Disorders of the Lower Bowel

• CONSTIPATION
• INGUINAL HERNIA
• HIRSCHPRUNG
DISEASE
• INFLAMATORY BOWEL
DISEASE
• ULCERATIVE COLITIS
• CROHN DISEASE
• IRRITABLE BOWEL
SYNDROME
• CHRONIC RECURRENT
ABDOMINAL PAIN
 CONSTIPATION
Rome III Diagnostic Criteria for Functional Constipation
➢In the , ≥2 of the following must occur:
Child with Developmental Age <4 Years:
1. ≤2 defecations per week
2. At least 1 episode of incontinence per week after the aquisition of toileting
skills
3. History of excessive stool retention
4. History of painful or hard bowel movements
5. presence of a large fecal mass in the rectum
6. History of large-diameter stools that may obstruct the toilet
Accompanying symptoms may include:
• irritability
• decreased appetite and /or early satiety - may disappear following passage of a large
stool
Child with Developmental Age ≥ 4 Years with Insufficient
Criteria for Irritable Bowel Syndrome:
1. ≤2 defecations in the toilet per week
2. At least 1 episode of fecal incontinence per week
3. History of retention posturing or excessive volitional stool
retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large-diameter stools that may obstruct the toilet
 CONSTIPATION
• 2 or less bowel movement per
week
• causes distress to the child
• painful
• stool holding- represses the next
urge
• encopresis - involuntary release
of stool
• maybe cofused with diarrhea
✓ abdominal pain
✓ decreased appetite
• hardened stool & anal fissures
• pain on defecation
 CONSTIPATION
• stool holding - psychological reason
➢counseling
➢treat physical symptoms
➢circumstances
▪ diet (low-fiber)
▪ little privacy in bathroom
▪ family stress
➢age - if toilet trained
➢no meconium in 48 hr of life
▪ differentiate constipation from Hirschsprung
disease
➢indications of an underlying problem:
➢ poor growth
➢ congenital abnormalities
➢ family history of GI disorders
 CONSTIPATION
Treatment/ Therapeutic Management
• polyethylene glycol - weight-
appropriate doses
- bowel cleansing to remove retained stool
• polyethylene glycol (Miralax) - as stool
softener
• drug of choice, effective
• normal fiber intake - recomended
• encourage to sit on the toilet after
meals
• recomend reward as motivation
 INGUINAL HERNIA
• Protrusion of a section of the bowel
into the inguinal ring
• usually occurs in boys
• as the testes descend from the
abdominal cavity into the scrotum late
in fetal life, a fold of parietal
peritoneum descends, forming a tube
from the abdomen to the scrotum
• In most infants, this tube closes
completely.
• if failure to close, intestines descend
into it (hernia)
• may occur at any time when there is
an increase in intra-abdominal
pressure
INGUINAL HERNIA
• In girls, the round ligament
extends from the uterus into
the inguinal canal to its
attachment on the
abdominal wall
• occurs beacuse of weakness
of the muscle surrounding
the round ligament.
 Assessment (INGUINAL HERNIA)
• lump in the left or right groin
• in some instances- apparent only on
crying (abdominal pressure
increases)
• not when children are less active
• painless
• Pain at the site implies that the bowel
has become incarcinated at the sac -
emergency & requires immediate
action to prevent bowel obstruction
and ischemia
 Diagnosis (INGUINAL HERNIA)
• history
• physical appearance
• ask parents if a lump has been
noticed by them in the groin of
the child
• may not be noticeable at the time
of health care visit, so unless
asked specifically, parents may
not mention it
• if present, the herniated intestine
can be palpated in the inguinal
ring on physical examination
Therapeutic Management (INGUINAL HERNIA)
• Laparoscopy surgery
• the bowel is returned to the abdominal
cavity & retained there by sealing the
inguinal ring
• Pneumoperitoneum - instillation of
carbon dioxide into the peritoneal
cavity
• performed during surgery to reveal
presence of inlarged inguinal ring
on the opposite side
• if present, both sides may be
repaired
• both groins dressing, post op
• Bowel strangulation - a complication if
not done immediately before the child is 1
year of age
(emergency surgery)
• Incarcenated hernia - occurs when herniated
tissue becomes trapped and cannot easily be moved
back into place.

