MANAGEMENT OF PATIENTS WITH ORAL AND ESOPHAGEAL DISORDERS

Presented by: Jomar P. Ronquillo, RN, MANc

NORMAL ANATOMY OF A TOOTH

NORMAL ANATOMY OF A TOOTH

DENTAL PLAQUE AND CARIES ‡ TOOTH DECAY: ‡ An erosive process that begins with the action of bacteria in the mouth .

.DENTAL PLAQUE AND CARIES ‡ DENTAL PLAQUE: ‡ A gluey. gelatin-like substance that adheres to the teeth.

extraction . Implant.DENTAL PLAQUE AND CARIES ‡ Dental decay begins with a small hole ‡ Enamel gets penetrated and the dentin as well ‡ Pulp is also affected ‡ Abscess ‡ Pain and soreness ‡ Facial swelling ‡ DIAGNOSTICS: ‡ TREATMENT: Fillings.

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DENTAL PLAQUE AND CARIES ‡ PREVENTION: ± ± ± ± ± Effective mouth care Diet Fluoridation Smoking cessation Sealants .

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continuous pain ± Facial edema ± Systemic reaction . gnawing. ‡ Has two forms: Acute and chronic ‡ CLINICAL MANIFESTATIONS: ± Dull.DENTOALVEOLAR ABSCESS OR PERIAPICAL ABSCESS ‡ Involves the collection of pus in the apical dental periosteum and the tissue surrounding the apex of the tooth.

DENTOALVEOLAR ABSCESS OR PERIAPICAL ABSCESS ‡ MANAGEMENT: ± Aspiration / Incision and drainage ± Tooth extraction ± Root canal therapy ‡ NURSING MANAGEMENT: ± WOF bleeding ± Mouth care ± Medications .

MALOCCLUSION ‡ Misalignment of the teeth in the upper and lower dental arcs ‡ Can be inherited or acquired ‡ Can be corrected early with orthodontics .

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throbbing pain Restricted jaw motion Clicking/grating noise Difficulty swallowing ‡ POSSIBLE CAUSES: ± Arthritis. stress.TEMPOROMANDIBULAR DISORDERS ‡ Categories: ± Myofascial pain ± Internal derangement of the joint ± Degenerative joint disease ‡ CLINICAL MANIFESTATIONS: ± ± ± ± Radiating dull. trauma. malocclusion .

TEMPOROMANDIBULAR DISORDERS ‡ MANAGEMENT: ± ± ± ± Stress management ROM Pain management Bite plate or splint ‡ SURGICAL MANAGEMENT: ± Rigid plate fixation (trauma) ± Bone grafting ‡ NURSING MANAGEMENT: ± No chewing post surgery ± Liquid diet .

swollen glands. discontinuing meds that affect salivation. red shiny skin ± Antibiotics. adequate nutrition. the acutely ill and the debilitated are at high risk ± Pain in the ear.DISORDERS OF THE SALIVARY GLANDS ‡ PAROTITIS: ± Inflammation of the parotid gland ± Elderly. parotidectomy .

hydration and steroids. malnutrition. swelling.DISORDERS OF THE SALIVARY GLANDS ‡ SIALADENITIS: ± Inflammation of the salivary glands ± Causes: Dehydration. improper oral hygiene ± Organisms: ± Pain. stress. massage. surgical drainage . salivary gland calculi. purulent drainage ± Antibiotics. radiation.

DISORDERS OF THE SALIVARY GLANDS ‡ SIALOLITHIASIS: ± ± ± ± Occurs in the submandibular gland Formed from calcium phosphate Can arise in the gland itself or in the ducts Lithotripsy or surgery .

DISORDERS OF THE ESOPHAGUS ‡ The esophagus is a mucus-lined muscular tube from the mouth to the stomach ‡ Has two sphincters .

perforation. GERD. foreign bodies. carcinoma ‡ ACHALASIA: ± MANIFESTATIONS: ‡ Difficulty swallowing ‡ Regurgutation ‡ Chest pain ‡ Pyrosis ‡ Secondary pulmonary complications .DISORDERS OF THE ESOPHAGUS ‡ DYSPHAGIA: ± Most common symptom of esophageal disease ± Possible causes: achalasia. hiatal hernias. diverticula. diffuse spasm. tumors.

