History of diverticular disease presents to the clinic with left lower quadrant (LLQ)

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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 thatis accompaniedby with constipation, nausea, vomiting and alow-gradefever (100.20F) 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.

 

Sample Solution

Diverticulitis vs. Diverticular Disease and Acute Diverticulitis Diagnosis

Diverticular Disease (Diverticulosis):

  • Pathophysiology: Diverticulosis is the presence of small pouches (diverticula) that form on the inner lining of the large intestine (colon). These pouches develop due to increased pressure within the colon, often caused by a low-fiber diet and chronic constipation. Diverticula themselves are usually asymptomatic.

Diverticulitis:

  • Pathophysiology: When one or more of these diverticula become inflamed or infected, it leads to diverticulitis. This inflammation can occur due to fecal matter getting trapped in the pouches, causing irritation and potential bacterial overgrowth.

Key Differences:

Feature Diverticular Disease Diverticulitis
Symptoms None (asymptomatic) Abdominal pain (often left lower quadrant), constipation, nausea, vomiting, fever
Complications No Bleeding, perforation (hole in the colon), abscess (collection of pus)

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Clinical Findings Supporting Acute Diverticulitis Diagnosis:

The case scenario presents several clinical findings consistent with acute diverticulitis:

  • Symptoms: Left lower quadrant abdominal pain, constipation, nausea, vomiting, and low-grade fever.
  • Physical Exam: Signs of dehydration (pale mucosa, poor skin turgor), hypotension, tachycardia, abdominal tenderness in the left lower quadrant, and faint/hypoactive bowel sounds.
  • Diagnostics: Positive occult blood test in stool suggests bleeding in the digestive tract, and the abdominal CT scan showing a distended small bowel indicates an obstruction or inflammation.

Risk Factors for Acute Diverticulitis:

  1. Low-Fiber Diet: Lack of fiber in the diet makes stool hard and difficult to pass, increasing pressure within the colon.
  2. Obesity: Excess weight puts strain on the colon and abdominal muscles.
  3. Smoking: Smoking can impair blood flow to the intestines and increase inflammation.
  4. Age: Diverticulitis is more common in older adults.
  5. Certain Medications: Steroid use and some nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk.

Rationale for Antibiotics and IV Fluids:

  • Antibiotics: Although not always necessary in mild cases, antibiotics are often prescribed to combat potential bacterial infection within the inflamed diverticula.
  • IV Fluids: Dehydration is a common complication due to vomiting and inability to tolerate fluids orally. IV fluids help restore hydration and promote healing.

By addressing dehydration, infection, and promoting gut rest, these interventions can help manage symptoms and facilitate recovery from acute diverticulitis.

 

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