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Med-Surg Ch 24

Bowel Disorders

QuestionAnswer
Diarrhea S/S, Complications Dehydration (orthostatic hypotension) Vascular collapse/hypovolemic shock Hypokalemia/Hypomagnemia Cause: Cramping, Heart/muscle issues, Vision changes, Chovostiks Chovos, Tetany, Perastisia, and Cardiac arrest Possible Metabolic Acidosis
Diarrhea Diagnostic Tests Looking for cause of diarrhea Culture Sigmoidscopy Electrolytes ABG’s
Nutritional Treatment for Diarrhea Fluid replacement Hold solid foods for 24 hours Re-introduce foods slowly Vitamin supplements Avoid: Raw fruits/veggies, Fried foods, Spices, Caffeine/ETOH, milk products, sugars (like apple juice), and antacids
Antidiarrheal Meds Kaolin and pection (Kaopectate) Bismuth subsalicylate (Pepto-Bismol) Diphenoxylate (Lomotil), Loperamind hydrochloride (Imodium) Side effects: Constipation, can be habit forming, take no more than 48 hrs
Constipation Infrequent stools or difficult passage of stools Affects older people more frequently than younger 20-35% of patients over 65 use laxatives Effects of medications/chronic laxative use Decreased physical activity
Constipation Medications Calcium polycarbophil (Fibercon) Mathylcellulose (Citrucel) Psyllium (Metamucil) Sorbital, Magnesium hydroxide (MOM) Docusate (Colace) Bisacodyl (Dulcolax) Mineral Oil
Non-medication relief for Constipation Enemas: Use for acute situations only, short-term basis Nutrition: Increase fluid intake, fiber, and activity
IBS Manifestations Abdominal pain relieved with defecation Bloating, excessive gas Tender abdomen over sigmoid colon Diarrhea Constipation Or combination of both Mucous stools
IBS Medications, Nutrition, and Complementary/Alternative Therapies Bulk-forming laxatives Anticholingerics (Antisps, Bentyl) Dicyclomine(Antispas) Antidepressant meds (Zoloft, Prozac, Lotronex) Fiber Camomile Peppermint Sage Aloe vera juice
Appendicitis Inflammation of the vermiform appendix Most common reason for emergency abdominal surgery in US Any age, but more common in adolescents and young adults (10-12ish) Slightly more common in males than females
Appendicitis Stages Simple appendix - Inflamed but intact Perforated appendix - contaminates the peritoneal cavity; risk for peritonitis Gangrenous appendicitis - areas of tissue necrosis and microscopic perforations
Appendicitis Manifestations Mild abdominal pain Localizes to RLQ over 4 hours Rebound tenderness at Mc Burney’s point (R iliac crest) Increased pain with extension or internal rotation of right hip Low grade temp, anorexia, n/v maybe present
Appendicitis Diagnostic Test WBC (elevated, more bands than segs) Abdominal Ultrasound
Appendicitis Surgical Options Laparoscopic Appendectomy: small incision, direct visualization, short hospitalization, less complications, and rapid recovery Laparotomy Appendectomy: small incision, appendix ligated (tied off), removed, usually used post rupture
Peritonitis Inflamed peritoneum Enteric bacteria enter the peritoneum through a perforation: ulcer, appendix, diverticulum, necrotic bowel, or during abdominal surgery; also pelvic inflammatory disease, ruptured gallbladder, or abdominal trauma
Peritonitis Manifestations Severe abdominal pain with guarding Board-like rigidity Distention Fever Rebound tenderness Confusion Tachycardia, Tachypnea Oliguria
Peritonitis Complications Abscess formation Fluid loss=hypovolemic shock Inflammation inhibits peristalsis may have ileus Without treatment will become septic
Peritonitis Diagnosed by Symptoms Elevated WBC (>20,000/mm3) Blood Cultures Abdominal CT scan Paracentesis fluid will contain WBC’s, protein
Treat Peritonitis with Antibiotics Laparotomy (Peritoneal lavage, Return often with a drains) If client has paralytic ileus (Intestinal decompression until peristalsis resumes, NG tube with suction, NPO) IV and electrolytes
Gastroenteritis Inflammation of the stomach and small intestine Cause: (bacteria, viruses, parasites or toxins, food poisoning) Generally mild and self-limiting Can be serious
Gastroenteritis Manifestations Anorexia Nausea Vomiting Diarrhea Abdominal Pain Borborygmi (loud, excessive, hyperactive bowel sounds) (Sets client up for loss of fluid and electrolytes)