DISORDERS OF THE ESOPHAGUS ‡ ACHALASIA: ± ASSESSMENT AND DX FINDINGS: ‡ Esophageal dilatation ‡ Barium swallow ‡ CT scan ‡ Endoscopy ‡ Manometry ± MANAGEMENT: ‡ Eat slowly and drink fluids ‡ Calcium channel blocker ‡ Botulinum toxin injection ‡ Pneumatic dilation and surgery ‡ Esophagomyotomy .

nitrates.DISORDERS OF THE ESOPHAGUS ‡ DIFFUSE SPASM ± ± ± ± A motor disorder of the esophagus Cause is unknown. odynophagia ‡ Chest pain ± ASSESSMENT AND DX FINDINGS: ‡ Irregular contractions of the esophagus on manometry ‡ Xray ± MANAGEMENT: ‡ Sedatives. stress is possible Most common in women CLINICAL MANIFESTATIONS: ‡ Dysphagia. small frequent meals. calcium channel blocker. soft diet. and surgeries same as achalasia .

HIATAL HERNIA ‡ A condition wherein the opening in the diaphragm through which the esophagus passes becomes enlarged. and part of the stomach tends to move up in the lower portion of the thorax ‡ Occurs more often in women than in men ‡ Two types: Sliding and Paraesophageal .

HIATAL HERNIA .

reflux (sliding type).HIATAL HERNIA ‡ CLINICAL MANIFESTATIONS: ± Heartburn. barium swallow. obstruction. strangulation ‡ ASSESSMENT AND DX FINDINGS: ± X-ray. fluoroscopy . regurgitation. dysphagia ± Sense of fullness (paraesophageal type) ± Complication: Hemorrhage.

HIATAL HERNIA ‡ MANAGEMENT: ± Small frequent feedings ± Management to prevent reflux: ‡ No reclining 1 hour post eating ‡ Elevate HOB ± Surgery ± Management techniques for Paraesophageal hernia are similar to GERD. but may also necessitate emergency surgery .

DIVERTICULUM
‡ Is an outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature ‡ May occur in one of the three areas of the esophagus (PME) or may occur along the border of the esophagus intramurally ‡ Zenker¶s diverticulum, most common type

DIVERTICULUM
‡ CLINICAL MANIFESTATIONS:
± Zenker¶s Diverticulum: Difficulty swallowing, fullness in the neck, belching, regurgitation, gurgling noises after eating ± Halitosis and a sour taste ± Dysphagia and chest pain (Epiphrenic type) ± Dysphagia (Intramural type)

‡ ASSESSMENT AND DX FINDINGS:
± ± ± ± Barium swallow Manometric disorders for epiphrenic type Esophagoscopy? Blind NGT insertion?

DIVERTICULUM
‡ MANAGEMENT:
± Surgical removal of the diverticulum (Zenker¶s type) and myotomy of cricopharyngeal muscle ± NGT insertion POST OP ± Surgical ncision monitoring ± NPO until clear in Xray ± DIET: liquid to DAT

MVC. severe hypotension ± Pneumothorax . fever. leukocytosis. dysphagia ± Infxn. caustic injury or inadvertent puncture ‡ CLINICAL MANIFESTATIONS: ± Persistent pain.PERFORATION ‡ May result from stab or bullet wounds of neck or chest.

parenteral nutrition Surgery ‡ Nursing management is similar to that for patients who have had thoracic or abdomial surgery . fluoroscopy ‡ MANAGEMENT: ± ± ± ± Broad-spectrum antibiotics NGT NPO.PERFORATION ‡ ASSESSMENT AND DX FINDINGS: ± X-ray studies.

FOREIGN BODIES ‡ Swallowed foreign object may injure the esophagus or obstruct its lumen ‡ Pain and dysphagia ‡ X-ray (diagnosis) ‡ Glucagon administration ‡ Endoscopy and dilation .

batteries. shock. difficulty breathing.CHEMICAL BURNS ‡ May be caused by undissolved medications in the esophagus. etc ‡ More common in the elderly ‡ Pain. swallowing of strong acid or base. respiratory distress ‡ DIAGNOSIS: Esophagoscopy and barium swallow .

NPO.CHEMICAL BURNS ‡ MANAGEMENT: ± NGT. corticosteroids and antibiotics ± Nutritional support ± Bougienage ± Esophagectomy and colon interpostion . lavage.

