Gastrointestinal Disorder

Lecture Note

Chronic Inflammatory Bowel Disease (IBD) It is used to designate two

chronic inflammatory GI disorders:1) Regional enteritis (Crohn's Disease)2) Ulcerative Colitis:-It is very serious and high mortality rate.

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Regional enteritis (Crohn's Disease)

Epidemiology; commonly occurs in adolescents

or young adults. It is more common in older

women population (50 and 80). Most common affected areas are

the distal ileum and colon.

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Cont…d

Pathophysiologic feature of the lesion: Subacute and chronic inflammation

that extends through all layers. Lesions are not in continuous

contact with one another and are separated by normal tissue.

In advanced cases, the intestinal mucosa has a cobblestone appearance.

It is characterized by periods of remissions and exacerbations.

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Clinical ManifestationsInsidious onset

Prominent lower right quadrant abdominal pain (crampy).

Diarrhea Weight loss Malnutrition Secondary anemia

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Intra-abdominal and anal abscesses.

Ulcers in the intestinal membrane.

Fever Leukocytosis Fistulas Fissures

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Chronic symptoms include;diarrhea, abdominal painsteatorrheaanorexiaweight lossnutritional deficiencies

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Symptoms extend beyond the GI tract;Joint involvement (e.g, arthritis)Skin lesions (e.g, erythema nodosum)

Ocular disorders (e.g, conjunctivitis)

Oral ulcers.04/08/23 8

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Assessment and Diagnostic Findings

Proctosigmoidoscopic examination (to determine the affected area).

Stool examination ( for identification of blood and abnormal fat).

Barium study on X-ray (most conclusive).

Endoscopy04/08/23 9

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Intestinal biopsy CT scan ( for bowel thickness and

fistula formation identification) CBC ESR Albumin and protein levels

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Complications Intestinal obstruction/stricture

formation. Perianal disease. Fluid and electrolyte imbalances. Malnutrition. Fistula. Abscess formation.

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Ulcerative Colitis

It is a recurrent ulcerative & inflammatory disease of the mucosal layer of the colon &rectum.

It affects superficial mucosa of the colon & is characterized by multiple ulcerations & diffuse inflammations which end up with shading of colonic epithelium.

The lesions are contiguous, occurring one after the other.

The disease process usually begins in the rectum and spreads proximally to involve the entire colon.

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Cont…d

Etiology – unknown (may be mycobacterium), and an auto immune response to certain predisposing factors.

Predisposing factors:- Anxiety Tobacco Radiation

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C/M Diarrhea (10 t0 20 liquid stools

daily) Abdominal pain Intermittent tenesmus Rectal bleeding Hypocalcemia Anemia

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Anorexia Weight loss Fever Vomiting Dehydration Rebound tenderness may occur

in the right lower quadrant.

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Extraintestinal symptoms; Skin lesions (eg, erythema nodosum)

Eye lesions (eg, uveitis)Joint abnormalities (eg, arthritis),

Liver disease.

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Diagnostic evaluation Careful steel exam;

to r/o amoeba (dysentry) is positive for blood

CBCLow hgb & Hct levelElevated WBC

Sigmoidoscopy & barium enema

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CT scanning Magnetic resonance imaging Ultrasound Abdominal x-ray Barium enema

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Complication Perforation Hemorrhage Malignant neoplasm Toxic mega colon Osteoporosis

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Medical Management of Chronic Inflammatory

Bowel Disease Management depends on the disease location, severity, and complications.

The goal of the management is: -1.To reduce the inflammation2.To suppress in appropriate immune response3.To provide rest for the diseased bowel4.To improve quality of life and5.To prevent complications

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Nutritional therapy Advice to have a low residual, high

protein, high-calorie diet with supplemental vitamin therapy & iron supplement.

Advice to take oral fluids/ IV fluids as tolerated.

Advice to avoid any food (milk) which exacerbate diarrhea.

Advice to avoid smoking and cold foods.

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Pharmacologic therapy Sedatives Anti-diarrheal/ anti peristaltic Amino salicylate (eg, sulfasalazine) Corticosteroids (eg, prednisone) Antibiotics (sulfapyridine, metronidazole) Immunomodulators (eg, azathioprene, 6-

mercaptopurine, methotrexate, cyclosporin)

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Cont…d

Surgical management The surgical procedure is termed as

proctocolectomy with ileostomy. Indication includes;

Profuse bleedingPerforation/Stricture forming

ulcers.Development of cancerLake of improvement with medical

managements.04/08/23 23

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Nursing management Education about diet, medications,

about management of the ostomy and referral to support groups.

Careful monitoring, parenteral nutrition, fluid replacement.