Gastroenteritis Causative Agents/Factors Traveler’s diarrhea (Don’t drink the water, food poisoning) Esherichia coli hemorrhagic colitis (F/O route) Cholera (F/O route, severe diarrhea (up to 1 liter/hour)) Clostridium Difficile Colitis (Cause/treat by antibiotics, soap, glove, gown, mask)
More Gastroenteritis Causative Agents/Factors Salmonella Shigellosis (dysentary)(F/O route, cooking utensils, fleas, bloody mucous) Norovirus (institutions, crowded facility,vomiting, diarrhea, wash)
Treat Gastroenteritis Generally resolves spontaneously Antibiotic therapy Antidiarrheal (but Caution!; you need the toxins to come out) Nutrition and fluids Gastric lavage (wash out stomach and intestines) Plasmapheresis (plasma exchange therapy) Dialysis
Health Promotion/Prevention of Gastroenteritis Proper food handling Avoid unpasteurized milk Traveling: use bottle water Refrigerate food promptly Wash raw foods and vegetables Avoid if immunocompromised
Protozoal Bowel Infections Giardiasis (F/O route, contaminated food water, frothy diarrhea) Amebiasis (F/O route, asymptomatic, cramps, flatulence, diarrhea) Cryptosporadiosis (like travelers diarrhea)
Helminthic Bowel Infections Roundworms Flukes Tapeworms
Care for Protozoal and Helminthic Bowel Infections O&P of stool Check for eosinophilia with helminths Teach: (good handwashing, safe water supplies, appropriate disposal of human feces (wash toilets), safe food storage and handling, adequate cooking, change bed linen daily)
Chronic Inflammatory Bowel Disease (IBD) Ulcerative colitis and Crohn’s disease More common in US and northern Europe 4-5x more likely to develop: Jewish Unknown cause: Believe it’s Genetic and environmental Peak incidence: ages of 15 – 35 Chronic with recurrent exacerbations
Ulcerative Colitis Affects mucosa and submucosa of colon and rectum Mucosa becomes granular, hyperemic (bright red), friable (fragile), pseudopolyps may develop Chronic and intermittent episodes Fulminant colitis-involves entire colon, at greater risk for complication
Ulcerative Colitis Manifestations Diarrhea containing blood and mucus (Mild: <4 stools/day, Severe: 6-10 stools/day, may have nocturnal diarrhea) May also have some systemic manifestations (Arthritis, Uveitis, Thromboemboli (blood clot), Stone formation, cirrohosis, uretheral obstruction
Ulcerative Colitis Complications Hemorrhage Toxic megacolon: Acute motor paralysis and dilation of the colon to greater than 6 cm. Colon perforation: Rare, dangerous, leads to peritonitis Increased risk of colorectal cancer
Uclerative Colitis Diagnosed Colonoscopy
Crohn's Disease Chronic, relapsing inflammatory disorder on any portion of GI tract Usually terminal ileum and ascending colon Aphthoid lesions: knife-like clefts extented deep in to bowel wall Cobblestone appearance of bowel Skip lesions (like many fever blisters
Crohn's Disease Manifestations Varies from person to person Slowly progressive, relapsing Persistent diarrhea typically without blood RLQ or periumbilical pain, relieved by defecation RLQ mass may be present Systemic: (fever, fatigue, malaise, weight loss and anemia)
Crohn's Disease Complications Intestinal obstruction: abd distention, cramping, borborygmi, nausea/vomiting Abscess: Chills, fever, tender abd mass, leukocytosis, s/s infestion Fistula: exacerbation of wt. loss and malnutrition; Bladder involved=UTI’s 5-6x risk of colorectal canc
Crohn's Disease Diagnostic Tests Sigmoidoscopy, colonoscopy, barium upper/lower x-rays Stool exam, stool cultures CBC Serum albumin (looking for malabsorption) Folic acid and vitamin levels Renal and liver function
Crohn's Disease Medications End acute attack and reduce relapse with local and systemic anti-inflammatory drugs Sulfasalazine (antibiotic with anti-inflammatory) Corticosteroids (may give as enema)(Methylprednisolone, prednisolone, prednisone) Immunosuppressant Antidiarrheal
Diet of Crohn's Disease Elimination of milk and milk products Increased dietary fiber When Acute: Promote bowel rest (No Food), May use enteral feedings, Total parenteral nutrition (TPN)
Risks of TPN Pneumothorax, hemothorax, brachial plexus injury Embolus Fluid overload, F&E imbalances Blood glucose, lytes must be monitored closely (on large amounts of sugars) Potential for infection: clean, hanging time policy, tube time policy)
