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.
Full Answer Section
The symptoms of diverticulitis can vary depending on the severity of the inflammation or infection. Mild diverticulitis may cause only mild abdominal pain, while more severe diverticulitis can cause severe pain, fever, nausea, vomiting, and constipation. In some cases, diverticulitis can lead to complications such as abscesses, fistulas, and peritonitis.
Clinical Findings That Support a Diagnosis of Acute Diverticulitis
The clinical findings from the case that support a diagnosis of acute diverticulitis include:
- Left lower quadrant (LLQ) pain: This is the most common symptom of acute diverticulitis. The pain is typically sharp and constant, and it may be worse with movement or straining.
- Constipation: This is another common symptom of acute diverticulitis. The constipation is caused by inflammation and blockage of the colon.
- Nausea and vomiting: These symptoms can occur with acute diverticulitis, but they are not as common as pain and constipation.
- Fever: A low-grade fever may be present in acute diverticulitis. A high fever, however, is more likely to indicate a complication such as an abscess or peritonitis.
- Tenderness to palpation in the LLQ: This is a physical exam finding that is often present in acute diverticulitis. The tenderness is usually over the area of the inflamed diverticulum.
- Rebound tenderness: Rebound tenderness is a more serious physical exam finding that may indicate a complication such as an abscess or peritonitis. Rebound tenderness occurs when the examiner presses down on the abdomen and then quickly releases the pressure. If the patient experiences pain when the pressure is released, this is a sign of rebound tenderness.
- Hyper-resonance to percussion: Hyper-resonance to percussion is another physical exam finding that may be present in acute diverticulitis. Hyper-resonance occurs when the abdomen sounds hollow when it is percussed. This is due to the presence of air in the colon, which is caused by the inflammation and blockage of the colon.
Risk Factors for Acute Diverticulitis
The following are three risk factors for acute diverticulitis:
- Age: Acute diverticulitis is more common in people over the age of 40.
- Diet: A low-fiber diet is a risk factor for diverticulosis, which can lead to acute diverticulitis.
- Constipation: Constipation is another risk factor for diverticulosis, which can lead to acute diverticulitis.
Why Antibiotics and IV Fluids Are Indicated in This Case
The patient in this case has a clinical presentation and diagnostic findings that are consistent with acute diverticulitis. The treatment for acute diverticulitis typically includes antibiotics and IV fluids.
The antibiotics are used to treat the infection that is causing the diverticulitis. The IV fluids are used to rehydrate the patient and to prevent dehydration, which can be a complication of acute diverticulitis.
In addition to antibiotics and IV fluids, the patient may also be prescribed pain medication and anti-emetics to manage the pain and nausea associated with acute diverticulitis.
The patient in this case was hospitalized and treated with antibiotics and IV fluids. Her symptoms improved and she was able to tolerate a regular diet before she was discharged to home.
Sample Answer
Pathophysiology of Diverticular Disease and Diverticulitis
Diverticulosis is a condition in which small pouches (diverticula) form in the wall of the colon. These pouches can develop anywhere in the colon, but they are most common in the sigmoid colon (the last part of the colon). Diverticula are thought to form when pressure builds up in the colon, causing the wall to bulge out.
Diverticulitis is a complication of diverticulosis that occurs when one or more of the diverticula become inflamed or infected. This can happen when food particles or bacteria get trapped in a diverticulum, causing an infection. Diverticulitis can also occur when a diverticulum ruptures, allowing bacteria to leak into the abdominal cavity.