GASTROINTESTINAL DISORDERS

ANATOMY
a. 23-26 feet from mouth to anus
b. Blood supply: gastric artery (stomach); mesenteric arteries (intestines)
c. Blood drainage: portal vein (straight to liver)
d. Blood flow: 20% of the total CO and  after eating

ESOPHAGUS
a. Back: Spine; Front: Trachea/Heart
b. Collapsible tube (10 inches)
c. Distends when food passes through it
d. Tube that connects the throat (pharynx) and the stomach.
e. The esophagus is made of muscles that contract to move food to the stomach.
STOMACH
a. Below the left diaphragm
b. 1500 ml
c. 4 regions: cardia, fundus, body and pylorus
✓ Inlet: cardiac sphincter
✓ Outlet: pyloric sphincter
d. Four functions of the stomach
✓ As reservoir
✓ Acid secretion
✓ Enzyme secretion
✓ Gastrointestinal motility.
SMALL INTESTINE
a. 15-17 feet
b. 7000 cm for secretion & absorption
c. 3 regions: duodenum, jejunum, ileum
d. Cecum – junction between small and large intestine
e. Ileocecal valve – found at the cecum
f. Appendix – found attached to the cecum, 4 inches long, prone to obstruction and infection
g. Main functions:
✓ To break down, or digest food
✓ To absorb nutrients, such as electrolytes, vitamins and minerals. The small intestine is the most important absorbing
organ in the GI tract. About 90% of nutrient absorption takes place in the small intestine
LARGE INTESTINE
a. 3 segments: ascending, transverse, descending
b. Internal and external sphincters
c. 3 primary functions:
✓ Absorbing water and electrolytes
✓ Producing and absorbing vitamins
✓ Forming and propelling feces toward the rectum for elimination.
PROCESS OF DIGESTION
a. Process of Digestion
b. Chewing and Swallowing
c. Beginning: Sight, smell, taste, thought
d. Saliva: Parotid, submandibular, sublingual
e. Ptyalin:Mucus and water
f. Swallowing
✓ Medulla oblongata
✓ Propels the bolus
✓ Epiglottis
Process of Digestion
A. Gastric Function
1. Gastric secretions
A. Hydrochloric acid
2 functions:
• Break down food
• Destroy bacteria
B. Pepsin
✓ Breaks down proteins into smaller amino acids.
✓ It is produced in the chief cells of the stomach lining and is one of the main digestive enzymes in
the digestive systems.
2. Intrinsic factor – Vitamin B12 absorption
3. Peristaltic contractions present
4. Controlled rate of entry – efficient absorption
B. Small Intestine Function
1. Aided by the pancreas, liver, gallbladder
2. Pancreas
a. Alkaline pH due to high concentrations of bicarbonate
b. Trypsin – protein digestion
c. Amylase – starch digestion
d. Lipase – fat digestion
3. Intestinal glands
a. Secrete mucus (protection)
b. Hormones, neuroregulators and local regulators
4. 2 types of contractions (stimulated by presence of chime)
a. Segmentation – back and forth
b. Intestinal peristalsis – propels
5. Villi
a. Finger-like projections
b. Absorption of nutrients
6. Duodenum – iron and calcium
7. Jejunum – Fats, proteins, carbohydrates, sodium and chloride
8 .Ileum – Vitamin B12 and bile salts, Everywhere – Magnesium, phosphate and potassium
C. Colonic Function
a. 4 hours – time waste reaches your colon
b. Bacteria
c. Major component
✓ breakdown waste materials
✓ Responsible for the fecal odor
✓ Responsible for the brown stool color (breakdown of bile)
d. 2 types of colon secretions:
✓ Electrolyte solution – bicarbonate solution
✓ Mucus – protection and “glue”
e. Elimination
✓ 12 hours
✓ Fecal matter – 75% fluid and 25% solid material
✓ 150 mL
✓ Voluntary and involuntary control
Diagnostic tests
Laboratory Test
1. CEA ( Carcinoembryonic Antigen)- A normal level of CEA is less than or equal to 3 nanograms per milliliter (ng/mL).
a. The CEA test is used especially for cancers of the large intestine and rectum.
b. A high amount of CEA in your body after a cancer treatment or surgery suggests the cancer is not gone.
c. It may also mean that the cancer has spread to other parts of your body.
d. (+) colorectal cancer
e. No heparin for 2 days
f. No smoking before the test (Smoking can increase the amount of CEA in your body even in the absence of cancer.)
g. Specimen by venipuncture
2. Exfoliative Cytology-Detect malignant cells; helicobacter pylori
a. Written consent
b. Liquid diet
c. UGI :
✓ NGT insertion
✓ Cells are obtained from saline lavage
d. LGI : - Detect malignant cells
✓ Written consent
✓ Cells are obtained by inserting a proctoscope
✓ Bowel prep required
3. Fecal Analysis
a. Stool for Occult Blood (Guaiac Stool Exam)
1. Detect G.I. Bleeding
2.  fiber diet 48 – 72 hours
3. No red meats, poultry, fish, turnips, horseradish, melon
4. Avoid dark foods
5. Withhold for 48 hrs: Iron, Steroids, Indomethacine, Colchicine
6. 3 stool specimen ( 3 successive days)
b. Stool for Ova and Parasites- send fresh, warm stool specimen
c. Stool Culture- Sterile test tube / cotton – tipped applicator
d. Stool for Lipids
1. Assess steatorrhea
2.  fat diet, No alcohol ( 3 days )
3. 72 hour stool specimen ( store on ice )
4. No mineral oil, neomycin SO4
4. Gastric Analysis
a. Measures secretion of HCI and pepsin
b. NPO for 12 hours
c. NGT is inserted , connected to suction
d. Gastric contents collected every 15 minutes to 1 hour
RADIOGRAPHIC TESTS
1. Scout Film / Flat Plate of the Abdomen
a. Plain X – ray of the abdomen
b. X belts / jewelries
2. UGIS (Barium Swallow)
a. To visualize the esophagus, stomach, duodenum and jejunum
b. NPO for 6 – 8 hours
c. Barium Sulfate (BaSO4) per orem
d. X – rays taken on standing, lying position
e. After the procedure:
1. Laxative
2. Increase fluid intake
3. Inform client that the stool is white for 24 – 72 hours
4. Observe for Ba impaction : distended abdomen, constipation
3. LGIS (Barium Enema)- To visualize the colon
a. Low residue / clear liquid diet for 2 days
b. Laxative for cleansing the bowel
c. Suppository / cleansing enema in A.M.
d. BaSO4 per rectum
 e. Care after the procedure – same as UGIS
ENDOSCOPY
1. UGI Endoscopy - Direct visualization of esophagus, stomach, and duodenum
a. Obtain written consent
b. NPO for 6 – 8 hours
c. Anticholinergic (AtSO4) as ordered
d. Sedatives, narcotics, tranquilizers- e.g. Diazepam, Meperidine HCl
e. Pre-op
✓ Remove dentures, bridges
✓ Local spray anesthetic on posterior pharynx – instruct : X swallow saliva
f. After the procedure
✓ Side – lying position
✓ NPO until gag reflex returns (2 – 4 hrs)
✓ NSS gargle; throat lozenges
✓ Monitor VS
✓ Assess : bleeding, crepitus (neck), fever, neck / throat pain, dyspnea, dysphagia, back / shoulder pain
✓ Advised to avoid driving for 12 hours if sedative was used.

