Lower GI-Lecture #2

11-19

• Perforation
• Peritonitis
• Abscesses

• Pain RLQ
• Anorexia
• N/V
• Rebound Tenderness
• Muscle Guarding

• ruptured appendix
• perforated gastric/duodenal ulcer
• severely inflamed gallbladder
• abdominal trauma-GSW/knife wound

• pancreatitis
• ascites
• peritoneal dialysis

• abdominal pain
• rebound tenderness
• muscular rigidity
• abdominal distention
• ascites
• fever
• tachycardia/tachypnea
• n/v

increases peristalsis and can cause perforation

Once you hear bowel sounds

• NPO
• fluid & electrolyte replacement
• antibiotics/antiemetics
• NG Tube with suction
• semi fowlers
• pain management

Ulcerative Colitis and Crohn's

chronic recurrent inflammation of the intestinal tract

Jewish white people....who have it in their family.  Inherited

starts in the rectum and sigmoid colon and spreads up the colon in a CONITNUOUS pattern of inflammation and ulceration of the mucosal layer

cuz there is a decreased mucosal area for absorption of F&E

• bloody diarrhea (4/5xday)
• abdominal pain
• fever
• malaise
• anorexia

• 10-20 stools per day
• mucous and blood in stools
• fever
• weight loss
• anemia
• tachy
• symptoms of dehydration

• Toxic Megacolon
• Perforation
• Hemorrhage causing anemia
• Increased risk of colorectal cancer

• arthritis
• eye inflammation
• skin lesions
• thromboembolism
• kidney stones
• sclerosing cholangitis

• CBC-iron deficiency anemia
• WBC count-megacolon/perforation
• Serum Protein-hypoalbuminemia
• Stool testing-OB and C&S

• colonoscopy
• pillcam
• barium enema

• decreased # of stools/day
• soft formed stools
• keep food in and maintain wt
• no anxiety

• IV fluids and electrolytes
• monitor # stools and appearance
• meticulous peri care

• Pentasa
• Colazal

it's a retention enema that is an anti inflammatory

• Prednisone PO
• Solumedrol IV

Imuran

total l colectomy with rectal mucosal stripping and ileal reservoir

CUREABLE

1500-2000ml/24 hrs!!!

change bag frequently

Encourage-high calorie, high protein low residue diet w/vitamins and iron supplements

Discourage-cold foods, high residue foods (wheat bread, cereal with bran, nuts, raw fruit) smoking

• discontinuous inflammation involving all layers of the bowel
• most common in the terminal ileum and colon

• diarrhea
• abdominal pain
• fever
• fatigue
• wt loss/malnutrition
• dehydration
• anemia
• v. deficiency
• electrolyte imbalance

• will need surgery, but it wont cure the problem
• due to multiple surgeries...they will ultimately have short bowel syndrome

severe malabsorption

• high calorie
• high nitrogen (replace protein loss)
• fat free
• no residue

v. B12 shots monthly

• Second peak occurs at 70
• riskier to have surgery
• hard to control F&E issues

caused by an occlusion of the lumen of the intestinal tract (usually small) from adhesions post op

cancer

• paralytic ileus (lack of peristalsis)
• vascular obstruction (emboli/atherosclerosis)
• Hernia
• Neoplasms

when the bowel cant tell that brain that it is full, and the brain cant tell the bowel to empty completely or at an appropriate time

• obstruction causes distention and stimulates intestinal secretions
• increased pressure causes capillary permeability and fluids shift in to the peritoneal cavity

• hypotension
• hypovolemia
• F&E imbalances

• N/V
• abdominal pain/distention
• NO FLATUS
• constipation
• Pain
• Fever

• CT
• Abdominal X ray (gas/fluids)
• CBC/Serum Chesistries
• Stool for OB
• Sigmoidoscopy/Colonoscopy with biopsy

• high-alkalosis
• low-acidosis

• watch for fluid and electrolyte imbalances
• replace potassium?
• NPO
• Manage NG tube

saccular dilations or outpouching of the mucosa thru the smooth muscle of the intestinal wall

sigmoid colon

lack of fiber and high carb diet

US Americans get it the most

transit time slows and more water is absorbed from the stool making it more difficult to pass thru the lumen

retention of stool and bacteria in the diverticula causing inflammation, abscesses and small perforations

• LLQ abdominal pain
• fever
• leukocytosis

• Perforation with peritonitis
• abscess and fistula formation
• bowel and ureteral obstruction
• bleeding

• High fiber...fruits and vegetables
• increased fluids

Avoid bending, heavy lifting and tight clothes

go back in to place by manipulation or when the patient lies down

cant be placed back in to the abdominal cavity and may become strangulated.

