Download Irritable bowel syndrome vs. diverticular disease

patho puzzler
Irritable bowel syndrome vs.
diverticular disease
HEIDI L. GARGUILO, ARNP,BC, MSN
Nurse Practitioner • Medicus Veincare • Jupiter, Fla.
SUSAN GABRIEL, ARNP, CCRN, MSN
Perianesthesia Nurse Practitioner • JFK Medical Center • Atlantis, Fla.
Read on for
important
similarities
and
differences.
Q: What’s irritable bowel
syndrome (IBS)?
A: IBS is a functional gastrointestinal disease
that originates in the intestines and is associated with gastrointestinal motility (see
Picturing IBS). More prevalent in women,
about 24 million people suffer from the disease, with an onset between the ages of 20
and 50. While the cause is unknown, several
factors are related to IBS, including heredity,
psychosocial stress, a high-fat diet, irritating
foods, and smoking.
Signs and symptoms
Signs and symptoms of IBS have a wide
variability. It’s associated with chronic, continuous, or intermittent abdominal pain described as cramping that’s relieved with
elimination, bowel pattern changes, and
bloating that may be associated with abdominal distention. Various changes in
bowel patterns include:
Picturing IBS
Colon
Spastic contractions
• episodes of diarrhea and/or constipation
• mucus in the stool
• changes in the frequency of elimination
• feelings of straining
• feelings of urgency or incomplete evacuation.
Physical findings
On physical exam, the patient with IBS may
exhibit no physical abnormalities or she
may experience mild tenderness over the
colon, epigastrum, and/or umbilicus. She
may also have various motility and sensory
abnormalities that precipitate symptoms.
Diagnosis
The diagnosis of IBS is based predominately
on the subjective information obtained during the initial exam. Although the patient
with IBS will generally have normal test results, a complete blood cell (CBC) count,
sedimentation rate (ESR), urinalysis, stool
samples, and a sigmoidoscopy may be ordered to rule out more severe pathology.
Unfortunately, there’s no definitive test to
diagnose IBS; however, The British Society
of Gastroenterology guidelines state that the
diagnosis should be made if the patient experiences abdominal pain relieved by defecation, changes in stool patterns, or other
somatization complaints; frequently visits
the office for such complaints; and has a
history of anxiety and/or depression.
Treatment
Treatment for IBS includes management of
the presenting symptoms. If the predominant symptom is constipation, the patient
may benefit from a high-fiber diet, a stool
softener, or other medications that increase
gastric motility. If diarrhea is the primary
complaint, and dietary causes such as lac-
22 Nursing made Incredibly Easy! September/October 2008
tose intolerance
Picturing diverticulosis
have been ruled out,
then bulking agents
should be used.
Medications and
stress management
Transverse
can treat the sympcolon
toms of pain and
Ascending
bloating. Lopcolon
eramide and diphenoxylate work to
Tenia coli
slow down forward
propulsion on the
gut, which results in
Cecum
decreased urgency
and frequency of
Vermiform
bowel movements.
appendix
Anticholinergics and
antispasmodics suppress smooth musCross section of colon
cle contractions to
relieve pain. TriRectum
cyclic antidepressants help minimize
Anus
diarrhea, while seroExternal anal
tonin reuptake inDiverticula
sphincter muscles
hibitors improve
constipation.
