Lower GI Disorder NS2P2 Exam 3

Chronic disorder characterized by intermittent and recurrent abdominal pain with stool pattern irregularities;pretty common, brought on by food intolerances usally-spicy and fatty

Multicomponent disorder: Altered bowel motility, increased visceral sensitivity, inflammation, neurotransmitter imbalance, psychological distress

• =>Most common lower GI condition
• Affects 10-15% of the Western population
• Affects twice as many women as menPossible genetic component

• **IBS: Triggers
• Psychological or physical stress: Anxiety, depression, posttraumatic stress disorder, stress,heredity
• High fat and other irritating foods
• Alcohol Smoking

• IBS: Clinical Manifestations
• Abdominal pain/bloating
• Constipation
• Diarrhea
• Constipation alternating with diarrhea
• =>Additional symptoms
• Bloating
• Flatulence
• Incomplete evacuation
• Fatigue
• Sleep disturbances-Symptoms can be mild to severe and possibly severe
• Can be disabling for a small amount of people

• =>Diagnosis
• Diagnosis of exclusion!
• Symptoms have been standardized (Rome criteria)

• =>Treatment
• Symptom and food intake diary to identify/eliminate triggers
• Probiotics-helpful for bowel management
• Stress management: usually decerases symptoms
• Regulation of stool- for diarrhea treated by imodium or lodimal; adding insoluble fiber,
• constipation=laxative milk of magnesia,increase dietary fiber
• Bentyl-causes smooth muscle relaxation and and decreases spasm of the gut

• =>Pain relief
• Anticholinergics (Dicyclomine)
• Tricyclic antidepressants (Amitriptyline) –decreases viseral sensitivity

Acute inflammation of the appendix;Appendicitis occurs when the vermiform appendix (a small projection of the cecum) becomes trapped with hard material (usually feces) that leads to a bacterial infection. The lumen of the appendix is blocked and edematous, which leads to abdominal pain.

• ●● Appendicitis is not preventable; therefore, early detection is important.
• Most common in young adults
• Most common cause of emergency abdominal surgery

• =>Obstruction is precipitating factor-blind tube at end of secum and eventually it becomes inflamed and infected
• Fecalith-hard stool that become hard like stone; obstructionTumor in cecum
• Excessive growth of surrounding lymphoid tissue (malignancy possiblility)
• Foreign body-seeds If ruptures leads to peritonitis; It empties inefficiently and is prone to infection

=> appendix: empties inefficiently

• => Clinical Manifestations
• Periumbilical pain that localizes to RLQ
• Acute pain at McBurney’s point-between belly botton and hip
• Anorexia, N/V
• Low grade fever
• Rebound tenderness - (pain after deep pressure is applied and released) over McBurney’s point (located halfway between the umbilicus and anterior iliac spine).
• Muscle guarding (involuntary rigid board like abdomen is bodies response to prevent pain )
• Pain that is relieved by right hip flexion and increases with coughing and movement may indicate perforation with peritonitis.
• Muscle rigidity, tense positioning, and guarding may indicate perforation with peritonitis.
• Normal to low-grade temperature (higher suggests peritonitis)
• NO PAIN IS BAD SIGN=RUPTURE.

• =>Diagnosis
• CT or abdominal ultrasound
• CBC
• Laboratory Tests: WBC count and differential – Mild to moderate elevation of 10,000 to 18,000/mm3 with left shift is consistent with appendicitis; greater than 20,000/mm3 may indicate peritonitis.

• An ultrasound of the abdomen may show an enlarged appendix.
• Abdominal computed tomography (CT) may be diagnostic if symptoms arerecurrent or prolonged. The CT may show the presence of fecal material in theappendix.

• -> other notes:
• Pain with pressure put on indication of peritinitus in contrast to rebound tenderness
• Bad sign is if initial pain and all of a sudden pain disappears=rupture
• InvoluntarPain then no pain = rupture. THEN EVENTUALLY: PERITONITIS!!