2. LGI Endoscopy
a. Proctosigmoidoscopy (sigmoid, rectum)
1. Clear liquid diet 24 hours before
2. Administer cathartic / laxative as ordered
3. Cleansing enema
4. Knee – chest / lateral position
5. After the procedure
a. Supine position for few minutes
b. Assess for signs of perforation- bleeding, pain, fever
c. Hot sitz bath to relieve discomfort
b. Colonoscopy
1. Informed consent
2. Bowel prep required
3. Sedation
4. Position : left side, knees flexed
5. After the procedure:
a. Monitor VS (note for vasovagal response)
b. Assess for s/s of perforation.
3. Ultrasonography
 NPO for 8 – 12 HOURS
 Laxative as ordered ( bowel gas)
GASTROSTOMY TUBES
Indications:
1. Head and neck cancers
2. Malignant Bowel obstructions
3. Neurological conditions
4. Disorders in swallowing
5. Burns
6. Crohn’s Disease

Procedure:
a. Informed consent
b. An endoscope is passed into the mouth, down the esophagus, and into the stomach.
c. Under direct visualization with the endoscope, a PEG tube passes through the skin of the abdomen, through a very small
incision, and into the stomach.
d. A balloon is then blown up on the end of the tube, holding in place.
Nursing Care
1. Should the tube accidentally come out it must be reinstated within twenty-four hours or the incision will begin to heal, and
new surgery may be required.
2. The tube is very narrow. CAN BE EASILY OBSTRUCTED
3. REDUCED RISK FOR ASPIRATION
4. To maintain patency, the patient should flush the tube with clear water before and after feedings, or after medications have
been administered through the tube.
Post Procedure
1. The stoma site should not need a dressing post insertion unless it is still healing.
2. If there is a dressing remove within 24 hours.
3. The stoma site should be cleaned daily with saline/sterile water and patted dry.
4. For the first 2 weeks avoid moving the fixation plate and the PEG tube should not be rotated.
5. From day 15 post-insertion the tube must be rotated daily and advanced 2-3 cm and rotated once weekly to prevent
buried bumper syndrome and over granulation of tissue.
Contraindications of Gastroscopy tube
• Gross ascites
• Peritonitis
• Esophageal obstruction/varices
• Malignancy at proposed puncture site
• Inability to pass an endoscope
• Active gastric ulceration
• Deranged clotting
• Gross obesity
 Gastric outlet obstruction
• Previous gastric surgery
• Patients whose anatomy or condition makes it hard to lie flat for the procedure
(e.g. Motor Neurone Disease or Cerebral Palsy)
JEJUNOSTOMY
✓ Enteral feeding is often required for patients with significant recurrent aspiration, intraabdominal trauma, long-term
ventilatory support, esophageal or gastric dysmotility, and complications following abdominal operations that render the
upper GI tract undesirable or inaccessible for enteral access.
✓ In addition to patients with long-term enteral feeding requirements, the surgeon anticipating a delay in oral intake after
complex abdominal procedures may elect to place a jejunostomy tube for early postoperative feeding.
Pre-procedure
1. Informed consent
2. Pre-op medications
3. Laboratory test- PT
4. Vital signs as baseline information
During procedure
1. The patient should be placed in the supine position.
2. General anesthesia with a naso- or orogastric tube for stomach decompression is required.
3. This procedure involves the placement of a 5 or 7 Fr catheter into the jejunum via a submucosal tunnel.
4. Feeding jejunostomies are generally placed in the left upper abdomen, slightly above the level of the umbilicus.

