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Case Study on Diverticulosis

Patient Profile and Health History

The patient, Edna Meyer, is a 62 year old African American female who is 51 tall and

weighs 155 pounds. Her BMI is 29.3, meaning she is in the overweight category. She has

suffered from intermittent constipation for most of her adult life. She recently began to have

episodes of diarrhea and cramping in the lower left quadrant of the abdomen.

Patient is a homemaker and works out of her home as a seamstress. She lives with her

husband, who is 66, and has two granddaughters ages 13 and 15. Her highest level of education

is high school. She reports having a good appetite and enjoys cooking and baking. She has

trouble maintaining regular bowel movements and believes that her consumption of prune juice

and prunes has improved her regularity to some extent. Normal intake includes coffee, white

toast with butter and jam, and a fried egg for breakfast, soup or sandwich with coffee for lunch,

and meat with vegetables, rice or potatoes, bread or biscuits, and iced tea or coffee for dinner.

She has had no previous medical nutrition therapy. She purchases her own food and does not

take any vitamins or supplements. She has no food allergies or intolerances. She does not smoke

or consume alcohol or recreational drugs. Note that her diet is particularly low in fiber, fruits

and vegetables, and she consumes large amounts of coffee and tea daily. Her low fiber

consumption could be a contributing factor to the development of diverticulosis and increasing

fiber intake would be beneficial.

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Overview of Diverticulosis

Diverticulosis is a disease state in which the patient has diverticula, or small pockets in weak

areas of the colon wall. It is most prevalent in older adults, occurring equally in men and

women, and in half of people between the ages of 60 and 80.

Symptoms: Diverticulosis is usually asymptomatic. When symptoms do occur, it is called

diverticular disease. The symptoms of diverticular disease include constipation, cramps,

bloating, and painless bleeding from rectum. Diverticulitis is included in diverticular disease, but

is not the same as diverticulosis. Diverticulitis is the term used when the diverticula become

inflamed or infected, and it is painful. Symptoms of diverticulitis include pain that is usually on

the left side of the abdomen, fever, nausea, cramps, and constipation. There are a number of

possible complications including abscess, stricture, which is the narrowing of the colon,

perforation or tear of the colon, peritonitis or inflammation of he abdomen occurring after a

perforation, and fistula, which are abnormal connections between the colon and bladder, small

intestine, vagina, or skin. Fever and increased white blood cell count can be signs of

diverticulitis.

Diagnosis: Since diverticulosis is usually asymptomatic and painless, it is usually discovered

through a colonoscopy done for another reason. It can also be diagnosed through a barium

enema and x-ray. Computed tomography of the abdomen is usually how diverticulitis is

diagnosed.

Prevention: A high fiber diet is often very effective in the prevention of constipation and

therefore decreases the risk of the development of diverticulosis. Chronic constipation exerts a

great deal of pressure on the walls of the colon, causing the diverticula to form. This is likely the
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case for Mrs. Meyer, as she has had chronic constipation for most of her adult life and the

constant pressure on her colon walls likely led to the formation of diverticula.

Treatment: The treatment for diverticulosis is a high fiber diet, either through consumption of

fiber rich foods, or through the use of a fiber supplement. It was previously thought that the

patient should avoid tough, fibrous foods such as nuts and seeds and popcorn. They were told to

avoid these foods in order to prevent diverticula from becoming inflamed or clogged. It has been

proven that these foods do not cause an increased risk of diverticulitis, and patients are no longer

told to avoid them. There may actually be a decreased risk of developing diverticulitis in patients

who eat nuts, seeds, and popcorn more often.

If the patient develops diverticulitis, this can be treated at home with a liquid diet and

antibiotics if an infection is present. The patient would progress to a low fiber diet in this case,

to reduce symptoms of pain and bleeding. As symptoms subside, they could then gradually

progress to a high fiber diet. Severe symptoms may need to be treated in the hospital with

intravenous antibiotics, bowel rest, which means no eating or drinking, and possibly surgery.