• => Appendectomy (laparoscopic or open)
• => Pre-op
• NPO
• Hold analgesic until diagnosis is confirmed-because pain must be assessed acurately
• No enemas or laxatives-dangerous because increase peristalsis which can cause perforation of appendix
• No heat application-no hot or warm compresses, ice is ok because it decreases inflamation (20-30 mins every hour)
• IV fluids and antibiotics

• => Post-op
• NPO until bowel sounds return
• Early ambulation day of surgery, post op day 1
• Semi-Fowlers position-takes pressure off abdomen
• Pain control, pulmonary toilet, incentive spirometer
• Tcbd every two hours

(Ambulation is done post op day 1, should hear bowel sounds after surgery same day once passing gas feed slowly with clear liquids)

• => Peritonitis, which is an inflammation of the peritoneum and viscera, can occur due to perforation of the appendix. The peritoneal area, which is normally sterile, becomescontaminated with bacteria and gastric juices from the gastrointestinal tract. When a client has appendicitis, the risk of perforation is greatest 24 hr following the onset of pain.
• Localized or diffuse inflammatory process of the peritoneum; May be sterile(mechanical disruption or chemical irritation from barium) but infection is more or infectious

=> Primary : via hematogeneous spread(bacteria perotonitis with acities

• =>Secondary : due to pathological processes of visceral organs(like ruptured appendix)
• Fluid shifts and infection predispose patient to life-threatening hypovolemic shock, sepsis, abscess formation, paralytic ileus

• => Clinical Manifestations
• Abdominal pain and distention: reflects in looking very sick, breathing shallowing due to pain with application of pressure, board like abdomen
• Pain with application of pressure, muscular rigidity when abdomen is touched, spasm
• fever
• increased HR/RR(breath shallowly because of pain)
• N/V

• => Diagnosis
• CBC
• Abdominal ultrasound or CT
• Paracentesis-fluid from paratenial cavity and it is tested

Surgery usually indicated; Surgery is to correct underlying cause goal is to remove infectious source like an abcess.

Aggressive antibiotics first--cephlasporins and quinolones

IV fluid replacement

Oxygen therapy PRN

Bowel rest (NPO, NGT)

Monitoring for fluid and electrolyte imbalances

Symptom relief

Diverticula- sac-like outpouchings of colon mucosa; little herniation of GI wall.

Diverticulosis: multiple diverticula that are not inflamed; asymptomatic

Diverticulitis: inflamed diverticula that may cause potentially fatal obstruction, abscess, and hemorrhage(perforation-symptomatic, eventually fatal like perforation..

• => Pathophysiology
• Diverticula develop with loss of muscle mass/collagen with aging and deficiency in dietary fiber (higher risk if you're constantly constipated b/c pressure from colon.)

Fecal material or food particles collect, causing obstruction and inflammation

Erosion of the wall can occur, leading to microperforations

May lead to localized abscess or peritonitis w/ bigger perforation

Repeated attacks lead to the formation of scar tissue and strictures and obstruction

• => Risk Factors
• Low fiber, high fat diet
• Sedentary lifestyle
• Obesity
• Increased intraabdominal pressure
• Usually found on routine colonoscopy
• And acute deverticulitis dx with ct scan

• => Clinical Manifestations
• Usually asymptomatic w/ diverticulosis
• Abdominal pain, bloating, gas, change in bowel habits
• Acute diverticulitis presents w/ acute pain, fever, leukocytosis, palpable mass

• => Diverticulosis: outpouching or herniations of the intestinal mucosa that can occur in any part of the intestine but is most common in the sigmoid colon.chronic diverticula
• High fiber diet
• Prevention/management of constipation
• Usually asymptomatic maybe abd pain gas , bloading and bowel habits change
• not inflammed and not causing any symptoms; bunch of these outpouchings

