8/29/2016 DIVERTICULAR DISEASE: WHAT EVERY NURSE PRACTITIONER SHOULD KNOW. LENORE LAMANNA Ed.D, ANP-C LEARNING OBJECTIVES

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1 DIVERTICULAR DISEASE: WHAT EVERY NURSE PRACTITIONER SHOULD KNOW LENORE LAMANNA Ed.D, ANP-C LEARNING OBJECTIVES Define Diverticular Disease Discuss Epidemiology and Pathophysiology of Diverticular disease Describe Classifications of Diverticular Disease Discuss Theories of Prevention for Diverticular Disease Discuss Modifiable Risk factors Review Signs and Symptoms of Diverticular Disease Review Differential Diagnoses for Lower Abdominal Pain Describe Strategies for Diagnosing Diverticular Disease Discuss Current Management Theories/Guidelines for Diverticular Disease DEFINITIONS ASSOCIATED WITH DIVERTICULAR DISEASE Diverticula-structural alteration of the colonic wall characterized by herniation of the colonic mucosa and submucosa Diverticulosis-presence of colonic diverticula; can be symptomatic or not Diverticular disease-umbrella term for diverticulosis that become clinically significant and symptomatic. Symptomatic Uncomplicated Diverticular Disease (SUDD) Persistent and recurrent abdominal symptoms attributed to diverticula without inflammatory changes in the colonic mucosa 1

2 DEFINITIONS-CONTINUED Diverticulitis-macroscopic inflammation of diverticula resulting in acute or chronic complications Acute uncomplicated-colonic wall thickening with fat stranding Complicated-results in abscess/perforation, fistula or obstruction/stricture formation SCADD-Segmental Colitis Associated with Diverticular Disease Rare form of chronic diverticulitis, hypothesized to be a form of IBD Diverticulosis Diverticular Disease Asymptomatic diverticulosis Diverticulitis SUDD Acute Diverticulitis Chronic Diverticulitis Chronic recurrent diverticulitis SCAD DIVERTICULA 2

3 DIVERTICULAR DISEASE-EPIDEMIOLOGY Sixth leading physician diagnosis for GI disorders in outpatient clinical visits in the U.S. Prevalence increases with age, however, one-third of adults under the age of 50 have colonic diverticula Lifetime risk for individuals with diverticulosis to develop acute diverticulitis is less than 5% Complicated diverticulitis occurs in 15% of patients Recurrent diverticulitis is more common in younger individuals, but less severe and better survival, occurs in 15-30% of patients (AGA). DIVERTICULAR DISEASE-PATHOPHYSIOLOGY Cause of pathological mechanisms for diverticula to form is unclear Potential factors: Colonic motility Dietary fiber Microbiota alterations Genetics PREVENTION STRATEGIES Diverticulosis-none confirmed Painter & Burkitt Diverticular Disease High fiber intake Vegetarian diet Nuts, seeds, corn, popcorn-bring it on! 3

4 MODIFIABLE RISK FACTORS-DIVERTICULITIS Obesity Smoking NSAID use INCREASE RISK OF FIRST OCCURRENCE Steroids & opiates increase risk of perforated diverticulitis DECREASE RISK OF FIRST OCCURRENCE Vegetarian diet High fiber diet Vigorous physical activity Statins & CCB s reduce risk of perforated diverticulitis PREVENTION RECURRENCE OF ACUTE DIVERTICULITIS No conclusive evidence for modifiable risk factors to reduce risk of recurrence Studies do not recommend Mesalamine Rifaximin Probiotics DIVERTICULAR DISEASE-SIGNS & SYMPTOMS Diverticulosis- usually asymptomatic Symptomatic Uncomplicated Diverticular Disease (SUDD) Nonspecific abdominal pain, usually left sided Colicky abdominal pain relieved by defecation or passing flatus and/or bloating and altered bowel movements Absence of fever Normal laboratory studies 4