Surgical Care for IBD Total Colectomy—removal of colon (Ileal pouch-anal anastomosis, Permanent ileostomy Ostomy Care: cherry/pink/red, stick out 2 cm) Avoid (spicy, nuts, acidic, seeds, prune juice) Drainage thin dark green first, then gradually thickens and browns
Diverticular Disease Sac-like projections of mucosa through the muscular layer of the colon that occur in rows 90% occur in the sigmoid colon Both sexes, increases with age RF: (low fiber diet, poor bowel habits, decreased physical activity) 2/3 of people are asymptoma
Diverticulosis Presence of diverticula Episodic pain, usually left-sided Constipation, diarrhea; Progresess Abdominal cramping, Narrowing of stools, Increased constipation Bleeding in stools Weakness and fatigue
Diverticulitis Inflammation in and around the diverticular sac Pain (steady or cramping)usually left-sided Constipation or increased frequency N/V, low-grade fever, tenderness May have palpable mass LLQ
Complications of Diverticular Disease Perforation/Peritonitis Abscess formation Bowel obstruction (Scarring can lead to narrowing, risk for obstruction of large intestine) Fistula formation (Usually between sigmoid and bladder (UTI) ) Hemorrhage
Diverticular Disease Diagnostic Tests WBC with diff Hemoccult Barium Enema Abdominal x-ray CT scan Sigmoidoscopy or colonoscopy
Diverticular Disease Medications Antibiotics: Flagyl, Cipro, Septra, if mild sx IVF and antibiotics, if severe Avoid Morphine for pain (Increases colon pressure, Constipation) Stool softener: Colace AVOID LAXATIVES!
Diverticular Disease Maintenance High-fiber low roughage diet Added bran or Metamucil Foods to Avoid: (things that don’t digest) (Seeds, Wheat and corn bran, Veggies/fruits skins, Nuts, Dry beans (that leave pieces)
Treatment for Acute Diverticular Disease Bowel rest (NPO, Parental Nutrition, Gradual advancement of diet) Surgery
Celiac Disease or Sprue Chronic, small intestine, impaired absorption nutrients (fats) Sensitivity to Gluten products Mucosa damaged by immunologic response Tropical sprue-chronic disease with possible bacterial or toxin causation, with similar changes in bowel mucosa
Manifestations of Sprue Abdominal bloating and cramps Diarrhea Steatorrhea Malabsorption (Anemia, Smallness in stature, and delayed maturity, May lead to tetany, vitamin deficiencies, muscle wasting, rickets)
Sprue Diagnostic Tests Fecal fat (all stool for 72-hours) IgA and IgG components Serum protein, albumin, cholesterol, electrolytes and iron, prothrombine time Anemia studies: H&H, RBC Enteroscopy with biopsy small intestine (Need for dx, Upper GI with sm bowel follow-throug
Sprue Treatments Nutritional supplements Corticosteroids Gluten-free diet, consultation with dietician High calorie, protein Limited fats Initially restricted lactose (reinstate last) May also have problem with Soy
Lactose Intolerence Lack enzyme Ferments in bowel Manifests with lower abd cramping, pain, diarrhea Diagnosed wiht history, removal of lactose products, lactose breath test, lactose tolerance tests) Treated by lactose-free, reduced lactose diet or milk treated with lact
Neoplastic Disorders Lower bowel cancer (2nd leading cancer death) Cancer is 2nd leading death behind heart disease Polyps (bowel tissue mass, >95% colorectal cancers) Colonoscopy (diagnosis, biopsy lesions, remove polyps, age 50 q5yrs, q3 years after polyectomy)
Risk Factor for Colorectal Cancer Age: >50 Polyps Family history Personal hx of cancer (colorectal, ovarian, endometrial, breast) Inflammatory Bowel Disease FAP, Lynch syndrome Dietary patterns (calories, meat proteins, fats) Obesity, smoking, ETOH use
Colorectal Cancer Manifestations No symptoms until advanced (5-15 years) Bleeding (anemia) Change in bowel habits (most common) (diameter of stool change, fist->pencil) Pain, anorexia, weight loss Palpable mass
Colorectal Cancer Diagnostics Screening CBC Fecal occult blood Carcinoembryonic antigen (CEA) Sigmoidoscopy/colonoscopy CXR to determine lung metastasis CT, MRI, Ultrasonic exam Tissue biopsy
Surgery for Colorectal Cancer Treatment of choice Surgical resection of tumor, adjacent colon, and regional lymph nodes with anastomosis of bowel Laser photocoagulation A permanent colostomy may be placed for elimination of feces