• => Diverticulitis (uncomplicated): Inflammation of one or more diverticula from pentraton of fecal matter through the thin walled diverticula.
• -treated as an outpatient
• Will have acute abd pain fever, leucocytosis and maybe palpable mass
• Clear liquids
• IV hydration
• Po antibiotics
• Parenteral antibiotics
• Pain management -elderly more likely needed to require hospitalization for acute episode

• => Diverticulitis (complicated):
• When Diverticulitis results in local abscess formation. A perforated diverticulum can progress to intraabdominal perforation with generalized peritonitis; doesn't respond to medications so you need surgery
• Surgical intervention: Which is usually a partial colectomy, and connect two pieces together or just put in a colostomy

• => Antibiotics used for treatments
• beta lactamse or metrominizal(flagyl)
• 3rd generation cephalosporins(rocefin)
• flouroquinolon(leviquine)

In two to three days patient should see a reduction in pain fever and wbc, if not abcess could be forming if having persistant fevers and high white count

Diverticulitis is an inflammation of the diverticula (hernia in intestinal wall) that frequently occurs in the colon.

• • Only about 10% of clients who have diverticula develop diverticulitis. Frequent episodes of inflammation from trapped feces or bacteria may lead to bleeding and infection.
• • Diverticula may bleed and the loss of blood may be minimal or severe.

• Diverticula may perforate and cause

• => S/S:
• • Abdominal pain in left-lowerquadrant
• • Nausea and vomiting
• • Fever
• • Chills
• • Tachycardia

• Autoimmune disorder of the GI tract
• Chronic inflammation w/ periods of remission and exacerbation
• Commonly presents in teens/early adulthood w/ second peak in the 60s
• Incidence higher in whites;
• More prevalence in jews
• Etiology complex interplay between genetics and environment
• Incidence increase when area becomes industrializedpeople taking too may antibiotics, not enough exposure to germs..

• **Subtypes of IBD
• =>Crohn’s disease
• Inflammation involves all layers of bowel wall
• Can occur anywhere in the GI tract from mouth to anus-not limited to large intestine
• Terminal ileum and colon most common
• comes and go, commonly in younger adults, higher in whites.

• =>Ulcerative Colitis
• Inflammation occurs in the mucosal layer ONLY, not throughout GI tract.
• Disease is primarily of the rectum and colon
• starts at one point then anything distal

• Can occur ANYWHERE along GI tract; with all layers of muscle affected
• Parts of normal bowel between diseased portions, called “skip” lesions

Ulcerations are deep and penetrate between islands of inflamed edematous tissue- “cobblestone” appearance

• Prone to fistulas (abnormal connections-bowel and skin, bowel and vagina..etc),
• strictures(can cause intestinal obsrtuction and narrow lumens!), and abscesses(if inflamation goes through entire bowel wall; microperforations that cause peritonitis); Can cause obstructions

Surgery is NOT curative BECAUSE IT JUMPS.

"Inflammatory disease that can occur anywhere in GI tract but most often affects the terminal ileum and leads to thickning and scarring, a narrowed lumen, fistulas, ulcerations, abscesses.; characterized by remissions and exaerbations."

• => Manifestations:
• Frequent diarrhea 5-6 stools a day, usually non-bloody-Liquid and semi loose !! (characteristic)
• Colicky(spasms) abdominal pain
• Fever, fatigue, malaise
• Malabsorption w/ small intestine involvement leading to weight loss because to much inflammtion in the small intestines
• Prone to anemia because lack of absorbtion (Iron and B12--no absorbtion)

Continuous pattern of inflammation and ulceration of the mucosal layer of the rectum and colon; results in poor absorption of nutrients, commonly begins in tehe rectum and spreads upward toward the cecum.

-colon becomes edematous and may lead to perforation.