GASTROSTOMY OR JEJUNOSTOMY FEEDING

a. Verify doctor’s order.
b. Assist client to a Fowler’s position.
c. Administer formula at room temperature.
d. Insert feeding tube into the ostomy opening 10 – 15 cm. (4 to 6 in.) if one is not sutured in place. (Lubricate tube before
insertion)
e. Check the patency of the tube sutured in place – pour 15 to 30 ml. of water into the asepto syringe.
f. Administer feeding slowly. Hold syringe 7 to 15 cm. (3 to 6 inches) above the ostomy opening.
g. Flush the tube with 30 ml. of water after feeding.
h. Keep the client in Fowler’s position or slightly elevated right lateral position for at least 30 minutes.
i. Assess status of peristomal skin.
j. Make relevant documentation.
COMMON PROBLEMS OF TUBE FEEDINGS
1. Vomiting
2. Aspiration
3. Diarrhea
4. Constipation
5. Hyperglycemia
6. Abdominal distention
TOTALTOTAL PARENTERAL NUTRITION (TPN)
Indications
✓ Major GI diseases, fistulas or inflammatory diseases
✓ Severe trauma or burns
✓ Severe GI side effects from radiation or chemotherapy
✓ Severe malnutrition
✓ Need for extensive support over an extended period.
1. Usual site of TPN catheter insertion is subclavian vein.
2. Place the client in Trendelenburg’s position during insertion of TPN catheter
3. The primary purpose of TPN is to administer glucose ( 25 – 35% dextrose)
4. Administer TPN solution at room temperature
5. Consume prepared formulas within 24 hours to prevent contamination.
6. Maintain a steady infusion rate
a. Use infusion pump e.g. IVAC
7. Do not attempt to “catch up” if infusion is delayed.
8. Monitor urine and blood glucose levels.
9. Care of catheter insertion site.
a. Practice strict aseptic technique
b. Cleanse site with antiseptic solution
c. Change sterile dressings daily.
d. Monitor for signs and symptoms of infection
10. Provide good oral hygiene
Complications of TPN
1. Infection
✓ Is a common cause of death in these patients.
✓ The subclavian (or axillary) vein is preferred due to its ease of access and lowest infectious complications compared to the
jugular and femoral vein insertions.
2. Catheter complications
✓ pneumothorax, accidental arterial puncture, and catheter-related sepsis
3. Blood clots
✓ Death can result from pulmonary embolism wherein a clot that starts on the IV line breaks off and travels to the lungs,
blocking blood flow.
✓ Patients on TPN who have such clots occluding their catheter may receive a thrombolytic flush to dissolve the clots and
prevent further complications.
4. Fatty liver and liver failure
✓ Fatty liver is usually a more long-term complication of TPN, though over a long enough course it is fairly common.
✓ The pathogenesis is due to using linoleic acid (an omega-6 fatty acid component of soybean oil) as a major source of
calories.
5. Cholecystitis
✓ Total parenteral nutrition increases the risk of acute cholecystitis due to complete disuse of the gastrointestinal tract,
which may result in bile stasis in the gallbladder.
6. Gut atrophy
✓ Infants who are sustained on TPN without food by mouth for prolonged periods are at risk for developing gut atrophy.
7. Hypersensitivity
✓ Hypersensitivity is thought to occur to the individual components of TPN, with the intravenous lipid emulsion being the
most frequently implicated component, followed by the multivitamin solution and the amino acid solution.
8. Metabolic Complications
✓ Metabolic complications include the refeeding syndrome characterized
by hypokalemia, hypophosphatemia and hypomagnesemia.
✓ Hyperglycemia is common at the start of therapy, but can be treated with insulin added to the TPN solution.
 ✓ Hypoglycaemia is likely to occur with abrupt cessation of TPN.
✓ Liver dysfunction can be limited to a reversible cholestatic jaundice and to fatty infiltration (demonstrated by elevated
transaminases).
GASTROESOPHAGEAL DISORDERS
Gastroesophageal Reflux Disease (GERD)-Gastric content flow back into the esophagus due to:
a. Incompetent LES (low esophageal sphincter)
b. Pyloric stenosis
c. Motility disorders
d. Hiatal hernia
e. Aging
Manifestations
a. Heartburn - (pyrosis) more common- typically 30 to 60 min after eating and in reclining position
b. Indigestion
c. Nausea and vomiting
d. Regurgitation
e. Dysphagia- less common symptom
f. Hypersalivation
g. Esophagitis

3. Diagnostics
a. Endoscopy or Barium swallow
b. 12- to 36-hour esophageal pH monitoring
c. Bilirubin monitoring
4. Management
a. Low-fat diet
b. Avoid irritating foods
c. Don’t eat 2 hours before bedtime
d. Maintain normal body weight
e. Avoid tight-fitting clothes
f. Elevate head of bed on 6-8 inch blocks
g. Elevate upper body on pillows
h. Medications
✓ Antacids or histamine receptor blockers
✓ Proton pump inhibitors (-prazole)
✓ Prokinetic agents (Domperidone [Motilium], Metoclopramide [Reglan])
i. Surgical management
✓ Fundoplication
Hiatal Hernia (Diaphragmatic Hernia)
1. Sliding Hiatal Hernia-Protrusion of the esophagogastric junction into the thoracic cavity and back into the
abdominal cavity in relation to position changes.
2. Paraesophageal / Rolling Hernia- Cause : anatomic defect
Causes:
✓ Muscle weakness in the esophageal hiatus:
a. Aging process
b. Congenital muscle weakness
c. Obesity
d. Trauma
 e. Surgery
f. Prolonged increases in intra-abdominal pressure