5 DIVERTICULAR DISEASE SIGNS & SYMPTOMS CONT. Acute Uncomplicated Diverticulitis LLQ or Suprapubic pain RLQ pain particularly in Asian patients Fever Leukocytosis may be present Diarrhea or Constipation Nausea, Vomiting Anorexia Hematochezia In some, Dysuria and Frequency DIVERTICULAR DISEASE-SIGNS & SYMPTOMS CONT. Complicated Diverticulitis: Abscess/Perforation-tenderness on abd. or rectal exam, persistent fever Fistulas-abscess ruptures colovesical-fever, abd. mass, fecaluria, hematuria colovaginal-passage of stool or flatus in the vagina, malodorous vaginal d/c, frequent vaginal infections Obstruction/Strictures-Change in bowel habit, abd. bloating DIFFERENTIAL DIAGNOSES OF DIVERTICULAR DISEASE Differential Diagnosis Location of Pain Associated Symptoms Appendicitis RLQ Vomiting after pain starts, constipation, fever Ectopic Pregnancy Lower quadrant Tender adnexal mass, vaginal bleeding Pelvic Inflammatory Disease Lower abdomen & pelvis Fever, heavy vag. d/c, dysuria, dysparemia, irregular menstrual bleeding Inflammatory bowel disease Generalized abdominal pain Diarrhea, mucus, fever, weight loss, apthous ulcer, rectal bleeding Irritable Bowel Syndrome Generalized abdominal pain Diarrhea, constipation or both Colon cancer Generalized abdominal pain Weight loss, rectal bleeding Ovarian cyst Pelvic pain radiating to back If large, polyuria 5

6 DIAGNOSIS OF DIVERTICULAR DISEASE Diverticulosis & Diverticular Disease- colonoscopy Symptomatic Uncomplicated Diverticular Disease- History & Physical examination-ask questions to rule out diverticulitis or IBS Physical exam is unremarkable Fecal calprotectin-used in IBD management, can be used to differentiate SUDD, IBS and Acute Uncomplicated Diverticulitis Acute Diverticulitis- History & Physical Examination CT Scan of the abdomen & pelvis with contrast MANAGEMENT OF DIVERTICULAR DISEASE Diverticulosis- high fiber diet SUDD-main goal is to improve symptoms, prevent symptoms from reoccurring and prevent complications Conflicting data Rifaximin-not recommended Mesalamine-not recommended Probiotics-not recommended WGO-high fiber diet MANAGEMENT CONT. Acute Uncomplicated Diverticulitis Mild symptoms-outpatient Clear liquids Low residue diet Fecal calprotectin WGO & ACG Guidelines: Antibiotics Ciprofloxacin and Metronidazole or Augmentin or Sulfamethoxazole-Trimethoprim Use of antibiotics is controversial 6

7 MANAGEMENT-ACUTE UNCOMPLICATED DIVERTICULITIS Once acute episode has resolved: High fiber diet- controversial Mesalamine, Rifaximin, Probiotics all not recommended Colonoscopy at least six - eight weeks after diagnosis-controversial (AGA recommends) In the decade after the first occurrence, 15-30% individuals will have recurrence (AGA) Risk is 1 in 4 in adults under 50 years old MANAGEMENT-ACUTE COMPLICATED DIVERTICULITIS Colonoscopy recommended following complicated diverticulitis due to greater risk of malignancy Antibiotics Colon resection on a case by case basis-experienced high volume colorectal surgeon Consider: age comorbidities chronic or lingering symptoms severity of attacks POST-DIVERTICULITIS IRRITABLE BOWEL SYNDROME After diverticulitis and acute inflammation is resolved: Abdominal pain (45% individuals in studies 1 year later) Cramping Bloating Diarrhea/Constipation (30% altered bowel habits 1 year later) Anxiety 7

8 QUESTIONS? THANK YOU!! 8