NR 507 Week 5 Discussion: Case Study – Diverticulitis Disease

Case Scenario:

An 84-year-old female with a history of diverticular disease presents to the clinic with left lower quadrant (LLQ) abdominal pain accompanied by constipation, nausea, vomiting, and a low-grade fever (100.2°F) for one day. On physical examination, the patient appears unwell with signs of dehydration, including pale mucosa, poor skin turgor, mild hypotension (90/60 mm Hg), and tachycardia (101 bpm). The remainder of her examination is normal except for the abdomen, where the nurse practitioner (NP) notes a distended, round contour. Bowel sounds are faint and very hypoactive. The patient is tender to light palpation of the LLQ without rebound tenderness, and there is hyper-resonance of her abdomen to percussion.

Discussion Questions:

1. Compare and contrast the pathophysiology between diverticular disease (diverticulosis) and diverticulitis.
   • Diverticular Disease (Diverticulosis): Diverticulosis refers to the presence of diverticula, which are small, bulging pouches that can form in the lining of the digestive system, most commonly in the lower part of the large intestine (colon). The formation of diverticula is believed to be due to increased intraluminal pressure, which causes weak spots in the intestinal wall to bulge outward. Diverticulosis is often asymptomatic and is commonly discovered incidentally during colonoscopy or imaging studies for other conditions.
   • Diverticulitis: Diverticulitis occurs when one or more of these diverticula become inflamed or infected. The pathophysiology of diverticulitis involves the retention of stool and bacteria within a diverticulum, leading to obstruction, increased pressure, decreased blood supply, and subsequent inflammation or perforation. This inflammation can cause symptoms such as LLQ pain, fever, and altered bowel habits. In severe cases, it may lead to complications such as abscess formation, perforation, peritonitis, or fistula development.
2. Identify the clinical findings from the case that support a diagnosis of acute diverticulitis.
   • The clinical findings supporting a diagnosis of acute diverticulitis in this case include:
     • LLQ pain: The patient reports left lower quadrant abdominal pain, a common symptom of diverticulitis due to the inflammation of diverticula in the sigmoid colon.
     • Constipation: This symptom is often associated with diverticulitis, reflecting altered bowel habits due to inflammation or obstruction.
     • Low-grade fever (100.2°F): Fever is indicative of an inflammatory or infectious process, supporting the diagnosis of diverticulitis.
     • Nausea and vomiting: These symptoms can occur due to intestinal irritation and the body’s response to inflammation.
     • Signs of dehydration: Poor skin turgor, pale mucosa, mild hypotension, and tachycardia indicate the patient is dehydrated, which can occur secondary to reduced fluid intake, vomiting, and systemic inflammation.
     • Abdominal examination: The distended abdomen, hypoactive bowel sounds, LLQ tenderness without rebound tenderness, and hyper-resonance on percussion suggest localized inflammation, consistent with diverticulitis.
3. List 3 risk factors for acute diverticulitis.
   • Advanced Age: The incidence of diverticulitis increases with age, particularly in individuals over the age of 60, due to weakening of the colonic wall and changes in bowel habits.
   • Low Fiber Diet: A diet low in fiber can lead to constipation and increased intraluminal pressure, promoting the formation of diverticula and increasing the risk of diverticulitis.
   • History of Diverticular Disease: Individuals with a history of diverticulosis are at a higher risk of developing diverticulitis due to the presence of pre-existing diverticula that can become inflamed or infected.
4. Discuss why antibiotics and IV fluids are indicated in this case.
   • Antibiotics: Antibiotics are indicated in this case to treat the infection associated with diverticulitis. The inflammation of the diverticula is often due to bacterial overgrowth and infection. Broad-spectrum antibiotics are typically used to cover both anaerobic and aerobic organisms that commonly cause infection in diverticulitis, such as Escherichia coli and Bacteroides fragilis.
   • IV Fluids: IV fluids are essential for rehydration and maintaining adequate fluid balance, especially given the patient’s signs of dehydration (e.g., poor skin turgor, hypotension, and tachycardia). Dehydration can worsen systemic symptoms, reduce blood pressure, and decrease perfusion to vital organs. IV fluids help stabilize the patient’s hemodynamic status, correct electrolyte imbalances, and support kidney function, which may be compromised due to the inflammatory process and reduced oral intake.

These measures are crucial to manage the acute phase of diverticulitis, prevent complications, and support the patient’s recovery.