NURSING MANAGEMENT OF GIT PROBLEMS

COMMON MANIFESTATIONS OF DIGESTIVE SYSTEM DISORDERS:
Changes in bowel habits – a signal of colon disease
a. Diarrhea – abnormal increase in frequency and liquidity of the stool

or daily stool weight or volume.

- Occurs when contents move so rapidly through the intestine and colon with inadequate time for absorption of GI contents. - Sometimes associated with abdominal pain or cramping and nausea and vomiting

CONSTITUENTS OF AN AVERAGE STOOL: 1. 1/3 unabsorbed food 2. Remainder made up of: - cast – off intestinal epithelial cells - microbes - partially dried secretions 150 – 200 grams daily 100 – 150ml of water lost in the stools

MECHANISMS OF DIARRHEA:
• 1. Accumulation of EXCESSIVE FLUID

VOLUME within the gut; • - distends the gut wall and thus initiates strong propulsive movements
• 2. INCREASE PROPULSIVE MOTILITY

- due to local reflex stimulation or generalized neural or Humoral stimulation of the intestines - less time for water to be absorbed in the small intestines

DIARRHEA: Pathophysiology
• Types of diarrhea: secretory, osmotic and

mixed diarrhea. • Secretory diarrhea is usually high-volume diarrhea caused by increased production and secretion of water and electrolytes by the intestinal mucosa into the intestinal lumen. • Osmotic diarrhea occurs when water is pulled into the intestines by the osmotic pressure of unabsorbed particles, slowing the reabsorption of water.

DIARRHEA: Pathophysiology
• Mixed diarrhea is caused by increased

peristalsis (usually from IBD) and a combination of increased secretion and decreased absorption in the bowel.

CLASSIFICATION OF DIARRHEA:
According to ONSET and DURATION 1. ACUTE DIARRHEA – sudden and short duration causes: infectious agent toxins poisons drugs 2. CHRONIC DIARRHEA – Insiduous onset long duration( three weeks)
A.

• B. SITE OF THE LESION

• 1. Small bowel diarrhea
• 2. Large bowel diarrhea

Small bowel

Large bowel

1. Vol of stool
2. frequency

large
1-2x daily

small
6-10x daily

3. Urgency or tenesmus 4. Blood or mucus 5.Abdominal pain or discomfort

absent
absent Worse after meals or just before bowel movment

present
present Relieved by defecation or passage of flatus

DIARRHEA: Clinical Manifestations
• Increased frequency and fluid content of

stools • Abdominal cramps and distention • Intestinal rumbling • Anorexia and thirst • Painful spasmodic contractions of the anus and ineffectual straining (tenesmus) • Watery stools are characteristic of small bowel disease. • Loose, semisolid stools are associated more often with disorders of the colon.

DIARRHEA: Clinical Manifestations
• Voluminous, greasy stools suggest intestinal

malabsorption. • Presence of mucus and pus suggests inflammatory enteritis or colitis.

DIARRHEA: Assessment and Diagnostic Findings
• Complete blood count
• Chemical profile • Urinalysis

• Routine stool examination
• Stool examinations for parasitic or infectious

organisms, bacterial toxins, blood, fat and electrolytes. • Barium enema may assist in identifying the cause.

DIARRHEA: Complications
• Fluid and electrolyte imbalance (cardiac

dysrhythmias) • Renal failure • Multiorgan failure and death

DIARRHEA: Medical Management
• Primary management is directed at controlling

symptoms, preventing complications, and eliminating or treating the underlying disease. • Certain medications may reduce the severity of the diarrhea and treat the underlying disease.

DIARRHEA: Nursing Management
• Assess and monitor the characteristics and

pattern of diarrhea. • Encourage bed rest and intake of fluids and food low in bulk until the acute attack subsides. • When food intake is tolerated, recommend a bland diet of semisolid and solid food. • Avoid caffeine, carbonated beverages and very hot and very cold food. • Restrict milk products, fat, whole-grain products, fresh fruits and vegetables for several days.

DIARRHEA: Nursing Management
• Administer antidiarrheal medications such as

diphenoxylate (Lomotil) and loperamide (Imodium) as prescribed. • IV therapy for rapid rehydration especially for the elderly and those with preexisting GI conditions. • Monitor serum electrolyte levels • Report immediately clinical evidence of dysrhythmias or a change in the level of consciousness.

DIARRHEA: Nursing Management
• The perianal area may be excoriated because

diarrheal stool contains digestive enzymes that can irritate the skin. The patient should follow a perianal skin care routine to decrease irritation and excoriation. • Use skin sealants and moisture barriers as needed.

b.

Constipation – decrease in the frequency of stool or stools that are hard, dry and smaller volume than normal.
-

May be associated with anal discomfort and rectal bleeding
Stool characteristics

 Normally light to dark brown  Indigestion of certain foods and

medications can change the appearance of stool.

