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Lower Gastrointestinal ProblemsLower Gastrointestinal Problemsadapted from Ms Ensoradapted from Ms Ensoradapted from Ms Ensor adapted from Ms Ensor

Diarrhea

3 loose or liquid stools/day

Acute or chronic

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Acute or chronic

Complications of Diarrhea

Dehydration

Electrolyte imbalances Electrolyte imbalances

Metabolic acidosis

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Causes Bacteria, viruses, parasites

Food poisoning or intolerance

Medications

Irritable bowel syndrome IBS Irritable bowel syndrome IBS

Emotional factors

AIDS & colon cancer

Malabsorption problems

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Clinical Manifestations

Frequent, watery stools

May contain undigested food

Foul smelling Foul smelling

Abdominal cramping, distention

Weight loss

Hyperactive bowel sounds

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Diagnostics

stool culture

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Treatment

Treat cause

Decrease intake Decrease intake

Parenteral fluids

Antidiarrheal medications8

Antidiarrheal Medications

Opioids –Suppress peristalsis (Paregoric, Lomotil)

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Adsorbents & Emulsions – sooth & absorb toxins (Kaopectate, Imodium)

Intestinal flora modifiers/probiotics (Lactinex)

Antidiarrheal Medications

Contraindicated with infectious diarrhea

Clostridium difficile unique odor Clostridium difficile – unique odor

Flagyl (metronidazole) metallic taste Vancomycin given to treat C diff

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Other med for C Diff

Fidaxomicin (Dificid)

Macrolide antibiotic Macrolide antibiotic

200mg dose twice a day

Adverse: N/V, abd pain, bleeding 11

Clostridium Difficile

Private room, isolation

Gloves & gown Gloves & gown

Wash hands & equipment

10% bleach used12

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Constipation

Decrease in frequency

Hard difficult to pass Hard, difficult to pass

Decrease in stool volume

Retention of stool in rectum13

Causes Decreased fluid &/or fiber intake

Immobility

Medications

Irritable bowel syndrome IBSy

Overuse of laxatives

Ignoring urge to defecate

Diverticulitis

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Clinical Manifestations

Abdominal distention

Straining to pass stool Straining to pass stool

Appearance

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Collaborative and NursingCare

Stool softeners, Laxatives, enemas

No long term use laxatives or enemasg

Increase fluid intake & fiber

Increase activity

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Impaction?

Assess if no bowel movement for 3 days or has passed small amounts of semisoft stool or has liquid stoolsq

Manual check & remove

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Signs of Cancer

√Change in bowel habits & characteristics of stool

√Blood in stool or from any orifice

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A sore that won’t heal

Thickening or lump in breast or elsewhere

√Indigestion or difficulty swallowing

Change in wart or mole

Nagging cough/hoarseness

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Normal bowel sounds are soft clicks and gurgles every 5-15 seconds

Bowel Sound Probable mechanism Probable causes

Hyperactive sounds not related to hunger

Abnormally rapid passage of air and fluid through the intestine

DiarrheaEarly intestinal obstruction

Hypoactive or absent Inactivity of smooth Paralytic ileusHypoactive or absent sounds

Inactivity of smooth muscle in the bowel

Paralytic ileusPeritonitisDecreased bowel motility

High-pitched rushing sounds

Intestinal straining to push fluid and air past an obstruction

Intestinal obstruction

High-pitched tinkling sounds

Intestinal fluid and air under tension

Dilated bowel loopsFecal impaction

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Bowel Sounds

Check for 5 minutes per quadrant if no sound heard immediately

Evidence Based Care – Passing of flatus & BM are better indicators of bowel function. Negative indicators include n/v & abd distention.

Abdominal Pain

Overview– Appendicitis

– Bowel ObstructionBowel Obstruction

– Diverticulitis

– Gastroenteritis

– Ulcerative Colitis

– Cancer

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Undiagnosed Cause Abdominal Pain

Do not let them eat

Do not use heat on the abdomen

Do not give an enema or a laxativeg

Do maintain bed rest, in position of comfort

Do assess bowel sounds, distention, passage of stool or flatus, pain (gen or local)

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Irritable Bowel Syndrome (IBS)

With diarrhea (mucus)

With constipation (mucus)

With mixed diarrhea & constipation With mixed diarrhea & constipation

Women 2-2.5 times more prone

Men – diarrhea; Women – constipation

Unknown cause23

IBS Symptoms

Abdominal distention & bloating

Excess flatulence

Continual urge to defecate

Urgency to defecate

Sensation of incomplete evacuation24

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IBS Diagnostic Criteria

12 weeks of pain in 12 months with two of the following:

Pain relieved with defecation Pain relieved with defecation

Onset of pain associated with change in stool frequency

Onset of pain associated with change in stool appearance

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In irritable bowel syndrome the spastic contractions of the bowel can be seen in x-ray contrast studies.