Emotional support if surgery is done.

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Comparison between UC and RE

See Medical-Surgical Nursing, 10th ed - Brunner & Suddarth, chapter 38, page 1041, table 38-4,

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Intestinal obstruction

Intestinal obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract.

It can be classified as the following:-A) Mechanical obstruction Vs

FunctionalB) Small bowel Obstruction Vs Large

bowelC) Partial Obstruction Vs Complete

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Causes of Intestinal Obstructions

1) Causes of Small bowel obstruction Adhesion (the most common) Surgery Intestinal Tuberculosis Inflammatory Condition of intestine.

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Paralytic ileus Hernia Gallstones ileus Tumor Ascaris bolus Intusscusption (It is the small

bowel telescopes, as if it were swallowing itself by invagination. It is the commonest problem in infants.)

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Intusscusption

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C/M of SBO Sudden Colicky pain intermittent

with 10 -20 minute Interval. Initial Vomiting Normal Stool may be passed or

bloody. Restless, dehydration &cry Distention is late

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2) Cause of large bowel Obstruction Colorectal Cancer Adhesion Paralytic ileus Inflammatory bowel disease Volvulus (It is twisting of a

mobile loop bowel on its mesentery. It occurs mostly in sigmoid colon but it can affect small intestine & caecum.)

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Volvulus

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Cont…d

Cardinal S/S of large bowel Obstruction Colicky lower abdominal pain Absolute Constipation ( Flatus &

Feces ) Gross abdominal distention Nausea and Vomiting Abdominal x-ray reveals grossly

distended 2 limbs of sigmoid colon often with fluid - air level.

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Comparison of obstruction

SBO LBO Abdominal

crampy Vomiting early

S/S Constipation

late sign Abdominal

distention

Abdominal crampy

Constipation is early S/S

Grossly distended abdomen

Fecal vomiting04/08/23 34

Cont..d

SBO… LBO…

Diagnostic method-Hx & P/E.

Abdominal X-ray indicates abnormal quantities of gas &/or air in the bowel.

Decompression of the bowel through NG tube.

Diagnostic method-Hx & P/E.

Abdominal x-rays reveals abnormally distended colon.

Colonoscopy may be performed to untwist & decompress the bowel in high colon obstruction.

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Cont…d

SBO… LBO…

IV fluid ( N/S or R/L ) administered to replace electrolyte and water.

Surgical Intervention is needed.

More severe because most of the GI content are absorbed in this part.

In lower bowel obstruction rectal tube may be used for decompression.

Surgical Intervention if it is caused by tumor

Iv fluid administration. Minor unless necrosis

occurred.

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Cont…d

Diagnostic evaluation of Intestinal Obstruction

1) Hx2) P/E - pt is acutely sick looking

V/S: - B/P - decrease due to fluid loss & sepsis

PR:- Tachycardia To :-Increases if there is complication HEENT :- dry buccal mucosa

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AbdomenDistendedMild tenderness on palpationVisible loop but not alwaysTympanic on percussionBowel sound may be absent or increase

Empty rectum or hard stool04/08/23 38

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CBC Hgb V/A Abdominal x-ray

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Medical Management:A) General Management

Keep the patient NPO NG tube should be inserted for

small bowel obstruction to aspirate intestinal content.

Secure IV line ( Normal Saline or ringer Lactate )

Triple antibiotic ( Ampicillin, Gentamycin,& CAF )

Sedation04/08/23 40

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B) Specific RX Sigmoid Volvulus :-

Rectal tube is inserted for deflation but contraindicated if gangrenous.

Laparatomy.1) If loop is viable= de-rotation2) If gangrenous= resection & Colostomy

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Hernias

Def.:-It is a protrusion of bowel through a weak point in the musculature of the anterior abdominal wall or an existing opening.

Etiology Powerful muscular effort or strain. Weakness or defect to the

wall of abdominal cavity.04/08/23 42

Cont…d

Predisposing factors:- Constipation Ascites Previous abdominal surgery

Lifting heavy load Chronic Cough

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Classifications of hernias

1. Based on Sites of Hernias :I) Inguinal Hernia

The protrusion of bowel through the weak point in the inguinal canal which contains the spermatic cord in the male & the round ligament in the female.

It occurs more commonly in males than females.

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Inguinal Hernia

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Cont…d

Inguinal Hernia Can be:-A) Direct inguinal

HerniaPush their way directly forward through posterior wall of the inguinal canal, into a defect in the abdominal wall.

Less common (20%).Strangulate Rarely.

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Cont…d

B) Indirect inguinal HerniaPass through the internal inguinal ring & then through the external ring.