Causes of Constipation:
• 1. Inadequate dietary fibers • 2. inadequate fluid intake • 3. failure to respond to the defecation reflex

because of pain or inconvenient timing • 4. muscle weakness and inactivity • 5. neurologic disorders • 6.drugs (opiates,antacids, iron medications • 7. obstructions caused by tumors and strictures

CONSTIPATION: Pathophysiology
• Poorly understood.
• Interference with mucosal transport,

myoelectric activity, or processes of defecation.

CONSTIPATION: Clinical Manifestations
• Abdominal distention
• Borborygmus • Pain and pressure

• Decreased appetite
• Headache, fatigue • Indigestion

• Sensation of incomplete emptying
• Passage of scybala

CONSTIPATION: Assessment and Diagnosis
• Chronic constipation is usually considered

idiopathic, but secondary causes should be eliminated. • Diagnosis is based on results of the patient’s history, physical examination, possibly a barium enema or sigmoidoscopy, and stool testing for occult blood.

CONSTIPATION: Complications
• Hypertension
• Fecal impaction • Hemorrhoids and fissures

• Megacolon

CONSTIPATION: Medical Management
• Treatment is aimed at the underlying cause of

constipation and includes education, bowel habit training, increased fiber and fluid intake, and judicious use of laxatives. • Enemas and rectal suppositories are generally not recommended for constipation and should be reserved for the treatment of impaction or for preparing the bowel for surgery or diagnostic procedures.

CONSTIPATION: Medical Management
• Further studies are being carried out on

cholinergic agents (e.g., bethanechol), cholinesterase inhibitors (e.g., neostigmine), and prokinetic agents (e.g., metoclopramide) to determine the role of these agents in treating constipation.

CONSTIPATION: Nursing Management
• Elicit information about the onset and duration

of constipation, past and present elimination patterns, the patient’s expectation of normal bowel elimination, and lifestyle information during health history review. • Past medical and surgical history, current medications, and laxative and enema use are important, as is information about the sensation of rectal fullness or pressure, abdominal pain, excessive straining at defecation and flatulence.

CONSTIPATION: Nursing Management
• Patient education and health promotion
• Restoring and maintaining a regular pattern of

elimination • Ensuring adequate intake of fluids and highfiber foods • Teach methods to avoid constipation • Relieve anxiety about bowel elimination patterns • Avoid complications

treatment
• Increasing intestinal bulk by increasing dietary fiber

content

NURSING MANAGEMENT OF GIT PROBLEMS
Esophageal disorders

The GIT ANATOMY The Esophagus • A hollow collapsible tube • Length- 10 inches • Made up of stratified squamous epithelium

The GIT ANATOMY
The Esophagus
• • •

The upper third contains skeletal muscles The middle third contains mixed skeletal and smooth muscles The lower third contains smooth muscles and the esophago-gastric/ cardiac sphincter is found here

The GIT PHYSIOLOGY
The Esophagus Functions to carry or propel foods from the oropharynx to the stomach Three Phases of Deglutition: 1. voluntary phase 2. pharyngeal phase 3. esophageal phase

NERVOUS CONTROL OF THE GIT

The GIT Physiology
SYMPATHETIC • Generally INHIBITORY! • Decreased gastric secretions • Decreased GIT motility PARASYMPATHETIC • Generally EXCITATORY! • Increased gastric secretions • Increased gastric motility

• But: Increased

sphincteric tone and constriction of blood vessels

• But: Decreased

sphincteric tone and dilation of blood vessels

DISORDERS OF THE ESOPHAGUS: Dysphagia
• The most common symptom of

esophageal disease. • Ranges from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing (odynophagia).

DISORDERS OF THE ESOPHAGUS: Achalasia
• Absent or ineffective peristalsis of the distal

esophagus, accompanied by failure of the esophageal sphincter to relax in response to swallowing. • Primary symptoms: - is difficulty of swallowing both liquids and solids, - regurgitation of food either spontaneously or intentionally, - chest pain and heart burn (pyrosis), - Nocturnal cough - and secondary pulmonary complications from aspiration of gastric contents.

Epidemiology: 1:100.000 in US equally in both sexes Age of Onset: 20 and 40 years Pathogenesis: 1. Primary achalasia: decreased ganglion cells, with fibrosis and scarring in Myenteric (Auerbach‟s) plexus. 2. Secondary achalasia: e.g Chagas disease, polio Diabetic autonomic neuropathy

Achalasia

DISORDERS OF THE ESOPHAGUS: Achalasia
• X-rays show esophageal dilatation above the

narrowing at the gastroesophageal junction. • Manometry 1. aperistalsis 2. Elevated LES pressure 3. Partial or incomplete relaxation of LES

DISORDERS OF THE ESOPHAGUS: Achalasia

DISORDERS OF THE ESOPHAGUS: Achalasia Management:
Eat slowly and drink fluids with meals Calcium channel blockers and nitrates

Pneumatic or forceful dilation or surgical separation of the muscle fibers. - Endoscopic injection of botulinum toxin Surgical treatment by esophagomyotomy (Heller myotomy) in which the esophageal muscle fibers are separated to relieve the lower esophageal stricture.
• Patients with achalasia have a slightly higher

incidence of esophageal cancer.

