Diverticulitis Case Study

Patient : Mrs. C

Age : 74 years old

History of Presenting Complaint

Mrs. C was seen at the surgery on 03/09/09 complaining of changes in bowel habits. She noticed her bowel habits had become more erratic over the last few months, where she had episodes of diarrhoea alternating with constipation. In the past, she used to have problems with chronic constipation. She also noticed bright red blood in her stools which normally came towards the end of defeacation. There was no mucus in her stools, malaena, pain noted on defeacation. She complained of left iliac fossa pain which came intermittently and mostly relieved upon defeacation. Despite having tenesmus and increasingly aware of passing flatus, there was no faecal incontinence. She agreed that her haemorrhoids had become more problematic recently. But, did not notice any peri-anal ulceration.

She denied any weight loss, changes in appetite, indigestion, heartburn, haematemesis or nausea/ vomiting. She did not complain of urinary symptoms (e.g. dysuria, haematuria, frequency, urgency, incontinence, etc).

She had some problems with stiff joints mainly in her wrists, hands, knees and ankles, which were worse in the morning. She has a history of rheumatoid arthritis. Occasionally, her joints would flare up and become swollen, erythematous and painful. At present, she did not complain of any joint problems as the anti-rheumatoid medications and analgesics provided symptomatic relief and remission of her RA. However, the co-codamol does not help with her constipation.

Past Medical History

• RA
• Chronic constipation
• Hyperlipidaemia
• Dyspepsia
• Dupuytren’s disease and thickening of Archilles tendon

Drug History

NKDA

Medication

Dosage

Frequency

Movicol

Daily

Lactulose

10ml

BD

Leflunamide

10mg

OD

Hydroxychloroquine

200mg

OD

Co-codamol

8/500mg

BD

Daktacort cream

Omeprazole

20mg

OD

Folic acid

5mg

OD

Salbutamol inhaler

100mg

2puffs BD

Sulfasalazine

500mg

OD

Proctosedyl suppositories

Family History

No significant family history.

Social History

Lives with her family. Does not smoke. Drinks occasionally.

Systemic Enquiry

Neurological

None to note.

Cardiovascular

None to note.

Respiratory

None to note.

Gastrointestinal

See above

Genitourinary

None to note. No dysuria, polyuria or haematuria.

Haematological

None to note. No fevers or rigors

Musculoskeletal

See above.

Endocrine

None to note. No polydipsia or polyuria.

Reproductive

No sexual dysfunction.

RELEVANT PHYSICAL EXAMINATION

General Inspection

• Not distressed
• Alert and not-lethargic
• Not breathless
• Apyrexial
• Not cushingoid

Gastrointestinal Examination

Inspection

Skin

Hands and nails

Eyes

Mouth

Chest

Abdomen

No jaundice/ skin-pallor

No generalised skin pigmentation of haemosiderin

No palmar erythema / Non-pallor palmar creases

Presence of dupuytren’s contracture on both hands

No asterixis

No finger clubbing, leuconychia, koilonychia

Non jaundiced eyes

No Kayser-Fleischer rings (brownish green rings)

Presence of corneal arcus

Good oral hygiene

No glossitis or angular stomatitis or ulceration

No spider naevi

No scars but striae present

No visible engorged veins or visible peristalsis or arterial pulsation

No caput medusae/ No Cullen’s (blue discolouration of umbilicus)/ No Grey-Turner’s sign (blue discolouration of flank)

Symmetrical movement of the abdomen with respiration

Palpation

Neck

Gentle palpation

Deep palpation

Liver

Spleen

Kidney

No enlarged supraclavicular lymph node

No tenderness/ guarding

No abnormal masses or organomegaly

Soft, regular liver edge, not enlarged or tender, non-pulsatile

Not enlarged

Non-palpable

Percussion

Liver

Spleen

Shifting dullness

Normal liver span (<13 cm)

No dullness on complete expiration (no splenomegaly)

Absence of shifting dullness (no ascites)

Auscultation

Bowel sounds increased

PR examination was not done. However, would expect to find piles if PR was performed.

Summary of problems

Mrs. C presented with chief complaint of alternating bowel habits, bright red blood in stools and increasing awareness of passing flatus. It is important to rule out the more sinister colorectal carcinoma especially in the older aged group patients like Mrs. C and particularly when she had been having chronic constipation in the past. It was encouraging that she did not have any weight loss and changes in her appetite.

Differential Diagnosis

*The most likely differential for Mrs. C’s case is bolded.

