Yamini Prakash

Chief Dietician, Department of Clinical Nutrition and Dietetics, Kauvery Hospital, Chennai

*Correspondence: +91 94865 93999; E-mail: [email protected]

Nutrition care process for Sigmoid Diverticulitis

Background

Diverticulitis (inflammation) develops when bacteria or other irritants are trapped in the pouches, causing spasm and pain in the lower left side of the abdomen, as well as distention, nausea, vomiting, constipation or diarrhea, chills, and fever. Bowel cancer has been associated with the presence of diverticular disease.

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Symptoms and signs

The signs and symptoms of diverticulitis include:

  • Pain – which may be constant and persist for several days. The lower left side of the abdomen is the usual site of the pain. Sometimes, the pain may occur on the right side of the abdomen.
  • Nausea and vomiting.
  • Fever
  • Abdominal tenderness.
  • Constipation or, less commonly, diarrhea.

Risk Factors

Several factors may increase the risk of developing diverticulitis;

  • Aging; the incidence of diverticulitis increases with age
  • Obesity: Being seriously over weight increases the odds of developing diverticulitis
  • Smoking: people who smoke cigarettes are more likely than non-smokers to experience diverticulitis.
  • Lack of exercise; vigorous exercise appears to lower the risk of diverticulitis.
  • Diet high in animal fat and low in fibre. A low fibre diet in combination with a high intake of animal fat seems to increase risk.
  • Several drugs are associated with an increased risk of diverticulitis, including steroids and opioids.

Case Presentation

A 62 year old male with k/c/o sigmoid diverticulitis, post Hartmann’s procedure for sigmoid diverticulitis, post polypectomy on pedunculated polyp in sigmoid colon, had been admitted for further management.

Past History

The patient was known to a have Hypertension and history of CAD and Stroke.

Surgical Management

Colonoscopy was planned, the patient had already undergone Laparotomy, Anastomosis, Re- laparotomy and Tracheostomy.

Nutrition Care Process

1. Anthropometric Data

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2. Biochemical Data

DAYS DATE Urea Creatinine Na K+ Cl2 HCo3 Sr. Uric acid
DOA 12/6/2021
Day 1 12/7/2021 141 4.1
Day 2 12/8/2021
Day 3 12/9/2021 32.4 1.22 140 4.4 104 20.6
Day 4 12/10/2021 39.7 1.08 139 4.5 105 22.6 5.69
Day 5 12/11/2021
Day 6 12/12/2021
Day 7 12/13/2021 37.4 0.85 138 4.2 103 21.7
Day 8 12/14/2021 49.4 0.86 142 4 105 19.3 4.93
Day 9 12/15/2021 78.9 1.63 142 4.6 107 17.4 7.17
Day 10 12/16/2021 75.2 1.32 144 4.5 108 17.1 7.54
Day 11 12/17/2021 93.1 1.3 147 4.4 109 18.6 7.91
Day 12 12/18/2021 109.2 1.19 150 4 113 17 8.45
Day 13 12/19/2021 93.3 1.14 155 4.4 116 17.7 6.88
Day 14 12/20/2021 85.7 1.11 158 4.1 120 19.8 6.11
Day 15 12/21/2021 72.6 0.95 159 3.7 121 19.8 4.55
Day 16 12/22/2021 145.9 2.64 158 6.1 121 17.5 7.38
Day 17 12/23/2021 198.7 4 154 4.6 119 16 7.99
226.9 4.57 153 3.7
Day 18 12/24/2021 159.2 3.53 147 3.6 113 14.8 5.24
Day 19 12/25/2021 126.5 3.26 139 3.6 104 15.7 4.12
Day 20 12/26/2021 166.3 4.56 138 3.9 105 20 5.55
Day 21 12/27/2021 129.9 3.97 137 4.1 105 19.3 4.72
Day 23 12/29/2021 131 4.18 140 4 105 18.1 5.07
Day 24 12/30/2021 190.1 6 137 4.1 105 18.3 7.95
Day 25 12/31/2021 115 4.11 139 3.2 104 20.9
Day 26 1/1/2022
Day 27 1/2/2022 97.3 4.03 138 4.2 105 19.8 5.4
Day 28 1/3/2022 142.5 5.65 138 3.9 105 15 7.9
Day 30 1/5/2022 142.5 5.65 138 3.9 105 15 7.9
Day 31 1/6/2022 70.5 3.79 138 3.5 104 21.8 4.04
Day 32 1/7/2022
Day 34 1/9/2022
Day 35 1/10/2022 166.2 5.73 136 3.4 104 15.6 6.57
Day 37 1/12/2022 145.2 5.15 3.3
Day 42 1/17/2022 121.9 3.71 135 5.1 110 14.7 6.35
Day 45 1/20/2022 117.6 2.41 136 4.6 108 17.7 6.34
Day 47 1/22/2022 98.5 1.6 133 4.3 106 6.65
Day 48 1/23/2022
Discharge 1/24/2022
Date Bilirubin-T Bilirubin-D Bilirubin-I SGOT (AST) SGPT T.Protein Albumin Globulin Sr.Al Phosphatase
12/15/2021 2.9 2.02 0.88 48.4 22.6 5.34 2.7 2.64
12/17/2021
12/18/2021 5.22 3.92 1.3 118.9 37.8 5.73 3.07 2.66 40.9
12/25/2021 2.73 2.07 0.66 115 60.5 4.27 1.97 2.3
1/6/2022 1.47 0.99 0.48 58.9 33.4 6.8 2.43 4.37 210.1