Colon

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IBS Care

Dietary management

Diary of food intake, symptoms, stress

No single drug therapy – symptom treatment

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g g py y p

Zelnorm – Used for women only. Off the market March 07 due to increased c/v ischemic events. Still available under protocols limiting it’s use.

Appendicitis

– Obstruction & inflammation of the appendix

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– Can get gangrenous & burst

– Incidence – Any age

– Etiology – obstruction of lumen

McBurney’s Point

Periumbilical pain moving to McBurney’s point. Localized and rebound tenderness

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Appendicitis

– Diagnostic: physical assessment, CT scan, WBC elevated

– Low grade fever, nausea, anorexia

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– Sudden pain relief may indicate rupture

– No laxatives, no enemas, no heat

– Surgical treatment – Laparoscopic removal

– 1 Day hospital stay unless ruptured, then several days of antibiotics & fluids

Gastroenteritis

●Inflammation of the mucosa of the stomach & small intestines

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Many possible causes: viral, bacterial, contaminated food (Salmonella, E.Coli, Shigella spp

Clinical Manifestations

Abd cramping

N/V & diarrhea N/V, & diarrhea

Fever & chills

Loss of appetite33

GastroenteritisTreatment

Identify cause

Treat cause & symptoms

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Peritonitis

Inflammation of the peritoneal cavity, leading to intraabdominal infection

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Chemical - rupture of gastric ulcer or ruptured ectopic pregnancy

Bacterial – trauma, ruptured appendix

Clinical Manifestations

Abd Pain

Abd mass, distention, or rigidity

Decreased or absent bowel sounds Decreased or absent bowel sounds

Fever, chills

Anorexia, N/V

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Peritonitis Treatment

Identify & treat cause – may require surgery

Antibiotics, analgesics

IV fluids, parenteral feeding

NG tube

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Inflammatory Bowel DiseaseCrohn’s and Ulcerative Colitis Auto Immune Disorders

Genetic

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Cause unknown

No cure

Collaborative Care Rest the bowel

Control inflammation

Combat infection

C Correct malnutrition

Decrease stress

Provide symptom relief

Improve quality of life

Decrease immune response39

Crohn’s Disease

– Chronic inflammatory disease of the intestine that causes ulcerations, especially in area of terminal ileum

– May extend through every layer of tissue

– Skip lesions (mouth to anus)

– Periods of remission, then exacerbation

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Crohn’s Disease

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Crohn’s Risk Factors

Incidence – 15-30 yrs, F>M, recurs in 60’sIncreased in Caucasians; Jewish descent

Familial tendencyFood allergiesFood allergiesSmokingOther immune disorders75% eventually require surgery, with high levels

of recurrence, leading to short bowel syndrome

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Crohn’s Clinical Manifestations

Abd pain

Chronic diarrhea

Nausea cramping flatulence

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Nausea, cramping, flatulence

Weight loss, malnutrition, fatigue

Fever with acute inflammation

Recurrence & remissions

Crohn’s Complications

– Malabsorption, Wt loss

– Bowel obstruction, strictures

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– Internal fistulas; abscesses

– Fissures in the anal rectal area

– Perforation of intestine leading to peritonitis

Complications Systemic

Arthritis, Ankylosing spondylitis (inflammation of vertebrae), eye inflammation, skin lesions – Lupus, p

Small bowel cancer

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Diagnostic Assessment

Tenderness over the area of inflamed bowel

Increased bowel sounds

UGI

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UGI

Decreased H & H

Barium enema study with air contrast

Medical Management Fluids, TPN for nutrition

Diet – increase calories & protein; decrease fats & residue; small servings,

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; g ,several meals per day

Surgery may be needed to remove scar tissue, fistula etc.