ASSESSMENTS
a. Heartburn due to gastroesophageal reflux
b. Dysphagia
c. Dyspnea
d. Abdominal pain
e. Nausea and vomiting
f. Gastric distention
g. Belching
h. flatulence
MEDICAL MANAGEMENT
AVOID: Anticholinergics, Xanthine derivatives, Calcium– channel blockers, Diazepam (These drugs lower the LES pressure (low
esophageal sphincter)
Nursing Management
1. Relieve pain
✓ Antacids
2. Modify diet
a. High CHON diet to enhance LES pressure
b. Small frequent feedings ( 4 to 6 )
c. Eat slowly and chew food properly
d. Avoid : Fatty foods, Cola beverages, Coffee, Tea, Chocolate, Alcohol
e. These foods and beverages decrease LES pressure
3. Assume upright position before and after eating (1-2 hrs.)
a. Do not eat at least 3 hrs. before bedtime to prevent nighttime reflux
b. No evening snacks
c. Reduce BW if obese
4. Promote lifestyle changes
a. Elevate HOB 6 to 12 in. for sleep
b. Avoid factors that increase intra-abdominal pressure
✓ Use of constrictive clothing
✓ Straining
✓ Heavy lifting
✓ Bending, stooping
✓ Coughing
c. No smoking (causes rapid and significant drop in LES pressure)
SURGERY
Nissen Fundoplication (gastric wrap – around)
Pre-op Care
a. Teach on DBCT exercises, incentive spirometry to prevent post-op respiratory complications
b. Inform on possible post-op contraptions:
✓ Chest tube
✓ NGT
Post-op care
1. Facilitate AW clearance
a. Semi – Fowler’s position
b. Reinforce DBCT exercises, incentive spirometry, chest physiotherapy
2. Facilitate swallowing
a. A large NGT is inserted to prevent the fundoplication from being made too tightly
b. Drainage from NG tube turns to yellowish green within first 8 hrs, post-op
c. Oral fluids after peristalsis returns; near normal diet within 6 weeks
d. Small, frequent meals
e. Maintain upright position
f. Avoid gas- forming foods
g. Frequent position changes and early ambulation to clear air from the GI tract
h. Report for persistent dysphagia and gas pain
Gastritis
✓ Short-term inflammation of the gastric or stomach mucosa due to ingestion of chemical agents or food products that
irritate and erode gastric mucosa

Causes
1. Acute Gastritis
a. Intake of irritating foods
b. Overuse of NSAIDS
c. Excessive alcohol intake
d. Bile reflux
e. Radiation therapy
f. Ingestion of strong acid or alkali
2. Chronic Gastritis
a. Helicobacter pylori
b. Benign or malignant ulcers
 c. Autoimmune processes
d. Long-term caffeine use
e. Long-term use of NSAIDS
Pathophysiology

Damage to the mucosa

↓
Disrupted cellular structures
↓
Increased intracellular pH
↓
Impaired enzyme function
↓
Ischemia
Tissue death

Manifestations
Acute gastritis
a. Abdominal discomfort
b. Headache
c. Exhaustion
d. Nausea/Vomiting
e. Anorexia
f. Hiccupping
Manifestations
Chronic gastritis
a. Anorexia
b. Heartburn after eating
c. Belching
d. Sour taste in the mouth
e. Nausea/Vomiting
f. Anemia
Diagnostics
a. Endoscopy
b. Upper GI series
c. Biopsy
d. Serologic testing for H. pylori antibodies
e. Breath test
Medical management
a. Start bland diet as tolerated
b. Antacids
c. Diluted lemon juice or vinegar
d. NO emesis and lavage!
e. Antibiotics (tetra or amoxicillin + clarithromycin) + proton pump inhibitor
Nursing management
a. Reduce anxiety
b. NPO until acute symptoms subside
c. Avoid caffeine
d. Avoid alcohol and smoking
e. Monitor vital signs and I/O
f. Relieve pain
Peptic Ulcer Disease
✓ Excavation that forms in the mucosal wall of the stomach, in the pylorus, in the duodenum or in the esophagus
Pathophysiology
 Concentration or activity of acid-pepsin
 mucosal resistance

Inability to withstand acid-pepsin
 
Erosion

 Secretion of mucus to protect against HCl

Aggravation of eroded mucosa
Stress Ulcers
⚫ Occurs after physiologically stressful events
⚫ Cushing’s ulcer
⚫ Curling’s ulcer
General Manifestations
a. Dull, gnawing pain or burning sensation in the mid-epigastrium or in the back
b. Pain relieved by eating
c. Heartburn with sour burping
d. Vomiting which may or may not be preceded with nausea
e. Constipation or diarrhea
f. Bleeding

