MANAGEMENT OF

PATIENTS WITH ORAL

AND ESOPHAGEAL
DISORDERS
Presented by:
Jomar P. Ronquillo, RN,
MANc
NORMAL ANATOMY OF A
TOOTH
NORMAL ANATOMY OF A
TOOTH
DENTAL PLAQUE AND CARIES
• TOOTH DECAY:

• An erosive process that begins with the

action of bacteria in the mouth
DENTAL PLAQUE AND CARIES
• DENTAL PLAQUE:

• A gluey, gelatin-like substance that

adheres to the teeth.
DENTAL PLAQUE AND CARIES
• Dental decay begins with a small hole
• Enamel gets penetrated and the dentin as
well
• Pulp is also affected
• Abscess
• Pain and soreness
• Facial swelling
• DIAGNOSTICS:
• TREATMENT: Fillings, Implant, extraction
DENTAL PLAQUE AND CARIES
• PREVENTION:
– Effective mouth care
– Diet
– Fluoridation
– Smoking cessation
– Sealants
DENTOALVEOLAR ABSCESS
OR PERIAPICAL ABSCESS
• Involves the collection of pus in the apical
dental periosteum and the tissue
surrounding the apex of the tooth.
• Has two forms: Acute and chronic
• CLINICAL MANIFESTATIONS:
– Dull, gnawing, continuous pain
– Facial edema
– Systemic reaction
DENTOALVEOLAR ABSCESS
OR PERIAPICAL ABSCESS
• MANAGEMENT:
– Aspiration / Incision and drainage
– Tooth extraction
– Root canal therapy
• NURSING MANAGEMENT:
– WOF bleeding
– Mouth care
– Medications
MALOCCLUSION
• Misalignment of the teeth in the upper and
lower dental arcs
• Can be inherited or acquired
• Can be corrected early with orthodontics
TEMPOROMANDIBULAR
DISORDERS
• Categories:
– Myofascial pain
– Internal derangement of the joint
– Degenerative joint disease
• CLINICAL MANIFESTATIONS:
– Radiating dull, throbbing pain
– Restricted jaw motion
– Clicking/grating noise
– Difficulty swallowing
• POSSIBLE CAUSES:
– Arthritis, trauma, stress, malocclusion
TEMPOROMANDIBULAR
DISORDERS
• MANAGEMENT:
– Stress management
– ROM
– Pain management
– Bite plate or splint
• SURGICAL MANAGEMENT:
– Rigid plate fixation (trauma)
– Bone grafting
• NURSING MANAGEMENT:
– No chewing post surgery
– Liquid diet
DISORDERS OF THE SALIVARY
GLANDS
• PAROTITIS:
– Inflammation of the parotid gland
– Elderly, the acutely ill and the debilitated are
at high risk
– Pain in the ear, swollen glands, red shiny
skin
– Antibiotics, adequate nutrition,
discontinuing meds that affect salivation,
parotidectomy
DISORDERS OF THE SALIVARY
GLANDS
• SIALADENITIS:
– Inflammation of the salivary glands
– Causes: Dehydration, radiation, stress,
malnutrition, salivary gland calculi, improper
oral hygiene
– Organisms:
– Pain, swelling, purulent drainage
– Antibiotics, massage, hydration and steroids,
surgical drainage
DISORDERS OF THE SALIVARY
GLANDS
• SIALOLITHIASIS:
– Occurs in the submandibular gland
– Formed from calcium phosphate
– Can arise in the gland itself or in the ducts
– Lithotripsy or surgery
DISORDERS OF THE
ESOPHAGUS
• The esophagus is a mucus-lined muscular
tube from the mouth to the stomach
• Has two sphincters
DISORDERS OF THE
ESOPHAGUS
• DYSPHAGIA:
– Most common symptom of esophageal disease
– Possible causes: achalasia, diffuse spasm,
GERD, hiatal hernias, diverticula, perforation,
foreign bodies, tumors, carcinoma
• ACHALASIA:
– MANIFESTATIONS:
