Medical and Nutritional Therapy for Acute Diverticulitis and Sigmoidovaginal Fistula

Vehik NazaryanDietetic Intern University of Maryland College Park

January, 30, 2014

Case Report• General Information• Social History• Medical History• Nutritional History• Medical Course of the Patient

Case Discussion Implications of Findings to the Practice of Dietetics References Questions

Overview

The Patient: “MS”, 66 year old obese Caucasian female

Admitted with abdominal pain, nausea, vomiting and acute diverticulitis with suspected colorectal bladder fistula

She was diagnosed with diverticulitis and colovaginal fistula ( the probable cause of continued urinary infections)

Total hospital stay – 8 days• admitted on 09/30/2013 and was discharged to home on 10/07/2013

8days

Introducition

Education: High school education

Occupation: Retired

Marital Status: Divorced with one daughter and brother

Smoker: Tobacco history of 40+ years of 1-2 packs of cigarettes a day, prior cessation a month ago was reported

Social History

Past medical Hx includes:

• Hypercholesterolemia( 10+years)

• Barrett Esophagus ( 10 Years)

• Chronic pain with possible fibromyalgia

• Chronic Bronchitis with Asthma

• Dyslipidemia

• Lumbar Degeneration

• Morbid Obesity

• Chronic Obstructive Pulmonary Disease (COPD)

• Depression

• Chronic Back Pain

Past Medical History

Barrett’s Esophagus

Surgical History

• Total abdominal Hysterectomy (1995)

• Cholecystectomy (1975)

• Abdominal Hernia Repair (1990)

• Bilateral cataract Surgery (2011 and 2013)

Urinary Tract History• 20+ UTI with most recent MUMH visit ~2 weeks

ago

• Symptoms in past several months includeprogressive lower abdominal painSome chillsSuprapubic discomfort

Esophagogastroduodenoscopy + colonoscopy demonstrated no colovesical fistula caused by diverticulitis

Pt denies • Hematuria, • Urinary urgency, frequency or dysuria.

Urinary Tract History

MS was admitted with following medications:

• Zantac 300mg, BID

• Pravachol 40mg, daily

• Neurontin 400mg BID

• Escitalopram 20mg,

Home Medications

MS was admitted to MUMH• Weight :127kg, 280lb• Temperature: 36.4C• Blood Pressure: 119/65 mmHg• Pulse: 91 beats/minute• Respiration:18• Alert and orientedx3• Abdomen: obese, mildly tender over suprapubic

area• Laboratory studies: within normal limits except

Glucose:163

Physical Examination

Diagnostic Tests and Results

Day Date Diagnostic Test Results

Day 1 09/30/2013 1.Chest, PA and LAT

2.Esaophagogastroduodenoscopy plus colonoscopy

1.No active pulmonary disease

2. Acute diverticulitis

• Medical treatment, Day 1

Zosyn 3.375g IV, every 6 hr for acute diverticulitis

Pt was placed on cardiac monitor, no arrhythmias

Stool culture sent for C.diff

Diet=NPO +ice chips + D5.NS at 100ml/hr

Day Date Diagnostic Test Results

Day 2 10/01/2013 Surgical Pathology

1.Duodenum, Biopsy2. Stomach, Biopsy

3.GEJ, Biopsy

4. Colon, Biopsy (distal Sigmoid)5. Rectal Biopsy

1. Normal findings2. Mild inflammation,

negative for H-Pylori3. Epithelial changes

consistent with GERD

4. Normal findings

5. Normal Findings

CT Abdomen Pelvis 1. Unchanged appearance of acute diverticulitis of the sigmoid colon.

2. Contrast suggests colovaginal fistula

Diagnostic Tests and Results

• Medical Treatment, Day 2Diet= NPO+ Ice Chips+ D5.NS at 100ml/hr

Diagnostic Tests and Results

Day Date Diagnostic Test Results

Day 3 10/02/2013 Echocardiogram/ECHO Ejection fraction of 60% otherwise normal

Day 4 10/03/2013 Chest X-ray, PA and LAT Normal findings

Medical Treatment, Day 3, No acute findings

Gynocologist surgeon, the fistula may close on its own with bowel rest

Diet: NPO, started PSS/PPN

Zosyn continues

IV dilaudid for significant pain

D5.NS at 100ml/hr

Day 4 Diet: NPO +PSS/PPN, No acute findings

Day5 Diet: NPO +PSS/PPN, No acute findings

Day6 Diet: Breakfast: Full Liquid, Lunch: GI Soft, Dinner: Regular

No acute findings, Fistula presumed to have healed

Day7 Diet: Regular, Pt was discharged

Diet History• Eating a regular diet with no restrictions • Eating less lately, having nausea for ~3months• Drinking Vanilla Ensure once a day• Last Po intake= ½ of an apple, 2 days before admission• Cultural Attitudes that may affect intake: Non reported

Weight history• 12-13lbs weight loss in one month• BMI:44, morbidly Obese• UBW:294lbs

Physical Activity= Sedentary

Nutritional History

Estimated Nutrient needs

Obese Adults[(kg body weight -20] + 1.500 = 3,105 ml

Obese Adults[(kg body weight -20] + 1.500 = 3,105 ml

Initial Nutrition Consult: 10/01/2013Diagnosis, 10/01/2013

1-Inadequate energy-protein intake related to diet order as evidenced by pt NPOx2days with h/o limited intake PTA.