‡ Unusual ‡ Causes: Any condition that leads to long term or forceful vomiting. causing bleeding. epileptic convulsions ‡ Results in vomiting or bright red vomitus.MALLORY-WEISS TEAR ‡ A Mallory-Weiss tear occurs in the mucous membrane where the esophagus connects to the stomach. coughing. melena or hematochezia ‡ DIAGNOSIS: Endoscopy . retching.

high gastrostomy . embolization. cauterization.MALLORY-WEISS TEAR ‡ MANAGEMENT: ± Usually supportive but may require endoscopy. epinephrine injection. surgery.

GASTROESOPHAGEAL REFLUX DISEASE ‡ Causes: incompetent LES. pyloric stenosis. or motility disorders ‡ Incidence increases with aging ‡ CLINICAL MANIFESTATIONS: ± ± ± ± ± ± ± Pyrosis Dyspepsia Regurgitation Dysphagia Odynophagia Hypersalivation Esophagitis .

GASTROESOPHAGEAL REFLUX DISEASE ‡ ASSESSMENT AND DX FINDINGS: ± Endoscopy ± Barium swallow ± Ambulatory 12.to 36 hour esophageal pH monitoring ± Bilirubin monitoring .

maintain ‡ Clothing: ‡ HOB elevation: ± Medications: ‡ Antacids ‡ Histamine receptor blockers ‡ PPI¶s ‡ Prokinetic agents .GASTROESOPHAGEAL REFLUX DISEASE ‡ MANAGEMENT: ± Teach patient to avoid situations that decrease LES sphincter pressure or cause esophageal irritation: ‡ Diet: ‡ Eating in relation to bedtime: ‡ Normal body weight.

GASTROESOPHAGEAL REFLUX DISEASE ‡ SURGICAL MANAGEMENT: ± Fundoplication .

BARRETT¶S ESOPHAGUS ‡ A precancerous condition of the esophagus commonly associated with longs-standing GERD ‡ CLINICAL MANIFESTATIONS: ± Symptoms of GERD ‡ ASSESSMENT AND DX FINDINGS: ± EGD ‡ MANAGEMENT: ± Monitoring ± Medical and surgical management are similar to that for GERD .

MANAGEMENT OF PATIENTS WITH GASTRIC AND DUODENAL ULCERS .

GASTRITIS ± A common GI problem ± Can be chronic or acute ‡ Acute Gastritis: ± ± ± ± ± ± ± Dietary indescretion Overuse of certain medications Excessive alcohol intake Bile reflux Radiation therapy Ingestion of strong acid or alkali May be a sign of an acute systemic infxn .

GASTRITIS ‡ CHRONIC GASTRITIS: ± ± ± ± ± ± ± ± Can be caused by benign or malignant ulcers Helicobacter pylori Autoimmune diseases Dietary factors Edema and hyperemia Decreased secretion Superficial erosion Hemorrhage ‡ PATHOPHYSIOLOGY: .

Discomfort ‡ Headache ‡ Lassitude ‡ N&V ‡ Anorexia ‡ Hiccuping ± Chronic form: ‡ Anorexia ‡ Heartburn ‡ Belching.GASTRITIS ‡ CLINICAL MANIFESTATIONS: ± Acute form: ‡ Abd. sour taste ‡ Vitamin B12 deficiency . n & v.

Diagnostic measures for HPylori .GASTRITIS ‡ ASSESSMENT AND DX FINDINGS: ± Achlorhydria/Hypochlorhydia to Hyperchlorhydia ± Endoscopy.. histologic exam. upper GI radiographic studies.

. reduce stress. pharmacologic therapy.GASTRITIS ‡ MEDICAL MANAGEMENT: ± Refrain from alcohol or food until sx subsides ± Control of bleeding ± Diluting/neutralizing offending agent (Ingestion of acid and alkalis) ± Emetics and lavage ± NGT ± Gastric resection ± CHRONIC GASTRITIS: Diet modification. Promoting rest.

NURSING PROCESS AND THE PARIENT WITH GASTIRITIS ‡ ASSESSMENT: ± Patient History ‡ Ask about the presenting signs and symptoms ‡ 72 dietary recall ‡ Any methods used to treat the symptoms ‡ NURSING DIAGNOSIS: ± Anxiety related to treatment ± Imbalanced nutrition. less than body requirements. related to inadequate intake ± Risk for imbalanced fluid volume related to insufficient fluid loss subsequent to vomiting ± Deficient knowledge ± Acute pain .