Diagnostics
a. Upper GI series
b. Endoscopy – preferred; allows visualization of inflammatory changes, ulcers & lesions
c. Biopsy
d. Guaiac, or occult blood, test
e. Breath test and serologic test for H. pylori antibodies
Management
1. Pharmacologic
1. H2 receptor antagonists (-tidine)
✓ Cimetidine (Tagamet) – least expensive; confusion, agitation or coma in the elderly and with hepato-renal insufficiency;
can also cause gynecomastia and impotence
2. Ranitidine (Zantac) – fewer side effects
3. Proton (gastric acid) pump inhibitors (-prazole)
✓ Omeprazole (Losec) – may cause gastric tumors
✓ Lansoprazole (Prevacid) – taken whole, PC
4. Cytoprotective medications- Sucralfate (Iselpin) – causes constipation; approved for duodenal ulcers only
5. Misoprostol (Cytotec) – preventive medication for those taking NSAIDs; give with food; causes uterine cramping
6. Antacids
✓ Milk of Magnesia (MgOH)
✓ Amphogel(AlOH)
✓ Maalox (Al-Mg-OH)
7. Antibiotics and bismuth salts
✓ Tetracycline – causes photosensitivity reaction; use sunscreen
✓ Amoxicillin
✓ Metronidazole
✓ Clarithromycin
8. Bismuth subsalicylate - helps with ulcer healing; take on an empty stomach
2. Surgical management
Reasons for surgery:
✓ Intractable ulcers
✓ Life-threatening hemorrhage
✓ Perforation – most dangerous
✓ Obstruction – spasm or inflammation
a. Vagotomy- Resection of vagus nerve to decrease cholinergic stimulation of the parietal cells decreasing gastric acid secretion
b. Pyloroplasty - Repair of the pyloric sphincter; improves gastric emptying of acidic chyme
c. Subtotal Gastrectomy - Removal of the 75% of the distal stomach with Billroth I or II repair
d. Antrectomy- Removal of the lower portion (50%) of the antrum (contains the cells that secrete gastrin) including a small
portion of the duodenum and pylorus.
e. Billroth I – Gastroduodenostomy; remaining segment is anastomosed to the duodenum
f. Billroth II – Gastrojejunostomy; remaining segment is anastomosed to the jejunum

Nursing Management
Pre-op Care
1. Psychological support – relieves anxiety
2. Teach about DBCT to prevent pneumonia and atelectasis
Post-op Care
1. Promote patent airway and ventilation
2. Semi-Fowler’s position
3. Reinforce breathing and coughing exercises
4. Teach splinting before coughing
5. Encourage ambulation
6. Check patency of the tubes
7. NGT is for decompression
8. Measure NG drainage accurately (blood-streaked for the 1st 24 hours, brownish to yellowish after 24 hrs)
9. Administer pain medications as ordered
10. Promote adequate nutrition
11. NPO until peristalsis returns
12. Initiate oral fluids when feeding – observe for dyspnea, pain and fever
13. Small, frequent feedings
14. Eat less food at a slower pace for early satiety
15. Monitor weight regularly
Prevent complications
1. Bleeding
a. Monitor for 1st 24 hours and on the 4th-7th day post-op
b. Monitor NG drainage for blood
c. Observe for signs of peritonitis (severe abdominal pain, rigidity and fever)
d. Notify the doctor immediately for any abnormalities
2. Dumping Syndrome
✓ A group of unpleasant vasomotor and GI symptoms caused by rapid emptying of gastric content into the jejunum
✓ Tremors, Irritability, Restlessness
 ✓ Excessive diaphoresis
✓ Diarrhea
✓ Position FLAT ON BED or on LEFT LATERAL POSITION
✓ High to moderate fat and high protein diet, low carbohydrates
✓ Limit sugar and salt intake
✓ Fluids should be given after meals

3. Pernicious Anemia
✓ Due to removal of parietal cells
✓ Vitamin B12 injections for life
Irritable Bowel Syndrome
✓ IBS is one of the most common GI problems (1 out of 6 healthy individuals experience this) and results from a functional
disorder of intestinal motility.
Risk Factors
a. Heredity
b. Psychological stress or conditions such as anxiety & depression
c. High fat diet
d. Irritating foods
e. Alcohol consumption
f. Smoking

Manifestations
a. Constipation or diarrhea or both
b. Abdominal pain precipitated by eating and relieved by defecation
c. Bloating
d. Abdominal distention
Diagnostics
a. Stool exams, contrast x-ray and proctoscopy
b. Barium enema and colonoscopy
Medical management
a. Hydrophilic colloids – controls diarrhea
 b. Loperamide (Imodium) – helps control fecal urgency
Nursing Management
a. Provide patient and family education
b. Identify and avoid irritating foods
c. High-fiber diet
d. Exercise
e. Advocate participation in stress reduction programs and exercises
f. Avoid taking fluids with meals
g. Chew food slowly and thoroughly
Appendicitis
✓ Most common reason for emergency abdominal surgery; the appendix becomes inflamed as a result of either being kinked
or occluded by a fecalith, tumor or foreign body
✓ More common in males, 10 to 30 years of age
✓ Causes
1. Obstruction by fecalith or foreign bodies infection
2. Low fiber diet
3. High intake of refined carbohydrates

Pathophysiology
Kinking or occlusion by fecalith, tumor or foreign body

Inflammatory process

 intraluminal pressure

RLQ pain, abscess

Perforation (24 hours after onset of pain)

Peritonitis
Manifestations
a. Vague epigastric pain to RLQ pain
b. Low-grade fever
c. Nausea and sometimes vomiting
d. Loss of appetite
e. Rigid abdomen, guarding
f. Local tenderness elicited at McBurney’s point
g. Rovsing’s sign –after palpation of LLQ
h. Blumberg sign – rebound tenderness
i. Abdominal distention – due to paralytic ileus