Surgery is often a treatment that is used for recurrent diverticulitis or bleeding that will not stop.

Nutrition Assessment:

In the past 24 hours patient has had 3 episodes of rectal bleeding. She complained of bright red

blood in her stool and cramping in the lower left quadrant of the abdomen. She was diagnosed

with hypertension 3 years ago and takes 5 mg of lisinopril daily. Family history includes her

mothers death from ovarian cancer and her fathers death from colon cancer. She appeared

somewhat anxious upon her visit to the physician, but otherwise not in any apparent distress.

The physical exam revealed a body temperature of 98.8 degrees F, heart rate of 72 BPM, and

blood pressure of 120/82. Heart sounds are normal with clear S1 and S2, and no rub, murmur, or
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gallop. Eyes and nose were clear, and throat was supple with no adenopathy, thyromegaly, or

bruits. Her neurological function is normal, and she does not have edema. Chest and lungs are

clear. Abdomen is not tender or distended and bowel sounds are present throughout. Peripheral

pulses are palpable. All biochemical labs are within normal ranges.

EER: 1722 kcal/day, EPR: 70-85 grams protein/day

24 hour recall:

2 slices white toast with 3 teaspoons margarine, 2 teaspoons jelly

1/2 cup sliced prunes

black coffee

2 slices white bread with 1 oz ham, 1 T mayonnaise

2 oz potato chips

black coffee

2-3 oz pork chop (trimmed & fried in corn oil)

1 cup macaroni and cheese

1 biscuit

water

2 (1) slices of pound cake

1/2 cup vanilla ice cream

Current medications:

Patient is currently taking 5 mg Prinivil (lisinopril) daily. Lisinopril is an ACE inhibitor. ACE

inhibitors are vasodilators that work to reduce blood pressure. Drug/nutrient interactions that can

occur with ACE inhibitors include reduced absorption of B12 and reduced serum B12. A vitamin

B12 supplement either taken orally or through an injection would be useful at DRI levels. While
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taking ACE inhibitors, the patient must avoid using salt substitutes, as they can lead to

hyperkalemia since ACE inhibitors can cause potassium retention.

The current treatment plan is NPO, NG to low wall suction, D5NS at 50 cc per hour,

metronidazole 1g loading dose, then 500 mg q 6 h, and ciprofloxacin at 400 mg q 12 h.

Metronidazole and Ciprofloxacin are antibiotics which are being used to kill bacteria in the colon

that may be causing an infection in the diverticula. D5NS is a water solution of 5% dextrose in

normal saline, or .9% saline in water. It is given intravenously to hydrate the patient and provide

some calories from dextrose. Strict monitoring of intake and output has been recommended,

meaning the patients intake or fluid and food will be carefully monitored as well as her output

through urine and feces. Update: The hospital ruled out an upper GI bleed by performing an NG

aspiration, in which no blood was found. The colonoscopy was also performed and found no

active bleeding but numerous diverticula. The medical diagnosis is Diverticulosis with

evidence of lower GI bleed in sigmoid colon.

The patients energy needs have been calculated using the Harris Benedict equation, 1722 kcal

per day.

ADIME note

A: Patient is a 62 year old African American female.

Height: 51

Weight: 155 lbs

BMI: 29.3 (overweight)

EER:1722 Kcal/day

EPR: 70-85 grams protein/ day

Medications: 5mg lisinopril daily

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Medical dx: diverticulosis with evidence of lower GI bleed in sigmoid colon

D: Inadequate fiber intake(NI-5.8.5) as related to low intake of fruits, vegetables, legumes, and

whole grains as evidenced by 24 hour recall and numerous diverticula found in colon.