CONDITION OF THE ESOPHAGUS
HIATAL HERNIA • Protrusion of the esophagus into the diaphragm thru an opening • Two types: 1. Sliding hiatal hernia or axial - 95% of cases 2. Nonaxial or paraesophageal hiatal hernia Occurs most often in women than in men

Etiology
• Causes is UNKOWN • 40-70 year old • Congenital weakening of the muscles in the diaphragm

around the esophagogastric opening • Increase intra abdominal pressure - obesity, pregnancy, ascites, trauma

CONDITION OF THE ESOPHAGUS
ASSESSMENT Findings in Hiatal hernia • 1. Heartburn • 2. Regurgitation and dysphagia • 3. Fullness after eating • 4. 50%- without symptoms

Complications: both types may ulcerate, causing bleeding and perforation Paraesophageal hernias – strangulation and obtruction

MEDICAL MANAGEMENT: 1. Drug therapy: antacids to reduce acidity and relieve discomfort 2. Modification of diet: elimination of spicy foods and caffeine 3. Surgery, reduction of hiatal hernia via abdominal or thoracic approach.

CONDITION OF THE ESOPHAGUS

DIAGNOSTIC TEST
Barium swallow And fluoroscopy/endoscopy

CONDITION OF THE ESOPHAGUS
NURSING INTERVENTIONS • 1. Provide small frequent feedings • 2. AVOID supine position for 1 hour after eating • 3. Elevate the head of the bed on 4-8-inch block • 4. Provide pre-op and post-op care • 5. Provide client teaching and discharge planning.

CONDITIONS OF THE GIT

UPPER GI system

DISORDERS OF THE ESOPHAGUS: Perforation

The esophagus is not an uncommon site of injury Result from: • stab or bullet wounds of the neck or chest • trauma from motor vehicle crash • caustic injury from a chemical burn puncture by surgical instrumentation Spontaneous perforation –Boerhaaves syndrome - violent retching Clinical Manifestations: Persistent pain followed by dysphagia Infection, fever, leukocytosis and severe hypotension Signs of pneumothorax * subcutaneous emphysema Diagnosis: Endoscopy

DISORDERS OF THE ESOPHAGUS: Perforation
• Management:

Broad-spectrum antibiotic therapy Suction by NGT insertion to reduce amount of gastric juice. NPO; parenteral nutrition Surgery may be necessary to close the wound Post-operative nursing management

DISORDERS OF THE ESOPHAGUS: Foreign Bodies
• Glucagon may be injected intramuscularly. • Endoscopy to remove the impacting food or object

from the esophagus. • Sodium bicarbonate + tartaric acid may be used to increase intraluminal pressure by the formation of gas. Caution must be used because of the risk of perforation.

DISORDERS OF THE ESOPHAGUS: Chemical Burns
• May be caused by undissolved medications in

• • • •

the esophagus, or by ingestion of caustic agents like strong acids and bases. May be intentional or accidental. Patient is usually emotionally distraught as well as in acute physical pain. The patient may be profoundly toxic, febrile, and in shock. Esophagoscopy and barium swallow are performed as soon as possible.

DISORDERS OF THE ESOPHAGUS: Chemical Burns
• Vomiting and gastric lavage are avoided to

• • • •

prevent further exposure of the esophagus to the caustic agent. Corticosteroids? Antibiotics? Nutritional support via enteral or parenteral feeding Prevent or manage strictures of the esophagus.

DISORDERS OF THE ESOPHAGUS: Chemical Burns
• Surgical management for strictures that do

not respond to dilation. • Reconstruction may be accomplished by esophagectomy and colon interposition to replace the portion of esophagus removed.

DISORDERS OF THE ESOPHAGUS: Chemical Burns

CONDITION OF THE ESOPHAGUS
Esophageal Varices • Dilation and tortuosity of the submucosal veins in the distal esophagus • ETIOLOGY: commonly caused by PORTAL hypertension secondary to liver cirrhosis • This is an Emergency condition!

CONDITION OF THE ESOPHAGUS ASSESSMENT findings for EV • 1. Hematemesis • 2. Melena • 3. Ascites • 4. jaundice • 5.hepatomegaly/splenomegaly

CONDITION OF THE ESOPHAGUS

ASSESSMENT findings for EV •Signs of Shock- tachycardia, hypotension, tachypnea, cold clammy skin, narrowed pulse pressure

CONDITION OF THE ESOPHAGUS

DIAGNOSTIC PROCEDURE •Esophagoscopy

CONDITION OF THE ESOPHAGUS

NURSING INTERVENTIONS FOR EV •1. Monitor VS strictly. Note for signs of shock •2. Monitor for LOC •3. Maintain NPO

CONDITION OF THE ESOPHAGUS
NURSING INTERVENTIONS FOR EV

•4. Monitor blood studies
•5. Administer O2 •6. prepare for blood

transfusion

CONDITION OF THE ESOPHAGUS
INTERVENTIONS FOR EV • 7. prepare to administer Vasopressin and Nitroglycerin • 8. Assist in NGT and SengstakenBlakemore tube insertion for balloon tamponade

