Diverticulitis

Original Editors - Cate Hurst and Katie Countryman from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Katie Countryman, Cate Hurst, Khloud Shreif, Elaine Lonnemann, Lucinda hampton, Kim Jackson, WikiSysop, 127.0.0.1, George Prudden and Karen Wilson  

Introduction

Showing multiple pouches (diverticula) colon

Colonic diverticulitis is a possible adverse result of colonic diverticulosis that develops adjacent to blood vessels that penetrate these layers. Colonic diverticulosis is characterized by the protrusion of both mucosa and submucosa layers of the colon and the sigmoid colon is the most affected segment of the colon. However, in recent studies its prevalence is more common in younger ages for years it was believed to be associated with old age above 50 years old as it was in the united Kingdom.

Diverticulosis is mainly asymptomatic whilst acute diverticulitis is a potentially life-threatening illness. It develops in approximately 10-25% of individuals with diverticulosis. However recent data, utilizing colonoscopy and CT scans, suggest the actual risk is below 5%.

Epidemiology

Diverticulitis is a complication of diverticulosis, and the demographics of the condition are much alike. It tends to be more common in the western world compared to Asian, but recently the incidence increased by 0.5% in Asian countries. However advanced colonoscopy and CT scan, In the USA diverticulitis remains a common condition as over half of Americans over 60 years have diverticulosis. It tends to increase with patient age but in recent decades there has been an increase in diverticulitis at a young age, there was a 132% increase in diverticulitis cases among individuals aged 40-49 between 1980 and 2007. The highest hospitalization rates for diverticulitis are among white individuals (62 per 100,000), followed by similar rates in African Americans and Hispanics (about 30 per 100,000), and the lowest in Asians (10 per 100,000).

On another side, Immigrants from non-Western countries initially show a reduced risk of being hospitalized for diverticular disease compared to those native to Western countries, but this risk escalates as the duration of their stay in the new country increases a study suggested diverticular disease of the colon tends to be an acquired disorder and the change in life style may have an impact on its development.

Etiology

Colonic diverticular development may involve involve bowel wall abnormality, increased intraluminal pressure, and lack of dietary fibre. Diverticulitis is the result of obstruction of the neck of the diverticulum (outpouch), with consequential inflammation, perforation, and infection. A walled region of soft tissue may later progress to abscess formation and generalised peritonitis.

Risk Factors include: Increased age; Constipation; Sedentary lifestyle; Obesity; Smoking; NSAIDS; Red meatgenetic facors.

Characteristics/Clinical Presentation

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:

• Sudden abdominal pain, usually in the left lower quadrant abdomen (49%), and is often associated with an increase in inflammatory markers and temperature.
• Palpable mass
• Irregular bowel movements and changes in bowel habits.
• Bowel sounds absent or decreased
• Flatulence
• Fever
• Nausea/ Vomiting
• Bloody stools
• Increased frequency of urination

Possible complications include perforation of bowels, and abscess formation that seen in around 17% of patients, fistula formation, gastrointestinal hemorrhage, obstruction, bleeding, and perforative peritonitis in 1-2% of patients.

Diagnosis

Diverticulitis is typically diagnosed during an acute attack due to complaints of severe abdominal pain. Diverticulitis diagnosis is typically confirmed with the presence of constitutional symptoms, bloody stools, elevated white blood cell count, and with the use of imaging studies. Due to the prevalence of abdominal pain in several conditions, the physician may order a number of tests to rule out other causes of abdominal pain and associated symptoms.

Ultrasound: good to detect simple cases of diverticular disease.

CT scan: helps to provide detailed and specific results, it will be useful for tracking treatment progress and planning for further interventions. Classification of diverticular disease depends on CT results.

Endoscopic evaluation: however it is used for tissue diagnosis and is helpful in direct visualization but their use during acute attacks of diverticulitis is controversial due to potential risks, and they are often avoided in such cases. Post-attack, there is debate over whether to routinely perform colonoscopy. Some experts suggest using flexible sigmoidoscopy instead, as it is less invasive and the sigmoid colon is the most commonly affected area in diverticular disease.

Classification of Diverticulitis Depending on CT scan

Class	CT findings
Mild disease	Bowel wall thickening, fat stranding
Moderate disease	Bowel wall thickness >3 mm, phlegmon/small abscess
Severe disease	Bowel wall thickening >5 mm, perforation with subdiaphragmatic free air, abscess >5 mm

Treatment

Treatment depends on a range of factors, in particular comorbidities and stage of the disease. Diverticulitis can be treated with rest, changes in diet, or antibiotics, and in severe cases may require surgery.

• Localised disease: conservative management with intravenous antibiotics and rehydration usually is enough, the antibiotics should be for both aerobic and anaerobic bacteria especially for mild cases to avoid and reduce the risk of developing complications as advised by American Gastroenterology Association.
• Surgery maybe required if a patient has a complication (abscess, fistula formation, bowel obstruction), has had multiple episodes of uncomplicated diverticulitis, or is immune-compromised. Surgery may be recommended or it may require emergency surgery. however, instead of deciding on elective segmental resection just by counting the number of episodes, it's better to make a personalized choice. This should involve considering how severe the disease is, what the patient prefers and values, and the risks and benefits of the procedure. There are two main types of surgery: Primary bowel resection/laparoscopic procedure; Bowel resection with colostomy.

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

Physical Therapy Management

McBurney's Point

As a physical therapist, the optimal goal is to help a patient return to 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.

Exercise can be seen as a protective mechanism because it promotes movement to the body, but also the different systems that could be affected by a sedentary lifestyle. 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.

The can advise and encourage the patient to maintain a lower bod mass index, be physically active, and consume high-quality diet.

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

References