GI/Renal Unit 5

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GI/Renal Unit 5
2013-11-09 12:15:52
GI Renal

Unit 5
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  1. Noninflammatory Bowel Disease
    • Functional GI D/O that causes chronic diarrhea, constipation, and/or abdominal pain/bloating
    • No structural or infectious etiology
    • No pathophysiologic bowel changes
  2. Irritable Bowel Syndrome (IBS)
    • functional GI /do that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain/bloating
    • AKA spastic colon, mucous colon, or nervous colon; most common
    • No actual pathophysiologic bowel changes; bowel motility changes and increased or decreased bowel transit times result
    • IBS-D-diarrhea; IBS-C-Constipation; IBS-A-alternating diarrhea and constipation; IBS-M-mixed diarrhea and constipation
    • Combination of environmental, immunologic, hormonal, genetic, and stress factors contribute; Begins in young adulthood
    • Most can identify triggers (stress)
  3. IBS Assessment
    • hx of weight change, fatigue, malaise, abdominal pain, changes in bowel pattern, consistency of stools, mucus; do not generally lose weight; medications, infections, nutrition (caffeine and sorbitol/fructose); lactose intolerance, raw fruits, grains cause gas, bloating, and abdominal distention
    • Pain in left lower quadrant (location, intensity, quality); belching, gas, anorexia, bloating
    • General well appearance, stable weight, nutritional status normal; patients are fine then a flare up occurs from trigger; motility changes (fast-diarrhea, slow-constipation)
    • CBC, albumin, ESR, FOBT, hydrogen breath test (excess hydrogen produced from overgrowth of bacteria in small intestine or malabsorption of nutrients causing an increase in hydrogen during exhalation; NPO for 12 h prior), lactose tolerance test
  4. IBS Interventions
    • Keep a symptom diary; assist to find triggers; avoid caffeine, alcohol, egg, wheat, sorbitol, fructose, lactose; increase dietary fiber with lots of water (30-40g), chew food slowly
    • IBS-C- Metamucil, lubiprostone (Amitiza) for women, a Cl channel activator that increases intestinal chloride without affecting Na and K, not effective on men; take with food and water
    • IBS-D-Imodium, psyllium; alosteron (Lotronex), a 5-HT3 receptor agonist for women that have not responded to traditional therapy, must agree to report symptoms of colitis or constipation early
    • Bloating and abdominal distention w/o constipation- rifaximin (Xifaxan), antibiotic
    • Inhibit intestinal motility- muscarinic receptor antagonist, darifenacin (Enablex) and fesoterodine (Toviaz)
    • Pain may receive TCA amitriptyline (Elavil); for postprandial discomfort, take 30-45 m before meals
    • CAM- probiotics, peppermint oil, acupuncture and moxibustion (gas and bloating), stress management, relaxation techniques, meditation, yoga, personal counseling, exercise
  5. Hernia
    • a weakness in the abdominal muscle wall through which a segment of the bowel or other abdominal structure protrudes; named by their location
    • Indirect inguinal hernia- sac formed from the peritoneum that contains portion of the intestine or omentum; can be large and descend into the scrotum; most common in men; follows the tract of the testes descending into the scrotum
    • Direct inguinal hernia- pass through a weak point in the abdominal wall; older adults;
    • Femoral- protrude through the femoral ring; plug of fat in the femoral canal enlarges and eventually pull the peritoneum and/or bladder into the sac; obese and pregnant women
    • Umbilical- congenital (infancy) or acquired (increased abdominal pressure);muscle weakness and pressure can occur from obesity, pregnancy, lifting
    • Incisional- previous surgical incision; abdominal surgery
    • Hernias result from weakened collagen or widened spaces at the inguinal ligament; increases in intra-abdominal pressure come from pregnancy, obesity, abdominal distention, ascites, heavy lifting, or coughing
    • Weight control can decrease the likelihood
  6. Hernia Classifications
    • Reducible- contents of the hernia sac can be placed back into the abdominal cavity by gentle pressure
    • Irreducible- cannot be reduced or pushed back into the abdominal cavity (incarcerated); requires immediate surgery
    • Strangulated-blood supply to the herniated segment of the bowel is cut off by pressure from the hernia ring; there is ischemia and obstruction of the bowel loop; S/S are N/V, abdominal distention, pain, fever, and tachycardia; can lead to necrosis of the bowel and possible bowel perforation; emergency
  7. Assessment
    • Bowel sounds are present unless strangulation has occurred or with a femoral hernia if it is a fat plug; a lump or protrusion is felt at the involved site