NURSING PROCESS AND THE PARIENT WITH GASTIRITIS ‡ PLANNING AND GOALS: ± ± ± ± ± ± ± ± ± Reduced anxiety Avoidance of irritating foods Fluid balance Relief of pain Dietary management Reduce anxiety Optimal nutrition Promote fluid balance Relieve pain ‡ NURSING INTERVENTIONS: .

NURSING PROCESS AND THE PARIENT WITH GASTIRITIS ‡ EVALUATION: ± Exhibits less anxiety ± Avoids eating irritating foods or drinking carbonated beverages ± Maintains fluid balance ± Adheres to medical regimen ± Maintains appropriate weigh ± Reports less pain .

GASTRIC AND DUODENAL ULCERS ‡ A peptic ulcer is an excavation that forms in the mucosal wall of the stomach. ‡ Depth of erosion is variable ‡ Occurs mostly in people between 40 and 60 y/o ‡ Results from infection with H. and duodenum. Pylori ‡ Excessive secretion of HCL may also be the cause . or in the esophagus. in the pylorus.

GASTRIC AND DUODENAL ULCERS ‡ ‡ ‡ ‡ ‡ DUODENAL VS. GASTRIC ULCER: INCIDENCE: SIGNS AND SYMPTOMS: MALIGNANCY POSSIBILITY: RISK FACTORS: .

GASTRIC AND DUODENAL ULCERS ‡ Risk factor: Familial tendency. excessive smoking. Zollinger-Ellison syndrome ‡ PATHOPHYSIOLOGY: ± Erosion is caused either by increased activity of pepsin and HCL or decreased resistance of the mucosa ± ZES is suspected in unresponsive peptic ulcer ± STRESS ULCERS can also be the cause: ‡ Ischemia. increased acid and pepsin production. use of NSAIDs. Alcohol ingestion. reflux ± Cushing¶s and Curlings¶s types .

constipation. diarrhea. gnawing pain/burning sensation in the midepigastiric area or in the back ± Eating usually relieves pain ± Pyrosis ± Vomiting. bleeding .GASTRIC AND DUODENAL ULCERS ‡ CLINICAL MANIFESTATIONS: ± May be asymptomatic ± Dull.

and histology with culture Urea breath test .GASTRIC AND DUODENAL ULCERS ‡ ASSESSMENT AND DX FINDINGS: ± ± ± ± ± ± Physical findings Upper GI barium study Endoscopy Stool analysis Biopsy.

GASTRIC AND DUODENAL ULCERS ‡ MEDICAL MANAGEMENT: ± PHARMACOLOGIC: ‡ Antibiotics (TAMCB) ‡ Proton-pump inhibitors (OLR) ‡ Bismuth salts ‡ H2 receptor antagonists (CRFN) ‡ Octreotide ‡ Cytoprotective agents ± Stress reduction and rest ± Dietary modification .

GASTRIC AND DUODENAL ULCERS ‡ MEDICAL MANAGEMENT: ‡ Vagotomy with or without pyloroplasty ± Vagotomy ‡ Truncal ‡ Selective ‡ Proximal gastric vagotomy ‡ Billroth I and Billroth II .

NURSING PROCESS AND PEPTIC ULCER ‡ ASSESSMENT: ± Chief complaint ‡ Ask about the nature of the pain ± 72 hour dietary recall ± Lifestyle habits ± Vital signs ± Physical exam .

NURSING PROCESS AND PEPTIC ULCER ‡ NURSING DIAGNOSIS: ± Acute pain related to the effect of gastric acid secretion on damaged tissue ± Imbalanced nutrition related to changes in diet ‡ Potential Complications: ± ± ± ± H P P P .

NURSING PROCESS AND PEPTIC ULCER ‡ GOALS: ± ± ± ± Relief of pain Reduced anxiety Nutrition maintenance Absence of complications .

NURSING PROCESS AND PEPTIC ULCER ‡ NURSING INTERVENTIONS: ± Relieving pain ‡ Avoid caffeine and aspirin ‡ Relaxation techniques .

