Case Scenario:
An 84- year-old -female who has a history of diverticular disease presents to the clinic with left lower quadrant (LLQ) pain of the abdomen that is accompanied by with constipation, nausea, vomiting and a low-grade fever (100.20 F) for 1 day.
On physical exam the patient appears unwell. She has signs of dehydration (pale mucosa, poor skin turgor with mild hypotension [90/60 mm Hg] and tachycardia [101 bpm]). The remainder of her exam is normal except for her abdomen where the NP notes a distended, round contour. Bowel sounds a faint and very hypoactive. She is tender to light palpation of the LLQ but without rebound tenderness. There is hyper-resonance of her abdomen to percussion.
- The following diagnostics reveal:
- Stool for occult blood is positive.
- Flat plate abdominal x-ray demonstrates a bowel-gas pattern consistent with an ileus.
- Abdominal CT scan with contrast shows no evidence of a mass or abscess. Small bowel in distended.
Based on the clinical presentation, physical exam and diagnostic findings, the patient is diagnosed with acute diverticulitis and she is admitted to the hospital. She is prescribed intravenous antibiotics and fluids (IVF). Her symptoms improved and she could tolerate a regular diet before she was discharged to home.
Discussion Questions:
- Compare and contrast the pathophysiology between diverticular disease (diverticulosis) and diverticulitis.
- Identify the clinical findings from the case that supports a diagnosis of acute diverticulitis.
- List 3 risk factors for acute diverticulitis.
- Discuss why antibiotics and IV fluids are indicated in this case.
- Pathophysiology of Diverticular Disease (Diverticulosis) and Diverticulitis:
- Diverticulosis: This is the presence of small pouches (diverticula) that can form in the walls of the colon, particularly the sigmoid colon. It is often asymptomatic and occurs due to increased intraluminal pressure and focal weakness in the colonic wall.
- Diverticulitis: This occurs when diverticula become inflamed or infected. Microperforations of the diverticula can lead to localized inflammation, and in severe cases, abscess formation, perforation, or fistula formation. The inflammation can involve adjacent structures, leading to the clinical manifestations seen in acute diverticulitis.
- Clinical Findings Supporting Diagnosis of Acute Diverticulitis:
- Abdominal Pain: Left lower quadrant (LLQ) pain is a hallmark of diverticulitis. Tenderness to light palpation in the LLQ without rebound tenderness is consistent with localized inflammation.
- Abdominal Distention: A distended, round contour of the abdomen can be observed, likely due to bowel inflammation and ileus.
- Signs of Dehydration: Pale mucosa, poor skin turgor, hypotension, and tachycardia are signs of dehydration, which can result from nausea, vomiting, and decreased oral intake.
- Bowel Sounds: Faint and hypoactive bowel sounds are indicative of ileus.
- Positive Stool Occult Blood: Suggests possible gastrointestinal bleeding, which can occur with inflammation and mucosal damage.
- Imaging Findings: Flat plate abdominal x-ray consistent with ileus and abdominal CT scan ruling out other complications like abscess or mass.
- Risk Factors for Acute Diverticulitis:
- Aging: Incidence increases with age.
- Low Dietary Fiber: Diets low in fiber can contribute to the development of diverticula.
- Previous Diverticular Disease: A history of diverticulosis increases the risk of developing diverticulitis.
- Use of Antibiotics and IV Fluids:
- Antibiotics: Given the signs of infection (fever, positive stool occult blood, and localized tenderness), antibiotics are indicated to treat the inflammatory process and prevent the spread of infection.
- IV Fluids: Dehydration is common in diverticulitis due to symptoms like nausea and vomiting. Intravenous fluids help restore hydration and maintain electrolyte balance. Additionally, IV fluids can support bowel rest in cases of ileus.
In summary, the case presentation, physical exam, and diagnostic findings support a diagnosis of acute diverticulitis, and the treatment with antibiotics and IV fluids is aimed at managing the infection and associated complications.