Pharmacologic Management

Symptom control– Antidiarrheals

– Opioids for pain relief

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Opioids for pain relief

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Pharmacologic Management

5-Aminosalicylate – decrease inflammation

Antimicrobials – prevent & treat infection

Corticosteroids – decrease inflammation in acute phase

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phase

Immunosuppressants – decrease immune response

Biologic & targeted therapy

Ulcerative Colitis

Inflammation & ulceration occur in the mucosal layer

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Rectum to cecum in a continuous pattern

Results in scar formation Associated with psychological (stress)

Ulcerative Colitis

May occur at any age

Autoimmune with genetic component

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Autoimmune with genetic component

25-40% eventually have surgery

Mild, moderate, & severe UC

Ulcerative Colitis

– Abd pain, cramping, N/V

– Diarrhea, rectal bleeding

– Electrolyte & protein losses

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y p

– Anorexia, weight loss

Complications– Colorectal cancer CRC

Ulcerative Colitis

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Table Page 1051Differentiation Between Crohn's Disease and Ulcerative Colitis

CHARACTERISTIC

CROHN’S DISEASE ULCERATIVE

COLITIS

Age at onset Young Young to middle

Depth of involvement Transmural -all layers of submucosa

Mucosa and submucosa

Rectal involvement 50% 95%

Right colon involvement Frequent Occasional

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Small bowel involvement Involved, ileum narrow Usually normal

Distribution of disease Segmental Continuous

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Differentiation Between Crohn's Disease and Ulcerative Colitis

CHARACTERISTIC

CROHN’S DISEASE ULCERATIVE

COLITIS

Malignancy results Rare After 10 years

Fibrous stricture Common Absent

Clinical

Course of disease Slowly progressive Remissions and relapses

Rectal bleeding Occasional Common 90-100%

Abdominal pain Colicky 45% Predefecation 60-70%

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Hematochezia Unusual or absent Almost always present

Diarrhea Present 65-85% Early and frequent 80-95%

Vomiting Present 35% Present 15%

Nutritional deficit Common Common

Weight loss Present 60-70% Present 20-50%

Differentiation Between Crohn's Disease and Ulcerative Colitis

CHARACTERISTIC

CROHN’S DISEASE ULCERATIVE

COLITIS

Fever Present 35% Present 10%`

Anal abscess Common 75% Occasional 10%

Fistula and anorectal fissure fistula

Common 80% Rare 10-20%

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IBD Indications for surgery

Abd abcess

Fistula

Massive hemorrhage Massive hemorrhage

Intestinal obstruction

Perforation

Severe anorectal disease

Cancer suspicion57

Intestinal Obstruction

GI contents can’t pass thru GI tract

Occurs in colon or small intestine

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Partial or complete obstruction

Types of obstruction

Mechanical – occlusion of lumen of bowel

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Neurogenic - paralytic ileus

Vascular – interference with bowel blood supply

Bowel Obstructions

ADCB

AdhesionsStrangulated

inguinal herniaIleocecal intussusception

Intussusception from polyps

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GFE

p p yp

Mesenteric occlusion

Neoplasm Vovulus of the sigmoid colon

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Clinical Manifestations

• Depends on:

• the level & length of bowel involved

• the completeness of the obstruction

h f l i d i h

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• the type of lesion producing the obstruction

–Pain

–Distention

–N/V

Assessment Abdominal distention

Bowel sounds – initially hyperactive proximal to obstruction & decreased or absent distal to obstruction (Eventually all bowel sounds

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absent)

Check for dehydration

Muscle guarding or abd pain

Characteristics of emesis

Obstruction

Diagnostic – Flat plate

– Barium studies

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Barium studies

– Complete Blood Studies

Medical Management – conservative (NPO, NG decompression, IV)

Surgery to correct cause

Page 1061Obstruction Comparison

Clinical Finding*Onset*Pain

*Vomiting

Small Intestine (SBO)*Rapid*Crampy, paroxysmal,abdominal pain in upperabdomen and in periumbilicalarea, followed by continuous pain

Frequent & copious

Large Intestine*Gradual*Occasional, low-grade, colicky abdominal pain

*Vomiting after prolonged

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Vomiting

*Bowel Movement

*Dehydration

*Abdominal distention

Frequent & copious

*Feces for a short time

*Rapid

*Minimally increased

Vomiting after prolonged obstruction; may be feculent

*Constipation

*Slow

*Present

Colon Polyps

Sessile –Flat & broad, attached to intestinal wall

Pedunculated – attached to wall by thi t lk

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a thin stalk

Found anywhere in large intestine

Rectal bleeding & occult blood most common symptoms

Diagnosis and Treatment

Barium enema

Sigmoidoscopy colonoscopy virtual Sigmoidoscopy, colonoscopy, virtual colonoscopy

All polyps considered abnormal & are removed

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Colon Polyps

Sessile Pedunculated

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Polyps

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Ostomy

Surgical procedure that allows intestinal contents to pass from the bowel through an opening in the skin on the abdp g

Stoma – The opening in the skin

Done when normal elimination route is no longer possible

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Ostomy Locations

Ileostomy – distal end of small intestine

Sigmoid colostomy

Transverse colostomy Transverse colostomy

The more distal the ostomy, the more the contents resemble normal feces

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Colostomies

Ascending colostomy

Ascending colon Transverse colon

Descending colon

71Sigmoid colostomy single-barreled Transverse colostomy double-barreled

Ascending colostomy

Descending colostomy

Ileostomy

Proximal loop Distal loop

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Ostomies

Temporary- Reasons for?

