MANAGEMENT OF CLIENTS WITH INTESTINAL

DISORDERS

• Michael D. Manglapus, BSN-RN, RM, MAN

Acute Inflammatory Disorders
• Appendicitis = is an inflammation of the
appendix, a narrow blind tube that extends
from the inferior part of the cecum.
– Cause:
• Obstruction of the lumen by a fecalith
(accumulated feces)
Acute Inflammatory Disorders
Appendicitis
– Classifications:
• Simple = appendix is inflamed but still
intact
• Gangrenous = there is tissue necrosis and
microscopic areas of perforation
• Perforation = there is large perforation,
which involves contents flowing into the
peritoneal cavity
Appendicitis
• Manifestations:
– Typically begins with periumbilical pain,
followed by anorexia, nausea, and vomiting
– Low-grade fever
– Pain becomes persistent and shifts to the RLQ
at McBurney’s point
Appendicitis
Appendicitis
• Blumberg’s sign (rebound tenderness) = painful
response when tips of the fingers are pressed
gently into the abdominal wall and then
suddenly withdrawn
– Classic sign of appendicitis
• Rovsing’s sign = pain felt at RLQ when LLQ is
palpated
• Psoas’ sign = lying still with right leg drawn up
Appendicitis
• Iliopsoas
muscle test =
pain in the
pelvis when
the patient
flexed the
right thigh
against
resistance
Appendicitis
• Obturator
muscle test =
pain when the
right thigh is
flexed 900 and
leg is rotated
internally and
externally.
Appendicitis
• Diagnostic studies:
– X-ray = confirmatory test
– CBC = reveals an elevated WBC (10,000/mm3
– 20,000/mm3)
– Urinalysis = is used to rule out UTI
Appendicitis
– Complication: perforation and peritonitis
– Surgical management: appendectomy (open
abdominal or laparoscopic)
Appendicitis
Nursing management:
– NPO
– Avoid laxative and enemas = may increase peristalsis
that would cause perforation
– Apply ice bag to the RLQ (avoid heat application)
– Placing the patient in high-fowler’s position before
and after surgery.
– Morphine Sulfate to relieve pain (postoperative)
– Monitoring the patient for signs of peritonitis
Acute Inflammatory Disorders
• Peritonitis = inflammation of the peritoneum
– Cause:
• Primary: Result of bacterial infection
(E.coli, Klebsiella, Proteus, and
Pseudomonas)
• Secondary: ruptured appendicitis,
ruptured diverticulitis, perforated PUD,
postoperative complications
Peritonitis
• Manifestations:
– Abdominal pain (most common symptom)
– tenderness, muscular rigidity and spasm,
absent bowel sounds (paralytic ileus),
– high fever, tachycardia, diaphoresis
– drawing the knees up to the chest.
Peritonitis
• Complications:
– Hypovolemic shock
– Septic shock
– Acute respiratory distress syndrome
Peritonitis
• Diagnostic studies:
– CBC = elevated WBC count,
hemoconcentration
– Peritoneal aspiration (paracentesis) = to
analyze blood, bile, pus, bacteria, fungus, or
amylase content.
– X-ray, CT scan, UTz
– Peritoneoscopy
Peritonitis
• Surgical management:
– Laparoscopic repair of the underlying cause
• Nursing management:
– NPO –Monitoring v/s
– Insert NGT, IVF frequently
– Semi-fowler’s position, –Oxygen therapy
with knees flexed –Analgesics, and
– Provide rest and a quiet antibiotics
environment
(postoperative)
Acute Inflammatory Disorders
• Diverticular disease
• Diverticulum = is a saccular dilation or
outpouching of the mucosa through the circular
smooth muscle of the intestinal wall.
• Diverticulosis = a condition of which an
individual has diverticula (non-inflamed)
• Diverticulitis = inflammation and obstruction of
a colonic diverticulum
Diverticular disease
• Cause:
– Lack of dietary fiber intake
– Loss of muscle mass and collagen with the
aging process
– Associated with obesity
Diverticular disease
• Manifestations:
– Diverticulum (asymptomatic)
– Diverticulitis:
• LLQ abdominal pain (most common
symptom)
• Nausea, vomiting, changes in bowel
habits, and bloating
• Palpable abdominal mass
Diverticular disease
• Diagnostic studies:
– UTz and CT Scan with contrast =
confirmatory diagnostic studies
• Barium enema and colonoscopy are