NURSING PROCESS AND PEPTIC ULCER ‡ NURSING INTERVENTIONS: ± Reducing anxiety .

NURSING PROCESS AND PEPTIC ULCER .

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CVP insertion.NURSING PROCESS AND PEPTIC ULCER ± Treat the bleeding! ± Replacing blood that was lost » IV line. blood component therapy ± NG Tube insertion » Monitoring » Lavage ± IFC and monitoring UO ± Proper positioning .

NURSING PROCESS AND PEPTIC ULCER ± Transendoscopic coagulation ± Selective embolization .

NURSING PROCESS AND PEPTIC ULCER .

constipation.NURSING PROCESS AND PEPTIC ULCER ‡ PYLORIC OBSTRUCTION (GOO): ± S/Sx: Nausea and vomiting. epigastric fullness. weightloss ± Management: Insertion of Ng Tube ± Upper GI endoscopy ± Balloon dilatation of the pylorus ± Surgery: Vagotomy. antrectomy. gestrojejunostomy and vagotomy .

MORBID OBESITY ‡ Morbid obesity is the term applied to people who are more than two times their ideal body weight or whose body mass index (BMI) exceeds 30 kg/m² ‡ 100 pounds greater than the ideal body weight .

MORBID OBESITY ‡ Patients with morbid obesity are at highest risk for health complications! .

Orlistat Increases BM.MORBID OBESITY ‡ MEDICAL MANAGEMENT: ± Weightloss diet with behavioral modification and exercise ± Treatment of depression ± PHARMACOLOGIC: ‡ Sibutramine HCL (Meridia) ‡ Orlistat (Xenical) ± SE: Sibutramine increases BP. decreases absorption of some vitamins .

MORBID OBESITY ‡ MEDICAL MANAGEMENT: ± Surgery: ‡ BARIATRIC SURGERY: ± Jejunoileal bypass ± Gastric bypass ± Vertical banded gastroplasty .

GASTRIC BYPASS .

GASTRIC BYPASS .

VERTICAL BANDED GASTROPLASTY .

MORBID OBESITY ‡ NURSING MANAGEMENT: ± General postop care similar to that for a patient recovering from a gastric resection ± Provide 6 small feedings ± Encourage fluid intake ± Teach patients signs of dehydration ± Discuss dietary instructions: ‡ Do not overeat! .

GASTRIC CANCER ‡ ‡ ‡ ‡ Incidence: MEN>WOMEN Japan has higher incidence Diet: Significant factor Other factors: ± ± ± ± ± ± Chronic inflammation of the stomach Pernicious anemia Achlorhydria Gastric ulcers H. Pylori infection Genetics .

dyspepsia. nausea and vomiting . weightloss. anemia. constipation.GASTRIC CANCER ‡ CLINICAL MANIFESTATIONS: ± Early stages: Asymptomatic ± Early symptoms seldom definitive: ‡ Pain relived with antacids ± Progressive: Anorexia. abdominal pain.

GASTRIC CANCER ‡ MEDICAL MANAGEMENT: ± ± ± ± REMOVAL OF THE TUMOR Gastrectomy (Total/subtotal) Chemotherapy Radiation therapy .

PATIENTS UNDERGOING GASTRIC SURGERY ‡ ASSESSMENT: ± ± ± ± ± Pt. and family knowledge Patient¶s nutritional status Assess for presence of bowel sounds Palpate the abdomen Assess for complication postop .

PATIENTS UNDERGOING GASTRIC SURGERY ‡ NURSING DIAGNOSIS: ± Anxiety related ton surgical intervention ± Acute pain related to surgical incision ± Deficient knowledge about surgical procedures and postoperative course ± Imbalanced nutrition. less than body requirements. related to poor nutrition before surgery and altered GI system after surgery .

PATIENTS UNDERGOING GASTRIC SURGERY ‡ NURSING INTERVENTIONS: ± Relieve anxiety ± Relieve pain ‡ Analgesics ‡ No sedation! ‡ Maintain NG tube ± Resume enteral intake ± Recognize obstacles to adequate nutrition: ‡ Dysphagia and gastric retention ‡ Bile reflux ‡ Dumping syndrome ‡ Vitamin and mineral deficiencies .

MANAGEMENT OF PATIENTS WITH INTESTINAL AND RECTAL DISORDERS .