    • Inspect the abdomen with the pt lying and standing; reducible hernias may disappear when lying flat; ask the pt to strain or perform the Valsalva maneuver and observe for bulging
    • Palpate an inguinal hernia by inserting a finger in the ring and noting any changes when the pt coughs; never forcibly reduce a hernia b/c it can cause intestinal rupture
    • Indirect inguinal hernia of the groin, have the pt stand, place the right hand on the pt right side and left hand for the pt left side and push the loose scrotal skin upward to the external inguinal cord, have the pt turn their head and cough
  8. Nonsurgical Management of Hernias
    • If not a surgical candidate, a truss may be used for an inguinal hernia
    • Truss is a pad with firm material, held in place over the hernia with a belt to keep abdominal contents from protruding into the hernia sac; applied after physician reduced the hernia if not incarcerated; teach pt to assess the skin daily and protect it with a layer of light powder; abdominal exercise and weight control
  9. Surgical Management of Hernias
    • Treatment of choice; typically laparoscopic; more extensive surgery may occur if strangulation results in a gangrenous section of the bowel (bowel resection or temporary colostomy)
    • MIIHR (herniorrhaphy) or conventional approach is used
    • Pt must be NPO, have someone to drive them home
    • Hernioplasty- reinforces the weakened outside muscle with mesh pads
    • MIIHR- d/c in 3-5h
    • Rest for several days before returning to work and normal routine; not to drive or operate machinery; observe incisions daily for redness, swelling, heat, drainage, and increased pain; should have soreness and discomfort, not severe acute pain; NO COUGHING; deep breathing and ambulation; indirect inguinal repair, use scrotal support and ice bags to decrease swelling and help pain, elevate the scrotum with a soft pillow; stand to void; report urine <30ml/h; drink at least 1500-2500 ml day; I&O; provide oral and written instructions and to report fever, chills, wound drainage, redness or separation of the incision, and increased incisional pain; keep wound dry and clean with antibacterial soap and water
  10. Colorectal Cancer
    See Unit 4, Cancer
  11. Intestinal Obstruction
    • Complete or partial, mechanical or nonmechanical; usually in the ileum
    • Mechanical obstruction- bowel is physically blocked by problems outside the intestine (adhesions), inside the bowel wall (Crohn's disease), or in the intestinal lumen (tumor); contents accumulate above the obstruction
    • Nonmechanical-(paralytic ileus) does not involve a physical obstruction in or outside the intestine; peristalsis is decreased or absent as a result of neuromuscular disturbance, resulting in a slowing of movement or a back up of intestinal contents; contents accumulate above the obstruction
    • Distention results from the intestines ability to absorb the contents and move them down the intestinal tract
    • In an attempt to compensate, peristalsis increases to try to move the contents which increases the secretions leading to more distention; bowel then becomes edematous, increased capillary permeability results; plasma leaks into the peritoneal cavity and trapped fluid in the intestinal lumen decreases the absorption of fluid and electrolytes into vascular spaces; hypovolemia and electrolyte imbalances occur
    • Obstruction high in the small intestines causes metabolic alkalosis
    • Obstruction below the duodenum but above the large bowel does not typically cause an acid base problem
    • Obstruction at the end of the small intestines and lower in the intestinal tract causes metabolic acidosis
    • Severe hypovolemia can lead to renal insufficiency or death
    • Bacterial peritonitis with or without perforation can result; bacteria in the intestinal contents lie stagnant in the obstructed intestine
    • Closed-loop obstruction (blockage in 2 different areas or Strangulated obstruction (obstruction w/ compromised blood flow) cause an increased risk for peritonitis; bacteria w/o blood supply can form and release an endotoxin into the peritoneal or systemic circulation causing systemic shock
  12. Intestinal Obstruction Etiology
    • usually in the ileum
    • Mechanical obstruction is most common and cause by adhesions, benign or malignant tumors, complications from appendicitis, hernias, fecal impactions, strictures, radiation therapy, intussusception (telescoping of a segment of the intestine within itself), volvulus (twisting of the intestine), fibrosis (endometriosis), vascular disorders (emobli or arteriosclerotic narrowing)
    • Age 65 or older, diverticulitis, tumors, and fecal impaction are most common