I: Recommend 1500kcal per day

Recommend 70-85 grams protein/day

Recommend avoiding caffeine

Recommend 20 grams of fiber daily, increasing to 45 grams as tolerated

Recommend at least 2100 mL fluid daily

Recommend at least 5 servings of fruits or vegetables daily

Recommend consuming at least half of grain products as whole grains

Recommend vitamin B12 supplement at DRI levels

Recommend 30 minutes of brisk walking daily

M/E: Monitor stool frequency and consistency

Monitor abdomen for pain and distention

Monitor for blood in stool

Monitor kcal count and fiber intake

Monitor body temperature

Long Term Plan:

Since the colonoscopy showed no evidence of current bleeding, the patient can progress from

NPO to a high fiber diet as tolerated. The patient should aim to consume 45 grams of fiber daily,

either in the form of high fiber foods, or in the form of a fiber supplement, if adequate fiber

cannot be consumed through food. A high fiber diet is being recommended because of the
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diagnosis of diverticulosis. The nutrition care manual recommends 6-10 grams more fiber for

diverticulosis patients than the normal recommended intake of 20-35 grams of fiber daily. It is

important to start with a lower amount of fiber and add more gradually to reduce cramping,

discomfort, diarrhea, or pain. It is also essential to ensure the patient is consuming adequate

fluid as fiber intake increases, to prevent bowel blockage. If the patient were diagnosed with

diverticulitis, a low fiber diet would be recommended to reduce pain and inflammation of the

diverticula until pain subsides, and then fiber would be increased as tolerated. High fiber foods

include whole grains, fruits, non starchy vegetables, and legumes. If the patient is unable to

consume sufficient fiber through food, a fiber supplement such as Citrucel, Fiberall, Benefiber,

or Metamucil may be used to meet fiber requirements. The patient should aim to consume at

least 5 servings of raw or cooked fruits or vegetables daily, and to consume at least half of grain

products as whole grains. Her 24 hour recall and usual dietary intake indicate that she consumes

bread and grain products at each meal, but none of them are whole grain. It s recommended that

she replaces as many of these as possible with whole grain alternatives, such as whole grain

bread, whole grain pasta, and brown rice instead of white rice. This will drastically increase her

fiber consumption without causing a large change in her normal preferred meals. Caffeine should

be avoided as this tends to irritate the GI tract and may worsen bouts of diarrhea. Her fluid intake

was mainly coffee and tea with very little water, and it is recommended that she eliminate as

many caffeinated beverages as possible and replace with water She should consume at least 2100

mL of fluid daily to help keep her bowel movements regular. This is based off of the calculation

30mL/kg weight. 1500 kcal per day is being recommended due to the patients BMI of 29.3.

70-85 grams of protein per day is recommended based on 1-1.2 grams of protein per kg of body

weight.
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Alternative Therapies:

Some research has shown benefit to adding probiotics and prebiotic supplements in the treatment

and prevention of diverticulosis. There is no research that has recommended any dose.

Probiotics are helpful bacteria reside in the gut which reduce the presence of pathogenic bacteria

and encourage healthy bowel movements. Prebiotic fiber is a form of fiber that can be fermented

by the helpful probiotics in the gut and provides a food source for them. Probiotics can be found

in many fermented foods including yogurt, kimchi, sauerkraut, miso, kefir, kombucha, and

tempeh. The patient could experiment with trying some of these foods in her diet. Prebiotic

fiber is often sold as a supplement or added to packaged foods such as protein bars and granola

bars. Probiotics and prebiotics may also be helpful to this patient since she is taking 2 antibiotics

to kill harmful bacteria in her colon. This will have killed the pathogenic bacteria as well as the

helpful probiotics. Adding probiotics to her diet after she has finished with these antibiotics will

help replenish her healthy gut flora and then adding prebiotics will provide a food source for

them to keep them alive. Studies have shown that probiotics can help reduce the duration of

infectious diarrhea, but this has been shown mostly in children, and there is no evidence to

confirm which specific probiotics are helpful. Adding probiotics to this patients diet may be

worth trying if she has sufficient finances to pay for these products. It is unlikely to cause any

adverse affects.