-Water and electrolytes cannot be absorbed through inflamed tissue-so diarrhea

Areas of inflamed mucosa form pseudopolyps=projections into intestinal cavity

Risk of perforation and carcinoma

• Surgery IS curative because it starts at one place, and you can take it out. But they'll need a colostomy
• -Acute: results in vascular congestion, hemmorrhage, edema, and ulceration of the bowel mucosa
• -Chronic: caues muscular hypertophy, fat deposits, and fibrous tissue with bowel thickening, shortening and narrowing.

• =>Clinical Manifestations
• 10-20 BLOODY diarrheal stools per day (severe disease)--> susceptible to anemia
• May be accompanied by s/s anemia and dehydration
• Abdominal pain and cramping
• Fever, malaise, anorexia, Vit K deficiet Definitive diagnosis w/ colonoscopy and biopsy
• Exteremely suseptible to anemia both can present with systemic complications

Both diseases can present with systemic complication --other autoimmune complication like arthrits skin legions clots and gall stones (psych issues-depression and stress that are also triiggers)

Stress can trigger episodes in both disease

• Additional diagnostics include
• CBC=anemia
• BMP-checking electrolytes
• ESR Estimated Sedimentation Rate-inflamation
• Stool cultures
• Stool for occult blood

• **Ulcerative Colitis (UC) Lifestyle & Dietary Modifications
• Avoid smoking
• Stress management
• Avoid NSAID use
• Eat a well-balanced diet
• Identify/eliminate triggers
• Supplementation PRN
• Bowel rest, parenteral nutrition w/ exacerbations (acute: maintain NPO)
• May need b12 injections and bile salts if terminal illeum is involved

Goal of drug treatment is to induce and maintain remission to improve quality of life

• => 5 major classes of drugs are used for treatment
• 1. Aminosalicylates-first line of treatment for ulcerative colitis but also works well for crohns
• 2. Antimicrobials
• 3. Corticosteroids
• 4. Immunosuppressants
• 5. Biologic/ targeted therapy

• Suppress proinflammatory mediators
• Both induce and maintain remission
• Can be administered orally or rectally

-PO: Sulfasalazine, mesalamine

-Topical: 5-ASA enema, mesalamine suppository

• May cause photosensitivity and yellowish/orange discoloration of skin and urine
• First line treatment for ulcerative colitis and works well with chrons disease
• Need to supplement folic acid because interferes with folic acid absorbtion
• Watch sulfa allergy

• No specific infectious agent identified
• May help control symptoms by reducing intestinal flora
• Often used to prevent or treat secondary infections

• Common agents (available IV and PO)
• 1. Metronidazole (Flagyl)
• -most common; Sharp metalic taste, tingling in hands with feet with long term uses no booze because liver can’t handle, reddish brown urine
• against anaerobic bacteria and parasite
• s/e:headaches, anorexic, n/v, metallic taste, brownish urine, tingling in hand/feet
• -hepatoxic: and interferes with alcohol! Exercise caution withliver patients

• 2. Ciprofloxacin (Cipro)
• works grand ; Tendonits and ruptureWorks on gram + and - bacteriawell tolerated
• s/e: tendonitis and rupture of achilles, CNS consequences--Cns decrease seizure threshold, prolonged qt interval in ekg, periph neuropathy

Used to induce remission but not to MAINTAIN; Not effective for maintaining remission

Avoid long-term use because of SE

Must taper down prior to surgery because decrease your immune response

Can be given systemically or topically

-Systemic: prednisone, hydrocortisone or methylprednisolone

-Topical: Hydrocortisone suppository, enema, or foam

• -> Side effects
• -weight gain , acne , peptic ulcers, increase infection risks, mood swings, hypergycemia, osteoporosis, and increase infection, hypokalemia, PUD

• Immunosuppressants'
• -target immune response rather than inflammation and increased risk for cancer

Given after steroids to maintain remission

Imuran, Purinethol, Cyclosporine

Prolonged use can lead to bone marrow suppression and inflammation of pancreas and gallbladder