• Can lead to a bowel obstruction or strangulation

• Strangulation - if an obstruction cuts off
the blood supply to the intestine

• usually results when part of the

intestine becomes trapped in an
abnormal opening (strangulated hernia)
• Nausea, vomiting or both
• Fever
• Sudden pain that quickly intensifies
• An hernia bulge that turns red, purple or dark
• Inability to move bowels or pass gas
• Strangulated hernia maybe present at birth

• can also occur at any time of life if the muscle tissue in

the abdomen weakens, leading to potential areas where
folds of tissue can slip through the muscle tissue
 • pregnancy
• strenuous activity
• history of abdominal surgery, including cesarean
delivery, which can weaken the abdominal wall
• straining during bowel movements
• chronic coughing

• should be treated as medical emergency

• Ultrasound
• X-ray
• Pre op Nursing Care Management
Therapeutic Management (INGUINAL HERNIA)
Post operatively:
• keep the suture line dry & free of urine
or feses to prevent infection
• closed with tissue adhesive -
waterproof to seal the incision
• frequent diaper changes
• good diaper care area
• assess circulation on the side of the
surgical repair
• make sure that edema of the
groin is not compressing blood
vessels & obstructing blood flow
to the leg.
 HIRSCHPRUNG DISEASE
Aganglionic Megacolon
• absence of ganglionic innervation to
the muscle of the section of the bowel
• usually at the lower portion of the
sigmoid colon, just above the anus
• there is absence of the nerve cells
• no peristaltic wave in this portion
to move fecal material
• results in chronic constipation
• ribbonlike stools
• the portion of the bowel proximal to
the obstruction dilates, thus distending
the abdomen.
HIRSCHPRUNG DISEASE
• incidence - higher in siblings of a
child with the disorder than in other
children.
• more often in males than in females
• caused by an abnormal gene on
chromosomes10
• incidence is approximately 1 in 5,000
live births
Chromosome 10 likely
contains 700 to 800 genes
that provide instructions for
making proteins. These
proteins perform a variety of
different roles in the body.
 Assessment (HIRSCHPRUNG DISEASE)
• not apparent until 6 to 12
months of age - newborn's stool
is usually soft
• appear thin & undernourished
• can be deceptive because:
• abdomen is large &
distended
• have a history of not having
bowel movement more than
once a week of ribbonlike or
watery stools
 Diagnosis (HIRSCHPRUNG DISEASE)
• Rectal examination
• empty rectum- fecal material can not
pass into the obstructed portion
• Ultrasound
• Barium Enema - outline the narrow
nerveless portion & the large
proximal distended portion of bowel
• must be used cautiously - children can
not expel effectively afterwards
• Biopsy of the affected segment to show
the lack of innervation
• anorectal manometry - a technique
that tests the strength or enervation
of the internal rectal sphincter
• inserting a balloon catheter into the
rectum and measuring the pressure
exerted against it
Therapeutic Management (HIRSCHPRUNG DISEASE)
• Repair of aganglionic megacolon
disection and removal of the
affected section, with anastomosis
of the intestine (pull through
operation)
• 2 Stage Surgery:
1. temporary colostomy is established
2. bowel repair - 8 to 12 months of age
• permanent colostomy - established in an
instance in which the anus is deprived of
nerve endings
 Nursing Diagnosis & Related Interventions
: Imbalance nutrition, less than body requirements, related to
reduced bowel function
: Child ingest a low residue diet; weight follows a percentile
curve on a growth chart.
Intervention:
• pre operative - children with poor health
• minimal-residue diet
• stool softeners
• vitamin supplements
• daily enemas
❖TPN can offer another source of nutrition

❖if child is to be cared at home - help parents regarding, low residue diet
(low in undigestible fiber)
 Interventions
• A low-residue diet is a low
fiber diet with added
restrictions that are
designed to reduce the
amount of stool in the large
intestine
• A low-residue diet is a
temporary eating plan with
the goal of "resting" the
bowel.
Examples of foods on a low-
residue/fiber diet include:
• White bread with no nuts or seeds
• White rice
• Well cooked vegetables without
skin or seeds
• fresh fruit like bananas,
cantaloupe, honeydew, and
watermelon
• Eggs
• Fish
• Poultry
• Dairy products
 Interventions
A low-residue diet also restricts foods
that increase bowel activity, and make
the stools looser.

These foods and drinks should be

avoided, for example:
• fruit juices like prune juice
• bran cereals
• legumes
• corn
• leafy vegetables
• popcorn
• cheese
❖Fried foods & highly seasoned foods
are omitted - to eliminate chemical
irritants in the intestinal tract
 Interventions
• parents may need to create a
reminder sheet for the stool softener
• children with beginning special diet
• advice parents to refrain
introducing new feeding methods
(cup or spoon)