    • Paralytic ileus is commonly caused by handling of the intestines during abdominal surgery; intestinal function is lost for a few hours to several days; hypokalemia predispose pt to problem
    • Can be a consequence of peritonitis; because it causes severe irritation and triggers inflammation
    • Vascular insufficiency (intestinal ischemia) from thrombosis or emboli decrease blood flow
  13. Intestinal Obstruction History
    • Hx of abdominal surgery, radiation therapy, IBS, gallstones, hernias, trauma, peritonitis, tumors
    • Ask about N/V, color of emesis; pain w/ attention to onset, aggravating factors, alleviating factors, patterns or rhythm of pain; severe pain that stops and changes to tenderness on palpation may indicate perforation; gas and the time, character, consistency of last BM; hiccups is common
    • Keep pt NPO
    • Hs of CRC; blood in the stool or change in bowel patter; a temp higher than 100 degrees with or without guarding and tenderness, and a sustained pulse could indicate strangulated bowel or peritonitis
    • Fever, tachycardia, hypotension, increasing abdominal pain, abdominal rigidity, or change in color of skin on the abdomen need to be reported immediately
  14. Intestinal Obstruction Assessment/Manifestations
    • Mechanical obstruction of the small intestine- mid-abdominal pain or cramping; sporadic with comfort between episodes; strangulation may cause the pain to become localized and steady; vomiting that is more profuse in obstructions in the proximal small intestine that may contain bile and mucus or orange/brown and foul smelling (lower obstruction); obstipation (no passage of stool) and failure to pass gas may indicate a complete obstruction
    • Mechanical colonic obstruction- milder, more intermittent colicky pain (small bowel); lower abdominal distention, ribbon like stools (partial); alterations in bowel pattern and blood accompany obstruction; observe abdominal distention, possibly peristaltic waves; proximal high pitched sounds (borborygmi) with cramping occur early as the bowel attempts to move obstruction; bowel sounds then become absent, especially distally; tenderness and rigidity are usually minimal; tense, fluid-filled bowel mimicking a mass may be a signal of closed loop or strangulated bowel
    • Nonmechanical- constant, diffuse discomfort; pain is usually severe and constant (vascular insufficiency or infarction); abdominal distention; decreased bowel sounds that become absent; frequent vomiting of bile that does not have an odor or not profuse; obstipation may or may not occur
  15. Key Features of Large/Small Bowel Obstruction
    • Small- abdominal discomfort or pain possibly accompanied by visible peristaltic waves in upper and middle abdomen; upper or epigastric abdominal distention; nausea and early, profuse vomiting (may contain fecal material); obstipation; severe fluid and electrolyte imbalances; metabolic alkalosis
    • Large- intermittent lower abdominal cramping; lower abdominal distention; minimal or no vomiting; obstipation or ribbon like stools; no major fluid and electrolyte imbalances; metabolic acidosis
  16. Labs, imaging, diagnostic assessments
    • No definitive lab
    • Labs- WBC normal unless strangulation; hgb, hct, creatinine, BUN elevated; Na, Cl, K decreased; amylase elevated with strangulation; high obstruction of small intestine, metabolic alkalosis; large intestine, metabolic acidosis
    • Imaging- supine or upright abdominal Xrays that show has in above the obstruction and nothing below the obstruction; CT; Xrays are normal with strangulated
    • Others- ultrasound to evaluate cause; sigmoidoscopy or colonoscopy to determine cause except for perforation or complete obstruction is suspected
  17. Nonsurgical Obstruction Management
    • Uncover the cause and relieve obstruction
    • NPO
    • NG tube, Salem sump with low continuous suction, Levin tubes with low intermittent suction; ask the pt about gas to determine if peristalsis has returned; assess for nausea and report; a decrease in gastric output or statis of the tube contents may indicate moved position or plugged tube; assess for N/v, increased abdominal distention and tube placement; aspirate contents and irrigate with 30 ml NS q4h; if pt has return of peristalsis, start clear liquids, if vomiting occurs, reinsert tube
    • IV fluids of LR or NS at 2-4 L with K added; watch for fluid overload, monitor lung sounds, weigh, I&O; monitor vitals q2-4h; TPN if chronic nutritional problems occurs or NPO for long period; frequent oral care; ice chips if pt not having surgery
    • Hold opioids and explain why pain meds are being held (so that symptoms are not masked, constipation not increased, and vomiting does not increase); be alert to N/V b/c signs of NG tube obstruction or worsening bowel obstruction
    • Frequent position changes to promote peristalsis; semi fowlers