Diagnostics
✓ Complete Blood Count – elevated WBC count >10000 cells/mm3
✓ Abdominal x-rays, ultrasound studies and CT scan – RLQ density or localized bowel distention
Surgical Management
Appendectomy – removal of the appendix; performed ASAP to reduce the risk of perforation
Pre-op:
a. IV infusion
b. Antibiotics
c. NGT insertion
d. NO ENEMA, LAXATIVE, and HOT COMPRESS
e. Spinal or general anesthesia
Post-op:
a. Flat on bed for 6-8 hours
b. Monitor for return of sensation in the legs
c. Semi-Fowler’s position
d. Morphine sulfate
e. NPO until peristalsis returns
f. Penrose drain
Nursing Management
Discharge planning
a. Visit the surgeon 5-7 days post-op
b. Resume normal activity in 2-4 weeks
c. Teach about wound dressing and incision care
d. Report any complications of the surgery (e.g., peritonitis, pelvic abscess, abscess under the diaphragm, ileus)
PERITONITIS- Inflammation of the peritoneum
Causes
1. Ruptured appendix
2. Perforated peptic ulcer
3. Diverticulitis
4. Pelvic inflammatory disease
5. Urinary tract infection or trauma
6. Bowel obstruction
7. Bacterial invasion
PATHOPHYSIOLOGY
Inflammation
↓

Adhesions  Peristalsis
↓ ↓
Abscess Fluid shift into
↓ abdominal cavity
Intestinal Obstruction (300 – 500 ml. / hr.)
↓
Bowel distended with gas
& fluid

➢ Hypovolemia
➢ Electrolyte Imbalance
➢ Dehydration
➢ Shock

ASSESSMENT
1. Abdominal pain and tenderness
2. Abdominal guarding and rigidity
3. Abdominal distention
4. Paralytic ileus
5. Fever
6. Elevated wbc (20,000/cu. mm. or higher)
7. Nausea and vomiting
Signs of early shock:
1. Tachycardia
2. Tachypnea
 3. Oliguria
4. Restlessness
5. Weakness
6. Pallor
7. Diaphoresis
8. Hypotension
NURSING MANAGEMENT
1. Monitor VS, I and O
2. NGT is inserted to relieve abdominal distention
3. Bed rest in Semi – Fowler’s position
4. Encourage deep breathing exercises
5. Peritoneal lavage with warm saline
6. Insertion of drainage tubes
7. Fluid, electrolyte and colloid replacement
8. Antibiotics
9. TPN solutions
Inflammatory Bowel Disease
2 chronic inflammatory GI disorders:
a. Regional Enteritis (Crohn’s Disease or granulomatous colitis)
b. Ulcerative Colitis

Surgical Management
Reasons for surgery:
a. Medically intractable disease
b. Poor quality of life
c. Complications from the disease
✓ Regional ileitis – total colectomy and ileostomy
✓ Ulcerative colitis – proctocolectomy with ileostomy
Nursing Management
a. Control diarrhea & inflammation
b. Antidiarrheals (loperamide)
c. Sulfasalazine (mild to moderate inflammation) or corticosteroids (severe)
d. Sulfasalazine causes Stevens-Johnson’s syndrome (exfoliative dermatitis)
e. Relieve pain and restore fluids
f. Anticholinergics (Buscopan) 30 minutes AC
g. Analgesics
h. Monitor I/O, weight and signs of fluid volume deficit
i. Encourage oral fluid intake and monitor IV rate
j. Decrease diarrhea
k. Antibiotics
l. Abscesses, peritonitis and perforation
m. Maintain optimal nutrition
n. TPN
o. Monitor I/O and daily weight (0.5 kg daily weight gain)
p. Monitor blood glucose levels every 6 hours
q. Activity restriction
r. Psychological counseling
s. Patient may respond to stress that may alienate others including ANGER, DENIAL and SOCIAL SELF-ISOLATION
t. Support emotionally and prepare for Surgery
u. Be attentive and display a calm, confident manner; allow time to VERBALIZE FEELINGS
Surgery: Bowel Resection
Pre-op
a. Low-residue diet 3-4 days before
b. Reduce amount of bacteria in colon: Neomycin, Metronidazole
c. Cleansing enema
Postop
a. Monitor color of stoma – beefy red, shiny and edematous; if PINKISH, call doctor because it indicates  blood supply
b. Monitor effluent (feces)
Ileostomy – liquid, permanent drainage (no sphincters)
Colostomy – watery (ascending), transverse (pasty/mushy), descending (formed), sigmoid (well-formed)
a. Low-residue diet- for watery effluent
b. Avoid eating hard to digest foods like corn and garlic
c. Avoid gas-forming foods
d. Apple, honey, milk, onion, wheat, cabbage, melon, coconut, celery, yeast
e. Encourage eating “deodorant” foods
f. Yogurt, soya, buttermilk
g. Meticulous skin care
h. Nystatin powder
i. Avoid contact sports
j. Encourage daily irrigation- for sigmoid colostomy
ABDOMINAL HERNIAS - A protrusion of an organ or structure through a weakened abdominal muscle; a congenital or acquired
defect.
Causes:
1. Congenital / acquired muscle weakness
2. Increased intra-abdominal pressure
a. Heavy lifting
b. Obesity
c. Pregnancy
TYPES OF HERNIA
1. Reducible – can be returned by manipulation
2. Irreducible – requires surgery
3. Inguinal Hernia – common among males
✓ Indirect Inguinal Hernia- Protrusion of bowel is through inguinal ring, follows the course of spermatic cord and moves
down into the scrotum
✓ Direct Inguinal Hernia - Protrusion is through inguinal wall at the point of muscle weakness
4. Umbilical Hernia – common among infants- Protrusion is through congenital defect in muscle
5. Femoral Hernia – common among females, Protrusion is through femoral ring and down the femoral canal
 6. Incisional Hernia – common after surgery, Protrusion is through inadequately healed surgical repair
7. Incarcerated Hernia - Characterized by bowel obstruction
8. Strangulated Hernia- Characterized by compromised blood flow to the trapped segment of bowel. Intestinal obstruction
occurs, and gangrene of the viscera can develop rapidly
ASSESSMENT
a. Disappears when lying down, reappears with standing, coughing, straining or lifting.
b. Sensation of heaviness
c. Vague discomfort
d. Nausea, vomiting, distention, pain (strangulated hernia)
e. Lump: groin, around umbilicus, from an old surgical incision
COLLABORATIVE MANAGEMENT
Surgery: Herniorrhaphy / Hernioplasty
Pre-op Care- Assess for presence of URTI. Sneezing or coughing could weaken the repair.
Postop Care
a. Encourage to deep breathe, but no coughing exercises
b. Increase fluid intake to prevent constipation.
c. Monitor for bladder distention.
d. Ice bags are applied after inguinal hernia repair to minimize discomfort during ambulation
e. Discharge Teachings:
✓ X heavy lifting, pushing, pulling for about 6 weeks
✓ X driving, climbing stairs for few weeks.
✓ Monitor incision for signs of infection.
✓ Stool softeners or bulk laxatives as prescribed to prevent straining at defecation.
✓ Sexual activity may be resumed once healing is complete and comfort assured.
COLORECTAL CANCER
Cause: Unknown
Predisposing Factors:
 Age above 40 years
 Diet
1.  low in fiber
2.  high in fat, protein and refined carbohydrates
3. Obesity
4. History of chronic constipation
5. History of IBD, familial polyposis or colon polyps
6. Family history of colon cancer
 Most Common Site: Rectosigmoid area (70%)