• Post operative:
• NGT, IVF, indweling cath. care
• observe for abdominal distention
• assess bowel sounds (passage of
flatus and stool)
• returned of peristalsis (approx. 24
hrs post op) NGT can be
removed
• offer small frequent feeding
with fluids
(water or gelatin)
 Interventions
➢gradually introduce to:
• full fluids
• soft diet
• minimal-residue diet
• normal diet for age
• Colostomy care
Nursing Diagnosis: Constipation related to redused bowel function
Outcome Evaluation: Child has a daily bowel movement through either a
colostomy or by enema.
Interventions:
Before Surgery
• Normal saline - fluid use for enema and not tap water
❖tap water readily crosses into intestinal walls at insterstitial & intravascular fluid
compartment
❖ cardiac congestion
❖ cerebral edema
❖ death of infant (water intoxication)
• ready-made saline preparation at the pharmacy
• home made - mix 2 teaspoon of noniodized salt to 1 qt of water
• explain to parents the importance of the rationale of the right
proportion of salt to water
Nursing Diagnosis: Risk for compromised family coping related to chronic
illness in child
Outcome Evaluation: Parents state they are able to cope with the level of
stress present from their child's condition
Intervention:
• Caution parents that the child may still be a “fussy eater” after the 2'nd stage
surgery
• Help parents to diminish the importance of meals gradually
• schedule periods during the day - give full & positive attention to the
child
• offer praise for pleasant behaviour
 INFLAMMATORY BOWEL DISEASE
➢inflamation of the intestine
• Ulcerative Colitis - affects only the
mucosal lining of the colon
• Crohn Disease - can affect any part of
the GI tract
❖terminal ilium - the area most
commonly involved (the last part of the
small intestine)
▪ the inflamation can extend through
the wall of the intestine and cause
abscesses and fistulae
▪ 25% of IBD - in children < 20 yrs of age
▪ unknown cause
Cause of IBD:
• multifactorial
• due to an abnormal response
by the immune system to an
environmental trigger in a
genetically susceptible
individual
• psychological problem often
occur secondary to the disease
• possibly intensifying
symptoms
• smoking - known to be a
precipitating factor in crohn
disease
Ulcerative Colitis • Infliximab is a TNF
• crampy abdominal pain (tumor necrosis factor)
blocker. It's used to treat
• urgency moderate to severe
• tenesmus (a continual or recurrent Crohn's disease.
inclination to evacuate the bowels) • It was initially designed
• frequent bloody stools as a chemotherapy drug
to treat cancer but wasn't
• Anemia & hypoabuminemia - losses effective for cancer.
in the stools
• The drug has been
❖treated in oral or IV medications shown to work against
▪ infliximab (Remicade) autoimmune diseases
like rheumatoid arthritis
and Crohn's.
❖Surgery - to remove the colon
❖if the disease persists over 10 years -
associated with carcinoma
▪ yearly colonoscopy- patient has
reached 8 to 10 years from
diagnosis
Crohn Disease
• symptoms depends on the severity
and location of inflammation
• abdominal pain
• diarrhea with or without blood
• weight loss may be present
• inflamed area - stricture of the bowel
& bowel obstruction
• fistulae - small tunnel from the bowel
to the skin or to another organ
(common - perianal area)
• also treated with oral & IV
medications depending on the
severity
Crohn Disease
• remissions - achieved with exclusive
enteral feeding
• surgery - to remove affected area &
repair fistulae
• can re develop in other areas of the
bowel
❖there are periods of exacerbations and
remissions in both disorders
• as inflammation becomes acute
• abdominal pain - most acute after
eating
(bowel beacomes active) - skip meals
• malnourished & vitamin and iron
deficiency develop
• diarrhea & malnutrition - no
absorption of nutrients and fluid
 Assessment IBD
• both conditions - diarrhea &
steatorrhea develop
(irritation & unabsorbed fluid)
• blood in the stool - inflamed
portion ulcerate
• weight loss occurs &
growth failure
• recurring fever may be
present
 IBD • Friable - easily crumbled or
Diagnosis pulverized
• endoscopy (friable carcinomatous tissue )
• colonoscopy
• Small biopsies with a very low risk
of bleeding - upper & lower GI tract
• inflamation
• friability
• bleeding
• Histology report - shows chronic
inflammation & sometimes
granulomas in CD
• MRI - to examine some parts of the
small bowel that can't be reach
with an endoscope
• mild to moderate cases - oral
medication
• Vitamin & Mineral deficiencies
should be corrected
• more severe case - bowel rest, to
allow the bowel to heal
• enteral or TPN provided
• can be treated at home with proper
health education to parents
regarding child's nutritional needs
• Re-introduction of food:
• high-protein
• high-carbohydrate
• high-vitamin diet
➢ prescribed to replace nutrients
➢ may eat cautiously
➢ assess intake and output carefully
❖Nursing Intervention for enteral
feeding or TPN:
• allow the enteral infusion to flow during
the night
• remove tube during the day
- can make feedings more tolerable
❖food provides social experiences as well
as nutrition
• help parents provide opportunities for
usual mealtime stimulation in other ways.
 Therapeutic Management (IBD) • Mesalamine
• may eat cautiosly - prevent re- belongs to a class
introduction of diarrhea of drugs known as
aminosalicylates.
• assess intake and output carefully
It works by
• treatment regimen depends on the decreasing
child's condition: swelling in the
• severe case - remission achieved with colon.
corticosteroid or
• infliximab (Remicade)
- an antibody to inflammatory cytokine
tumor necrosis factor alpha
• maintenance therapy with infliximab or
• mercaptopurine
- immunomodulator
or
• mesalamine alone or a combination of
medications
❖Nursing Intervention for ineffective
coping
• caution children about posible side
effects of medication:
corticosteroid therapy
• excessive weight gain
• a round facial appearance
• facial acne
Assess the following:
• blood pressure
• intake & output
• weight
• sleep patterns
• provide time to listen so children have
someone outside their family to talk
about symptoms or stress problems
 Therapeutic Management (IBD)
Surgery for UC - 2 stages:
• Total colectomy & an ileostomy is
created
• ileoanal pouch - created several
months later & ileostomy is taken
down - child is continent of stool
• bowel surgery - done to reduce
possibility of colon cancer
❖remind parents to monitor for
change in color or consistency of
bowel movements - to detect
relapse
Ileoanal anastomosis
 Assignment:
1) Comparison of Crohn disease and Ulcerative Colitis
- page 1285 textbook
2) Nursing Care Planning Based on Responsibility for
Pharmacology
- page 1286 textbook
 IRRITABLE BOWEL SYNDROME
• Irritable bowel syndrome (IBS) is a
group of symptoms—including
abdominal pain and changes in the
pattern of bowel movements without
any evidence of underlying
damage. ...
• Disorders such as anxiety, major
depression, and chronic fatigue
syndrome are common among
people with IBS.
• The causes of IBS are not clear.
 IRRITABLE BOWEL SYNDROME
• Functional bowel disorder that
typically causes symptoms of
abdominal pain & related bowel
habits
• no underlying organic cause
• it may be either constipation or
diarrhea predominant or there
may be mixed picture
• Diagnosis - based on Rome III
Criteria
Child with Developmental Age ≥ 4 Years with Insufficient
Criteria for Irritable Bowel Syndrome:
1. ≤2 defications in the toilet per week
2. At least 1 episode of fecal incontinence per week
3. History of retention posturing or excessive volitional stool
retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large-diameter stools that may obstruct the toilet
 IRRITABLE BOWEL SYNDROME
• common disorder in adolescents
and adults
• affect 15% of population
• 2:1 female to male predominance
• symptoms adversely affect quality
of life - children miss to school
• cause - unknown
• onset of loose stool - follow an
infection
• alteration in intestinal flora
• intestinal bacterial overgrowth
• food sensitivities
• visceral hyperalgesia (heightened
sensitivity to bowel distension)
• psychosocial factors
 Nursing Management (IBS)