contraindicated
– CBC = leukocytosis, and elevated
sedimentation rate
Diverticular disease
• Nursing management:
– Emphasize high-fiber diet, fruits and
vegetables
– Decrease intake of fat and red meat
– High levels of physical activity
– Weight reduction for obese client
– Avoid increasing intra-abdominal pressure
– Observe signs of possible peritonitis
Diverticular disease
• Pharmacological management:
– Bulk-forming laxatives (Psyllium [Metamucil])
– Stool softeners (Docusate [Colace])
– Bisacodyl (Dulcolax)
– Antispasmodics (Propantheline [Pro-Banthine])
– Pain reliever (Meperidine [Demerol])
• Morphine is contraindicated
 Diverticular disease
• Surgical procedure:
– One-stage resection = inflamed area is removed
and a primary end-to-end anastomosis is
completed
– Hartmann procedure = “double-barrel” temporary
colostomy,
Diverticular disease
• diseased colon is
resected, but no
anastomosis is
performed. Both
ends of the
bowel are
brought out onto
the abdomen.
Acute Inflammatory Disorders
• Acute Gastroenteritis (AGE) = is an
inflammation of the mucosa of the stomach
and small intestine
– Manifestations:
• Nausea, vomiting, diarrhea, abdominal
cramping, and distension
• Fever, increased WBC count, blood or
mucous in the stool
Acute Gastroenteritis
• Cause:
– Salmonella and trichinosis (street foods and
contaminated water)
• Nursing management:
– Monitoring of I and O
– IVF and NPO – if patient is vomiting and with
signs of dehydration
– Strict medical asepsis and infection control
Acute Gastroenteritis
• Instruct the patient about proper handwashing.
• Instruct the patient about proper food handling
and preparation of food.
Malabsorption Syndrome
• Celiac Disease = also known as “Nontropical
Sprue”, and “Gluten-Sensitive Enteropathy”
– Characterized by marked atrophy of the villi in
the proximal small intestine induced by
ingestion of gluten-containing foods.
– Gluten = is a high-molecular weight protein
found in barley, rye, oats, wheat
Celiac Disease
• Associated with autoimmune diseases,
particularly rheumatoid arthritis, type 1
diabetes mellitus and thyroid disease
• Manifestations:
– Foul-smelling diarrhea – Wasting
– Abdominal distension – Failure to thrive
– Anorexia
Celiac Disease
– Confirmatory diagnostic: histologic
examination with biopsy
• Biopsies show flattened mucosa and
noticeable losses of villi
– Management:
• Gluten-free diet for life
• Corticosteroids
Celiac Disease
Examples of foods free of gluten:
- Eggs - Flax, corn, rice
- Potatoes - Soy products
- Butter - Unflavored milk
- Cheese, cottage- Gluten-free breads,
cheese crackers, pasta, and
- Meat, fish, poultry cereals
- Yogurt - Peanut butter
- Fresh fruits - Coffee, tea, and
- Tapioca cocoa
- Corn tortillas
Malabsorption Syndrome
• Lactase deficiency = is a condition in which the
lactase enzyme is deficient or absent.
– Lactase = is the enzyme that breaks down
lactose into simple sugars glucose and
galactose.
– Cause: genetic factors
– Predisposing factors: IBD, gastroenteritis,
and celiac disease
Lactase deficiency
• Manifestations:
– Bloating, flatulence, cramping abdominal
pain, and diarrhea.
• Confirmatory diagnosis: lactose tolerance test
or a lactose hydrogen breath test.
Lactase deficiency
• Management:
– Avoid milk and milk products
– Calcium supplements; and live culture yogurt
is an alternative source of calcium.
– Lactase enzyme (Lactaid) = is a commercially
available OTC product. It is mixed with milk.
Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Patholog ➢Most frequent ➢Usually starts
y site of in rectum and
inflammation spreads in a
and ulceration is continuous
the terminal pattern up the
ileum colon
Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Clinical ➢Inflammation ➢Inflammation
Manifesta involves all layers involves
tions of the bowel wall mucosa and
(transmural lesions) submucosa
➢Deeper
ulcerations,
fissures,
granulomatous
lesions
 Inflammatory Bowel Disease/ Disorder