Clinical Data

Chief Complaints  Sigmoid Diverticulitis with Post Hartmann’s Procedure and Pedunculated Polyp in Sigmoid Colon
Diagnosis  Sigmoid diverticulitis
History of past illness HTN, stroke, CAD
Plan of treatment  Surgical management

Post hartmann’s surgery, laparotomy- anastomosis, relaparotomy, tracheostomy.
Clinical appearance Eyes, hair, nails, skin, mouth, lips and extremities – normal
Personal diet history Non – smoker, non-alcoholic, high consumption of bakery products
Diet habit 

Food allergy

 Non – vegetarian

nil
Subjective global assessment  Well-nourished but at risk & well built

PES STATEMENT

Problem Etiology Symptoms
Inadequate fibre intake

Related to

 High consumption of bakery products

As evidenced by

 Patients diet history and diverticula found in colon
Altered biochemical parameters Medical condition of the patient Elevated renal parameters

( urea, creatinine, sodium)
Altered GI functions diverticulitis Abdominal pain& bloating

Medical Nutrition Therapy:

  • Energy: To provide adequate calories to maintain optimal body weight.
  • Carbohydrate: To provide moderate carbohydrate to prevent protein catabolism.
  • Protein: To provide high protein in order to aid in tissue repair and growth.
  • Fat: To provide moderate fat to aid in optimal growth.
  • Fibre: Limit the intake of fibre; fibre intake can be increased gradually to promote satiety.
  • Fluids: To provide liberal fluids to maintain hydration status
  • Probiotics: Adequate probiotics are effective in the management of this disorder