Diet is an important component to
any IBS treatment
plan. Avoiding lactose, caffeine, fatty foods, alcohol, tobacco,
ity levels, and psychological interventions.
some artificial sweeteners, and beans may
Encourage your patient to keep a food dieliminate or reduce the symptoms of IBS.
ary to track which foods aggravate her
The British Society of Gastroenterology
symptoms so she’ll know what to avoid.
guidelines suggest that dietary management
She should maintain an adequate fluid inshould begin with moderate if any contake, avoid stimulants such as caffeine and
sumption of lactose, wheat, and insoluble
tobacco, and maintain a high-fiber diet
fiber. Exercise is also encouraged to help
from 20 to 35 grams per day. Be sure to edrelieve stress and because low physical activ- ucate her to avoid fluid intake with meals
ity may cause constipation. And remember
and encourage her not to use straws to
not to overlook the psychological component help reduce gas and bloating. Encourage
of the disease. To assist with depression or
the use of stress management techniques
other psychological etiology, your patient
because emotional stressors can aggravate
may need counseling, stress management, or IBS symptoms. Follow up isn’t required unmedications.
less there’s a change in the patient’s condition. Make sure your patient is aware that
Patient teaching
IBS is a self-limiting disorder that doesn’t
A patient diagnosed with IBS will need edprogress into a more serious disorder or
ucation on how to manage her disease, inshorten her life expectancy; however, comcluding dietary changes, medications, activ- plications such as blood in the stool should
Descending
colon
Jejunum
Ileum
Sigmoid colon
September/October 2008 Nursing made Incredibly Easy! 23
patho puzzler
The older your
patient is,
the higher the
probability
he has
diverticulosis.
be reported to her health care provider immediately.
Q: What’s diverticular disease?
A: Diverticular disease includes the diagnoses of diverticulitis and diverticulosis. Diverticulitis occurs when food and bacteria
are retained in the diverticulum (a small
pocket that forms as the result of herniation
of mucosa through the muscular wall of the
colon), producing infection and inflammation. Diverticulosis is when multiple diverticulum (known as diverticula) are affected. More than 10% of Americans
over age 40, about 50% over age 60, and
almost all people over age 80 have diverticulosis (see Picturing diverticulosis). It’s
commonly thought that a low-fiber diet is
the main cause of diverticular disease.
Signs and symptoms
Symptoms typically include:
• persistent left lower quadrant abdominal
pain
A closer look at a low-residue diet
Foods included
• Cheeses: soft or mild
• Dairy (if tolerated): milk, ice cream, yogurt, puddings
• Eggs: hard or soft boiled, scrambled, poached
• Potatoes: boiled, baked, creamed, mashed
• Meats: boiled or broiled chicken and turkey, well-cooked beef, broiled fish
• Breads and pasta: white flour, plain
• Cereals: any corn or rice without added sugar
• Vegetables: well-cooked
• Fruits: soft fruits (such as bananas), hard fruits cooked and without skins
or seeds (such as applesauce)
• Sweets: white sugar, brown sugar, clear jelly, honey, molasses
Foods excluded
• Cheeses: sharp, fried, or with added spices
• Eggs: fried
• Potatoes: fried and/or processed
• Meats: tough meat and meat with gristle
• Breads and pasta: whole wheat, graham crackers, pretzels, pancakes,
waffles, muffins, corn bread, quick-breads, whole grain rice/barley/pasta
• Cereals: whole wheat, bran, shredded wheat
• Vegetables: Raw with skins or seeds, whole kernel corn, dried beans,
peas
• Fruits: raw with skins or seeds, raisins, dates, figs, canned plums,
berries, pineapple, strawberries
• Sweets: containing fruit or nuts, jams, marmalade
24 Nursing made Incredibly Easy! September/October 2008
• fever
• altered bowel function
• nausea and vomiting (usually caused by
bowel obstruction, an abscessed diverticulum, spasm of the bowel, or electrolyte
abnormalities)
• malaise
• urinary complaints
• constipation (more common than diarrhea).
Complications associated with diverticular disease include self-limiting bleeding
caused by a small blood vessel in the diverticulum that weakens and then bursts, infections, perforations, and/or blockages. If the
infection causing diverticular disease worsens, an abscess may form in the colon. This
collection of pus may cause swelling and
destroy the surrounding colonic tissue. If the
diverticula form small holes, called perforations, the bowel contents may leak into the
abdomen and/or pelvis and cause peritonitis, a surgical emergency. A fistula may form
when damaged tissue makes a connection,
causing a communication between two
organs or an organ and the skin. The most
common type of fistula is found between the
bladder and the colon. Significant intraabdominal infection can cause scarring that
may lead to a partial or total blockage of the
large intestine. A complete blockage is a surgical emergency. Surgery for a partial blockage isn’t emergent, but is usually still necessary.