• Difficulty swallowing
• Regurgutation
• Chest pain
• Pyrosis
• Secondary pulmonary complications
DISORDERS OF THE
ESOPHAGUS
• ACHALASIA:
– ASSESSMENT AND DX FINDINGS:
• Esophageal dilatation
• Barium swallow
• CT scan
• Endoscopy
• Manometry
– MANAGEMENT:
• Eat slowly and drink fluids
• Calcium channel blocker
• Botulinum toxin injection
• Pneumatic dilation and surgery
• Esophagomyotomy
DISORDERS OF THE
ESOPHAGUS
• DIFFUSE SPASM
– A motor disorder of the esophagus
– Cause is unknown, stress is possible
– Most common in women
– CLINICAL MANIFESTATIONS:
• Dysphagia, odynophagia
• Chest pain
– ASSESSMENT AND DX FINDINGS:
• Irregular contractions of the esophagus on
manometry
• Xray
– MANAGEMENT:
• Sedatives, nitrates, calcium channel
blocker, small frequent meals, soft diet, and
surgeries same as achalasia
HIATAL HERNIA
• A condition wherein the opening in the
diaphragm through which the esophagus
passes becomes enlarged, and part of the
stomach tends to move up in the lower
portion of the thorax
• Occurs more often in women than in men
• Two types: Sliding and Paraesophageal
HIATAL HERNIA
HIATAL HERNIA
• CLINICAL MANIFESTATIONS:
– Heartburn, regurgitation, reflux (sliding type),
dysphagia
– Sense of fullness (paraesophageal type)
– Complication: Hemorrhage, obstruction,
strangulation
• ASSESSMENT AND DX FINDINGS:
– X-ray, barium swallow, fluoroscopy
HIATAL HERNIA
• MANAGEMENT:
– Small frequent feedings
– Management to prevent reflux:
• No reclining 1 hour post eating
• Elevate HOB
– Surgery
– Management techniques for Paraesophageal
hernia are similar to GERD, but may also
necessitate emergency surgery
DIVERTICULUM
• Is an outpouching of mucosa and
submucosa that protrudes through a weak
portion of the musculature
• May occur in one of the three areas of the
esophagus (PME) or may occur along the
border of the esophagus intramurally
• Zenker’s diverticulum, most common type
DIVERTICULUM
• CLINICAL MANIFESTATIONS:
– Zenker’s Diverticulum: Difficulty swallowing,
fullness in the neck, belching, regurgitation,
gurgling noises after eating
– Halitosis and a sour taste
– Dysphagia and chest pain (Epiphrenic type)
– Dysphagia (Intramural type)
• ASSESSMENT AND DX FINDINGS:
– Barium swallow
– Manometric disorders for epiphrenic type
– Esophagoscopy?
– Blind NGT insertion?
DIVERTICULUM
• MANAGEMENT:
– Surgical removal of the diverticulum (Zenker’s
type) and myotomy of cricopharyngeal muscle
– NGT insertion POST OP
– Surgical ncision monitoring
– NPO until clear in Xray
– DIET: liquid to DAT
PERFORATION
• May result from stab or bullet wounds of
neck or chest, MVC, caustic injury or
inadvertent puncture
• CLINICAL MANIFESTATIONS:
– Persistent pain, dysphagia
– Infxn, fever, leukocytosis, severe hypotension
– Pneumothorax
PERFORATION
• ASSESSMENT AND DX FINDINGS:
– X-ray studies, fluoroscopy
• MANAGEMENT:
– Broad-spectrum antibiotics
– NGT
– NPO, parenteral nutrition
– Surgery
• Nursing management is similar to that for
patients who have had thoracic or
abdomial surgery
FOREIGN BODIES
• Swallowed foreign object may injure the