Regional Enteritis (Crohn’s Ulcerative

Disease) Colitis
Clinical ➢Skip-lesions = healthy ➢Continuous
Manife tissue is interspersed areas of
station with areas of ulcerations
s inflammation (classic (rectum and
“cobblestone” colon)
appearance)
➢Palpable mass felt in
right iliac fossa
Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Clinical ➢RLQ pain, crampy ➢LLQ pain,
Manifesta abdominal pain after intermittent
tions meals, abdominal tenesmus,
tenderness, and rectal
spasm (pain relieved bleeding
by defecation)
Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Clinical ➢Weight loss and ➢Minimal
Manifesta anemia (due to nutritional
tions malabsorption) deficiencies
 
➢Steatorrhea ➢Common
(excessive fat in the rectal
stool) bleeding
Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Clinical ➢Characteristic
Manifesta periods of remission
tions and exacerbation
➢Diarrhea ➢Bloody
diarrhea (10 –
20x a day)
➢Fever ➢Fever
 Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Complicatio ➢Malnutrition ➢Toxic
ns megacolon =
(severe
episode of
colitis with total
dilatation of
the colon)
 Inflammatory Bowel Disease/ Disorder

eiti Regional Enteritis Ulcerative Colitis

(Crohn’s Disease)
Complic ➢Fistula ➢Perforation
ations (enterocutaneous ➢Colon cancer
fistula = abnormal ➢Hemorrhage
opening between ➢Skin lesions
the small bowel and (erythema nodosum)
the skin, most ➢Eye lesions
common type of (Uveitis)
fistula in Crohn’s ➢Arthritis
disease)
Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Complicatio ➢Increased ➢Can be
ns incidence of cured with
recurrence after surgery
surgery (colectomy)
 Inflammatory Bowel Disease/ Disorder
Regional Enteritis Ulcerative
(Crohn’s Disease) Colitis
Diagnostic ➢Barium study ➢Barium
s (Upper GI) = shows enema =
the classic “string shows
sign” on an x-ray mucosal
film of the terminal irregularities,
ileum, indicating shortening of
constriction of a the colon and
segment of intestine dilation of
bowel loops
Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Diagnostic ➢CT scan = shows ➢Colonoscop
s bowel wall y = shows
thickening and friable,
fistula formation inflamed
➢Capsule mucosa with
endoscopy exudates and
ulcerations
 Inflammatory Bowel Disease/ Disorder

Regional Enteritis Ulcerative

(Crohn’s Disease) Colitis
Diagnostic ➢CBC = reveals decreased
s hemoglobin and hematocrit
➢ESR/ D reactive protien = reveals
elevation, indicating chronic
inflammatory reactions
➢Serum albumin = reveals diminished
level, indicating malnutrition
➢WBC = reveals infectious process
 Inflammatory Bowel Disease/ Disorder
Regional Enteritis (Crohn’s Ulcerative
Disease) Colitis
Incidence ➢Prevalent in Ashkenazi Jews (whites)
➢Commonly diagnosed from adolescence
through 30 year-old

Cause ➢Unknown
➢Autoimmune = susceptibility gene, CARD
15 on chromosome 15 (Crohn’s disease)
➢Hereditary
➢Environmental factors = food additives,
pesticides, tobacco, radiation
Inflammatory Bowel Disease/ Disorder

• Pharmacological management:
– Aminosalicylates = decrease GI inflammation
• Sulfasalazine (Azulfidine) = may cause
yellowish orange discoloration of skin and
urine, avoid exposure to sunlight
• Mesalamine (Pentasa, Asacol)
• Olsalazine (Dipentum)
Inflammatory Bowel Disease/ Disorder

• Antimicrobials = prevent or treat secondary

infections
– Metronidazole (Flagyl)
– Ciprofloxacin (Cipro)
– Clarithromycin (Biaxin)
• Corticosteroids = decrease inflammation
– Prednisone, Hydrocortisone,
Methylprednisolone
Inflammatory Bowel Disease/ Disorder

• Immunosuppressants = suppress immune

response
– Azathioprine (Imuran)
– Cyclosporine
– 6-Mercaptopurine (Purithenol)
• Biologic therapy = inhibits the cytokine Tumor
Necrosis Factor (TNF)
– Infliximab (Remicade)
Inflammatory Bowel Disease/ Disorder