2- Involuntary weight loss related to decreased intake as evidenced by self reported 13lbs weight loss in a month PTA

Diet Recommendation:Advance pt diet to clear liquid and then to low residue /low fiber as tolerated.

Nutritional Treatment

Nutritional Interventions:• Recommend physician order a general low residue/low

fiber diet.• Add commercial beverage • provide diet education for diverticulitis and fistula

Nutritional goals • Goal1: Pt receive adequate PO/nutrition support within

next 1-2 days• Goal2: Achieve normal GI function• Goal 3: meet 70% Kcal and nutrient needs by next day• Goal 4: Pt will be able to describe why a diet is necessary

and list at least two foods to avoid or eat in limited amounts.

Nutritional Treatment

Diagnosis, 10/04/2013Inadequate energy-protein intake related to NPO/CLD x 5days as evidenced by diet order that does not meet estimated energy needs.

Diet Recommendation:Advance pt diet to clear liquid and then to low residue /low fiber as tolerated.

Nutrition Treatment:Follow up Assessment on 10/04/2013

Nutritional Interventions:• Recommend physician order a general low residue/low

fiber diet.• Add commercial beverage (Ensure x 1/d)• provide diet education for diverticulitis and fistula

Nutritional goals • Goal1: Pt receive adequate PO/nutrition support within

next 1-2 days• Goal 2: meet 70% Kcal and nutrient needs by next day• Goal 3: Pt will be able to describe why a diet is

necessary and list at least two foods to avoid or eat in limited amounts.

Nutritional Treatment

Diverticulosis:• A gastrointestinal disease that affects the colon• Disease of Western Civilization because of its geographic

preponderance• Rare in rural Africa and Asia, highest prevalence in the USA,

Europe and Australia• Caused 814,000 hospitalization and 2, 889 deaths(2010)

Diverticular disease:

• Diverticulosis=Presence of pouches(diverticulas) in the colon• Diverticulitis= when pouches become inflamed or infected (cause

of inflammation is not clear, may be fecal bacteria

Case Discussion

Risk Factors:• Age• Low fiber diet• Obesity• Sedentary life style• Note: MS is positive for all four of them

Symptoms:• Most common symptom= abdominal pain• May experience nausea, vomiting, fever, chills, loss of appetite

Diagnosis:• Most common diagnostic test= CT scan• Colonoscopy, digital rectal exam, blood test, stool sample

Case DiscussionDiverticulitis

Medical Treatment:• Intravenous antibiotics• Bowel rest

NPOClear liquid diet for few days adding soft solids regular diet)

• Colon resection for patients with recurrent, resistant DV

Nutritional Therapy (DV)• Focused on fiber intake and probiotic and prebiotic• To reduce the luminal trauma, avoid high-residue

foods( such as nuts, seeds, popcorn)Norte: Recent literature has indicated that these recommendations are controversial and that avoidance is not necessary

Case Discussion

Many clients use Complementary and Alternative Medications(CAM)

Common CAM therapies:Glutamin, omega-3 fatty acids, prebiotics, herbs,wild yam, marshmallow, chamomile, licoriceHomeopathyAcupuncture

Treatment

• Evidence suggesting that high fiber diet can help prevent diverticular disease is based largely on observational, epidemiological studies and few small clinical studies.

• Recent study found high fiber diet may increase the prevalence of diverticulosis.

• Not enough evidence to support general recommendation of low fiber diet during diverticulitis flare-ups

Implications of Findings

• New studies purport that pt may benefit from consumption of probiotic.

• Based on review of available research it is reasonable to recommend high-fiber diet until large scale, well conducted randomized controlled longitudinal studies demonstrate a clear benefit of failure of this practice

• Dietitians need to teach patients how to increase their fiber intake

Implications of Findings and Practice of Dietetics

References

Diverticular Disease: University of Maryland Medical Center. Source: http://umm.edu/health/medical/altmed/condition/diverticular-disease. Accessed November 11, 2013.

National Digestive Diseases Information Clearinghouse (NDDIC). Source: http://digestive.niddk.nih.gov/errors/404.aspx. Accessed December 13, 2013. 

Painter N, Burkitt D. Diverticular disease of the colon: A deficiency disease of Western civilization. BMJ. 1971; 2:450–454.

Diverticulosis and Diverticulitis: National Institute of Diabetes and Digestive and Kidney Diseases. Source: http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/. Accessed December 31, 2013.

Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004; 363: 631-639.

Brodribb AJ. Treatment of symptomatic diverticular disease with a high-fiber diet. Lancet 1977; 1: 664–66. 

Strate L, Yan L, Walid A, Sapna S, Edward L. Giovannucci. Obesity Increases The Risks Of Diverticulitis And Diverticular Bleeding. Gastroenterology. 2009; 136(1):115-122.

Tursi A. The current and evolving treatment of colonic diverticular disease. Alimentary Pharmacology & Therapeutics. 2009; 30: 532-546. 

Rees Carol. Diverticular Disease: Evidence for Dietary Intervention? Nutrition Issues In Gastroenterology. 2007; 47: 41-46.

Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999; 42: 470–475

Dietary Guidelines for Americans 2010: Fiber. Source: http://www.health.gov/dietaryguidelines/dga2010/dietaryguidelines2010.pdf. Accessed December 6, 2013

Academy of Nutrition and Dietetics, Nutrition Care Manual. Diverticular Conditions. https

://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145209&ncm_toc_id=33991&ncm_heading=Nutrition%20Care. Accessed January 29, 2014.

Thank You!

Questions