esophagus or obstruct its lumen
• Pain and dysphagia
• X-ray (diagnosis)
• Glucagon administration
• Endoscopy and dilation
CHEMICAL BURNS
• May be caused by undissolved
medications in the esophagus, swallowing
of strong acid or base, batteries, etc
• More common in the elderly
• Pain, difficulty breathing, shock,
respiratory distress
• DIAGNOSIS: Esophagoscopy and barium
swallow
CHEMICAL BURNS
• MANAGEMENT:
– NGT, NPO, lavage, corticosteroids and
antibiotics
– Nutritional support
– Bougienage
– Esophagectomy and colon interpostion
MALLORY-WEISS TEAR
• A Mallory-Weiss tear occurs in the mucous
membrane where the esophagus connects
to the stomach, causing bleeding.
• Unusual
• Causes: Any condition that leads to long
term or forceful vomiting, coughing,
retching, epileptic convulsions
• Results in vomiting or bright red vomitus,
melena or hematochezia
• DIAGNOSIS: Endoscopy
MALLORY-WEISS TEAR
• MANAGEMENT:
– Usually supportive but may require endoscopy,
surgery, cauterization, epinephrine injection,
embolization, high gastrostomy
GASTROESOPHAGEAL
REFLUX DISEASE
• Causes: incompetent LES, pyloric
stenosis, or motility disorders
• Incidence increases with aging
• CLINICAL MANIFESTATIONS:
– Pyrosis
– Dyspepsia
– Regurgitation
– Dysphagia
– Odynophagia
– Hypersalivation
– Esophagitis
GASTROESOPHAGEAL
REFLUX DISEASE
• ASSESSMENT AND DX FINDINGS:
– Endoscopy
– Barium swallow
– Ambulatory 12- to 36 hour esophageal pH
monitoring
– Bilirubin monitoring
GASTROESOPHAGEAL
REFLUX DISEASE
• MANAGEMENT:
– Teach patient to avoid situations that decrease
LES sphincter pressure or cause esophageal
irritation:
• Diet:
• Eating in relation to bedtime:
• Normal body weight, maintain
• Clothing:
• HOB elevation:
– Medications:
• Antacids
• Histamine receptor blockers
• PPI’s
• Prokinetic agents
GASTROESOPHAGEAL
REFLUX DISEASE
• SURGICAL MANAGEMENT:
– Fundoplication
BARRETT’S ESOPHAGUS
• A precancerous condition of the
esophagus commonly associated with
longs-standing GERD
• CLINICAL MANIFESTATIONS:
– Symptoms of GERD
• ASSESSMENT AND DX FINDINGS:
– EGD
• MANAGEMENT:
– Monitoring
– Medical and surgical management are similar
to that for GERD
MANAGEMENT OF PATIENTS
WITH GASTRIC AND
DUODENAL ULCERS
GASTRITIS
– A common GI problem
– Can be chronic or acute
• Acute Gastritis:
– Dietary indescretion
– Overuse of certain medications
– Excessive alcohol intake
– Bile reflux
– Radiation therapy
– Ingestion of strong acid or alkali
– May be a sign of an acute systemic infxn
GASTRITIS
• CHRONIC GASTRITIS:
– Can be caused by benign or malignant ulcers
– Helicobacter pylori
– Autoimmune diseases
– Dietary factors
• PATHOPHYSIOLOGY:
– Edema and hyperemia
– Decreased secretion
– Superficial erosion
– Hemorrhage
GASTRITIS
• CLINICAL MANIFESTATIONS:
– Acute form:
• Abd. Discomfort
• Headache
• Lassitude
• N&V
• Anorexia
• Hiccuping
– Chronic form:
• Anorexia
• Heartburn
• Belching, n & v, sour taste
• Vitamin B12 deficiency
GASTRITIS
• ASSESSMENT AND DX FINDINGS:
– Achlorhydria/Hypochlorhydia to
Hyperchlorhydia
– Endoscopy, upper GI radiographic studies,,