Differentials of change in bowel habits:-

Change in diet – low fibre/ decreased fluid intake

Inflammatory bowel disease (Crohn’s/ ulcerative colitis)

Diverticular disease

Colorectal carcinoma

Irritable bowel syndrome

Drug-induced

Constipating drugs – opiods, antihypertensives, aluminium alkali

Purgative dependence

Metabolic disturbances

Hypothyroidism/ hyperthyroidism

Hypercalcaemia/ hypokalaemia

Neurological – cerebral or spinal cord lesion e.g. post-stroke (abnormal sphincter tone/ anal sensation (unlikely in Mrs. C’s case)

Differentials of passage of blood per rectum:-

Bleeding haemorrhoids (bright red commonly, soiling pan following defeacation)

Anal fissure

Diverticulitis

Colorectal carcinoma

Inflammatory bowel disease

Massive upper GI bleed

Meckel’s diverticulum

Trauma

Ischaemic colitis, infectious colitis, angiodysplasia

Recent Investigation and Results:

Sigmoidoscopy (done on 11/08/09)

Sigmoid diverticulosis at (a)

(a)

Management plan:

Mrs. C was found to have diverticular disease on sigmoidoscopy which was done last month. Her PR bleed is highly likely due to her haemorrhoids. Giving her a compound haemorrhoidal preparation containing corticosteroids and LA would hopefully help to relieve her symptomatic haemorrhoids.

If the piles do not improve, it may be an option to consider rubber band ligation, infra-red coagulation, sclerosants, cryotherapy or haemorrhoidectomy if the piles become persistently prolapsed.

To address her alternating diarrhoea and constipation would be difficult especially when she has diverticulosis. It takes time for the patient to adjust to the right dose of laxative combined with diet modification.

Reflective Commentary: Diverticular disease (DD)

A diverticulum is defined as an outpouching of the bowel wall.[1] Diverticulosis is when diverticula are present and diverticular disease is when diverticula is symptomatic. Diverticulitis happens when the diverticulum is inflamed.[2] Diverticula may either be congenital or acquired and can arise in any part of the bowel. Commonly, they occur in the colon in patients over 50 years old. They are frequently found in the sigmoid and descending colon. Passing from left to right side of colon, they reduce in occurrence.

DD is associated with low fibre diet. Diets low in fibre usually do not distend the colon, allowing high pressure in the lumen to develop resulting in outpouching at site of weakness.

Diverticulitis

Diverticulitis occurs when the neck of the diverticulum becomes obstructed. [1] This can lead to perforation into:- [3]

1) general peritoneal cavity to cause generalized peritonitis

2) the pericolic tissues with formation of pericolic abscess

3) adjacent structures (e.g. bladder, small bowel, vagina) forming a fistula.

Signs and symptoms

In 95% of cases, diverticulosis is asymptomatic in 95%. No treatment other than dietary advice is indicated in these patients.

Acute Diverticulitis

Known as “left-sided appendicitis” [2] – acute onset of low central abdominal pain, which shifts to LIF

Fever + tachycardia

Vomiting

Constipation

Local tenderness and guarding

Vague mass in LIF and also on rectal exam

Perforation into peritoneal cavity causes peritonitic abdomen (rigid board like)

Pericolic abscess may mimic appendix abscess but on left side – a tender mass + swinging fever + leucocytosis

Chronic Diverticular Disease

Presents with erratic bowel habits and intermittent LIF pain. It may also mimic features of colorectal CA:- [2]

Large bowel obstruction or small bowel obstruction.

Blood and mucus per rectum – episodes of severe pain in LIF, passage of mucus/ bright red blood/ maleana/ anaemia due to chronic occult blood loss.

Thickened mass in sigmoid colon felt per rectum.

How this case relates to the GMC themes in ‘Tomorrow’s Doctors’:

Theme 2: Treatment

Investigations

Blood test – neutrophilia, raised ESR/CRP.

USS – thickened bowel and large pericolic collections, but less sensitive than CT.

Barium enema

Sigmoidoscopy

Colonoscopy

Spiral CT of lower abdomen – gives additional information about colonic wall thickening, fistula formation,etc.

Treatment [2]

Acute diverticulitis

Mild attacks can be managed at home with bowel rest (fluids only) + antibiotics.

If oral fluids/ pain cannot be tolerated, admit to hospital for analgesia, NBM, fluids, antibiotics (cefuroxime + metronidazole until culture results available).

General peritonitis – manage as an acute abdomen. At lapartomy, Hartmann’s procedure may be done.

Pericolic abscess – initially this can be treated conservatively similar to appendix abscess. But if enlarging, drainage is often required.

Chronic diverticular disease

If symptoms are mild, conservative treatment is often preferred. Bowels should be regulated by lubricant laxative and high fibre diet. If symptoms are severe or if carcinoma cannot be excluded, laparotomy and resection of the sigmoid colon is indicated.

Summary

Mrs. C’s diverticular disease is producing mild to moderate symptoms of erratic bowel habits and probable occasional bleeds which is hard to determine for certainty as she has ongoing haemorrhoids trouble. It is important to recheck her haemoglobin levels from time to time to ensure that she is not having long-term occult bleed. If her problems of erratic bowel habits and PR bleed persist, it is important to perform more detailed investigations (e.g. colonoscopy / CT of lower abdomen) to rule out any possibility of colorectal CA which may co-exist with diverticular disease. This may mean a laparotomy with sigmoidectomy if the condition aggravates.