Most common hernia and most common in men

Pushes through inguinal ring

Occurs most in women

pushes thru the femoral ring in to the femoral canal

occur when the rectus muscle is weak or the umbilical opening fails to close after birth

occur due to a weakness in the abdominal wall at the site of a previous incision

• obese
• have had multiple surgeries in the same area
• inadequate wound healing

• Protrusion
• Severe pain if strangulated

surgical repair of a hernia...done laparoscopically

reinforcement of a weakened area around a hernia

• necrosis/gangrene
• bowel resection with temporary colostomy

• don't sneeze/cough
• don't lift heavy things for 6-8 weeks

chronic, progressive degeneration and destruction of liver cells

• inadequate blood flow
• poor cellular nutrition/hypoxia

further decreases fxn of liver

• Alcoholism
• Chronic Hepatitis
• Biliary cirrhosis
• Cardiac problems

B&C

caused by long standing Rt. sided heart failure causing venous flow to back up in to the liver

• GI Distress
• Anorexia
• Dyspepsia
• Flatulence
• N/V
• Diarrhea/Constipation

• Jaundice
• Peripheral Edema
• Ascites
• Skin lesions
• Endocrine disturbances
• Peripheral Neuropathies

• Thrombocytopenia
• Leukopenia
• Anemia

• Portal HTN
• Esophageal Varices
• Ascites
• Peripheral Edema
• Hepatic Encephalopathy
• Hepatorenal Syndrome

large torturous veins at the lower end of the esophagus as a result of portal hypertension causing high pressure and they are weak so they may hemorrhage.

Vericose veins of the esophagus

the liver doesn't metabolize the ammonia in the body so it accumulates and crosses over the blood brain barrier causing neurologic changes

lethargy to coma

occurs with cirrhosis....renal failure with azotemia and is a result of portal hypertension

• Excess fluid volume
• Imbalanced nutrition
• impaired skin integrity
• bleeding
• acute confusion

• reduce/eliminate risk factors for alcoholism
• rest to decrease metabolic demand on liver
• Banana Bag-B complex vitamins
• Assess for F&E imbalances
• Address skin

• High calories/carbs
• Low fat/protein

• diuretics
• sodium restrictions
• paracentesis
• peritoneal shunt

• Goal is to reduce risk of bleeding....
• Give Beta Blockers to reduce BP
• TIPS-Transjugular Intrahepatic Portosystemic Shunt
• Vitamin K

to correct clotting abnormalities

• it is going to be removed via the intestines with Lactulose 3-4x/day
• Antibiotics impair bacterial action on protein in the feces to decrease ammonia production.

• LUQ abdominal pain
• N/V
• Leukocytosis
• Hypotension
• Tachycardia
• Jaundice

eating

• seen in pt. with pancreatitis
• bluish discoloration of the blank areas

• seen with Pancreatitis
• Bluish periumbilical discoloration resulting from seepage of blood stained exudates from the pancreas

• weight loss
• constipation
• mild jaundice
• dark urine
• steatorrhea
• DM

fat in stool

• pleural effusion
• atelectasis
• pneumonia
• hypotension
• thrombi
• bleeding

• NPO
• NGT with suction
• F&E balance
• PAIN MANAGEMENT (#1)
• Monitor infections
• Nutritional therapy

gall stones

inflammation of the gallbladder

increased precipitation of cholesterol, bile salts and calcium.  Infection and disturbances of cholesterol metabolism create an environment for gallstones to form

cholesterol

stones from the gallbladder migrate to the cystic/bile duct causing a blockage.  There will be a blockage of bile from the gallbladder causing stasis and cholecystitis?

• RUQ pain
• N/V
• Fever
• Leukocytosis
• Jaundice

• fat intolerance
• dyspepsia
• heartburn
• flatulence

• pain management
• antibiotic for infections
• F&E balance per labs
• NGT tube with suction

ERCP-stone removal

cuz carbon dioxide wasn't released or absorbed by the body

Demoral

ADEK

low fat

• a condition seen in people with UC and Crohns.  Inflammation and infection cause a widening of the colon:
• abdominal pain/distention/tenderness
• fever
• tachy
• SHOCK!!