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Medical and Nutritional Therapy for Acute Diverticulitis and Sigmoidovaginal Fistula

Vehik Nazaryan Dietetic Intern University of Maryland College Park January, 30, 2014


Overview 

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

  


Introducition 

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


Social History 

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


Past Medical 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

Barrett’s Esophagus


Surgical History • Total abdominal Hysterectomy (1995) • Cholecystectomy (1975) • Abdominal Hernia Repair (1990) • Bilateral cataract Surgery (2011 and 2013) Urinary Tract History


Urinary Tract History 

Esophagogastroduodenoscopy + colonoscopy demonstrated no colovesical fistula caused by diverticulitis

Pt denies

• Hematuria, • Urinary urgency, frequency or dysuria.


Home Medications 

MS was admitted with following medications: • Zantac 300mg, BID • Pravachol 40mg, daily • Neurontin 400mg BID • Escitalopram 20mg,


Physical Examination 

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 • • • • • • •


Diagnostic Tests and Results Day

Date

Day 1

09/30/2013

Diagnostic Test

Results

1.Chest, PA and LAT 1.No active pulmonary disease 2.Esaophagogastroduodenoscopy plus colonoscopy

• 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

2. Acute diverticulitis


Diagnostic Tests and Results Day Day 2

Date 10/01/2013

Diagnostic Test

Results

Surgical Pathology 1.Duodenum, Biopsy 2. Stomach, Biopsy 3.GEJ, Biopsy

1. Normal findings 2. Mild inflammation, negative for H-Pylori 3. Epithelial changes consistent with GERD

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

4. Normal findings

CT Abdomen Pelvis

1. Unchanged appearance of acute diverticulitis of the sigmoid colon. 2. Contrast suggests colovaginal fistula

5. Normal Findings

• Medical Treatment, Day 2 ďƒź Diet= 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


Nutritional History 

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


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


Nutritional Treatment Initial Nutrition Consult: 10/01/2013 Diagnosis, 10/01/2013 ďƒ˜

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.


Nutrition Treatment: Follow up Assessment on 10/04/2013 Diagnosis, 10/04/2013 Inadequate 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.


Nutritional Treatment 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.


Case Discussion 

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 Diverticulitis 

• • • • •

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 Discussion Medical Treatment: • Intravenous antibiotics • Bowel rest NPOClear 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


Treatment 

Many clients use Complementary and Alternative Medications(CAM)

Common CAM therapies:

 Glutamin, omega-3 fatty acids, prebiotics, herbs,  wild yam, marshmallow, chamomile, licorice  Homeopathy  Acupuncture


Implications of Findings • 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 and Practice of Dietetics • 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


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!


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