histologic exam, Diagnostic measures for H-
Pylori
GASTRITIS
• MEDICAL MANAGEMENT:
– Refrain from alcohol or food until sx subsides
– Control of bleeding
– Diluting/neutralizing offending agent (Ingestion
of acid and alkalis)
– Emetics and lavage
– NGT
– Gastric resection
– CHRONIC GASTRITIS: Diet modification,
Promoting rest, reduce stress, pharmacologic
therapy,
NURSING PROCESS AND THE
PARIENT WITH GASTIRITIS
• ASSESSMENT:
– Patient History
• Ask about the presenting signs and
symptoms
• 72 dietary recall
• Any methods used to treat the symptoms
• NURSING DIAGNOSIS:
– Anxiety related to treatment
– Imbalanced nutrition, less than body
requirements, related to inadequate intake
– Risk for imbalanced fluid volume related to
insufficient fluid loss subsequent to vomiting
– Deficient knowledge
– Acute pain
NURSING PROCESS AND THE
PARIENT WITH GASTIRITIS
• PLANNING AND GOALS:
– Reduced anxiety
– Avoidance of irritating foods
– Fluid balance
– Relief of pain
– Dietary management
• NURSING INTERVENTIONS:
– Reduce anxiety
– Optimal nutrition
– Promote fluid balance
– Relieve pain
NURSING PROCESS AND THE
PARIENT WITH GASTIRITIS
• EVALUATION:
– Exhibits less anxiety
– Avoids eating irritating foods or drinking
carbonated beverages
– Maintains fluid balance
– Adheres to medical regimen
– Maintains appropriate weigh
– Reports less pain
GASTRIC AND DUODENAL
ULCERS
• A peptic ulcer is an excavation that forms
in the mucosal wall of the stomach, in the
pylorus, and duodenum, or in the
esophagus.
• Depth of erosion is variable
• Occurs mostly in people between 40 and
60 y/o
• Results from infection with H. Pylori
• Excessive secretion of HCL may also be
the cause
GASTRIC AND DUODENAL
ULCERS
• DUODENAL VS. GASTRIC ULCER:
• INCIDENCE:
• SIGNS AND SYMPTOMS:
• MALIGNANCY POSSIBILITY:
• RISK FACTORS:
GASTRIC AND DUODENAL
ULCERS
• Risk factor: Familial tendency, use of
NSAIDs, Alcohol ingestion, excessive
smoking, Zollinger-Ellison syndrome
• PATHOPHYSIOLOGY:
– Erosion is caused either by increased activity of
pepsin and HCL or decreased resistance of the
mucosa
– ZES is suspected in unresponsive peptic ulcer
– STRESS ULCERS can also be the cause:
• Ischemia, increased acid and pepsin
production, reflux
– Cushing’s and Curlings’s types
GASTRIC AND DUODENAL
ULCERS
• CLINICAL MANIFESTATIONS:
– May be asymptomatic
– Dull, gnawing pain/burning sensation in the
midepigastiric area or in the back
– Eating usually relieves pain
– Pyrosis
– Vomiting, constipation, diarrhea, bleeding
GASTRIC AND DUODENAL
ULCERS
• ASSESSMENT AND DX FINDINGS:
– Physical findings
– Upper GI barium study
– Endoscopy
– Stool analysis
– Biopsy, and histology with culture
– Urea breath test
GASTRIC AND DUODENAL
ULCERS
• MEDICAL MANAGEMENT:
– PHARMACOLOGIC:
• Antibiotics (TAMCB)
• Proton-pump inhibitors (OLR)
• Bismuth salts
• H2 receptor antagonists (CRFN)
• Octreotide
• Cytoprotective agents
– Stress reduction and rest
– Dietary modification
GASTRIC AND DUODENAL
ULCERS
• MEDICAL MANAGEMENT:
• Vagotomy with or without pyloroplasty
– Vagotomy
• Truncal
• Selective
• Proximal gastric vagotomy