CONDITION OF THE ESOPHAGUS NURSING INTERVENTIONS FOR EV • 9. Prepare to assist in surgical management:
• Endoscopic sclerotherapy

• Variceal ligation
• Shunt procedures

Conditions of the Esophagus
Gastro-esophageal reflux • Backflow of gastric contents into the esophagus

Conditions of the Esophagus Gastro-esophageal reflux FACTORS • Usually due to incompetent lower esophageal sphincter , pyloric stenosis or motility disorder • Symptoms may mimic ANGINA or MI

Conditions of the Esophagus
Gastro-esophageal reflux: Pathophysio incompetent lower esophageal sphincter regurgitation of acidic contents
Erosion of esophageal mucosa Pain

Conditions of the Esophagus
ASSESSMENT ( for GERD) • Heartburn • Dysphagia • Dyspepsia • Regurgitation • Epigastric pain • Ptyalism

Conditions of the Esophagus

Diagnostic test • Endoscopy or barium swallow • Gastric ambulatory pH analysis • Note for the pH of the esophagus, usually done for 24 hours • The pH probe is located 5 inches above the lower esophageal sphincter • The machine registers the different pH of the refluxed material into the esophagus

DISORDERS OF THE ESOPHAGUS: GERD

Conditions of the Esophagus
NURSING INTERVENTIONS • 1. Instruct the patient to AVOID stimulus that increases stomach pressure and decreases GES pressure • 2. Instruct to avoid alcohol , spices, coffee, tobacco and carbonated drinks • 3. Instruct to eat LOW-FAT, HIGH-FIBER diet, BLAND DIET

Conditions of the Esophagus

NURSING INTERVENTIONS • 4. Avoid foods and drinks TWO hours before bedtime • 5. Elevate the head of the bed with an approximately 8-inch block

Conditions of the Esophagus

NURSING INTERVENTIONS • 6. Administer prescribed H2blockers, PPI and prokinetic meds like cisapride, metochlopromide • 7. Advise proper weight reduction

DISORDERS OF THE ESOPHAGUS: GERD
• Management:

Proton-pump inhibitors Prokinetic drugs (urecholine, domperidone, metoclopramide) Surgical intervention (fundoplication)

Disorders of the Esophagus: Barrett’s Esophagus
• Believed to result from long-standing

untreated GERD. • Identified as a precancerous condition that, if left untreated, can result in adenocarcinoma of the esophagus. • Patients complain of symptoms of GERD. • EGD is performed revealing an esophageal lining that is red rather than pink. On biopsy, cells obtained from the esophagus resemble those of the intestine.

Disorders of the Esophagus: Barrett’s Esophagus
• Monitoring varies depending on the

amount of cell changes. • EGD should be done every 6 to 12 months if there are minor cell changes.

Disorders of the Esophagus: Barrett’s Esophagus

CANCERS OF THE ESOPHAGUS
• Carcinoma of the esophagus occurs

• • • • •

more than three times as often in men as in women. (4:1) 50-70yr old Often in middle and lower portion Chronic irritation is a risk factor. Associated with ingestion of alcohol and with the use of tobacco. Vitamin deficiency – Vit A & C Usually of the squamous cell epidermoid type, but the incidence of adenocarcinoma is increasing.

CANCERS OF THE ESOPHAGUS
• Clinical Manifestations:

Dysphagia, initially with solid foods and eventually with liquids Sensation of mass in the throat Odynophagia Substernal pain or fullness Regurgitation of undigested food with foul breath and singultus.
• Diagnosis is confirmed most often by EGD

with biopsy and brushings.

CANCERS OF THE ESOPHAGUS
• Medical Management:

Early stage: cure; Late stage: palliation Surgery, irradiation, chemotherapy or a combination
• Nursing Management:

Improving the patient’s nutritional and physical condition in preparation for surgery, radiation therapy or chemotherapy Immediate postoperative care is similar to that provided for patients undergoing thoracic surgery.

Conditions of the Stomach
PEPTIC ULCER DISEASE • An ulceration of the gastric and duodenal lining • May be referred as to location as Gastric ulcer in the stomach, or Duodenal ulcer in the duodenum • Most common Peptic ulceration: anterior part of the upper duodenum

Acids, bile salts, NSAID’s Alcohol, ischemia, H. pylori Destruction of mucosal barrier Acid back diffusion into the mucosa Destruction of mucosal cells Inc. Acid and Pepsin in mucosa Histamine

Further mucosal erosions Inc. Vasodilation Destruction of blood vessels Inc. capillary permeability Bleeding Loss of plasma protein into
gastric lumen

Ulceration

Mucosal edema

GASTRIC AND DUODENAL ULCERS
DUODENAL ULCER GASTRIC ULCER

AGE
MALE:FEMALE RATIO INCIDENCE STOMACH ACID BODY WEIGHT EPIGASTRIC PAIN

30 – 60 years
2-3:1 80% of peptic ulcers Hypersecretion Normal or weight gain 2-3 hrs post-meal, early morning awakenings, relieved by food intake Uncommon Less common, melena More common