    • Sandostatin (octreotide acetate) is a broad spectrum antibiotic used to enhance gastric motility for partial obstruction or paralytic ileus
  18. Intestinal Obstruction Surgical Management
    • exploratory laparotomy
    • complete obstruction be sure to reinforce info to family member because pt may feel to ill
    • Adhesions are lysed; obstruction from tumor or diverticulitis require colon resection w/ primary anastomosis or temporary permanent colostomy; intestinal infarction, embolectomy, thrombectomy, or resection of gangrenous bowel may be necessary
    • NGT until peristalsis returns, clear liquids and NGT disconnected from suction and capped for 1-2 h to determine if pt can tolerate them, if vomiting returns then suction is restarted; return of peristalsis warrants NGT removal, first discontinuing suction then clamping the tube fore small amounts of time, residual drainage is checked at each stage to assess decompression before NGT removal
    • MIS may stay for 1-2 days and conventional may stay 3 or more days
  19. Malabsorption Syndrome
    • Interferes with the ability to absorb nutrients and is a result of a generalized flattening of the mucosa of the small intestines
    • Limits absorption of one or more: bile salt deficiencies, enzyme deficiencies, presence of bacteria, disruption of the mucosal lining of the small intestine, altered lymphatic and vascular circulation, decrease n gastric or intestinal surface area
    • The nutrient involved depends on the type and location of the abnormality in the intestinal tract
    • Most common is gluten (Celiac Disease)
    • Deficiency of bile salts can lead to malabsorption of fats and fat soluble vitamins; small intestine
    • Lactase can be genetic, injury to intestinal mucosa from viral hepatitis, bacterial proliferation in the intestine, or sprue
    • Pancreatic enzymes are needed to absorb vitamin B12
    • Loops of bowel can accumulate intestinal contents resulting in bacterial overgrowth when peristalsis is decreased; break down bile salts, ingest vitamin B12; common after gastrectomy
    • Disruption of the mucousal lining is responsible for celiac (nontropical) sprue, tropical sprue, Crohn's disease, and ulcerative colitis; Celiac is caused a genetic hypersensitivity to gluten or its breakdown products or to result from the accumulation of gluten in the diet with peptidase deficiency; tropical sprue is caused by an unidentified infectious agent causing malabsorption of fat, folic acid, Vitamin B12; Crohn's disease interferes with absorbing bile salts and leads to fat malabsorption; ulcerative colitis causes protein loss
    • Obstruction of lymphatic flow can lead to loss of plasma proteins along with loss of minerals (iron, copper, calcium), vitamin B12, folic acid, and lipids; cx such as lymphoma, inflammatory states, radiation enteritis, Crohn's disease, heart failure, constrictive pericarditis are causes
    • Intestinal surgery causes a loss of surface area needed to facilitate absorption; all of the bowel is needed to absorb nutrients and when it is decreased in size, less nutrients are absorbed
  20. Assessment of Malabsorption Syndrome
    • CHRONIC DIARRHEA, steatorrhea, unintentional weight loss, bloating, gas, decreased libido, easy bruising, anemia (iron/folic acid), bone pain (calcium/vitamin D), edema (hypoproteinemia)
    • Labs- decrease MCV, MCH, MCHC- hypochromic microcytic anemia (iron deficiency); increased MCV, variable MCH and MCHC-macrolytic anemia (B12,folic acid deficiency); low iron (protein malabsorption); low cholesterol (vitamin D/amino acids); low vitamin A and carotene (bile salt/fat); fecal fat analysis (malabsorption/maldigestion)
    • Lactose tolerance test- <20% rise in blood glucose over the fasting blood glucose level; hydrogen breath test can detect this problem; xylose absorption test-low urine and serum D-xylose levels (celiac sprue), abnormal D-xylose test (bacterial overgrowth in small intestine)
    • Schilling test- urinary excretion of vitamin B12 for pernicious anemia; bile acid breath test-malabsorption of bile salt, bacterial overgrowth causes bile salts to deconjugae and CO2 levels in the breath will peak early
    • Biopsy of small intestine for dx of tropical or Celiac sprue; ultrasound for pancreatic tumors and small intestine tumors; Xrays of GI for pancreatic calcifications, tumors, or other abnormalities; CT
  21. Interventions for Malabsorption Syndrome
    • Avoid substances that aggravate malabsorption and supplement nutrients
    • Low fat diet for gallbladder disease, severe steatorrhea, or cystic fibrosis; possibly for pancreatic insufficiency
    • High protein, high calorie diet with small, frequent meals for gastrectomy
    • Lactose free or lactose restricted diet for lactose intolerance
