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Case Scenario

Pathophysiology between Diverticulitis and Diverticulosis

Collectively diverticulitis and diverticulosis are referred to as diverticular diseases, and both occur in the large intestine. They also share the same feature of diverticula, a pocket or protrusion in the colon wall. Diverticular disease is categorized by the presence of tiny pouches in the wall of the large intestine; diverticulosis develops when these pouches push through the colon’s thin outer muscle layers; it may occur everywhere in the colon but is more common in the sigmoid and descending colons (Ghoulam, 2019). Diverticulosis is categorized by saclike protrusions formed when conic submucosa and mucosa are herniated via the large intestine’s muscle layer defects. Besides, diverticulosis may sometimes become symptomatic, resulting in severe complications. According to Elisei and Tursi (2018), diverticulosis has been studied for decades, but researchers have recently revised the pathophysiologic theory that underlies the condition. Even though constipation is no longer thought to be the primary cause of diverticulosis, it is still essential to recognize that there are likely other causes, from structural changes in the colonic wall to microbial dysbiosis that contributes to the development of diverticulosis.

Furthermore, inflammation of the diverticulum also causes Diverticulitis. Diverticulitis is the infection and inflammation in a single or more diverticulum. Diverticulitis develops when bacteria and food in the diverticulum produce inflammation and infection, which can impede drainage and result in abscess formation or perforation. Besides, ten percent or more of patients with diverticulosis will develop Diverticulitis. Diverticulitis can exist as either a chronic or an acute process. In 10%-25% of individuals, diverticulosis will progress to Diverticulitis, the disease’s most serious consequence. Pathophysiologically, Diverticulitis develops when fecalith blocks off the diverticulum sac, causing discomfort of the mucosa and subsequent low-grade congestion, irritation, and additional diverticulum blockage (Rezapour et al., 2018).

Clinical Findings Backing up Acute Diverticulitis Diagnosis in the Case

Some of the clinical results from this case that backing up acute diverticulitis diagnosis include; positive stool for occult blood, which is due to the of erosion and destruction of the arterial blood vessels leading to bleeding, low-grade fever of about 100.20 F caused by dehydration and infection, and the patient suffering from left lower quadrant (LLQ) ache of the abdomen convoyed by vomiting, nausea, and constipation. This is caused by recurrent local inflammation of the diverticula. Also, the large bowel may be slender with fibrotic strictures, resulting in narrow stools, cramps, and increased constipation, or may sometimes result in intestinal obstruction. Another clinical finding supporting the diagnosis of acute Diverticulitis, in this case, is the flat plate abdominal x-ray which shows a bowel-gas pattern in line with the ileus. In such cases, an abdominal x-ray may indicate free air beneath the diaphragm if a perforation occurs from the Diverticulitis.

Other clinical findings that support acute diverticulitis diagnosis are the patient’s dehydration signs, such as the patient’s poor skin turgor with tachycardia [101 bpm] and mild hypotension [90/60 mm Hg], and the patient having pale mucosa. The signs mentioned above and the symptoms are a clear indication of peritonitis. Besides, peritonitis is a condition triggered by leakage of abdominal organs’ contents into the abdominal cavity, mainly due to inflammation, trauma, ischemia, infection, and tumor perforation. In addition, the clinical finding that the patient has left lower quadrant and has tender to light palpation lacking rebound tenderness supports acute diverticulitis diagnosis. Besides, increased tenderness and abdominal pain indicate signs and symptoms of perforation, which is a surgical emergency. The last clinical finding that supports acute diverticulitis diagnosis, in this case, is the hyper-resonance of the patient’s abdomen to percussion due to air in the peritoneum which shows signs of peritonitis.

Risk Factors for Acute Diverticulitis

Some risk factors that increase the chances of developing acute Diverticulitis include; age, where the probability of developing Diverticulitis increases with age. This is due to cellular hypertrophy, structural changes, and deterioration in the circular muscle layers of the large intestine. Even though older age is often associated with acute Diverticulitis, this relationship is strong per se. The prolonged period in which the colonic wall is susceptible and exposed to other pathogenetic factors plays a vital role in the development of acute Diverticulitis (Alessandra et al., 2018).

Another risk factor that increases the odds of developing acute Diverticulitis is nutrition low in fiber and rich in animal fat. A high intake of animal fat in combination with a low-fiber diet seems to increase the risk of developing acute Diverticulitis. Lastly, opioids, steroids, and nonsteroidal anti-inflammatory drugs such as naproxen, sodium, and ibuprofen are associated with high odds of causing acute Diverticulitis. A high risk of diverticular bleeding is linked with the regular usage of aspirin and nonsteroidal anti-inflammatory drugs (Alessandra et al., 2018).

Why IV Fluids and Antibiotics are Specified in this Case

In this case, since the patient shows clear signs and symptoms of experiencing dehydration, the patient requires to be hydrated with electrolytes and the IV fluids she has lost. In addition, it is clear that the 84-year-old patient is suffering from acute Diverticulitis with noticeable symptoms, and thus hospitalization is urgently needed. In most cases, hospitalization is indicated for those immunocompromised and elderly patients or those taking corticosteroids. Administering IV fluids, withholding oral intake, and instituting nasogastric suctioning in case of distention or vomiting are utilized to rest the bowel. The IV fluids have been indicated in this case since they will be administered to the patient to replace the electrolyte and fluid she has lost. Besides, colloid, fluid, and electrolyte replacement is the main focus in managing acute Diverticulitis (Hinkle & Cheever, 2018). Apart from IV fluids, administration of some quantity of an isotonic solution can be prescribed in this case. Lastly, IV fluids have been specified in this case to help the patient’s gastrointestinal tract restore from the severe bouts of acute Diverticulitis and clear the gastrointestinal tract before certain tests and procedures like colonoscopy, which might be performed on the patient.

Moreover, since the patient is showing signs of infection, antibiotic therapy is required, which is why antibiotics have been indicated in this case. Antibiotic therapy is usually introduced early in the treatment of acute Diverticulitis. In this case, antibiotics have been indicated to stop the inflammation from spreading further (Van Dijk et al., 2018). Besides, these antibiotics can be used as tablets, syrup, or an infusion. During the treatment of acute Diverticulitis, large amounts of broad-spectrum antibiotics are intravenously administered until the exact organism leading to the infection is determined and the necessary antibiotic therapy can be started. In addition, antibiotics such as rifaximin and Flagyl are often utilized to treat GI infections such as Diverticulitis.

References

Alessandra, V., Ginevra, C., Chiara, M., Alberto, B., Antonio, N., Mario, C., … & Gian, L. D. A. (2018). Epidemiology and risk factors for diverticular disease. Acta Bio Medica: Atenei Parmensis, 89(Suppl 9), 107.

Elisei, W., & Tursi, A. (2018). The pathophysiology of colonic diverticulosis: inflammation versus constipation? Inflammatory Intestinal Diseases, 3(2), 55-60.

Ghoulam, E. (2021, November 24). Diverticulitis. Practice Essentials, Background, Pathophysiology. https://emedicine.medscape.com/article/173388-overview#a6.

Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd.

Rezapour, M., Ali, S., & Stollman, N. (2018). Diverticular disease: an update on pathogenesis and management. Gut and liver, 12(2), 125. DOI: 10.5009/gnl16552Van Dijk, S. T., Bos, K., de Boer, M. G. J., Draaisma, W. A., van Enst, W. A., Felt, R. J. F., … & Boermeester, M. A. (2018). A systematic review and meta-analysis of outpatient treatment for acute Diverticulitis. International journal of colorectal disease, 33(5), 505-512.