Usually 50 and over
1:1 15% of peptic ulcers Normal or hyposecretion Weight loss ½ - 1 hr post-meal, rarely occurs at night; food intake aggravates pain Common (relieves pain) More common, hematemesis Less common

VOMITING HEMORRHAGE PERFORATION

MALIGNANCY
RISK FACTORS

Rare
H. pylori, alcohol, smoking, cirrhosis, stress

Occasionally
H. pylori, gastritis, alcohol, smoking, NSAIDs, stress

Pathogenesis
1. 2. 3. 4. 5.

6.

Social Factors – tobacco smoking, drugs, alcohol Physiologic factors – Gastric acid Genetic Factors Infectious etiology – H. pylori Associated dse – e.g. Antral atropic gastritis Psychosomatic factors – chronic anxiety, Type A personality

Stress ulcers:
• Cushing’s ulcers are common in patients with

trauma to the brain. They may occur in the esophagus, stomach or duodenum and are usually deeper and more penetrating than stress ulcers. • Curling’s ulcers are frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.

Conditions of the Stomach
DIAGNOSTIC PROCEDURES • 1. EGD to visualize the ulceration • 2. Urea breath test for H. pylori infection • 3. Biopsy- to rule out gastric cancer • 4. Barium swallow • 5. Gastric analysis

GASTRIC AND DUODENAL ULCERS: Assessment
• Endoscopy is the preferred diagnostic

procedure because it allows direct visualization of inflammatory changes, ulcers and lesions. • Stools may be tested periodically until they are negative for occult blood. • H. pylori infection may be determined by biopsy and histology with culture, as well as a breath test and serologic test for H. pylori antibodies.

Conditions of the Stomach
NURSING INTERVENTIONS • 1. Give BLAND diet, small frequent meals during the active phase of the disease • 2. Administer prescribed medications- H2 blockers, PPI, mucosal barrier protectants and antacids

Conditions of the Stomach NURSING INTERVENTIONS • 3. Monitor for complications of bleeding, perforation and intractable pain • 4. Provide teaching about stress reduction and relaxation techniques

Conditions of the Stomach

NURSING INTERVENTIONS FOR BLEEDING • 1. Maintain on NPO • 2. Administer IVF and medications • 3. Monitor hydration status, hematocrit and hemoglobin

Conditions of the Stomach

NURSING INTERVENTIONS FOR BLEEDING • 4. Assist with iced SALINE lavage • 5. Insert NGT for decompression and lavage

Conditions of the Stomach
NURSING INTERVENTIONS FOR BLEEDING • 6. Prepare to administer blood transfusion • 7. Prepare to give VASOPRESSIN to induce vasoconstriction to reduce bleeding • 8. Prepare patient for SURGERY if warranted

Conditions of the Stomach

SURGICAL PROCEDURES FOR PUD •Total gastrectomy, vagotomy, gastric resection, Billroth I and II, pyloroplasty

1.Vagotomy – severing of part of the vagus nerve
innervating the stomach to decrease gastric acid secretion.

2. Antrectomy – removal of the antrum of the stomach to eliminate the gastgric phase of digestion 3. Pyloroplasty – enlargement of the pyloric sphincter with acceleration of gastric emptying

4. Gastroduodenostomy (Billroth I) removal of the lower portion of the stomach with anastomosis of the remaining portion of the duodenum. 5. GAstrojejunostomy (Billroth II): removal of the antrum and the distal portion of the stomach and duodenum with anastomosis of the remaining portion of the stomach in the jejunum.

6. Gastrectomy: removal of 60% to 80% of the stomach. 7. Esophagojejunostomy (total gastrectomy): removal of the entire stomach with a loop jejunum anastomosed to the esophagus

Conditions of the Stomach
SURGICAL PROCEDURES FOR PUD Post-operative Nursing management • 1. Monitor VS • 2. Post-op position: FOWLER‟S • 3. NPO until peristalsis returns • 4. Monitor for bowel sounds • 5. Monitor for complications of surgery

Conditions of the Stomach
Post-operative Nursing management • 6. Monitor I and O, IVF • 7. Maintain NGT • 8. Diet progress: clear liquid full liquid six bland meals • 9. Manage DUMPING SYNDROME

DUMPING SYNDROME:

Control of gastric emptying is lost, following gastric resection • Ingested food are rapidly “dumped” into the intestine Signs and Symptoms: 1. Abdominal cramps 2. Nausea and diarrhea 3. Hypovolemia – dizziness, weakness, rapid pulse and sweating 4. Hypoglycemia – 2 to 3 hrs after meal

Management: 1. Dietary changes – small frequent feeding high protein low carbohydrates 2. Fluids should be taken between meals 3. Medication to decreased intestinal motility