Colorectal Cancer Colostomies Sigmoid colostomy Double-barrel colostomy Transverse loop colostomy Hartmann procedure Care/Teaching (Management of colostomy, Skin care, Dietary information like foods that increase gas and odor, that thicken or loosen stools, and that color stoo
Colorectal Cancer Radiations therapy Along with surgical treatment for rectal tumors Small tumors may be treated with intracavitary, external or implantation rad. Pre-op to shrink tumors for surgical removal
Colorectal Cancer Chemotherapy Chemotherapeutic agents—5-FU and folinic acid (leucovorin) Combined with radiation to reduce recurrence and prolong survival Reduce spread to the liver; prevent recurrence
Hernia A defect in the abdominal wall that allows contents to protrude out of the abdominal cavity Identified by location Risk factors (Surgery, Trauma, increased intra-abdominal pressure, pregnancy, obesity, weight lifting, or tumors
Inguinal Hernia Indirect inguinal hernia (Improper closure of tract during dissention of testes, Abdominal contents descend into scrotum) Direct inguinal hernia (Acquired defects that result from weakness in the posterior inguinal wall, elderly, obese, pregnant wome
Umbilical Hernia Pregnancy and obesity More common in females Congenital and evident during infancy Acquired as umbilical ring weakens Risk factors (multiple pregnancies, prolonged labor, ascites, tumors)
Ventral Hernia Previous surgical incision site Abdominal muscle tears Factors: (poor wound closure, postop infection, age, debility, obesity, inadequate nutrition, incision stress) Bulge when pulling to a sitting position Asymptomatic, low risk of incarceration
Hernia Complications Reducible hernia (move contents, return to normal, push it back in/up) Incarcerated hernia (trapped, can lead to obstruction/strangulation) Strangulated hernia (dec blood supply = necrosis = infarction = perforation, severe pain, N/V, tachycadia, fever)
Care for Hernia Diagnosed by physical examination Herniorrhaphy (emergency surgery: incarcerated hernia, painful or tender hernia, MAY NEED BOWEL RESECTION, avoid heavy lifting x 3 wks after surgery) Binder/Truss Self Reduction NEVER REDUCE INCARCERATED HERNIA
Small Bowel Obstruction More common than obstruction in large bowel Most common reason for small bowel surgery Adhesions and hernias account for 70-75% of mechanical small bowel obstructions
Mechanical Sm Bowel Obstructions Simple - a single blockage (adhesions) Closed-loop - two portions of bowel obstructed (incarcerated hernia) Intussusception - telescoping bowel Volvulus - twisted bowel Foreign bodies or strictures
Functional Sm Bowel Obstructions Peristalsis can't move intestinal contents—paralytic ileus High bowel sounds to none Post gastrointestinal surgery Tissue anoxia or peritoneal irritation Causes Peritonitis Hypokalemia Narcotics, anticholinergic drugs, antidiarrheal medications
Small Bowel Obstruction Manifestations First: Cramping/colicky abd pain, vomiting, distal obstruction-fecal matter, borborygmi & high-pitched tinkling sounds) Later: (abdomen silent—ileus, distention, min. with proximal, pronounced with distal obstructions, hypovolemia, elevated temperature)
Small Bowel Obstruction Complications Hypovolemic shock Death Renal failure Pulmonary ventilation impairment Gangrene from strangulation Perforation/Peritonitis Septic Shock
Large Bowel Obstruction Causes and Manifestations Cancer Volvulus Diverticular disease Inflammatory disorders Fecal impaction Constipation, colicky pain Severe continuous pain may signal bowel ischemia and possible perforation
Diagnostics for Large Bowel Obstruction X-ray (can see poop) CT scan Fluid and electrolytes NGT or long intestinal tube Bowel rest Surgery Laparotomy Primary goal, relieve colonic distention Secondary goal, remove obstructing lesion May require anastomosis, or permanent colostomy or il
Anorectal Lesions Hemorrhoids, anal fissures, anorectal abscesses, anorectal fistula, pilonidal cysts Hi-fiber diet Respond to urge to defecate Do not strain Keeping perianal area clean and dry Use of sitz baths Use of analgesics Preparation-H Witch-Hazel Increase
Created by: nimeggs