Physical findings
On physical exam of the abdomen, the patient will have mild to moderate tenderness
localized to the left lower quadrant. Severe
abdominal tenderness, sometimes referred
to as an acute abdomen, is uncommon and
likely the result of diffuse peritonitis caused
by a perforation of bowel. Bowel sounds
may be hypoactive (most common), highpitched, or absent. High-pitched, or tinkling, bowel sounds are heard in patients
with an impending or early bowel obstruction. Absent bowel sounds may occur if the
patient has an ileus, a complete obstruction,
or a perforation of bowel. Sometimes an abdominal mass due to a large abscess or significant inflammation can be felt on exam.
The patient may also have occult blood in
his stool and a high serum white blood cell
count.
Diagnosis
Diagnostic testing includes a CBC count, an
ESR, a urinalysis, abdominal X-rays, a computerized tomography (CT) scan of the
abdomen/pelvis (test of choice), a barium
enema, and an abdominal ultrasound. Endoscopy may be performed, but not in
acute diverticular disease.
Treatment
The treatment for diverticular disease depends on the severity of your patient’s
symptoms (see Treatment guidelines for patients with severe acute diverticulitis). Outpatient therapy can be effective if the patient
has mild pain and is able to hold down liquids and medications. If there’s no improvement after 24 to 36 hours of outpatient
treatment, hospitalization should be considered. Hospitalization is required for most
cases due to the need for surgical evaluation, pain control, and I.V. antibiotics.
Oral tetracylines and sulfa drugs are used
in combination with antifungals for mild
cases of diverticular disease, but more severe
cases require I.V. broad-spectrum antibiotics.
Your patient will also need I.V. hydration,
pain control with analgesics, and possibly a
nasogastric tube if abdominal distention is
present. While receiving treatment, he’ll be
NPO (nothing by mouth) to rest his bowel.
After a diet is started, it’s imperative that he
start with liquids and build up to a lowresidue diet that’s high in fiber (see A closer
look at a low-residue diet). Stool softeners and
antispasmodic medications for pain may be
necessary. Surgery may also be an option
(see The Hartmann procedure for diverticulitis).
Patient teaching
On discharge from the hospital, educate
your patient about his new diet restrictions,
the need to maintain high fiber intake, the
importance of adequate fluid intake, and
the avoidance of dietary fat. Follow up may
include endoscopy and/or a CT scan or
barium enema. Up to 30% of patients will
have recurring symptoms.
The Hartmann procedure for
diverticulitis
The affected segment of the colon is divided at its distal end. In a primary
anastomosis, the proximal margin (dotted line) is transected and the bowel
attached end-to-end. In a two-stage procedure, a colostomy is constructed at the proximal margin with the distal stump oversewn or brought to the
outer surface as a mucous fistula. The second stage consists of colostomy
takedown and anastomosis.
Transverse
colon
Descending
colon
Proximal margin
(site of stoma
for colostomy)
Ascending
colon
Cecum
Closed
distal stump
Q: What are the similarities
and differences between IBS
and diverticular disease?
A: Both disease processes are relatively
common. IBS tends to affect younger patients, while the incidence of diverticular
disease increases with advancing age. IBS
is more specific to women than men,
whereas diverticular disease is generally
thought to have equal incidence in both
genders.
IBS and mild cases of diverticular disease may present similarly. Both disease
processes involve abdominal pain: The
pain associated with IBS is described as
cramping and is relieved with elimination,
whereas the pain from diverticular disease
is constant and usually focused in the left
lower quadrant of the abdomen. Also, the
pain can be much more severe with diverticular disease if serious complications are
present. Patients may experience diarrhea
and/or constipation with either disorder.