Case Study questions

1. What are the possible complications of diverticulosis?

Complications of diverticulosis include infection of the diverticula, bloody stool, and

pain/cramping in the abdomen. The major complication from diverticulosis is the progression to

diverticulitis which is when the diverticula become infected and inflamed. Diverticulitis can
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cause nausea, abdominal pain and cramping, bloody stools, fever, and elevated white blood cell

count. Complications of diverticulitis can include sepsis and abscess which may require surgical

resection of the colon.

5.Research indicates that a low fiber intake may be related to the development of diverticulosis.

That is the optimal fiber intake for Mrs. Meyer? What guideline would you use to determine this

optimal fiber intake? The recommended fiber intake for the average adult is 20-35 grams of

fiber daily. Since she has been diagnosed with diverticulosis, it would benefit her the most to

have a higher fiber intake. The nutrition care manual recommends 6-10 grams more fiber than

the general recommendation of 20-35 grams per day. For this reason, 45 grams daily is being

recommended for this patient. It is important to add fiber gradually to minimize discomfort,

pain, or diarrhea.

6. What are the recommendations for percentage of calories from carbohydrate, protein, and fat

for Mrs Meyer? What guideline did you use and why?

The percentage of calories from fat is 20%, from carbohydrates is 57%, and from protein is

23%. This was based on the recommendation for the patient to eat 1500 kcal's daily and 70-85

grams protein. 85 grams of protein was used and is 340 kcal's from protein, or 23% of kcals. Fat

was calculated at 20% of kcal, which is 33 grams of fat or 300 kcal from fat. The remainder of

the kcal are from carbohydrate which was 860 kcal from carbohydrate, 215 grams of

carbohydrate, or about 57% of total kcal. This is based on the AMDR guidelines of 50-65%

calories from carbohydrate, 10-35% of calories from protein, and 20-35% of calories from fat.

Fat was kept lower as she is overweight and fat is the most calories dense macronutrient. Cutting

out some fat will help to lower her total calories.

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9.Mrs Meyer is currently on clear liquids. What diet would you recommend for her to progress

to while she is in the hospital?

If Mrs. Meyer is currently on a clear liquid diet, the recommendation would be that she progress

to a high fiber diet gradually since her diagnosis is diverticulosis, rather than diverticulitis. Had

she been diagnosed with diverticulitis, the recommendation would have been a low fiber diet

until her pain and inflammation were gone. Progressing to the high fiber diet while she is still in

the hospital will be beneficial to her because her tolerance of the diet will be monitored and the

diet can be adjusted while still in the hospital if needed. The general recommendation for adults

for fiber is 25-35 grams per day, so she could begin with 25 grams per day and progress to 35

grams as tolerated, as long as there is no abdominal pain or diarrhea.

12. Dr, Greer has suggested that Mrs. Meyer take Fiberall, Benefiber, or Metamucil to increase

her fiber intake. What are these medications and how might they help?

The fiber supplements recommended to Mrs. Meyer by her doctor are Fiberall, Metamucil, or

Benefiber. There are different types of fiber supplements that are available in most drugstores.

Most of them are available in a powder that can be stirred into water, juice, or any beverage.

Benefiber has guar gum as the fiber source, and Metamucil and Fiberall have psyllium as the

fiber source. These are all soluble fibers that may help improve the regularity and consistency of

her stools, as well as helping to keep food moving through the colon and preventing it from

becoming stuck in the diverticula and causing inflammation and infection.

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References

Allen, S., Martinez, E., Hregorio, G., & Dans, L. (2010). Probiotics for treating acute infectious
diarrhoea. Cochrane.

Diverticular disease. (n.d.). Retrieved March 27, 2017, from

http://umm.edu/health/medical/altmed/condition/diverticular-disease

Nutrition Intervention - Nutrition Care Manual. (n.d.). Retrieved March 27, 2017, from
https://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=268930

Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci EL. Nut, Corn, and Popcorn
Consumption and the Incidence of Diverticular Disease. JAMA. 2008;300(8):907-914.
doi:10.1001/jama.300.8.907

Thompson AE. Diverticulosis and Diverticulitis. JAMA. 2016;316(10):1124.

doi:10.1001/jama.2016.3592
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