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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