This case study demonstrates how an episode of diverticulitis developed and eventually resulted in surgery.
James was a 48-year-old man who lived with his wife and two grown-up children. He was a plumber by trade with his own company. James was first admitted to hospital with an episode of acute diverticulitis about 6 months before he eventually had surgery. On James's first admission his symptoms of abdominal pain, fever, nausea and change in bowel habit resolved in 3 days with the administration of broad-spectrum antibiotics and intravenous fluids. He experienced three more episodes during the following 8 months, although none of these required admission into hospital.
Following James's only admission to hospital, he and his wife had a consultation with the colorectal nurse specialist (CNS) to discuss his diagnosis of diverticular disease. The CNS had explained about the aetiology of the diverticula, how they are thought to arise and the long-term outcomes. Ivy, James's wife, asked about diet and what change she should be making to their eating habits. The CNS explained to them that increasing their intake of fibre was said to be of benefit; however, they should not increase their intake suddenly but adopt a slow gradual increase over about 6 weeks (see Chapter 10). Increasing the intake of fibre will not cure the diverticula but can help control the symptoms. Diet and an increase in fluid intake are important to help control the symptoms of diverticular disease, but there is no cure; once the diverticula are present in the bowel, they are there to stay. The CNS also gave them written literature about the symptoms, and useful tips and advice on controlling the symptoms. The CNS also gave James contact telephone numbers in case he needed any more advice.
James did indeed telephone the CNS several times during the next few months either for advice or to report an episode of pain that had required his
GP to prescribe antibiotics. James also had a number of consultations in the outpatients' department to discuss his condition and to plan for admission for surgery. The consultant colorectal surgeon had, together with James, concluded that a planned operation would be in James's best interest.
This was the reason for James's current admission; he was due to have anterior resection to remove the area of his colon affected by the diverticular disease. He was admitted to the colorectal ward and, after routine admission observations and investigations by the colorectal team, he was seen by the CNS. The rationale for seeing the CNS at this stage was to clarify the preoperative, postoperative and operative procedures. The CNS explained with the support of a diagram, showing James the part of his bowel that the surgeon expected to remove. The colorectal consultant had already explained the operation, its risks and its outcomes, including the possibility of a stoma. A stoma is one of the outcomes that the consultant always discusses with patients undergoing a resection of the colon, or colectomy. The CNS explained the need for siting of a stoma before surgery (Black, 2000) The CNS also explained the implications of having a stoma (see Chapter 8) and introduced him to the stoma care nurse.
James commenced his bowel preparation regimen; at the authors' hospital it is commenced at 06:00 hours in order that the patient has completed the preparation before the end of the day and is not in the toilet all night emptying the bowel. It is important for the ward staff to monitor the outcome of bowel preparation to check that the bowel has been cleansed. Failure to achieve a cleansed bowel can compromise the surgical outcome by faecal contamination. The day of surgery arrived and James was taken to the operating theatre for his surgery. James underwent a sigmoid colectomy to remove the diseased section of his bowel without the necessity of a stoma. The diverticula had not spread into the descending colon and were only in the sigmoid area. The specimen of colon was sent to the histopathology laboratory for analysis. This is a routine procedure to confirm the diagnosis and make sure that the specimen shows no other pathology. Depending on the histopathology laboratory's workload, this result can be confirmed either within days or up to 2 weeks later.
James returned to the colorectal ward after his operation and time in the recovery ward. He was sleepy but easily roused; he had intravenous fluid and a urinary catheter in situ. James's bed was now in the postop. section of the ward, near the nurse's station; he was being observed at regular intervals, having his pulse, temperature and blood pressure recorded. The nurse also checked and recorded the amount of fluid transfused and the amount of urine passed every hour; his wound dressing was also checked for any oozing of blood. The CNS also checked up on James's condition, as did the stoma nurse - to check that James had not had a stoma. The stoma care nurse would have been involved with James's care if his surgery had meant that the formation of a stoma was required.
The first day postoperatively for James included taking care of his personal needs, mobilizing him, and the authors' hospital regimen for postoperative care included James being nil by mouth until bowel sounds are present.
The resumption of bowel sounds indicates that peristalsis has recommenced and that oral intake can be restarted; this process can take 5-7 days to happen (see Chapter 7). The colorectal team saw James on the ward round and they explained the outcome of the surgery. James was pleased that he did not have a stoma. The team told him that his urinary catheter would be removed later in the week and they checked his wound dressing. The CNS also saw James to see how he was progressing.
On James's fourth postoperative day, his urinary catheter had been removed and he was taking fluids orally but he had not yet had his bowels opened. The team were pleased with his progress; his wound was healing and James was walking up and down the ward. The CNS visited James to discuss his progress and plan with him for his discharge. They had already discussed these aspects of his discharge and had made plans for return to work but had not set any dates. James was keen to know if the CNS had any idea when he might be discharged; the CNS said that discharge was dependent on when he had his bowels open and his histology results. James continued making good progress and his bowels were open on day 6 which coincided with the team receiving confirmation of the histology.
The consultant explained to James that the histology confirmed the diagnosis of diverticular disease and that there had not been any presence of colorectal cancer. The consultant said that James could be discharged and have an outpatient appointment for 6 weeks' time. James was very pleased with the news and telephoned his wife to come and take him home.
The CNS spoke to James and Ivy before he was discharged to remind them of everything that they had discussed about the next few weeks and to give them the discharge leaflet. James was reminded that he would need:
• To continue his pre-surgery diet of increased fluid and fibre to maintain his bowel
• To remember that his normal bowel habit may have changed
• Not to lift anything heavy
• Not to return to work before he had his 6-week check-up or saw his GP
• And that he could telephone the CNS if he had any problems.
James returned to the outpatient clinic 6 weeks later looking fit and well, eager to go back to work. He was not having any problems and was very grateful to the surgical team.
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