Diverticulitis

 

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Definition/Description

Diverticula are small, bulging pouches that can form in the lining of your digestive system and are prevalent in adults after the age of 60.[1] They are found most often in the lower part of the large intestine (colon). Sometimes, one or more of the pouches may become inflamed or infected. This inflammation or infection is known as diverticulitis.[2]

The most common symptoms of diverticulitis include severe left lower quadrant abdominal pain, marked changes in bowel habits, fever, and nausea. Possible complications include perforation of bowels, abscess formation, fistula formation, obstruction, and bleeding.

Diverticulitis diagnosis is typically confirmed with the presence of constitutional symptoms, bloody stools, elevated white blood cell count, and with use of imaging studies.[2] Depending on the severity of the condition, diverticulitis can be treated with rest, changes in diet or antibiotics, and in severe cases may require surgery.[1]

Prevalence

Diverticultis.jpg

Diverticula are common in more than half of adults over the age of 60, with 10%-25% developing diverticulitis. Diverticulitis is more common in males, younger than 50 years old, but is seen more frequently in women in older age groups.[2] Diverticulitis is increasing in incidence in westernized countries. This is thought to be due to a diet low in fiber. It has been shown that diets high and fiber, however, do not protect people from the disease. Patients have a higher risk of developing diverticulitis if they are on chronic steroids and immunosuppressants. The disorder is most common in people over the age of 60, although the average age of incidence has been decreasing. Younger individuals typically have more aggressive forms of diverticulitis and may require surgery after an initial episode. Approximatley one-third of individuals will have another acute bout after an inital episode of diverticulits. 25% will develop some type of complication.[3]

Characteristics/Clinical Presentation

Abdominal Quadrants - Abdominopelvic Quadrants. This image was donated by Blausen Medical. Please visit our website to see more medical illustrations and animations.

The presentation and signs and symptoms can vary for each individual patient. Although many of the patients have the same side effects, they are usually experienced at different intensities and at various times. Some of the most common signs and symptoms that are present with the diverticulitis diagnosis include the following[2]:
• Sudden abdominal pain usually in LLQ - cramping, bloating, tenderness, but can still occur on the right
• Palpable mass
• Irregular bowel movements
• Bowel sounds absent or decreased
• Flatulence
• Fever
• Nausea/ Vomiting
• Bloody stools
• Increase frequency of urination




Associated Co-morbidities

Obesity.png

Risk Factors[3]:

  • increase age
  • constipation
  • sedentary lifestyle
  • obesity
  • smoking
  • NSAIDS
  • red meat

Diverticulitis is more common as the person ages and if the person is overweight. Increasing the amount of exercise that is done each day has shown less of a risk for being diagnosed with diverticulitis. Patients who smoke and /or drink heavy amounts of alcohol have a higher chance of developing diverticulitis than those who do not. Certain medications, such as NSAIDS, steroids, and opiates put a person more at risk for developing this problem[3]. When looking at diet, if people do not get enough fiber, this could lead to decreased bowel movements, causing constipation.[3].

In acute diverticulitis, patients can get an abscess or blockage in their colon or small intestine from the scarring that took place during the episode. Fistula, an abnormal connection between two body parts, can also form between the colon and bladder or vagina, leading to a medical emergency[3]. Another medical emergency is if a person gets peritonitis, which occurs when contents of the intestine get into the abdomen from a ruptured inflamed pouch. Quick attention is necessary for the patient to begin fighting a possible infection.

Medications

Physicians will suggest a variety of treatments based on the severity of patient’s diverticulitis.

Uncomplicated diverticulitis with mild signs and symptoms may be treated with[1]:
• Antibiotics, if infection is present
• Clear, liquid diet until bowels heal
• Tylenol or other over the counter pain reliever

Colostomy.png

Complicated diverticulitis includes individuals who have severe attacks, hospitalizations, or have other comorbidities/health problems. Physicians may recommend[1]:
• IV antibiotics
• Drainage of abscess (if one has formed due to complications)

Surgery may be required if patient has a complication (abscess, fistula formation, bowel obstruction), has had multiple episodes of uncomplicated diverticulitis, or may be immune compromised. Surgery may be recommended, but is an individual decision. There are two main types of surgery[1]:
• Primary bowel resection/laparoscopic procedure
• Bowel resection with colostomy


Follow up care may be suggested such as colonoscopy to rule out colon cancer or other digestive issues[3].