Fever isn’t generally found in patients with
IBS, but it may be present when a patient
presents with diverticular disease due to
September/October 2008 Nursing made Incredibly Easy! 25
patho puzzler
Irritable bowel syndrome vs. diverticular disease
cheat
sheet
Irritable bowel syndrome
Diverticular disease
Signs and symptoms
• Chronic, continuous, or intermittent abdominal
pain described as cramping that’s relieved
with elimination
• Bowel pattern changes (episodes of diarrhea
and/or constipation, mucus in the stool, changes
in the frequency of elimination, feelings of
straining, feelings of urgency or incomplete
evacuation)
• Bloating
• Persistent left lower quadrant
abdominal pain
• Fever
• Altered bowel function
• Nausea and vomiting (usually caused by
bowel obstruction, an abscessed diverticulum, spasm of the bowel, or electrolyte
abnormalities)
• Malaise
• Urinary complaints
• Constipation (more common than diarrhea)
Physical findings
• The patient may have no physical abnormalities
• Mild tenderness over the colon, epigastrum,
and/or umbilicus
• Various motility and sensory abnormalities
that precipitate symptoms
• Mild to moderate tenderness localized
to the left lower quadrant and hypoactive
(most common), high-pitched, or absent
bowel sounds
• Sometimes an abdominal mass due to a
large abscess or significant inflammation can
be felt on exam
Diagnosis
• Based predominately on the subjective
information obtained during the initial exam;
diagnosis should be made if the patient
experiences abdominal pain relieved by
defecation, changes in stool patterns, or other
somatization complaints; frequently visits the
office for such complaints; and has a history of
anxiety and/or depression
• Complete blood cell (CBC) count, sedimentation rate (ESR), urinalysis, stool samples, and
sigmoidoscopy may be ordered
• CBC count
• ESR
• Urinalysis
• Abdominal X-rays
• Computed tomography scan of the
abdomen/pelvis (test of choice)
• Barium enema
• Abdominal ultrasound
• Endoscopy may be performed (contraindicated in acute diverticular disease)
• The patient may have occult blood in the
stool and a high serum white blood cell count
Treatment
• Management of the presenting symptoms
with medications
• Dietary management (moderate if any
consumption of lactose, wheat, and insoluble
fiber)
• Exercise to reduce stress
• Outpatient therapy may be effective if the
patient has mild pain and is able to hold
down liquids and medications; if there’s no
improvement after 24 to 36 hours of outpatient treatment, hospitalization is usually
required
• I.V. broad-spectrum antibiotics
• I.V. hydration
• Pain control with analgesics
• Low-residue diet
• Surgery may be an option
26 Nursing made Incredibly Easy! September/October 2008
inflammation or
Treatment guidelines for patients with severe
abscess formation.
acute diverticulitis
In IBS, the physical exam findings
Patients with severe acute diverticulitis require hospitalization for I.V. hydration, broad-spectrum
antibiotics, and bowel rest with or without nasogastric tube decompression. The initiation of medical
are essentially northerapy usually results in rapid clinical improvement with resolution of pain, fever, and ileus within 48
mal, while the
to 72 hours. Broad-spectrum antibiotics are continued for 7 to 10 days and oral feedings are gradually
patient with diverreintroduced as tolerated. Following resolution of signs and symptoms, patients should consume a
ticular disease may
high-fiber diet to decrease the likelihood of repeated attacks.
have hypoactive,
Surgery for diverticulitis and its complications may be either an elective or emergency procedure.
high-pitched, or
Indications for elective surgery include:
absent bowel
• two or more acute attacks of diverticulitis successfully treated medically
sounds, as well as a
• a single attack requiring hospitalization in a patient younger than age 40
palpable mass if
• one attack with evidence of contained perforation, colonic obstruction, or inflammatory involvement
there’s severe
of the urinary tract
inflammation or an
• inability to rule out a colonic carcinoma.