Common (80%)Can Strangulate

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Distinguishing direct from indirect hernias; The best way is to reduce the hernia & occlude the internal ring with 2 fingers. Ask the pt. to cough - if the hernia is restrained it is indirect; if it pops out it is direct.

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II) Femoral Hernia More Common in women than men. Bowel enters the femoral canal,

presenting as a mass in the upper middle thigh or above the inguinal ligament where it points down the leg, unlike an inguinal hernia which points to the groin.

It is frequently strangulate & irreducible.

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III) Para-umbilical Hernias: These occur just above or below the

umbilicus.

IV) Epigastric Hernias : These pass through linea alba above the

umbilicus.

V) Incisional Hernias: These follow breakdown of muscle

closure after previous Surgery. If obese, repair is not easy.

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VI) Umbilical Hernia: - Results from failure of

umbilical orifice to close. Occur most often in obese women

& children & in patients with cirrhosis and ascites.

C/F:- Only abdominal mass if not complicated.

Bowel sound on auscultation.04/08/23 51

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2. Based on severityi) Reducible Hernia :- The protruding mass can be replaced in abdomen.ii) Irreducible Hernia :- The protruding mass cannot be moved back into abdomen.iii) Incarcerated: - An irreducible hernia in which the intestinal flow is completely obstructed.

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IV) Strangulated: - an irreducible hernia in which the blood & intestinal flow is completely obstructed.

C/F of Strangulation: Pain, vomiting Swelling of hernial sac,fever Lower abdominal sign of

peritoneal irritation04/08/23 53

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Treatment1) Mechanical ( reducible hernia

only) A truss is an appliance having a pad that is held snugly in the hernial orifice.

Does not cure a hernia - it prevents abdominal contents from entering hernial sac.

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Cont…d

2) Surgical Recommended to correct the

hernia before a strangulation occurs which then becomes on emergency situation.

I. Hernial Sac, is dissected freeII.Contents of sac, are replaced in

abdominal cavity.

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III. Neck of sac is legatedIV. Muscle and fascial layers are

sawed together firmely.V. Strangulated hernia requires

resection of ischemic bowel in addition to hernia repair.

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Disorders of the rectum

1) Haemorrhoids Def: - It is an enlarged & congested

patch of mucosa & sub-mucosa at anorectal junction or

Are dilated portions of veins in the anal canal.

Sites: - at 3, 7, 11 O'clock, on lithotomy position.

Hemorrhoid based on its site:-1) Internal hemorrhoid (if it is above internal

sphincter.)2) External ( if it is outside external

sphincter)04/08/23 57

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C/F Bright red blood occurring at

the end of defecation (Late) Mass Per-rectum Peri-anal Discomfort Pruritus Mucosal Discharge

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Pain when complicated External hemorrhoids are associated with severe pain due to inflammation & edema caused by thrombosis. Clotting of blood (thrombosis) lead to necrosis & ischemia.

Internal Haemorrhoids are painless until they bleed.

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Classification of heamorhoids based on its

stage(severity)a) 1st degree:- Bleed but no prolapsed

b) 2nd degree :- Prolapsed but reduce spontaneously

c) 3rd degree :- but need manual replacement

d) 4th degree :- not returned.

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Etiology: - idiopathicPredisposing factor:-

Chronic Constipation Excessive use of purgative Pelvic masses ( Pregnancy ) Portal HTN

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Rx: Regulating bowel by laxatives

Avoid Constipation Advice high - residue diet that contain fruit.

Sitz bath

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Good personal hygiene & by avoiding excessive straining during defecation, haemorrhoid symptoms & discomfort can be relieved.

Non-operative Treatment:-1) Infrared Photocoagulation (rays)2) Bipolar Diathermy (Heat)3) Laser Therapy4) Injecting Sclerosing Solution

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Conservative Surgical Rx of internal Haemorrhoid;

A) Rubber - band ligation procedure: - The haemorthoid is visualized through the anoscape, & its proximal portion above the muco-cutaneous lines is grasped with an instrument. A small rubber band is then slipped over the hemorrhoid. Tissue distal to the rubber band becomes necrotic after several days & sloughs off. It may cause infection, pain & hemorrhage.

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B) Cryosurgical Hemorrhoidectomy Involves freezing the tissue of the

hemorrhoid for a sufficient time to cause necrosis.

Not used widely because the discharge is very foul-smelling & wound healing is prolonged.

C) Hemorrhoidectomy, or surgical excision, can be performed to remove all of the redundant tissue involved in the process.

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Ano-rectal Abscess

Def: It is an infection in the para-rectal spaces.

Risk Factors: Regional enteritis Immuno-defcient States (HIV/AIDS)

Many of these abscesses will result in fistulas.