• Dairy products, including milk and cheese (Lactose

intolerance symptoms can be similar to IBS
symptoms.)
• Certain vegetables that increase gas (such as
cauliflower, broccoli, cabbage, Brussels sprouts)
and legumes (such as beans)
• Fatty or fried foods.
• Alcohol, caffeine, or soda.
 IRRITABLE BOWEL SYNDROME

• Antidepressants
• anticholinergics
• Antibiotics - rifaximin
➢work to reduce bacteria in
the gut
➢prescribed to treat the
symptoms of IBS
 CHRONIC RECURRENT ABDOMINAL PAIN
• A functional disorder
• pain - episodic to continuous
• cause - unknown
• 6 to 7 years of age - prepuberty
• pain is not accompanied by a
change in bowel habits
• no association with meals
• generally, poorly localized although
children may point to the umbilicus
as the primary site
• on physical examination
• no abdominal tenderness
• no distention
• no guarding or muscle spasm
CHRONIC RECURRENT ABDOMINAL PAIN
• Symptoms of stress maybe
present:
• sleep disturbances
• fears
• eating problems
• Family Hx. - problems in the family:
• marital discord
• financial problems
• physical illness in parents or siblings
• cause of pain may not identified but
it's real
• Treatment is similar with IBS
• dietary changes - increase fiber,
probiotics
• medications
• behavioral and comlementary therapy
 CHRONIC RECURRENT ABDOMINAL PAIN
• Cognitive behavioral
therapy
• teaches the child coping
strategies
• distruction technique
• relaxation
• parents - trained to
redirect the child after
pain complaints & use
positive reinforcement
• Hypnosis - effective
adjunct therapy
• Hypnosis -- or hypnotherapy --
uses guided relaxation, intense
concentration, and focused
attention to achieve a heightened
state of awareness that is
sometimes called a trance.
• The person's attention is so focused
while in this state that anything
going on around the person is
temporarily blocked out or ignored.
• Hypnotherapy can be used
to treat anxiety, phobias,
substance abuse including
tobacco, sexual
dysfunction, undesirable
spontaneous behaviors,
and bad habits.

• It can be used to help

improve sleep, learning
disorders, communication,
and relationship issues.
THANK YOU