ASSESSMENT
Ascending (Right) Colon Cancer
1. Occult blood in stool
2. Anemia
3. Anorexia and weight loss
4. Abdominal pain above umbilicus
 5. Palpable mass
Distal Colon / Rectal Cancer
1. Rectal bleeding
2. Changed bowel habits
3. Constipation or Diarrhea
4. Pencil or ribbon – shaped stool
5. Tenesmus
6. Sensation of incomplete bowel emptying
Duke’s Classification of Colorectal Cancer
1. Stage A: confined to bowel mucosa, 80 – 90% 5- year survival rate
2. Stage B: invading muscle wall
3. Stage C: lymph node involvement
4. Stage D: metastases or locally unresectable tumor, less than 5% 5 – year survival rate
Guidelines for Early Detection of Colorectal Cancer
1. Digital rectal examination yearly after age 40
2. Occult blood test yearly after age 50
3. Proctosigmoidoscopy every 5 years after age 50, following 2 negative results of yearly examination
COLLABORATIVE MANAGEMENT
A. Surgery
1. Hemicolectomy for ascending and transverse colon cancer
2. Abdomino – Perineal Resection (APR) for rectosigmoid cancer
✓ There are 2 incisions: lower abdomen incision to remove to sigmoid; perineal incision to remove the rectum
✓ T – binder is used to secure perineal dressing
✓ Necessitates permanent colostomy
B. Chemotherapy- Fluorouracil is the most effective drug for colorectal cancer
C. Radiotherapy - Adjuvant treatment for rectal cancer
COLONIC SURGERY
Pre-op Care
1. Provide psychosocial support
2. Thorough bowel cleansing:
✓ Diet modification
1. Low residue diet 3 to 5 days pre-op, to reduce the bulk of stool in the colon
2. Clear liquid diet 24 hours pre-op
✓ Mechanical cleansing
1. Laxatives as ordered
2. Cleansing enema as ordered
✓ Pharmacologic suppression of colon bacteria
1. Neomycin sulfate tablets to reduce bacterial flora. (it is poorly absorbed in the colon, thereby enhance excretion
of colonic bacteria)
2. Vitamin C and K supplement because these are lost during repeated enema administration
TYPES OF COLOSTOMIES
1. Ascending Colostomy
a. Stoma is on the right abdomen
b. Fecal drainage is watery
2. Transverse (Double – Barreled) Colostomy
a. The right stoma is called proximal stoma; drains semi – formed feces
b. The left stoma is called distal stoma; drains mucus
3. Transverse Loop Colostomy
a. Has 2 openings in the transverse colon, but one stoma
b. Indicated in IBD’s
4. Descending and Sigmoid Colostomy
a. Stoma on the left abdomen
b. Fecal drainage is well - formed
Post-op Care
1. Managing the perineal wound (APR)
a. May require up to 6 months to completely heal
b. Wound irrigations with normal saline and absorbent dressings until wound closes.
c. Drainage is initially copius and serosanguinous, to be drained at regular basis to prevent infection and abscess formation.
d. T – binder is used to secure perineal dressing.
 e. Sitz baths once more the patient is ambulatory
f. Foam pads or soft pillows to promote comfort when sitting.
g. Side – lying position during sleep.
2. Stoma Monitoring
a. The stoma is red and with slight edema for 5 – 7 days
✓ Dark, dusky, or brown – black stoma indicates ischemia and necrosis
b. The stoma should protrude by ½ to ¾ inches over abdomen
c. Flatus and fecal drainage usually begin in 4 to 7 days, as peristalsis returns
d. Empty the pouch when it is 1/3 to ½ full of stool
e. Loop colostomy is opened 48 – 72 hours post-op, with cautery at bedside
3. Teaching for Self – Care
Stoma Care
a. Gently encourage the client to look at the stoma
b. Inform that stoma has no touch or pain sensation
c. Instruct to report immediately any purple or black discoloration of the stoma
d. Cleanse the stoma initially with antiseptic
Skin care
a. Wash the skin with warm water, pat dry
b. Assess skin for signs of irritation or infection.
c. When pouch seal leaks, change pouch immediately
d. Use skin barrier to protect the peristomal skin from liquid stool
a. E.g. karaya preparation
e. Skin infection caused by Candida Albicans is treated with nystatin (Mycostatin) powder
COLOSTOMY IRRIGATION
1. Initial colostomy irrigation is done to stimulate peristalsis; subsequent irrigations are done to promote evacuation of feces
at a regular and convenient time
2. Recommended with sigmoid colostomy
3. Initiated 5 to 7 days post-op
4. Done in semi – Fowler’s position; then sitting on a toilet bowl once ambulatory.
5. Use warm normal saline solution
6. Initially, introduce 200 mls. of NSS then 500 to 1,000 mls. Subsequently
7. Dilate stoma with lubricated gloved finger before insertion of catheter
8. Lubricate catheter before insertion.
9. Insert 2 to 4 inches of the catheter into the stoma
10. Height of solution 18 inches above the stoma
11. If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution until peristalsis relaxes.
12. Allow the catheter to remain in place for 5 to 10 minutes for better cleansing effect; then remove catheter to drain for 15
to 20 minutes.
13. Clean the stoma, apply new pouch
MANAGING ODOR
1. Avoid gas – forming and foul odor foods, e.g. dairy products , highly seasoned foods, fish, cabbage, celery, cauliflower,
eggs, carbonated beverages, nuts
2. Rinse pouch with tepid water or weak vinegar solution.
3. Place deodorant tablet or small amount of mouthwash or a piece of charcoal into the pouch.
4. X use pulverized ASA – it causes irritation of the stoma and damages the colostomy appliance
5. Supporting a Positive Self – Concept
a. Encourage to view the stoma
b. Encourage to verbalize feelings, fears and concern about stoma
c. Encourage to participate in colostomy care
d. Encourage to gradually resume all usual activities
e. Avoid tight belts or waistbands over the stoma
f. Advise to always carry colostomy supplies when travelling
6.Resolving Grief
a. Encourage client to express feelings of loss
b. Explore client’s usual coping strategies for handling grief
c. Preventing Sexual Dysfunction
✓ Explore positions that minimize stress and pressure on the pouch
✓ Empty and clean the pouch before sexual activity
✓ Use smaller – sized pouch or pouch cover during sexual activity
 ✓ Use of a binder or special underwear to hold the pouch secure
Hemorrhoids
a. Abnormal engorgement of rectal vein
b. Causes: chronic constipation, prolonged standing and sitting, genetic predisposition
c. Manifestations: itching and pain (most common cause of bright red bleeding) , tissue protruding on the rectal vault,
internal hemorrhoids – not painful until they bleed or prolapse