Nutrition Care Process

DOA: 06-12-2021 @ 11.50 PM      
DAYS DATE TYPE OF DIET ENERGY(kcal) PROTEIN(g) REMARKS
Day 2 12/7/2021 NPO 0 0 Pre-operative
Day 3 12/8/2021 NPO 0 0 Procedure done -Laprotomy colorectal; Anastomosis
Day 4 12/9/2021 NPO 0 0 Post-operative (Day-1)
Day 5 12/10/2021 NPO 0 0 Post-operative (Day-2)
Day 6 12/11/2021 NPO 0 0 Post-operative (Day-3)
Day 7 12/12/2021 Oral Clear liquid diet @ 30ml/hr 120 8  
Day 8 12/13/2021 Oral Clear liquid diet 150 9  
Day 9 12/14/2021 Oral Clear liquid diet 150 9  
Day 10 12/15/2021 NPO 0 0 Procedure done-Relaprotomy
Day 11 12/16/2021 NPO 0 0 Post-operative (Day-1)
Day 12 12/17/2021 NPO 0 0 Post-operative (Day-2)
Day 13 12/18/2021 NPO 0 0 Post operative (Day-3); Suggested TPN @ 50ml/day
Day 14 12/19/2021 TPN @ 45ml/hr; Total volume: 630ml 703 32 TPN initiated
Day 15 12/20/2021 TPN @ 45ml/hr ; Total volume:1080ml 1205 55  
    RT feed @ 10ml/hr; Total volume: 110ml 112 5 RT feed initiated
    TOTAL 1317 60  
Day 16 12/21/2021 TPN @ 45ml/hr; Total volume: 630ml 703 32 C/O RT Aspiration – 1000ml; Stopped TPN and RT feed
    RT feed @ 20ml/hr; Total volume: 300ml 306 12  
    TOTAL 1009 44  
Day 17 12/22/2021 NPO due to RT aspiration 0 0 RT feed stopped – 250ml RT aspiration
Day 18 12/23/2021 TPN @ 50ml/hr; Total volume: 250ml 275 12.5 TPN stopped and RTH initiated
RTH feed @ 30ml/hr; Total volume: 480ml 720 30 SLED x 6 hour
    TOTAL 995 42.5  
Day 19 12/24/2021 NPO 0 0 Procedure done-Tracheostomy; SLED x 6 hour
    RT feed @ 40ml/hr followed by 50ml/hr; Total volume: 710ml 604 24 RT feed initiated [4pm]
Day 20 12/25/2021 RT feed @ 50ml/hr followed by 70ml/hr; Total volume: 1380ml 1257 49  
Day 21 12/26/2021 RT feed @ 70ml/hr; Total volume: 1540ml 1402 55 Hemodialysis
Day 22 12/27/2021 RT feed @ 70ml/hr; Total volume: 1400ml  1275 50  
Day 23 12/28/2021 RT feed @ 70ml/hr followed by 100ml/hr; Total volume: 1670ml 1737 67 Hemodialysis
Day 24 12/29/2021 RT feed @ 100ml/hr followed by 50ml/hr; Total volume: 1600ml  1600 77  
Day 25 12/30/2021 RT feed @ 50ml/hr; Total volume: 1000ml 1777 86 Hemodialysis
Day 26 12/31/2021 RT feed @ 50ml/hr; Total volume: 760ml 1351 65  
Day 27 1/1/2022 RT feed @ 30ml/hr; Total volume: 600ml 1066 51 Hemodialysis
Day 28 1/2/2022 RT feed @ 30ml/hr followed by 50ml/hr; Total volume: 780ml 1386 66  
Day 29 1/3/2022 RT feed @ 50ml/hr; Total volume: 950ml 1688 81.2 Hemodialysis
Day 30 1/4/2022 RT feed @ 50ml/hr followed by 70ml/hr; Total volume: 1100ml 1238 53.1  
Day 31 1/5/2022 RT feed @ 70ml/hr followed by 100ml/2nd hrly ; Total volume:1200ml 1689 72 Shifted from ICU to 511
Day 32 1/6/2022 RT feed @ 100ml/2nd /hrly; Total volume: 700ml 1470 61  
Day 33 1/7/2022 RT feed @ 100ml/2nd/ hrly; Total volume: 900ml 1900 81 Hemodialysis
Day 34 1/8/2022 RT feed @ 120ml/2nd / hrly; Total volume: 1080ml 1900 81  
Day 35 1/9/2022 RT feed @ 120ml/hr; Total volume: 1080ml  + oral trials 1900 81  
Day 36 1/10/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral trial liquids 1900 81 Hemodialysis
Day 37 1/11/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral trial liquids 1900 81 Hemodialysis
Day 38 1/12/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral trial semi solids 1900 81 Hemodialysis
Day 39 1/13/2022 RT feed @ 150ml/hr; Total volume: 1350ml+ oral trial semi solids 1900 81  
Day 40 1/14/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral trial semi solids  1900 81 Hemodialysis
Day 41 1/15/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral trial semi solids 1900 81  
Day 42 1/16/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral trial semi solids 1900 81  
Day 43 1/17/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral trial semi solids 1900 81 Hemodialysis
Day 44 1/18/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral  semi solids 2000 89 Oral semi solids was improved
Day 45 1/19/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral  semi solids 1900 81 Oral intake was fair
    Oral semi solids 320 14 Oral soft solid diet modified
    TOTAL 2220 95  
Day 46 1/20/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral soft solids 1900 81 Intake was improved
    Oral soft solids 380 14  
    TOTAL 2446 116  
Day 47 1/21/2022 RT feed @ 150ml/hr; Total volume: 1350ml + oral soft solids 1900 81 Diet modifications done
    Oral soft solids 610 36  
    TOTAL 2510 117  
Day 48 1/22/2022 RT feed @ 120ml/hr; Total volume: 750ml  1050 45 RT Feed modified to 5 feeds since intake was improved
    Oral soft solids 780 40  
    TOTAL 1830 85  
Day 49 1/23/2022 RT feed @ 120ml/hr; Total volume: 750ml  1050 45  
    Oral soft solids 980 44 ORAL INTAKE WAS GOOD
    TOTAL 2030 89  
discharge 1/24/2022 DISCHARGE ADVICE GIVEN ON RT FEEDS AND ORAL VITAMIN K RESTRICTED DIET   WEIGHT :77kgs
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Conclusion

A 62-year-old male with k/c/o sigmoid diverticulitis, post Hartmann’s procedure for sigmoid diverticulitis, pedunculated polyp in sigmoid colon with post polypectomy, had been admitted for tfurther management. The patient had past history of Hypertension, CAD, Stroke. Surgical management – colonoscopy was planned and the patient had undergone Laparotomy, Anastomosis, Relaparotomy and Tracheostomy. The patient also had abnormal renal parameters (insufficient renal function) and had undergone series of dialyses. During the hospital stay the nutritional management was planned according to the health condition of the patient. Total Parenteral Nutrition was provided for 4 days followed by Enteral Nutrition. At the beginning of EN (RT feed) semi elemental formula was prescribed since it is a peptide based and easily digestible; later the EN feed was modified to disease specific formula based on patient’s health and medical condition. As the patient’s condition improved oral semi solid diet was initiated along with RT feed until discharge. The patient’s discharge weight was 78.4kg. Two weeks soft solids along with oral nutritional supplement were given, and NG FEEDS stopped. Weight was monitored. High protein and vitamin K restricted diet was prescribed at the time of discharge as the patient is on acitrom medication.

yamini-prakash

Ms. Yamini Prakash

Chief Dietician

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