Diverticulitis - Nursing Case Study

Pathophysiology

• Primary mechanism: Diverticulitis arises when small pouches (diverticula) formed due to pressure on weak spots in the colon's wall become inflamed or infected. This inflammation is typically caused due to waste getting trapped in these pouches, leading to bacterial growth and subsequent infection and inflammation.

• Secondary mechanism: Chronic inflammation leads to formation of scar tissue, which can result in bowel obstruction. This obstruction can cause severe pain, constipation, and distention. Furthermore, if the infected diverticula rupture, it can lead to peritonitis, a life-threatening condition that requires immediate medical attention.

• Key complication: Abscess formation is a serious complication of diverticulitis. An abscess occurs when pus collects within the inflamed diverticulum, leading to more severe abdominal pain and potentially sepsis if left untreated. Another crucial complication is the formation of fistulas, abnormal connections between different parts of the

Patient Profile

Demographics:

67-year-old, female, retired nurse

History:

• Key past medical history: Diagnosed with hypertension, Type 2 Diabetes Mellitus, and Celiac disease; history of alcohol abuse

• Current medications: Metformin, Lisinopril, and a gluten-free diet

• Allergies: Penicillin, Sulfa drugs

Current Presentation:

• Chief complaint: Severe abdominal pain and bloating

• Key symptoms: High fever, nausea, vomiting, constipation, bloody stools, loss of appetite

• Vital signs: Blood pressure 165/95, Pulse rate 120, Respiratory rate 26, Temperature 102.3°F, Oxygen saturation 92%

Section 1

New Diagnostic Results:

Upon laboratory testing, the patient's white blood cell count was elevated at 18,000/mm3, indicating an active infection. Her Hemoglobin A1c was 8.3, suggesting poorly controlled diabetes. Additionally, her liver function tests were mildly elevated, with an AST of 50 U/L and ALT of 60 U/L, which may be related to her history of alcohol abuse.

A CT scan of the abdomen revealed an abscess in the sigmoid colon, supporting the diagnosis of diverticulitis. The abscess measures 3.5 cm, and there is also evidence of bowel wall thickening and inflammation. The scan further revealed a suspicion of a fistula formation between the sigmoid colon and bladder, indicating a possible complicated diverticulitis.

This new information complicates the patient's case as the abscess will need to be drained, and the fistula may require surgical intervention. Additionally, the patient's poorly controlled diabetes and history of alcohol abuse can further complicate her recovery and increase her risk of other complications. Considering the patient's allergy to Penicillin and Sulfa drugs, alternative antibiotics should be carefully selected for treatment. This situation requires advanced critical thinking to manage the multiple complexities appropriately while ensuring the patient's safety.

Section 2

Change in Patient Status:

Over the next 24 hours, the patient's condition deteriorated. Her blood glucose levels spiked to 300 mg/dL despite sliding-scale insulin administration, and her temperature spiked to 38.9 degrees Celsius, indicating ongoing infection. The patient reported increasing abdominal pain, rated at 8/10 on the pain scale, and more frequent episodes of urgency and discomfort during urination, suggesting the possible progression of the fistula.

Her latest blood work showed further elevation in her white cell count to 22,000/mm3 and increased liver enzymes with an AST of 75 U/L and ALT of 85 U/L. A repeat CT scan showed enlargement of the abscess to 4.5 cm and increased bowel wall thickening. The patient's worsening clinical picture, coupled with the escalation in her lab values and CT findings, suggest a rapid progression of her diverticulitis and potential sepsis. The team will need to reassess her treatment plan urgently to prevent further deterioration. This situation calls for advanced clinical reasoning to balance the management of her complicated diverticulitis, poorly controlled diabetes, and escalating liver values, all while considering her drug allergies.

Section 3

New Diagnostic Results:

As part of the diagnostic workup, an emergency colonoscopy was performed, revealing multiple diverticula with signs of severe inflammation and rupture. The colonoscopy also showed a fistula between the sigmoid colon and bladder. Her urine analysis revealed the presence of fecal matter, providing further evidence of the suspected colovesical fistula. In addition, a liver function test was ordered due to her elevated liver enzymes. Results indicated the presence of a non-alcoholic steatohepatitis, a progressive liver disease.

The patient's HbA1c was also checked due to her uncontrolled blood glucose levels, and it was found to be at 9.5%, indicating poor long-term glycemic control. A random blood glucose test showed an alarming value of 400 mg/dl, signifying hyperglycemia. Her glycosylated hemoglobin levels and blood glucose spike indicate that her diabetes management needs to be reassessed.

These new diagnostic results further complicate the patient's medical situation. The team now has to manage a complicated diverticular disease with a fistula, uncontrolled diabetes, and a progressive liver disease. This requires an interdisciplinary approach, involving the gastroenterologist, endocrinologist, and hepatologist to formulate a comprehensive plan to manage her diverse conditions. It is crucial to balance the patient's urgent need for surgical intervention for the diverticulitis and fistula, with the potential risk posed by her unstable glucose levels and liver disease. This will require advanced clinical judgment and critical thinking.

Section 4

New Complications:

Over the next few days, the patient's condition deteriorated. She became increasingly confused and lethargic, and also developed a low-grade fever of 100.4°F. Her vitals displayed tachycardia with a heart rate of 110 beats per minute and hypotension with a blood pressure reading of 90/60 mmHg. Her respiratory rate was also elevated at 22 breaths per minute, indicating possible respiratory distress. Laboratory results revealed a significantly elevated white blood cell count of 18,000 cells/mcL, suggestive of a systemic infection.

The patient's liver function tests showed a further increase in liver enzymes, and a coagulation profile revealed a prolonged prothrombin time of 16 seconds and an INR of 1.5, indicating an impaired ability to form blood clots. Blood glucose levels remained extremely high at 420 mg/dl despite insulin therapy, and she was also found to have significant ketones in her urine, suggesting that she was in diabetic ketoacidosis.

These new complications pose a serious threat to the patient's health. The combination of her worsening infection, deteriorating liver function, and poorly controlled diabetes has resulted in a critical situation. The team must act quickly to stabilize her condition, and adjust her management plan to better control her multiple health issues. This complex case requires careful monitoring and a high level of clinical reasoning to manage her evolving health status.

Section 5

New Diagnostic Results:

The patient's condition continued to decline, prompting the healthcare team to order more extensive diagnostic tests. An abdominal CT scan revealed diffuse wall thickening of the sigmoid colon with signs of perforation, giving credence to the suspicion of a complicated diverticulitis. An additional finding was the presence of free air and fluid in the abdominal cavity, indicative of a perforated bowel. This explained the elevated white blood cell count and fever, as these are signs of peritonitis, a severe abdominal infection.

The patient's blood cultures came back positive for Escherichia coli and Bacteroides fragilis. In addition, her arterial blood gas (ABG) showed a pH of 7.28, PaCO2 of 35 mmHg, PaO2 of 60 mmHg, and bicarbonate level of 16 mEq/L, confirming the presence of metabolic acidosis likely due to the diabetic ketoacidosis. Her anion gap was also significantly elevated at 20 mEq/L, further supporting this diagnosis.

These new findings paint an alarming picture of the patient's current health status. Not only is she suffering from a severe systemic infection due to the diverticulitis and bowel perforation, but she is also grappling with uncontrolled diabetes that has progressed to diabetic ketoacidosis. The healthcare team will need to adjust her treatment plan immediately to address these life-threatening complications. This could include surgical intervention for the bowel perforation and aggressive management of her diabetes and infection. This complex situation requires the utmost clinical reasoning and decision-making skills from the healthcare team.