1. Food intake

2. Gastric resection ecresed gastric capacity and loss of pyloric sphincter 3. Large amt of undiluted chyme is dumped in small intestine

Fluid shifts fromm blood into small intestines To dilute hypertonic chyme 6. Distended intestine -pain,cramps - nausea and vomitin

5. Hypovolemia: -decreased blood pressure -faint,weak pulse, dizzy -tachycardia - pallor, diaphoresis

7. Rapid digestion and absorption of food intake Hyperglycemia and inc. insulin secretions 9. Hypoglycemia -weak, confused -Tachycardia -Pallor, diaphoresis

Follow-Up Care
• Recurrence within a year may be prevented with the

prophylactic use of H2-receptor antagonists given at a reduced dose. Not all patients require maintenance therapy. • Likelihood of recurrence is reduced if the patient avoids smoking, coffee and other caffeinated beverages, alcohol, and ulcerogenic medications.

CONDITIONS OF THE LOWER TRACT
Small and Large Intestine

INFLAMMATORY BOWEL DISEASE
• Refers to two chronic inflammatory GI disorders:

• •

• •

regional enteritis (i.e., Crohn’s disease or granulomatous colitis) and ulcerative colitis. The cause is still unknown. Researchers think it is triggered by environmental agents such as pesticides, food additives, tobacco, and radiation. NSAIDs have been found to exacerbate IBD. Allergies and immune disorders have also been suggested as causes.

INFLAMMATORY BOWEL DISEASE
CROHN’S DISEASE COURSE EARLY PATHOLOGY Prolonged, variable Transmural thickening ULCERATIVE COLITIS Exacerbations, remissions Mucosal ulceration

LATE PATHOLOGY
LOCATION BLEEDING PERIANAL INVOLVEMENT

Deep, penetrating granulomas
Ileum, right colon (usually) Usually not, but may occur Common

Mucosal minute ulcerations
Rectum, left colon Common – severe Rare – mild

FISTULAS
RECTAL INVOLVEMENT DIARRHEA

Common
About 20% Less severe

Rare
Almost 100% Severe

INFLAMMATORY BOWEL DISEASE
CROHN’S DISEASE RADIOGRAPHY Regional, discontinuous lesions Narrowing of colon Thickening of bowel wall Mucosal edema Stenosis, fistulas May be unremarkable unless accompanied by perianal fistulas Distinct ulcerations separated by relatively normal mucosa in the right colon ULCERATIVE COLITIS Diffuse involvement No narrowing of colon No mucosal edema Stenosis rare Shortening of colon Abnormal inflamed mucosa Abnormal inflamed mucosa

SIGMOIDOSCOPY

COLONOSCOPY

Friable mucosa with pseudopolyps or ulcers in the left colon.

INFLAMMATORY BOWEL DISEASE
CROHN’S DISEASE THERAPEUTIC MANAGEMENT Corticosteroids, sulfonamides Antibiotics Parenteral nutrition Partial or complete colectomy, with ileostomy or anastomosis Rectum can be preserved in some patients Small bowel obstruction Right-sided hydronephrosis Nephrolithiasis Cholelithiasis Arthritis, retinitis, iritis Erythema nodosum ULCERATIVE COLITIS Corticosteroids, sulfonamides Bulk hydrophilic agents Antiobiotics Proctocolectomy, with ielostomy Rectum can be preserved in only a few patients “cured” by colectomy Toxic megacolon, perforation, hemorrhage Malignant neoplasms Pyelonephritis Nephrolithiasis Cholangiocarcinoma

SYSTEMIC COMPLICATIONS

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE

CONDITIONS OF THE SMALL INTESTINE

CROHN‟S DISEASE •Also called Regional Enteritis •An inflammatory disease of the GIT affecting usually the small intestine

CONDITIONS OF THE SMALL INTESTINE

CROHN‟S DISEASE • ETIOLOGY: unknown • The terminal ileum thickens, with scarring, ulcerations, abscess formation and narrowing of the lumen

CONDITIONS OF THE SMALL INTESTINE
ASSESSMENT findings for CD • 1. Fever • 2. Abdominal distention • 3. Diarrhea • 4. Colicky abdominal pain • 5. Anorexia/N/V • 6. Weight loss • 7. Anemia

Ulcerative Colitis

CONDITIONS OF THE LARGE INTESTINE
ULCERATIVE COLITIS • Ulcerative and inflammatory condition of the GIT usually affecting the large intestine • The colon becomes edematous and develops bleeding ulcerations • Scarring develops overtime with impaired water absorption and loss of elasticity

CONDITIONS OF THE LARGE INTESTINE
ASSESSMENT findings for UC • 1. Anorexia • 2. Weight loss • 3. Fever • 4. SEVERE diarrhea with Rectal bleeding • 5. Anemia • 6. Dehydration • 7. Abdominal pain and cramping

INFLAMMATORY BOWEL DISEASE: Signs and Symptoms

Crohn‟s Dse SYMTOMS Diarrhea Rectal Bleeding Tenesmus Abdominal Pain Fever Vomiting Weight loss +++ + 0 +++ ++ +++ +++ +++ +++

