Bowel Disorders
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| 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
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| Diarrhea Diagnostic Tests | Looking for cause of diarrhea
Culture
Sigmoidscopy
Electrolytes
ABG’s
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| 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
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| 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
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| 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
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| Constipation Medications | Calcium polycarbophil (Fibercon)
Mathylcellulose (Citrucel)
Psyllium (Metamucil)
Sorbital, Magnesium hydroxide (MOM)
Docusate (Colace)
Bisacodyl (Dulcolax)
Mineral Oil
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| Non-medication relief for Constipation | Enemas: Use for acute situations only, short-term basis
Nutrition: Increase fluid intake, fiber, and activity
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| IBS Manifestations | Abdominal pain relieved with defecation
Bloating, excessive gas
Tender abdomen over sigmoid colon
Diarrhea
Constipation
Or combination of both
Mucous stools
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| 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
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| 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
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| 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
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| 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
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| Appendicitis Diagnostic Test | WBC (elevated, more bands than segs)
Abdominal Ultrasound
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| 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
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| 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
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| Peritonitis Manifestations | Severe abdominal pain with guarding
Board-like rigidity
Distention
Fever
Rebound tenderness
Confusion
Tachycardia, Tachypnea
Oliguria
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| Peritonitis Complications | Abscess formation
Fluid loss=hypovolemic shock
Inflammation inhibits peristalsis may have ileus
Without treatment will become septic
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| Peritonitis Diagnosed by | Symptoms
Elevated WBC (>20,000/mm3)
Blood Cultures
Abdominal CT scan
Paracentesis fluid will contain WBC’s, protein
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| 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
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| Gastroenteritis | Inflammation of the stomach and small intestine
Cause: (bacteria, viruses, parasites or toxins, food poisoning)
Generally mild and self-limiting
Can be serious
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| Gastroenteritis Manifestations | Anorexia
Nausea
Vomiting
Diarrhea
Abdominal Pain
Borborygmi (loud, excessive, hyperactive bowel sounds)
(Sets client up for loss of fluid and electrolytes)
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| 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)
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| More Gastroenteritis Causative Agents/Factors | Salmonella
Shigellosis (dysentary)(F/O route, cooking utensils, fleas, bloody mucous)
Norovirus (institutions, crowded facility,vomiting, diarrhea, wash)
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| 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
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| 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
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| Protozoal Bowel Infections | Giardiasis (F/O route, contaminated food water, frothy diarrhea)
Amebiasis (F/O route, asymptomatic, cramps, flatulence, diarrhea)
Cryptosporadiosis (like travelers diarrhea)
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| Helminthic Bowel Infections | Roundworms
Flukes
Tapeworms
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| 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)
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| 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
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| 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
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| 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
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| 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
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| Uclerative Colitis Diagnosed | Colonoscopy
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| 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
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| 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)
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| 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
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| 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
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| 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
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| 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)
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| 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)
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| 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
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| 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
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| 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
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| 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
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| 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
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| Diverticular Disease Diagnostic Tests | WBC with diff
Hemoccult
Barium Enema
Abdominal x-ray
CT scan
Sigmoidoscopy or colonoscopy
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| 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!
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| 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)
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| Treatment for Acute Diverticular Disease | Bowel rest (NPO, Parental Nutrition, Gradual advancement of diet)
Surgery
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| 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
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| 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)
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| 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
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| 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
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| 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
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| 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)
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| 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
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| 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
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| Colorectal Cancer Diagnostics | Screening
CBC
Fecal occult blood
Carcinoembryonic antigen (CEA)
Sigmoidoscopy/colonoscopy
CXR to determine lung metastasis
CT, MRI, Ultrasonic exam
Tissue biopsy
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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)
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| 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
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| 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)
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| 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
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| 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
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| 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
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| 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
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| 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)
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| Small Bowel Obstruction Complications | Hypovolemic shock
Death
Renal failure
Pulmonary ventilation impairment
Gangrene from strangulation
Perforation/Peritonitis
Septic Shock
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| 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
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| 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
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| 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
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