Diagnostic Tests/Lab Tests/Lab Values

Diverticulitis is typically diagnosed during an acute attack due to complaints of severe abdominal pain. Due to the prevalence of abdominal pain in a number of conditions, the physician may order a number of tests to rule out other causes of abdominal pain and associated symptoms.[1]

D 1.png
A thorough physical examination that includes palpation of the abdomen for tenderness is necessary to rule out other conditions and rule in diverticulitis. Women may also have a pelvic exam to rule out gynecological involvement of abdominal pain.[1]

Physicians may suggest the following test to help rule in and out the cause of abdominal pain:[1][3]
• Blood and urine tests for signs of infection, elevated WBC count
• Pregnancy test, to rule out cause of abdominal pain in women who are of childbearing years
• Liver function tests
• Stool tests
• CT Scan of abdomen and pelvis to identify inflammation of diverticula or complications such as abscess formation or
• Colonoscopy in chronic cases (avoided during acute attacks due to risk of perforation) 



Etiology/Causes

Diverticula typically develop in older adults (over the age of 40) when naturally weak places in the colon give way under pressure. Diverticulitis occurs when the individual diverticula tear, which then can make them susceptible to inflammation or infection.[1]

It was thought that foods such as nuts and corn could cause diverticulitis, however recent research does not support this theory. Fruits and vegetables, even those with small seeds, should not be avoided since they are a vital part of our diet and contain a good source of fiber.[3]

Diverticula.jpg

Systemic Involvement

<span style="color: rgb(51, 51, 51); font-family: arial, sans-serif; -webkit-text-size-adjust: auto;" />The NIDDK Joshua Katz, M.D., George Washington University School of Medicine; Vicki L. McClelland, Free Medical Clinic of the Northern Shenandoah Valley.<span style="color: rgb(51, 51, 51); font-family: arial, sans-serif; -webkit-text-size-adjust: auto;" />


Diverticulitis can cause problems in some of the systems in the body.

The main system that is involved is the Gastrointestinal system because the lining of the intestines and colon develop pouches that can progressively get larger, bulge out, and cause a possibility of a rupture[4].

This can cause serious bleeding problems or infection[1].  If the rupture happens multiple times, scarring can form leading to possible blockage for feces to pass[1].




Medical Management (current best evidence)

Asymptomatic diverticulitis requires no medical management or treatment.[3]

Uncomplicated diverticulitis typically is treated with bowel rest (or clear liquids), antibiotics, and pain control. Antibiotic treatment may be given on outpatient basis for 7-10 days for patients with stable vitals, absence of fever, and no significant results on CT or laboratory values. Treatment is 70-100% effective in patients with uncomlicated diverticulitis.[1]
Stoamch.jpg

Patients who have diverticulitis with complications (25% of patients), other health conditions, or have had multiple attacks (one-third of patients) may require surgery. Currently, laparoscopically surgery is performed on case-by-case basis with good outcomes reported.[3] 

Emergency surgery is necessary within 48 hours for patients who have a ruptured intestine, peritonitis, or severe symptoms.[5] Hospitalization is suggested for patients with radiographic abnormalities, fever, and leukocytosis. Symptoms should improve within 2-3 days, when diverticula start to heal. Failure to improve warrants revaluation with a CT and other laboratory tests.[3]
Four-six weeks following resolution of symptoms, a colonoscopy may be suggested to verify the presence of diverticulitis and to rule out colon cancer.[1]

Prevention of diverticulitis is from a variety of lifestyle changes. Adherence to a high-fiber diet, decreased red meat intake, prevention of constipation with adequate balance of fluids and fiber intake, cessation of smoking, and regular exercise during remission may decrease risk of diverticulitis.[3]


Physical Therapy Management (current best evidence)

As a physical therapist, the optimal goal is to help a patient return moving in a functional way. Being active helps decrease the chances of developing diverticulitis because movement helps promote proper bowel movement. Therapists can help patients with proper exercise, strengthening, and positioning to help them get the best and safest movement possible. Patients with diverticulitis must be cautious about doing activities that increase the pressure on their abdomen so further herniation does not happen[2].

