Chapter 34: Lower GI

Constipation
 Categorized by bowel movements that occur less than 3 times per week
 Obstipation – prolonged constipation
 Can be caused by medications
o Narcotics, tranquilizers, antacids with aluminum
 Metabolic conditions that can cause constipation
o Diabetes Mellitus, Multiple Sclerosis, systemic Lupus, Scleroderma
 Can be caused by low intake of fiber and fluids, decreased mobility, weakness, and
fatigue
Signs and symptoms:
 Abdominal pain, distention, indigestion, rectal pressure, intestinal rumbling. Headache,
fatigue, decreased appetite, straining on bowel movements
Complications:
 Fecal impaction
 Straining to have a BM can result in cardiac, neurologic, and respiratory complications
Diagnosed by:
 Sigmoidoscopy, colonoscopy, radiographic exam, rectal exam
Treatment:
 Bulk forming agents, stool softeners, laxatives
 Opioid induced constipation is treated with Methylnaltrexone and Naloxegol

Diarrhea:
 Characterized by three or more loose or watery stools in 24 hours
 Chronic diarrhea lasts more than 14 days
Signs and symptoms:
 Foul smelling, abdominal cramping, intestinal rumbling, and thirst.
Diagnosed by:
 Determined by onset and progression
 Stool mixed with red blood cells and mucus is associated with Cholera, Typhoid,
Typhus, large bowel cancer, or Amebiasis.
 Stool mixed with white blood cells and mucus is associated with Shigellosis, Intestinal
tuberculosis, salmonellosis, regional enteritis, or ulcerative colitis
 Bulky frothy stool is seen with celiac disease
 Pasty stool is seen with common bile duct obstruction or celiac disease.
Treatment:
 Diphenoxylate, Difenoxin Hydrochloride, and Loperamide
Appendicitis:
 Inflammation of the Appendix
Signs and symptoms:
 Fever, increased WBC, generalized pain in the upper abdomen.
o Pain usually localizes to the right lower quadrant at McBurney’s point.
o Sometimes there is pain in the right lower quadrant when the left lower
quadrant is palpated (rovsing’s sign)
Diagnosed by:
 CBC with elevated leukocyte and neutrophil counts
 Ultrasound, CT, and MRI reveal enlargement in the cecum
Treatment:
 Patient is NPO and surgery is performed immediately
 Apply ice and place patient semi-fowlers
 AVOID laxatives and enemas
 If the appendix has ruptured, IV therapy and antibiotics are started. NG tube may be
used

Peritonitis:
 Inflammation of the Peritoneum
 Can be caused by trauma, ischemia, perforation of the abdomen.
 Common causes of peritonitis that permit GI bacteria to enter the peritoneum
o Ruptured appendix, peptic ulcer, perforated colon, pancreatitis, diverticulitis.
Signs and symptoms:
 Area of abdomen that is affected is tender and aggravated by movement. Decreased
peristalsis, bloating, nausea, vomiting, no bowel movements.
Diagnosed by:
 Abdominal xray or CT scan
Treatment:
 NPO
 Fluid and electrolyte replacement
 Abdominal distention is relieved by an orogastric tube or NG with low suction
Complications:
 Intestinal obstruction, hypovolemia, septicemia, shock, death
Diverticulosis:
 When multiple diverticula are present without evidence of inflammation
 With increased pressure within the colon or stool trapped in a diverticulum, a tear and
inflammation can lead to Diverticulitis.
 Caused by chronic constipation
 Most common in sigmoid colon
Risk factors:
 Over age 60, low fiber intake, high animal fat intake, obesity, smoking
 Use of NSAIDS, opioids and steroids
Signs and symptoms:
 Constipation and diarrhea
 Steady or cramping pain in the left lower quadrant of the abdomen
 Possible bleeding and abdominal tenderness
Diagnosed by:
 Flexible sigmoidoscopy, colonoscopy

Ulcerative Colitis:
 Occurs in the large intestine and rectum
 Possible causes are infection, allergy, and autoimmune responses, pesticides, tobacco,
radiation, and food additives.
 Usually begins between ages 15 and 30
Signs and symptoms:
 Diarrhea with blood or pus, abdominal pain, rectal pain, rectal bleeding, fecal urgency,
weight loss, cramping, vomiting, fever, fatigue
Complications:
 Hemorrhage, toxic megacolon, perforation, peritonitis, osteoporosis, increased risk for
colorectal cancer
Diagnosed by:
 Stool specimen (must be positive for blood)
 Colonoscopy, sigmoidoscopy, biopsy specimen
 Barium enema, ultrasound, CT scan, MRI
Treatment:
 High fiber foods, caffeine, spicy foods, and milk is avoided

Crohn’s disease:
  Autoimmune inflammatory bowel disease & involves any part of the GI tract.
 Most commonly affects the terminal portion of the Ileum or the first part of the large
intestine.
 Has inflamed areas that are referred to as skip lesions
 Leads to the formation of Fistulas (abnormal connection between structures) and
Fissures (unnatural tracts or ulcers)
Risk factors:
 Hereditary, infections and environmental agents
 Most often diagnosed between the ages of 15 and 30
 More often in women than men
Signs and symptoms:
 Crampy abdominal pain, diarrhea, weight loss, fatigue, fever, and mouth sores
 Inflammation of the eyes, liver, bile ducts, skin and joints
Diagnosed by:
 Endoscopy, capsule endoscopy, ultrasound, double balloon enteroscopy
 Confirmed by granulomas in the biopsy
Treatment:
o 5-aminosalicylates – decrease intestinal inflammation
 Mesalamine, Olsalazine, Balsalazide, and Sulfasalazine
o Corticosteroids – suppress immune system and decrease inflammation
 Prednisone, methylprednisolone
o Biologic response modifiers
 -mab medications
o NSAID – reduce inflammation
 Budesonide
o Immunomodulators – immunosuppression
 Azathioprine, Methotrexate