• Billroth I and Billroth II

NURSING PROCESS AND
PEPTIC ULCER
• ASSESSMENT:
– Chief complaint
• Ask about the nature of the pain
– 72 hour dietary recall
– Lifestyle habits
– Vital signs
– Physical exam
NURSING PROCESS AND
PEPTIC ULCER
• NURSING DIAGNOSIS:
– Acute pain related to the effect of gastric acid
secretion on damaged tissue
– Imbalanced nutrition related to changes in diet
• Potential Complications:
– H
– P
– P
– P
NURSING PROCESS AND
PEPTIC ULCER
• GOALS:
– Relief of pain
– Reduced anxiety
– Nutrition maintenance
– Absence of complications
NURSING PROCESS AND
PEPTIC ULCER
• NURSING INTERVENTIONS:
– Relieving pain
• Avoid caffeine and aspirin
• Relaxation techniques
NURSING PROCESS AND
PEPTIC ULCER
• NURSING INTERVENTIONS:
– Reducing anxiety
NURSING PROCESS AND
PEPTIC ULCER
• NURSING INTERVENTIONS:
– Monitoring and managing potential
complications:
• HEMORRHAGE
– Usually manifested by:
– Monitor the patient for signs of
hypotension
– Monitor Hgb and Hct
NURSING PROCESS AND
PEPTIC ULCER
• NURSING INTERVENTIONS:
– Monitoring and managing potential
complications:
• HEMORRHAGE
– Treat the bleeding!
– Replacing blood that was lost
» IV line, CVP insertion, blood
component therapy
– NG Tube insertion
» Monitoring
» Lavage
– IFC and monitoring UO
– Proper positioning
NURSING PROCESS AND
PEPTIC ULCER
• NURSING INTERVENTIONS:
– Monitoring and managing potential
complications:
• HEMORRHAGE
– Transendoscopic coagulation
– Selective embolization
NURSING PROCESS AND
PEPTIC ULCER
• NURSING INTERVENTIONS:
– Monitoring and managing potential
complications:
• PERFORATION AND PENETRATION
– Perforation S/sx:
» Intractable pain radiating to the right
shoulder
» Tender, rigid, board-like abdomen
» Vomiting, htn, tachycardia, fainting
– Penetration S/Sx:
» Back and epigastric pain
– Surgery
– Post Op: Monitoring
NURSING PROCESS AND
PEPTIC ULCER
• NURSING INTERVENTIONS:
– Monitoring and managing potential
complications:
• PYLORIC OBSTRUCTION (GOO):
– S/Sx: Nausea and vomiting,
constipation, epigastric fullness,
weightloss
– Management: Insertion of Ng Tube
– Upper GI endoscopy
– Balloon dilatation of the pylorus
– Surgery: Vagotomy, antrectomy,
gestrojejunostomy and vagotomy
MORBID OBESITY
• Morbid obesity is the term applied to
people who are more than two times their
ideal body weight or whose body mass
index (BMI) exceeds 30 kg/m²
• 100 pounds greater than the ideal body
weight
MORBID OBESITY
• Patients with morbid obesity are at highest
risk for health complications!
MORBID OBESITY
• MEDICAL MANAGEMENT:
– Weightloss diet with behavioral modification
and exercise
– Treatment of depression
– PHARMACOLOGIC:
• Sibutramine HCL (Meridia)
• Orlistat (Xenical)
– SE: Sibutramine increases BP; Orlistat
Increases BM, decreases absorption of
some vitamins
MORBID OBESITY
• MEDICAL MANAGEMENT:
– Surgery:
• BARIATRIC SURGERY:
– Jejunoileal bypass
– Gastric bypass
– Vertical banded gastroplasty
GASTRIC BYPASS
GASTRIC BYPASS
VERTICAL BANDED
GASTROPLASTY
MORBID OBESITY
• NURSING MANAGEMENT:
– General postop care similar to that for a patient
recovering from a gastric resection
– Provide 6 small feedings
– Encourage fluid intake
– Teach patients signs of dehydration
– Discuss dietary instructions:
• Do not overeat!
GASTRIC CANCER
• Incidence: MEN>WOMEN
• Japan has higher incidence
• Diet: Significant factor
• Other factors:
– Chronic inflammation of the stomach
– Pernicious anemia
– Achlorhydria
– Gastric ulcers
– H. Pylori infection
– Genetics
GASTRIC CANCER
• CLINICAL MANIFESTATIONS:
– Early stages: Asymptomatic
– Early symptoms seldom definitive:
• Pain relived with antacids
– Progressive: Anorexia, dyspepsia, weightloss,
abdominal pain, constipation, anemia, nausea
and vomiting
GASTRIC CANCER
• MEDICAL MANAGEMENT:
– REMOVAL OF THE TUMOR
– Gastrectomy (Total/subtotal)
– Chemotherapy
– Radiation therapy
PATIENTS UNDERGOING
GASTRIC SURGERY
• ASSESSMENT:
– Pt. and family knowledge
– Patient’s nutritional status
– Assess for presence of bowel sounds
– Palpate the abdomen
– Assess for complication postop
PATIENTS UNDERGOING
GASTRIC SURGERY
• NURSING DIAGNOSIS:
– Anxiety related ton surgical intervention
– Acute pain related to surgical incision
– Deficient knowledge about surgical procedures
and postoperative course
– Imbalanced nutrition, less than body
requirements, related to poor nutrition before
surgery and altered GI system after surgery
PATIENTS UNDERGOING
GASTRIC SURGERY
• NURSING INTERVENTIONS:
– Relieve anxiety
– Relieve pain
• Analgesics
• No sedation!
• Maintain NG tube
– Resume enteral intake
– Recognize obstacles to adequate nutrition:
• Dysphagia and gastric retention
• Bile reflux
• Dumping syndrome
• Vitamin and mineral deficiencies
MANAGEMENT OF PATIENTS
WITH INTESTINAL AND
RECTAL DISORDERS
ABNORMALITIES OF
FECAL ELIMINATION