Source: Society for Surgery of the Alimentary Tract. Surgical treatment of diverticulitis. http://www.guidelines.gov/summary/
abscess. When a
summary.aspx?doc_id=5509&nbr=003752&string=surgical+AND+treatment+AND+diverticulitis. Accessed June 16, 2008.
patient presents
with abdominal
pain, similar workups will be ordered. The
symptoms; however, with thorough history
difference is that the tests will be essentialtaking, a complete physical exam, and an
ly normal in the patient with IBS, whereas
appropriate diagnostic workup, an accutests may be abnormal in the patient with
rate diagnosis can be made. This allows the
diverticular disease.
nurse to aid in individualizing the approBecause there’s no definitive test for IBS,
priate treatment regimen, follow-up plan,
the diagnosis is made based on the present- and significant education vital to a successing symptoms after more serious diseases
ful outcome. ■
are ruled out. Patients with diverticular
Learn more about it
disease will likely have an elevated white
British Society of Gastroenterology. New guidelines for
blood cell count, an elevated ESR, and/or
the treatment of adults with IBS. http://www.medscape.
guaiac-positive stools. Plain X-rays may
com/viewarticle/556356. Accessed June 16, 2008.
show distended bowel loops, ileus, abscess, Dalton CB, Drossman DA. The use of antidepressants in
the treatment of irritable bowel syndrome. http://www.
or obstruction. A CT scan of the abdomen
med.unc.edu/medicine/fgidc/antidepressants.pdf. Acand pelvis is the test most commonly used
cessed June 17, 2008.
to make the diagnosis of diverticular disLongstreth GF, Yao JF. Irritable bowel syndrome and
surgery: A multivariable analysis. Gastroenterology.
ease.
126(7):1665-1673, June 2004.
Treatment plans will be similar for both
Pathophysiology Made Incredibly Visual! Philadelphia, Pa.,
patient populations. All patients with IBS
Lippincott Williams & Wilkins, 2008: 106-107.
and diverticular disease should avoid those Peppercorn MA. The overlap of inflammatory bowel disease and diverticular disease. Journal of Clinical Gastroenthings that have been identified as triggers.
terology. 38(5 suppl):S8-S10, May/June 2004.
Maintenance of a high-fiber diet and adeSmeltzer SC, et al. Brunner and Suddarth’s Textbook of
quate fluid intake are also important in the
Medical-Surgical Nursing, 11th edition. Philadelphia, Pa.,
Lippincott Williams & Wilkins, 2007:3237-3238,1242-1245.
limiting of future exacerbations. Patients
Society for Surgery of the Alimentary Tract. Surgical
with IBS may also benefit from managetreatment of diverticulitis. http://www.guidelines.gov/
ment of psychological stressors. Patients
summary/summary.aspx?doc_id=5509&nbr=003752&stri
ng=surgical+AND+treatment+AND+diverticulitis. Acwith diverticular disease will need antibicessed June 16, 2008.
otics in addition to dietary modification.
Stollman N, Raskin JB. Diverticular disease of the colon.
The Lancet. 363(9409):631-639, February 2004.
Abdominal pain is a common complaint
University of Texas, School of Nursing, Family Nurse
that has numerous differential diagnoses,
Practitioner Program. The efficacy of antidepressants and
ranging from mild, self-limiting diseases
various psychotherapies as adjunctive treatments for irritable bowel syndrome. http://www.guidelines.gov/
to severe pathology. In the examples
summary/summary.aspx?doc_id=9437&nbr=005058&
described here—IBS and diverticular disstring=adjunctive+AND+treatments+AND+IBS. Accessed June 16, 2008.
ease—patients may present with similar
September/October 2008 Nursing made Incredibly Easy! 27