Ulcerative colitis +++ +++ +++ + + 0 + 0 0

SIGNS Perianal disease Abdominal mass Malnutrition

+++

+

NURSING INTERVENTIONS for CD and UC
• 1. Maintain NPO during the active

phase • 2. Monitor for complications like severe bleeding, dehydration, electrolyte imbalance • 3. Monitor bowel sounds, stool and blood studies

NURSING INTERVENTIONS for CD and UC
• 4. Restrict activities= rest and

comfort • 5. Administer IVF, electrolytes and TPN if prescribed • Monitor complications of diarrhea

NURSING INTERVENTIONS for CD and UC
• 6. Instruct the patient to AVOID

gas-forming foods, MILK products and foods such as whole grains, nuts, RAW fruits and vegetables especially SPINACH, pepper, alcohol and caffeine

NURSING INTERVENTIONS for CD and UC
• 7. Diet progression- clear

liquid LOW residue, high protein diet • 8. Administer drugs- antiinflammatory, antibiotics, steroids, bulk-forming agents and vitamin/iron supplements

IRRITABLE BOWEL SYNDROME
One of the most common GI problems

Women > men
Cause is unknown Factors associated with the syndrome  Heredity, psychological stress or condition, high fat diet, stimulating or irritating foods, alcohol consumption and smoking

Pathophysiology
Functional disorder of intestinal motility

Related to neurologic regulatory system, infection or

irritation Vascular or metabolic disturbance Evidence of inflammation or tissue changes in the intestinal mucosa

Irritable Bowel Syndrome

• Due to stress and irritants • R/t sensitivity to motor activity and distention • CRAMPY LOWER ABDOMINAL PAIN • Relieved by defecation • Pain increases 1-2 hrs after meal • Alternating C & D

Clinical Manifestations
Altered bowel patterns

Constipation, diarrhea or combination
Pain, bloating and abdominal distention Abdominal pain sometimes preciipitated by eating and

frequently relieved by defecation.

CONDITIONS OF THE LARGE INTESTINE
DIVERTICULOSIS AND DIVERTICULITIS Diverticulosis • Abnormal out-pouching of the intestinal mucosa occurring in any part of the LI most commonly in the sigmoid Diverticulitis • Inflammation of the diverticulosis

Diverticulitis

CONDITIONS OF THE LARGE INTESTINE
PATHOPHYSIOLOGY • Increased intraluminal pressure, LOW volume in the lumen and Decreased muscle strength in the colon wall herniation of the colonic mucosa

CONDITIONS OF THE LARGE INTESTINE
ASSESSMENT findings for D/D • 1. Left lower Quadrant pain • 2. Flatulence • 3. Bleeding per rectum • 4. nausea and vomiting • 5. Fever • 6. Palpable, tender rectal mass

CONDITIONS OF THE LARGE INTESTINE
• DIAGNOSTIC STUDIES

• 1. If no active inflammation, COLONOSCOPY and

Barium Enema • 2. CT scan is the procedure of choice! • 3. Abdominal X-ray

CONDITIONS OF THE LARGE INTESTINE

NURSING INTERVENTIONS • 1. Maintain NPO during acute phase • 2. Provide bed rest • 3. Administer antibiotics, analgesics like meperidine (morphine is not used) and anti-spasmodics • 4. Monitor for potential complications like perforation, hemorrhage and fistula • 5. Increase fluid intake

CONDITIONS OF THE LARGE INTESTINE
NURSING INTERVENTIONS • 6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping • 7. introduce soft, high fiber foods ONLY after the inflammation subsides • 8. Instruct to avoid activities that increase intraabdominal pressure

BOWEL OBSTRUCTION
• -

interference with the normal aboral transit of intestinal contents.

Extraluminal – e.g. adhesions Intraluminal – bezoar, gallstones Itramural - Crohn‟s disease

Types of Obstruction:

A. Mechanical Obstruction

- actual physical barriers B. Functional Obstruction - ileus/ a functional failure of progressive intestinal transit

Mechanism of Intestinal Obstruction:
A. a.

MECHANICAL OBSTRUCTION: Obturation of the lumen -meconium -intussusception -gallstones -impactions – fecal, barium, bezoar, worms

b.

Lesions of Bowel *Congenital - atresia and stenosis - Imperforate anus - Duplications *Traumatic * Inflammatory - regional enteritis - Diverticulitis - Chronic ulcerative colitis

*Neoplastic *Miscellaneous - K induced stricture - Radiation stricture - Endometriosis

• c. Lesions Extrinsic to the Bowel

- Adhesive Band constriction - Hernia - Extrinsic masses d. Volvulus

B. INADEQUATE PROPULSIVE MOTILITY a. Neuromascular defects - Megacolon - Paralytic ileus Abdominal causes -Intestinal distention - Peritonitis - Retroperitoneal lesions Systemic causes - Electrolyte imbalances - Toxemias

Classification of Intestinal Obstruction:
1. 2. 3.