CONSTIPATION
CONSTIPATION
• Is a term used to describe an abnormal
infrequency or irregularity of defecation,
abnormal hardening of stools that makes
their passage difficult and sometimes
painful, a decrease in stool volume, or
retention of stool for a prolonged period.
CONSTIPATION
• Causes:
– Medications: Tranquilizers, anticholinergics,
antidepressants, opiods
– Rectal or anal disorders: Hemorrhoids
– Obstruction
– Metabolic, neurologic and neuromuscular
conditions (DM, Hirschsprung’s dse,
parkinson’s, MS)
– Endocrine disorders
– IBS, diverticular dse
– Immobility
– Dietary habits
CONSTIPATION
• CLINICAL MANIFESTATIONS:
– Abdominal distention
– Borborygmus
– Pain and pressure
– Decreased appetite
– Headache
– Fatigue
– Indigestion
– Straining at stool
– Small, hard, dry stools
CONSTIPATION
• COMPLICATIONS:
– Hypertension
– Fecal impaction
– Hemorrhoids and fissures
– Megacolon
CONSTIPATION
• MEDICAL MANAGEMENT:
– Education
– Bowel habit training
– Increase fiber and OFI
– Judicious use of laxatives:
• Psyllium hydrophilic mucilloid (Metamucil)
• Magnesium OH
• Mineral oil
• Bisacodyl (Dulcolax)
ABNORMALITIES OF
FECAL ELIMINATION

DIARRHEA
DIARRHEA
• Increased frequency of bowel movements,
increased amount of stool, and altered
consistency of stool.
• Frequent causes:
– IBS
– IBD
– Lactose intolerance
– Medications, endocrine disorders, infection
• Can be acute or chronic
DIARRHEA
• TYPES:
– Secretory
– Osmotic
– Mixed
• CLINICAL MANIFESTATIONS:
– Increased frequency and fluid content of stools
– Abdominal cramps
– Distention
– Intestinal rumbling
– Anal spasms and tenesmus
– S/sx of dehydration
DIARRHEA
• The characteristic of the stools can tell the
location of the g.i. problem
• DIAGNOSTIC TESTS:
– CBC
– Urinalysis
– Stool exam
– Endoscopy
– Barium enema
DIARRHEA
• COMPLICATIONS:
– Potential for cardiac dysrhythmia

• NURSING INTERVENTIONS:
– Monitoring through physical assessment
– Bed rest
– Increased OFI
– No intake of foods that increase intestinal
motility
– Administer antidiarrheal meds: Diphenoxylate
and loperamide
– Perianal hygiene
FECAL INCONTINENCE
FECAL INCONTINENCE
• The involuntary passage of stool from the
rectum
• Possible causes:
– Trauma
– Neurologic disorders
– Infection
– Radiation treatment
– Fecal impaction
– Pelvic floor relaxation
– Laxative abuse
– Advancing age
FECAL INCONTINENCE

What are the clinical

manifestations?
FECAL INCONTINENCE
FECAL INCONTINENCE
FECAL INCONTINENCE
FECAL INCONTINENCE
FECAL INCONTINENCE
FECAL INCONTINENCE
• ASSESSMENT AND DIAGNOSTIC
FINDINGS:
– Rectal exams
– Endoscopic examinations
– X-ray
– Barium enema
– Computed tomography scans
– Anorectal manometry
– Transit studies
FECAL INCONTINENCE
• MEDICAL MANAGEMENT:
– No specific cure
– Biofeedback therapy
– Bowel training programs
– Surgery
FECAL INCONTINENCE
• NURSING MANAGEMENT:
– Take health history
– Bowel training program
– Encourage meticulous skin hygiene
– Facilitate use of internal or external
incontinence devices
IRRITABLE BOWEL
SYNDROME (IBS)
IRRITABLE BOWEL SYNDROME
(IBS)
• It is a functional bowel disorder
characterized by chronic abdominal pain,
discomfort, bloating, and alteration of
bowel habits in the absence of any
detectable organic cause.
• Various factors are associated with the
syndrome:
– Heredity, stress, diet high in fat, smoking and
alcohol consumption
IRRITABLE BOWEL SYNDROME
(IBS)