Exercise can be seen as a protective mechanism because it is promoting movement to the body, but also the different systems that could be affected from a sedentary lifestyle[2]. Depending on the symptoms that the patients present with, it is up to the therapist to do appropriate screening or testing to identify what is involved and what is causing the issues.

A common area of pain is the left lower quadrant, including referred pain to low back or thigh from an abscess[6]. For example, the obturator test, manual muscle testing and palpation of the illiopsoas,or McBurney’s point palpation can be done to look at positive or negative testing of referred pain to the thigh[2][6].

McBurney's Point

Differential Diagnosis

Differential diagnosis of diverticulitis can include many different areas of the body.

  • Gastrointestinal disorders, such as inflammatory bowel disease, constipation, appendicitis or a hernia can cause the abdominal pain[2].
  • Genitourinary problems, such as inflamed prostate or urinary tract infection are possible[6].
  • Gynecological problems, including ectopic pregnancy, miscarriage, hemorrhage, ovarian cyst, or malignancy are other possible problems[6].
  • Vascular issues, such as aneurysms or vasculitis could occur[6].
  • An abscess in the abdominal wall or psoas can all be a possible diagnosis when presenting with similar symptoms as diverticulitis[6].
  • Ehlers-Danlos, Marfan Syndrome, and Scleroderma are all connective tissue disorders that are shown to be similar to diverticulitis[2].
  • Diverticulitis can also be a genetic disorder where there can be a defect in the intestine wall[3].


Case Reports/ Case Studies

1. Schattner A, Klein Y, Herskovitz P. An atypical presentation of a common disease. QJM. 2011;105(9):891-893.

https://www.ncbi.nlm.nih.gov/pubmed/21840885

2. Caecal diverticulitis, an uncommon mimic of appendicitis. Case Reports. 2013;2013(feb06 1):bcr2012007820-bcr2012007820.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3604511/

3. Tsalis K. Cecal Diverticulitis is a Challenging Diagnosis: A Report of 3 Cases. Am J Case Rep. 2015;16:206-210.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395017/

Resources

1. National Institute of Diabetes and Digestive and Kidney Disease:[7]

http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticular-disease/Pages/ez.aspx

2. Merck Manual - Diverticulitis:[8]

http://www.merckmanuals.com/home/digestive-disorders/diverticular-disease/diverticulitis

3. U.S. National Library of Medicine - Diverticulitis:[5]

https://www.nlm.nih.gov/medlineplus/ency/article/000257.htm

4. Polish Medical Center- Diet for Diverticulitis[9]

http://medpress.com.pl/pubmed.php?article=226228

Recent Related Research (from Pubmed)

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References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 MCS. Diverticulitis Disease and Condition [Internet]. - Mayo Clinic. 2014 [cited 2016Mar31]. Retrieved from: http://www.mayoclinic.org/diseases-conditions/diverticulitis/basics/definition/con-20033495
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Goodman CC, Snyder TE. Differential diagnosis for physical therapists: screening for referral. 4th ed. St. Louis: Saunders Elsevier, 2007.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Goodman CC, Fuller KS. Pathology: implications for the physical therapist. 3rd ed. St. Louis: Saunders Elsevier, 2009.
  4. What I need to know about Diverticular Disease [Internet]. National Institute of Diabetes and and Digestive Kidney Disease; 2012 [cited 2016Apr1]. Retrieved from: http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticular-disease/pages/ez.aspx
  5. 5.0 5.1 Diverticulitis: MedlinePlus Medical Encyclopedia [Internet]. Nlm.nih.gov. 2016 [cited 7 April 2016]. Available from: https://www.nlm.nih.gov/medlineplus/ency/article/000257.htm
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Hammond N. Left Lower-Quadrant Pain: Guidelines from the American College of Radiology Appropriateness Criteria. American Family Physician. 2010;82(7):766-770.
  7. Stollman N, Smalley W, Hirano I. American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis. Gastroenterology. 2015;149(7):1944-1949.
  8. Diverticulitis [Internet]. Merck Manuals Consumer Version. 2016 [cited 7 April 2016]. Available from: http://www.merckmanuals.com/home/digestive-disorders/diverticular-disease/diverticulitis
  9. Milewska M. Dietary prevention and treatment of diverticular disease of the colon. Polish Medical Journal [Internet]. 2015 [cited 8 April 2016];38(226):228-232. Available from: http://medpress.com.pl/pubmed.php?article=226228