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Diverticulitis Case Study

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by

Nissa Mickelsen

on 5 March 2013

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Transcript of Diverticulitis Case Study

-High-fiber diets require large fluid intakes to help keep stool soft

-Eat fruits and vegetables dried or raw -Don't start patient on high-fiber diet

-Start slow on clear liquid diet

-Increase fiber intake once symptoms clear
-Abdominal pain, nausea, vomiting, chills, fever -Diverticulosis starts when you strain to pass hard stools associated with low-fiber diets

-Soluble fiber combines with water in intestines to create jelly-like substance

-Helps keep bowel movements regular
-Oatmeal, apples, oranges, beans

-Insoluble fiber increases bulk and size of stool
-Produces soft, formed stools that pass easily
-Whole grains, seeds, nuts, broccoli, celery

-High fiber diets reduce inflammation of patients with diverticulosis -Institute of Medicine suggest 30g a day of dietary fiber for women

-After the age of 50, decreases to 21g/day

-Mrs. Meyer should be consuming 21g/day Why fiber? Typical Diet:
Breakfast: White toast with butter and jam; fried egg, coffee
Lunch: Soup or Sandwich- sometimes leftovers from the previous day; coffee
Dinner: Meat, 1-2 vegetables, rice or potatoes, bread or biscuits, iced tea or coffee

24hr Recall:
2 slices white toast with 3t margarine, 2 t jelly, c sliced prunes, black coffee
2 slices white bread with 1 oz. ham, 1 T mayonnaise, 2oz potato chips, coffee
2-3 oz pork chop fried, 1c macaroni cheese, 1 biscuit, water2 slices pound cake with 1c vanilla ice cream. Patient: Edna Meyer
62 y.o. female Chief Complaint: " I had a lot of bright red blood in my bowel movement yesterday morning"
Age: 62
Sex: Female
Ethnicity: African American

Height 5’1”
Weight: 155 lb, 70 kg PMH: HTN Dx 3 years
Type of Tx: none at present
Previous Meds: Prinivil (lisinopril) 5mg

Family Hx: Cancer; mother died of ovarian cancer, father of colon cancer

Daily Smoker: No
Food allergies/intolerances/aversions: None

Previous MNT: No
Food purchase/preparation:Self
Vit/min intake: None Patient History: General appearance: Slightly overweight 62 year old African American woman in no acute distress, somewhat anxious

Vitals: Temp 98.8F,
BP 120/82,
HR 72 bpm
RR 15 bpm

Heart: S1 and S2 clear, no rub, gallop, or mummer; regular rate
HEENT: Unremarkable, normal
Neurologic: Alert and Oriented X 4; strength 5/5 throughout, DTRs 2+ and symmetrical, sensation in tact.

Extremeties: no edema
Skin: Warm, dry to touch
Chest/lungs: Clear to auscultation and percussion
Peripheral vascular: peripheral pulses palpable

Abdomen: positive bowl sounds throughout, nontender, nondistended

Lab values: WNLs Physical Exam: More on our patient: History of Symptoms:

Onset: History of constipation throughout adult life.

Recently, some episodes of diarrhea with crampy LLQ pain.

Presented to MD’s office with complaint of blood in stool that morning. Has had 2 other episodes of bleeding in past 24 hours. What is it? Treatment plan/ Investigation: -NPO
-NG to low wall suctionD5Ns @ 50cc/hr
-Metronidazole 1g loading dose, then 500mg q6h, ciprofloxacin 400mg q12h
-Strict I/O
-Schedule for colonoscopy Results of colonoscopy:
-NG aspirate heme negative

-Upper GI source of bleed ruled out.

-Colonoscopy negative for active bleeding but numerous diverticula noted Diagnosis: Diverticulosis With evidence of lower GI bleed in sigmoid colon What is Diverticulosis? The presence of small bulging sacs or pouches of the inner lining of the intestine that become inflamed or infected More on Diverticulosis Causes The exact cause of the sac formation in the intestine is unknown

Low fiber diets can play a big role in pouch formation by causing constipation which results in increased colonic pressure that can create pouches in the colon