 Foods that increase symptoms: dairy, fatty food, fresh fruits, and vegetables
IBS:
 Disorder of altered intestinal motility in which the colon muscle contracts more easily
o IBS with diarrhea, IBS with constipation, IBS with mixed bowels
 Heredity tendency
 More common in women who are young to middle aged.
Signs and symptoms:
 Abdominal pain, bloating, gas, constipation, diarrhea, depression, anxiety
Diagnosed by:
 Stool exam, colonoscopy, sigmoidoscopy, CT, lower GI series
Treatment:
 Avoid gluten and gas producing foods
 Laxatives and antidiarrheals for bowels
 Antidepressants for pain
 IBS with constipation – SSRIs (Fluoxetine or paroxetine hydrochloride)
 IBS with diarrhea – SSRIs (desipramine, imipramine, nortriptyline), and Antispasmodics
(hyoscyamine or dicyclomine). Rifaximin (antibiotic)

Hernia:
 Abnormal protrusion of an organ through a weakness in the wall of the cavity normally
containing it.
 Occur from increased intra-abdominal pressure (coughing, straining, or lifting)
 Umbilical hernias – seen in obesity, ascites, peritoneal dialysis, or multiple pregnancy
 Inguinal hernias – located in the groin
 Ventral hernias – weakness in the abdominal wall after abdominal surgery
Signs and symptoms:
 Abnormal bulging in the affected area, discomfort due to tension on tissues, pain may
disappear when the patient lies down
Complications:
 May become strangulated if the blood and intestinal flow are cut off in the trapped loop
of the bowel.
o Symptoms of strangulation: pain, nausea, vomiting, colicky pain
Treatment:
 Physical exam
 Observation and possible no treatment needed.
 Surgical repair is recommended for Inguinal hernia (hernioplasty or herniorrhaphy)
 Bowel resection or temporary colostomy for strangulated hernia
Postoperative care:
 Avoid coughing, use ice packs and elevation. Outpatient procedure. No sexual activities
for 2 to 6 weeks.

Diagnostic tests for Disorders of malabsorption:

  Hematocrit (anemia)
 Mean corpuscular volume (malabsorption of B12)
 Upper GI series
 D-xylose absorption test
 Sudan stain for fecal fat
 72-hour stool collection for fat
 Biopsy

Anal Fissures:
 Cracks or ulcers in the lining of the anal canal.
 Most commonly associated with constipation and stretching of the anus.
Signs and symptoms:
 Bright red blood in stool

Anorectal Abscess:
 Collection of pus in the rectal area.
 Caused by E coli, Proteus spp, Staph, Streptococci
Signs and symptoms:
 Pain, redness, swelling, and fever. Possible drainage.

Lower GI bleed:
 Can be caused by diverticulitis, polyps, anal fissures, IBD, and cancer
Signs and symptoms:
 Melena in stools or hematochezia (bright red blood from colon or rectum)
Diagnosed by:
 Decreased Hematocrit and Hemoglobin levels. Elevated BUN. Stool for occult blood
 Sigmoidoscopy and colonoscopy

Colorectal cancer:
 Risk factors include family or personal hx of ulcerative colitis, colon cancer, or polyps of
the rectum or large intestine, personal gallbladder removal or dietary carcinogens
Signs and symptoms:
 Change in bowel habits
 Tumors in the descending colon and rectum do not cause GI upset.
Diagnosed by:
 Biopsy done during endoscopy
 CT scan
 CEA blood test

Intestinal Obstruction:
  Mechanical – blockage occurs within the intestine from conditions causing pressure on
the intestinal walls
 Nonmechanical – peristalsis is impaired, and the intestinal contents cannot be propelled
through the bowel
Small bowel obstruction:
 Collection of intestinal contents, gas, and fluid occurs proximal to the obstruction.
 Decrease in venous and arterial capillary pressure, resulting in edema, necrosis, and
perforation
 Causes of mechanical: hernias and neoplasms, foreign bodies, strictures, volvulus.
o Volvulus – occurs when the bowel twists, occluding the lumen
o Intussusception – peristalsis causes the intestine to telescope into itself
 Causes of nonmechanical: abdominal surgery, hypokalemia, MI, peritonitis, pneumonia,
spine injury, trauma, vascular insufficiency
Signs and symptoms:
 Wavelike abdominal pain and vomiting
 Fecal vomiting
 Abdominal distention
 Mechanical obstructions – high pitched tinkling bowel sounds are heard proximal to
obstruction and are absent distally.
 Nonmechanical obstructions – absence of bowel sounds
Diagnosed by:
 CT scan and radiograph tests show dilated loops
 Leukocytosis is evident in strangulation or perforation
Treatment:
 NPO (no ice chips)
 Decompressed using NG tube with suction
 Complete mechanical intervention is surgery
Large bowel obstruction:
 Radiological exams reveal distended colon
 Occur in the sigmoid colon
 Can be caused by carcinoma, IBD, Diverticulitis, benign tumor.
Signs and symptoms:
 Develop slowly
 Obstruction in rectum or sigmoid – constipation
 High pitched tinkling noises on auscultation
 Fecal vomiting
Complications:
 Gangrene, perforation, and peritonitis

Ostomy:
 Ileostomy – liquid to mushy stool
 Cecostomy, ascending colostomy – liquid to mushy, foul odor
 Right transverse colostomy – mushy to semi formed
 Left transverse colostomy – semi formed, soft
 Descending or sigmoid colostomy – soft to hard formed