Permanent Reasons for?

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Permanent- Reasons for?

Location of Stoma

Wound, Ostomy, and Continence Nurses Society

“Wound Care Nurse” or “ET Nurse”

Pre Op marking of stoma site Pre-Op marking of stoma site

Pre-Op & Post-Op care/teaching

Referrals to Support Group 74

Post-Op

Watch for Unusual Bleeding

Signs of ischemia & necrosis

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Signs of ischemia & necrosis

Healthy Stoma

Cherry Red

Glossy

Slight protrusionStoma Picture Gallery Slight protrusionStoma Picture Gallery -ostomates.org

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Healthy Stoma – 6 months

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Complications & Nursing Care

Stomal Necrosis

Stomal Retraction

Stomal Prolapse

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Stomal Prolapse

Diarrhea or constipation

Skin excoriation

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Psychosocial Considerations

Body image/self esteem concerns

Self Care Concerns Self Care Concerns

Relationship concerns

Colostomy Care & teaching

Stoma in ascending or transverse colon will need pouching (bag)

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Sigmoid colostomy, if able to regulate, no bag

Colostomy irrigation to regulate bowel function

Care of Ostomy by Discharge

– Draining

– Pouching

– Skin Care

– Odor Control – Asparagus, beans, eggs, fish, onions, garlic

– Gas control – Cabbage, onions, beans, cauliflower

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Food considerations

Foods to thicken stool: Applesauce, bananas, rice, tapioca, cheese, yogurt

Foods to loosen stool: Chocolate, beans, fried foods, highly spiced foods, leafy green vegetables, raw fruits & vegetables

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DIVERTICULOSIS

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DIVERTICULITIS

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Diverticulitis/Diverticulosis

Outpouching of the intestinal mucosa through the intestinal wall

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Non-Inflamed – Diverticulosis

Inflamed erosion of bowel wall –Diverticulitis

Clinical Manifestations

– Diverticulosis: abd pain, bloating, gas, change in bowel habits (or may be asymptomatic)

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– Diverticulitis: LLQ pain, fever, elevated WBC, palpable abd mass

Complications

Lower GI bleeding (most common)

Perforation with peritonitis Perforation with peritonitis

Abscess & fistula formation

Bowel obstruction87

Collaborative Care

High fiber, low fat, little red meat

Teach to avoid increased Teach to avoid increased intraabdominal pressure

Colon resection done in 25% of cases of diverticulitis

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Hernia

An abnormal protrusion of an organ, tissue, or part of an organ through the structure that normally contains it.

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Inguinal – weakness in which the spermatic cord in men and the round ligament in women passes through the abdominal wall in the groin area. More common in men

Types

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– Femoral – protrusion of the intestine through the femoral ring; more common in women

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– Umbilical – More common in children. Occurs in adults in an area where the rectus muscle is weak

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– Incisional/Ventral Hernia – Weakness in abdominal wall caused by a previous incision

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Classification of Hernias

Reducible: Replaced into the abdominal cavity manually

Incarcerated, irreducible: Can’t be pushed back into place

Strangulated: Blood & intestinal flow are obstructed

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Medical Management– Lose weight– Truss

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Surgical Management– Herniorrhaphy/plasty

Post op

No coughing after surgery

No lifting for 6 8 weeks No lifting for 6-8 weeks

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Hemorrhoids

Dilated portions of veins in anal canal causing itching & pain

May have bright red bleeding with stools

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Hemorrhoids

Internal External Anal

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Internalhemorrhoids

Externalhemorrhoids

Anal fissures

Internal Hemorrhoids

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External Hemorrhoids

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Anal Fissure

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Hemorrhoid with polyp

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Hemorrhoid causes

Straining for BM

Constipation Constipation

Sitting or standing for long periods

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Treatment

Medical Management – many OTC drugs.

Surgical Management

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g g– Ligation

– Cryosurgery

– Laser removal

– Hemorrhoidectomy

– Sclerotherapy

Nursing Management

Avoid constipation

Fiber

Avoid laxatives when possible

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Avoid laxatives when possible

Don’t sit on commode longer than necessary

Postoperatively

Keep stool soft

Wash area after BM & pat dry

Sitz baths 3 4 times a day

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Sitz baths 3-4 times a day

Post-op complications: hemorrhage, urinary retention, & PAIN