    • Gluten free for Celiac sprue
    • Supplements of folic acid, B complex, Vitamin A, Vitamin D, Vitamin K, calcium, iron, magnesium, pancrelipase
    • Antibiotics for tropical sprue (trimethoprim/sulfamethoxazole, Bactrim, Septra); others tetracycline and metronidazole (Flagyl); Steroids for inflammation
    • Antidiarrheals (Lomotil), anticholinergics (Bentyl) to inhibit gastric motility, IV fluids
    • Protect the skin
  22. Appendicitis
    • Acute inflammation of the vermiform appendix that occurs most often in young adults; common cause of RLQ pain; extends off the proximal cecum of the colon just below the ileocecal valve; inflammation from the lumen of the appendix is obstructed which leads to infection as bacteria invades the wall of the appendix
    • Obstruction is usually the result of fecaliths (hard pieces of feces) composed of calcium phosphate rich mucous and inorganic salts; other causes are malignant tumors, worms, or other infections
    • When the lumen is blocked, mucosa secretes fluid, increasing the internal pressure and restricting blood flow that causes pain; if it occurs slowly, an abscess may develop, but a rapid process may result in peritonitis; Gangrene can occur within 24-36h and indicates emergency surgery; perforation may develop within 24h, but risk rapidly rises after 48h; Perforation also results in peritonitis with a temp greater than 101 and a rise in pulse
    • Can affect small, large intestine or both; restricts blood flow; too much pressure causes it to burst (pain with sudden relief)
  23. Appendicitis Assessment
    • N/V before abdominal pain can indicate gastroenteritis; Abdominal pain followed by N/V indicates appendicitis
    • Risk factors-age, familial tendency, intra-abdominal tumors
    • S/S-cramplike pain in the epigastric or periumbilical area; anorexia with N/V
    • Pain can initially be present in anywhere in the abdomen or flank; inflammation and infection causes the pain to become more severe and shift to the RLQ between the anterior iliac crest and umbilicus (McBurney's point); Abdominal pain that increases with cough or movement and is relieved by bending the right hip or knees suggests perforation and peritonitis
    • Assess for muscle rigidity and guarding on palpation and rebound tenderness
    • WBC count between 10000-18000 with a shift to the left; WBC >20000 may indicate perforated appendix; ultrasound may show enlarged appendix; recurrent or prolonged symptoms a CT may be used
    • Dull umbilical pain progresses over 4-6h to RLQ
  24. Appendicitis Nonsurgical Management
    NPO to prepare for surgery; IV fluids, semi-fowlers (drain), analgesics, no laxatives or enemas (increased pressure is not good), no heat to area
  25. Appendicitis Surgical Management
    • Appendectomy- removal of the inflamed appendix by one of several surgical approaches (laparoscopically-MIS; laparotomy- large abdominal incision)
    • return to usual activities in 1-2 weeks
    • If at high risk for complications from suspected appendicitis a laparotomy is performed
    • Preop teaching usually limited due to little time or emergency situations
    • Peritonitis or abscess is found, wound drains are inserted and a NGT to decompress the stomach and prevent abdominal distention; IV antibiotics and opioid analgesics; out of bed the evening of surgery; hospitalized for 3-5 days and return to normal activity in 4-6 weeks.
  26. Peritonitis
    • Life threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity
    • Peritoneal cavity contains 50 ml sterile fluid
    • When the peritoneal cavity is contaminated by bacteria, the body begins an inflammatory reaction walling off a localized are to fight the infection; if walling off fails, the inflammation spreads and contamination becomes massive, resulting in diffuse peritonitis
    • Caused by contamination of the peritoneal cavity by bacterial or chemicals
    • Bacteria can enter via perforation (appendicitis, diverticulitis, PUD), an external penetrating wound, gangrenous gallbladder, bowel obstruction, or ascending infection from the genital tract, tumors, contamination during surgery, and an infection by skin pathogens in pt undergoing continuous ambulatory peritoneal dialysis
  27. UC Drugs
    • hct, hgb low; increase WBC, C-reactive protein, ESR; low Na, K, Cl
    • aminosalicylates (5-ASA)- mild to moderate UC; anti-inflammatory effects by inhibiting prostaglandins and are usually effective in 2-4 weeks; sulfasalazine (Azulfidine, Azulfidine EN) is metabolized by the intestinal bacterial into ASA which delivers the beneficial effects of the drug and sulfapyridine which causes unwanted effects; mesalamine (Asacol, Pentasa, Rowasa, Apriso, Canasa) is better tolerated, Asacol is enteric coated and released in terminal ileum