 112(12):1868-1876. 8. McSweeney, W. and Srinath, H. (2017). Diverticular disease practice points. AFP. Volume 46, No.11; 829-832.

41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M

The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.

42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.co M