Assessment:
1. Constipation (in an effort to prevent pain or bleeding associated with defecation.)
2. Anal pain
3. Rectal bleeding
4. Anal itchiness
5. Mucous secretion from the anus
6. Sensation of incomplete evacuation of the rectum
7. Internal hemorrhoids may prolapsed
Management
a. Relieve constipation
b. Drink at least 2 L of water daily
c. High-fiber foods
d. Administer laxatives and stool softeners
e. Relaxation exercises before defecating – relaxes the abdominoperineal muscles
f. Relieve pain
g. Prime consideration – more compliant and less apprehensive if free of pain
h. Apply ice and topical anesthetics (Nupercaine)
i. Hot sitz bath – relieve soreness and pain by relaxing sphincter spasm
j. Wet dressings (cold water + witch hazel) – relieves edema
k. Reduce pressure on the site (side-lying position) or prone (promotes dependent drainage of edematous fluid)
l. Reduce anxiety
m. Maintain privacy while providing care
n. Remove soiled dressings promptly to prevent unpleasant odors
o. Promote urinary elimination
p. Encourage voluntary voiding ( fluid intake, listening to running water and dripping water over meatus)
q. Last resort: catheterization
r. Hemorrhoidectomy
✓ Removal of the hemorrhoids
✓ Monitor for rectal bleeding
✓ Apply pressure over the area and NOTIFY physician!
✓ Avoid using moist heat
✓ Hot sitz bath PRN to relieve discomfort especially after defecation
Patient Teaching
1. Clean rectal area thoroughly after each defecation
2. Sitz bath at home especially after defecation
3. Avoid constipation:
✓ High – fiber diet
 ✓ High fluid intake
✓ Regular exercise
✓ Regular time for defecation
4. Use stool softener until healing is complete
5. Notify physician for the following:
✓ Rectal bleeding
✓ Suppurative drainage
✓ Continued pain on defecation
✓ Continued constipation