Simple Obstruction - obstructed lumen with intact blood supply Strangulated Obstruction - messenteric vessels are occluded Closed loop Obstruction - both limbs of the loop are obstructed

Four CARDINAL symptoms and signs of Intestinal Obstruction:

1. Crampy abdominal pain 2. Vomiting 3. Obstipation 4. Abdominal distention

Bowel obstruction
• Signs and Symptoms • Abdominal pain • Abdominal rigidity • Increased BOWEL sound in early stage and ABSENT BOWEL sound in late stage • Abdominal distention • Vomiting and fluid imbalance

HIRSCHSPRUNG’S DISEASE (Aganglionic Megacolon)
• Failure of the ganglion cells of the myenteric plexuses to migrate down the developing colon – lower portion of the sigmoid colon just above the anus. • Abnormally innervated distal colon remains tonically contracted and obstructs the flow of feces Assessment: • Chronic constipation or Ribbon-like stools • Abdominal distention, poor feeding habits, bilious vomiting • Failure to pass meconium within 24hrs • Requires rectal stimulation to induce bowel movement Diagnostic: 1. Digital Examination: (+) hard, caked stool 2. Barium Enema: narrow, nerveless, distended bowel 3. Biopsy: lack of innervation 4. Anorectal manometry: decreased pressure in the sphincter

Hirschsprung’s Disease

Bowel obstruction
• Diagnosis

: Abdominal x-ray

MANAGEMENT: 1. Fluid and electrolyte therapy 2. Decompression of the gastrointestinal tract. 3. Timely surgical interventions

HERNIAS • protrusion of an organ or part of an organ through the wall of the cavity

HERNIAS FACTORS:

•caused by failure of certain normal openings to close during fetal development • increased intra-abdominal

pressure

INGUINAL and FEMORAL HERNIA Inguinal hernia -protrusion of peritoneum through a defect in the abdominal wall in the inguinal canal - account for 75% of all hernias Two Types: 1. Indirect Inguinal Hernia 2. Direct Inguinal Hernia

Indirect Inguinal Hernia
• - due to persistence of the processus vaginalis • - occurs lateral to Hessebach‟s Triangle • - protrude through the inguinal ring and may

extend in the scrotum • The herniated viscus or fat lies within the spermatic cord • The hernia is directed by the spermatic cord toward the scrotum • Inc. risk of strangulation and infarct • Much more common than direct inguinal hernia • Common in children 10% bilateral

Boundaries Of Inguinal Triangle (Hesselbach‟s Triangle) Lateral – inferior epigastric artery Medial – lateral rectus abdominis muscle border Inferior – Inguinal ligament

Direct Inguinal Hernia
- Are associated with tissue laxity (old age) - Factors that increases intra abdominal pressure: a. obesity b. chronic cough c. straining with bowel movements or micturition (BPH) - They protrude through the floor of the inguinal canal and Hasselbach‟s triangle - Herniated viscus or fat lies adjacent ( not within ) the spermatic cord - Are always acquired

• Femoral hernia

• – protrusion of peritoneum through the wall femoral

canal • more frequent in girls • mass at anterior surface of the thigh

Petit‟s Triangle Hernia (Lumbar triangle) - affects all age group - males are frequently affected - presents with a “lump near the buttocks”
Boundaries of lumbar Triangle: Lateral : External oblique muscles Superior : Latissimus dorsi muscles Inferior : Iliac crest

Richter‟s Hernia - Hernia in which one wall of intestine is trapped by constricting ring of hernia - More common in femoral henia - Presents with a painful tender groin mass

Assessment: • history of intermittent appearance of a mass in the groin Complication: 1. Incarceration – (irreducibility without vascular compromise) 2.Strangulation – ( ischemia and necrosis ) 3.Intestinal obstruction with fluid sequestration and electrolyte imbalance and damage to the urinary bladder or spermatic cord during surgical repair

Intervention: • surgery – as soon as diagnosis is made; rarely close spontaneously • Acute incarceration or strangulation requires emergent surgical repair • Elective herniorrhaphy

Nursing intervention: • if incarceration occurs – apply ice bag; elevate foot of bed • post op: small dressing; encourage to ambulate; resume activities gradually

“Hanggang…” Sa mundong puno ng pakikipagsapalaran, Ang bawat tanong ay kung kailan… Kailan matatapos ang dusa? Kailan hahantong ang wakas, Nang bawat kabanatang „di tiyak ang tema? Kailan makikita ang tagumpay Bunga ng matinding pagsusumikap? … ang tanging sagot ay hanggang! Hanggang patuloy na tumatakbo ang orasan ng ating buhay, Patuloy na pipintig ang bawat puso Upang gisingin ang ating hangaring magtagumpay … Hanggang may buhay, may mananatiling PAG-ASA Oras-oras, araw- araw…bawat panahon.

• Arrow moves forward after pulling it backward • Bullet moves forward after pressing the trigger backward • Every human being will get happy

• Only after facing the difficulties in their life path…
• So do not be afraid to face difficulties. • They will push you forward