ABNORMALITIES OF FECAL ELIMINATION CONSTIPATION .

or retention of stool for a prolonged period. abnormal hardening of stools that makes their passage difficult and sometimes painful.CONSTIPATION ‡ Is a term used to describe an abnormal infrequency or irregularity of defecation. . a decrease in stool volume.

anticholinergics. parkinson¶s. antidepressants.CONSTIPATION ‡ Causes: ± Medications: Tranquilizers. neurologic and neuromuscular conditions (DM. opiods ± Rectal or anal disorders: Hemorrhoids ± Obstruction ± Metabolic. Hirschsprung¶s dse. diverticular dse ± Immobility ± Dietary habits . MS) ± Endocrine disorders ± IBS.

CONSTIPATION ‡ CLINICAL MANIFESTATIONS: ± ± ± ± ± ± ± ± ± Abdominal distention Borborygmus Pain and pressure Decreased appetite Headache Fatigue Indigestion Straining at stool Small. hard. dry stools .

CONSTIPATION ‡ COMPLICATIONS: ± ± ± ± Hypertension Fecal impaction Hemorrhoids and fissures Megacolon .

CONSTIPATION ‡ MEDICAL MANAGEMENT: ± ± ± ± Education Bowel habit training Increase fiber and OFI Judicious use of laxatives: ‡ Psyllium hydrophilic mucilloid (Metamucil) ‡ Magnesium OH ‡ Mineral oil ‡ Bisacodyl (Dulcolax) .

ABNORMALITIES OF FECAL ELIMINATION DIARRHEA .

and altered consistency of stool. endocrine disorders.DIARRHEA ‡ Increased frequency of bowel movements. infection ‡ Can be acute or chronic . ‡ Frequent causes: ± ± ± ± IBS IBD Lactose intolerance Medications. increased amount of stool.

DIARRHEA ‡ TYPES: ± Secretory ± Osmotic ± Mixed ‡ CLINICAL MANIFESTATIONS: ± ± ± ± ± ± Increased frequency and fluid content of stools Abdominal cramps Distention Intestinal rumbling Anal spasms and tenesmus S/sx of dehydration .

problem ‡ DIAGNOSTIC TESTS: ± ± ± ± ± CBC Urinalysis Stool exam Endoscopy Barium enema .i.DIARRHEA ‡ The characteristic of the stools can tell the location of the g.

DIARRHEA ‡ COMPLICATIONS: ± Potential for cardiac dysrhythmia ‡ NURSING INTERVENTIONS: ± ± ± ± Monitoring through physical assessment Bed rest Increased OFI No intake of foods that increase intestinal motility ± Administer antidiarrheal meds: Diphenoxylate and loperamide ± Perianal hygiene .

FECAL INCONTINENCE .

FECAL INCONTINENCE ‡ The involuntary passage of stool from the rectum ‡ Possible causes: ± ± ± ± ± ± ± ± Trauma Neurologic disorders Infection Radiation treatment Fecal impaction Pelvic floor relaxation Laxative abuse Advancing age .

FECAL INCONTINENCE What are the clinical manifestations? .

FECAL INCONTINENCE .

FECAL INCONTINENCE .

FECAL INCONTINENCE .

FECAL INCONTINENCE .

FECAL INCONTINENCE .

FECAL INCONTINENCE
‡ ASSESSMENT AND DIAGNOSTIC FINDINGS:
± ± ± ± ± ± ± Rectal exams Endoscopic examinations X-ray Barium enema Computed tomography scans Anorectal manometry Transit studies

FECAL INCONTINENCE
‡ MEDICAL MANAGEMENT:
± ± ± ± No specific cure Biofeedback therapy Bowel training programs Surgery

FECAL INCONTINENCE
‡ NURSING MANAGEMENT:
± ± ± ± Take health history Bowel training program Encourage meticulous skin hygiene Facilitate use of internal or external incontinence devices

IRRITABLE BOWEL SYNDROME (IBS) .

IRRITABLE BOWEL SYNDROME (IBS) ‡ It is a functional bowel disorder characterized by chronic abdominal pain. ‡ Various factors are associated with the syndrome: ± Heredity. smoking and alcohol consumption . stress. and alteration of bowel habits in the absence of any detectable organic cause. diet high in fat. discomfort. bloating.

IRRITABLE BOWEL SYNDROME (IBS) .