• => Biologic therapy also
• Anti-TNF agents-proinflamatory cytokine extremely expensive, complications fungal infection
• Remicade IV, Humira , and Cimzia SQ
• Costly
• Serious SE: lymphomas, reactivation of TB and hepatitis, opportunistic infections (candida, thrush), and malignancies

Can’t get live vaccines and are prone to infection be cautious around infectious people

• 75% of Crohn’s sufferers will require surgery; Not curative
• 25-40% of UC sufferers will require surgery; Total resection of colon is curative
• Large resections can lead to absorption issues; Short bowel syndrome-because not enough small intestines to absorb nutrients

• => Total proctocolectomy with permanent ileostomy;
• Removal of colon rectum and anus end of the terminal illium and made into stoma so you have ostomy --> Incontinent
• -Illeostomy: High risk for dehydration because don’t have large intestines to reabsorb water
• -removal of entire colon, end of the terminal illeum form s the stoma, located at lower right quad

• => Total colectomy with ileoanal reservoir
• most common for ulcerative collitis; elimates and does not require permanent ileostomy
• take part of illeum, make a pouch that ccan hold stool, and connect to rectum/anus so almost normal stool --> continent!
• J or S pouchTemporary ileostomy to allow reservoir to fully heal2 stage approach 8-12 weeks apartIleostomy closure-patient is continent

• => Total proctocolectomy with CONTINENT ileostomy
• Kock pouch: make a resevoir, still comes out abdomen, continent because you insert a cath to drain it. -an intraabdominal pouce that stores the feces and is contructed fro mthe terminal ileum. Connected to the stoma, wtih niple like valve, constructed from a portion of the ileum, the stoma is flush with the skin. Cath is used to emtpy the pouch and a sall dressing or adhesive bahdange is worn over the stoma between emptyigns.
• Allow patient to hold fluid until he/she decides to empty it
• -Initially must be emptied every 3 hrs by two month then need to do it only 3 to 4 times a day

Complication=valve failure and pouchitis , and internal leakage

Diarrhea r/t bowel inflammation and intestinal hyperactivity

Imbalanced nutrition <IBR r/t decreased intake and absorption

Risk for impaired skin integrity r/t frequent diarrheal stools, peristomal drainage

Fatigue, activity intolerance r/t increased metabolic demands and decreased oxygen delivery

Anxiety, Ineffective Coping, Ineffective self-health management, Disturbed Body Image, Knowledge deficit

• =>Acute phase priorities
• Pain control, fluid and electrolyte balance, nutritional support, skin care
• Emotional support

• => Ostomy surgery
• Consultation with an ET nurse
• Stoma care –should be pink and beefy red-if purple or grey lack of circulation
• Minimal bleeding after surgery
• Discharge teaching-perform pouch care and signs and system complications
• Emotional support
• Change colostomy 4 to 7 day
• Introduce high fiber foods slowly; chew well still illeostomy movment is small.

• Third most common cancer
• Lifetime risk is 1 in 20 (5%);Screening is very important to catch cancer early because once there’s symptoms it’s to late
• Slow growing adenocarcinoma-usually begins as benign polyp, or little projection into large intestine, trace mucosal layer and eventually lymph nodes.

• => Risk factors include
• Male gender
• Age >50
• Family or personal history of CRC, colorectal polyps, IBD
• Obesity
• Smoking
• Alcohol
• Red meat intake
• stage 1: 75% and stage 4: 6% chance

**Colorectal Cancer Clinical Manifestations

• => Left colon tumor
• Rectal bleeding; may lead to anemia
• Alternating constipation/diarrhea
• Narrow, ribbonlike stool
• Obstruction

• => Right colon tumor
• higher up in colon
• May be asymptomatic
• Abdominal discomfort/cramping
• Occult bleeding

• Diagnosis
• Colonoscopy w/ biopsy
• CT/MRI for staging
• CBC, LFTs, coagulation studies

• => Treatment
• Surgery is the only cure
• Chemotherapy/radiation with metastasis
• TNM staging

The TNM staging system is based on the size and/or extent (reach) of the primary tumor (T), whether cancer cells have spread to nearby (regional) lymph nodes (N), and whether metastasis (M), or the spread of the cancer to other parts of the body, has occurred.