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Cont…d

C/M: Abscess may occur in a variety of

spaces in & around the rectum. Pain Foul - Smelling pus In Superficial abscess, (Swelling,

redness & tenderness). Deeper abscess ( Fever, abdominal

Pain ) Fistula

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Mx :1) Palliative Rx;

Sitz Bath Analgesics

2) Surgical Rx:- Incision & drainage

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Anal fistula

Def:- It is a tiny, tubular, fibrous tract that extends into the anal canal from an opening located beside the anus.

Cause: Fistula usually results from an

infection. Trauma Fissures Regional Enteritis

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Cont…d

C/M Pus or stool may leak constantly from

the cutaneous opening Passage of flatus or feces from the

vaginal or bladder depending on the fistulas tract.

Fever

Mgx Surgery is always recommended Fistulectomy (excision of the fistulous

tract)04/08/23 70

Anal fissure

Def: It is a longitudinal tear or ulceration in

the lining of the anal canal Cause:

Trauma of passing a large firm stool Persistent tightening of the anal canal

secondary to stress or anxiety (leading to Constipation)

Child birth Trauma

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C/M Extremely Painful Defecation

Burning Bleeding

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Mgx Increase water intake Sitz bath Emollient Suppositories Corticosteroid Suppositories

(Relieve Discomfort) Surgery

*Most of the fissures will heal by conservative measures.

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Cancer of the large intestine:

Colon & Rectum Tumors of the small intestine are rare; conversely tumors of the colon & rectum are relatively common.

Cause: - Unknown

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Percentage distribution of colorectal cancer

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Cont…d

Risk factors:- Age: - incidence increases with age

(most patients are over age 55). It is the most common cancer in old age except for prostates cancer in men.

Family history of colon cancer Chronic inflammatory bowel

disease Polyp A diet high in fat, protein, & beef

& low in fiber04/08/23 76

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C/M It is determined by the location,

stage of cancer & function of the intestinal segment. Unexplained anemia Anorexia Weight loss Fatigue

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Symptoms most Common in right side lesions;Abdominal PainMelena

Symptoms most commonly associated with left side lesions.Abdominal painCrampyConstipationDistention

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Symptoms associated with rectal lesion;TenesmusRectal PainFeeling of incomplete evacuation after a bowel movement

Alternating Constipation & Diarrhea

Bloody Stool04/08/23 79

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Diagnostic Evaluation Fecal occult blood testing Barium enema Procto-sigmoidoscopy Colonoscopy Biopsy or cytology smears.

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Cont…d

Medical Mgx The patient with symptoms of intestinal obstruction is treated with IV fluids & nasogastric Suction.

Treatment depends on the stage of the disease & related complications.

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Cont…d

The most widely used staging method is duke's classification:- Class A- tumor limited to mucosa &

Sub-mucosa Class B- Penetration through bowel

wall Class C- Invasion into regional

draining lymph system. Class D- Advanced & widespread

regional metastasis

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Cont…d

Radiation Therapy Surgical Removal

It is primary treatment Indicated for most class A- lesions

& all class- B and C. Segmental Resection with

anastomosis Temporary Colostomy followed by

segmental resection & anastomosis Permanent Colostomy or ileostomy

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Cont…d

Complications of Colorectal Cancer Partial or Complete bowel

obstruction Hemorrhage Perforation

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Nursing Care for Patient with Colostomy

Colostomy; Is the surgical creation of an

opening (stoma) into the colon.

It can be temporary or permanent divertion.

It allows for the drainage or evacuation of colon contents to the outside of the body.

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Cont…d

Colostomy Irrigation; It is washing out of the intestinal

content through the stoma.Indicationa) It is done to permit escape of

feces when there is an obstruction of the large bowel or a known lesion, such as cancer, that will eventually cause an obstruction.

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Cont…d

b) It also may be done to permit healing of the bowel distal to it after an infection, perforation or traumatic injury since it diverts the fecal stream from the affected area.

c) It may be done as a palliative measure in the treatment of an obstruction caused by an inoperable growth of the colon or if the rectum must be removed to treat cancer.

d) It may be done to provide a permanent means of bowel evacuation.

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Cont…d

Purpose of colostomy irrigation1. To encourage a bowel motion in a

recently established colostomy and to ensure that the opening is patent.

2. To relieve constipation in patients who has difficulty managing their colostomy.

3. To teach the patient how to establish regularity of evacuation through the colostomy.

4. To reduce distention before closure of colostomy

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Cont…d

Read about/Remind your fundamentals of nursing course about; The equipments needed. The procedure. The special considerations.

Develop nursing care plan for a patient with colostomy.

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