The sacs can then get infected from small pieces of feces in the sacs. Factors that increase risk:
Obesity
Decreased physical activity
steriods
Alcohol
Caffeine intake
Smoking
Age Signs and Symptoms: Most cases of diverticulosis are asymptomatic, but in about 20% of cases people experience:
Fever
Abdominal pain
Gastrointestinal bleeding
Elevated white blood cell count Caused by food and bacteria collecting and causing infection in the mucosa. Symptoms/complications include:
Bleeding
Abscess
Obstruction
Fistulas
Perforation of the colon Diverticulitis: Acute inflammation of the diverticula. Treatments: Rest and possible use of heating pad and/or pain relievers for symptom relief

Treatment involves mainly nutrition therapy - a focus on fiber intake and probiotics/ prebiotics

For treatment of diverticulitis : Start NPO with bowel rest until symptoms subside. Antibiotics can be used to treat infections. Then drink only fluids for a day or two, slowly begin drinking thicker liquids and then eating foods.

Complications can require surgical resections

"Once these pouches have formed, you will have them for life. If you make a few simple changes in your lifestyle, you may not have diverticulitis again" - NIH Fiber Nutrients, Minerals and Vitamins Nutrients Minerals Vitamins Food Groups Nutritional Therapy High fiber diet
Vegetables
Omega-3 fatty acids
High fat foods should be avoided
Low residue diets often recommended
Probiotics
Flaxseed, chamomile, licorice Nutritional Recommendations for living with Diverticulosis: -Diverticulosis starts when you strain to pass hard stools associated with low-fiber diets

-Soluble fiber combines with water in intestines to create jelly-like substance

-Helps keep bowel movements regular
-Oatmeal, apples, oranges, beans

-Insoluble fiber increases bulk and size of stool
-Produces soft, formed stools that pass easily
-Whole grains, seeds, nuts, broccoli, celery

-High fiber diets reduce inflammation of patients with diverticulosis Why fiber? High-fiber diets require large fluid intakes to help keep stool soft
Eat fruits and vegetables dried or raw Don't start patient on high-fiber diet
Start slow on clear liquid diet
Increase fiber intake gradually once symptoms clear
-Abdominal pain, nausea, vomiting, chills, fever
- Begin with refined grains and other low fiber foods and progress to a high fiber diet which should be maintained Fiber As Nutritional Therapy: Nutrition Prescription: Wt. 155lbs (70.4kg)
Ht. 5'1"
IBW =105lbs(47.7kg) 157%IBW
47.7kg x 25kcal/kg for maintenance= 1,192.5 kcal
Protein for maintenance= 47.7kg x 1.5g/kg = 71.55g Protein x 4kcal/g =286.2 or 23.8%, round to 25%
Protien(25%) = 298kcal - 75 g
Fat(20%) = 238 kcal - 27g
CHO(55%) = 655 kcal - 164g The patient is adequately nourished, it is best to keep all the macronutrients moderately in the middle of the recommended ranges of 10-35% Protein, 20-35% Fat, and 45-65% CHO. The great majority of calories from CHO should be focused on sources of fiber such as fruits, vegetables, and whole grains (without seeds). The dietary recommendations for diverticulosis treatment should be taken into consideration Fluid intake 30-35 mL/kg/day
Fiber intake 21g/day when maintaining health Edna's Banana Bread Edna's Low Fat - High Fiber Banana Bread Changing Edna's Diet At Home Prinivil (Lisinopril) Treats hypertension and CHF
Functions as ACE inhibitor
5mg once daily Do take with potassium supplements, aspirin or other NSAIDs Metronidazole (Flagyl) Treats infections caused by bacteria/ fungi
1 g loading dose, then 500 mg q6h
Take with food to decrease GI distress
No alcohol to avoid nausea, vomiting... Ciprofloxacin Antibiotic in class called fluoroquinolones
400 mg q12h ________________________________________ _________________ Drug- Nutrient Interactions What is she eating now? Macronutrients Minerals Vitamins Diet Analysis 24 Hour Recall with incidence of Diverticulitis Diverticulitis Case Study Brought to you by:
Brenna Bowman
Robert Carroll
Danae Cook
Catherine Crinigan
Neiman Gougerchian
Zara Guinard
Scott Kendrick
Kyra Loehnis
Nissa Mickelsen
Benjamin Pohle Avoid iron salts (ferrous sulfate) and antacids since it may reduce absorption Ertapenem Broad Spectrum Antibiotic
Used in short term treatment
4 day treatment found to be equally effective as standard treatment (7 days) Future Research
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