• Left hemicolectomy or Right hemicolectomy
• side of cancer dictates side of resection
• -Goal:complete resection of the tumor and clear margins
• Abdominal perineal resection

• =>Possible outcomes include
• Immediate reanastomosis of bowel(no colostomy)
• Resection w/ temporary colostomy
• Total colectomy w/ permanent or temporary ileostomy
• Removal of anal sphincters w/ permanent colostomy
• Temporaey colostomy is done when there is bowel perforation and perotonitis occurred and patient is unstable

• => Primary prevention
• Avoid smoking
• Well balanced diet w/ high fruit and vegetable intake
• Moderate alcohol intake
• Exercise

• =>Secondary prevention
• Regular ColoRectalCancer screening for all patients >50 all people
• (Screening is essential because it takes 10 years for tumor to grow)
• Earlier screening for high risk patients pt with history and smoking risks
• Provide patient teaching regarding adequate bowel prep -24 hours prior to surgery , only clear liquids up until midnight before surgery then NPO

• =>Ostomys: The more distal the ostomy the more regular stool looks
• If its proximal near illium drainage is greenish
• Stomal should be beefy red grey... dusky color indicates poor circulation and need to go back to surgery (necrotic-cut it out)

Examines the ENTIRE length of the colon; sigmoidoscopy examines only the LOWER THIRD.

• => Need regular screening if have history of Polyps
• Polyps = can be precancerous lesion

Regular screening if had history of polyps because at greater risk for cancer

• => Familial Adenomatous Polyposis
• Inherited autosomal disease
• Large number of polyps of the colon and rectum appear early in life 100’s to thousands of polyps
• If polyps are not treated, 100% of all affected persons will develop cancer by the time they are 40 years of age
• Early screening indicated

Treatment of choice: Total colectomy and creation of ileoanal reserve (j/s pouches)

-If family history Need to get genetic genetic testing as a child and screening colonoscopy begins by 10-12 years olds and surgery is indicated by age 25

=>Upper GI/Barium(white chalky substance) swallow white chalky substance: Administration of contrast medium and fluoroscopy to view esophagus, stomach, and duodenum.

=>Lower GI: Administration of contrast medium into colon (enema) then; Iodine contrast plus scan

=>Small bowel series: Ingested contrast medium films taken every 3 minutes until medium reaches terminal ileum watching contrast go down the system

=>Ultrasound

=>MRI: Detects soft masses and organ abnormalities, bleeding sources

=>CT Scan (Computed Tomography): Can be with or without contrast medium

=>Upper GI Endoscopy/gastrostomy (EGD) Visual look inside stomach and duodnem=>Fiberoptic ColonoscopyRecommended to have 1st one done at age 50 if NO PRIOR FAMILY HISTORYWith Family history: at age 40, or 10 years before youngest case of dx or death of family

• Consent required
• Bowel prep
• -Allergies to contrast medium or iodine
• NPO status
• Anesthesia-any prior complications with anethesia

• What are some of the pre-procedure instructions and post-procedure care the nurse must know?
• =>Pre-procedure:When to start prepWhen to start NPO need to be on iv fluidsHydration needs
• =>Post-procedure:Hydration needs
• When can patient drink/eat-can eat once they stat passing gas bowel sounds or had bm Type of contrast use
• Bowel function

• => Extra notes: 'If they need to be on iv fluids before, they will need to be on iv fluids after procedure
• Might be on bicarbonate iv drip to protect the kidneys from contrast
• If a person is metformin and you give them iv contrat you can throw them into renal failure. Need to be off metformin 48 hrs prior to and don’t restart till 48 hrs after
• If they had barium will turn stool white for several day’s need to educate patient