• Surgical managements:
– Total Colectomy with Ileoanal Reservior =
removal of entire colon, ileal reservoir
construction, ileoanal anastomosis, and
temporary ileostomy. After 3 – 6 months of
adaptation of the reservoir, second surgery is
performed which involves closure of the
ileostomy to direct stool toward the new
reservoir.
Inflammatory Bowel Disease/ Disorder

• Total Proctocolectomy with Permanent

Ileostomy = involves removal of the colon and
rectum with closure of the anus. The end of the
terminal ileum is brought out through the
abdominal wall and forms a stoma, or ostomy.
Inflammatory Bowel Disease/ Disorder

• The stoma is usually

placed in the RLQ
below the belt line.
 Inflammatory Bowel Disease/ Disorder
• Total Proctocolectomy
with Continent
Ileostomy = “Kock
pouch”, the distal
segment of the ileum is
surgically split, a fold is
made, and a one-way
nipple valve is created
and sutured into place
on the abdomen.
Inflammatory Bowel Disease/ Disorder
• Nursing managements:
– Enhance nutritional status/ nutritional
therapy
• Diet high in CHON, calories, low residue,
low in fat
• Supplemental vitamin therapy and iron
supplement
• IV fluid therapy, electrolytes and blood
replacement
Inflammatory Bowel Disease/ Disorder

• Avoid foods that exacerbate diarrheal

episodes
• Avoid smoking/ alcohol
• TPN
– Emotional support = referrals to support
group, psychotherapy
– Promote rest periods
Irritable Bowel Syndrome
• is a complex symptom characterized by
intermittent and recurrent abdominal pain and
stool pattern irregularities. Peristaltic waves are
affected at specific segments of the intestine and
in the intensity with which they propel the fecal
matter forward.
• Manifestations:
– Alteration in bowel pattern: constipation,
diarrhea, or a combination of both
Irritable Bowel Syndrome
• Abdominal distension, excessive flatulence,
continual defecation urge, urgency, and
sensation of incomplete evacuation
Irritable Bowel Syndrome
• Rome criteria: abdominal discomfort or pain
for at least 12 weeks (not necessary
consecutive) within 12 months that has at least
two of the following characteristics:
– Relieved with defecation
– Onset associated with a change in stool
frequency
– Onset associated with a change in stool
appearance
Irritable Bowel Syndrome
• Cause: unknown; functional disorder of
intestinal motility
– Related to neuroendocrine dysregulation,
vascular metabolic disturbance
• Incidence: more common in women than in
men
Irritable Bowel Syndrome
• Predisposing factors:
– Stress, psychologic factors, prior
gastroenteritis, and specific food intolerance
• Nursing management:
– IBS with constipation:
• 20 g per day of dietary fiber
• Bulking agent (Metamucil)
• Tegaserod (Zelnorm)
 Irritable Bowel Syndrome
• IBS with diarrhea:
– Antispasmodic agents (Dicyclomine [Bentyl],
Propantheline [Pro-Banthine]) = taken before
meals
– Loperamide (Imodium) = a synthetic opioid that
decreases intestinal transit and enhances
intestinal water absorption
– Alosetron (Lotronex) = side effects: severe
constipation, ischemic colitis
Irritable Bowel Syndrome
• Avoid gas-forming foods (broccoli, cabbage),
avoid alcohol use and cigarette smoking
• Cognitive-behavioral therapy
• Relaxation and stress management techniques
• Acupuncture
• Hypnosis
• Chinese herbs
• (no single therapy has been found effective)
Intestinal Obstruction
• Partial or complete impairment of the forward
flow of intestinal contents.
• Blockage in the movement of intestinal
contents through small or large intestine
Intestinal Obstruction
• Causes:
– Mechanical obstruction = an intraluminal
obstruction or mural obstruction from
pressure on the intestinal wall occurs.
• Adhesions = loops of intestine become
adherent to areas that heal slowly
Intestinal Obstruction
• Intussusceptions = one part of the intestine
slips into another part located below it (like
a telescope shortening)
• Volvulus = bowel twists and turns on itself
• Hernia = protrusion of intestine through a
weakened area in the abdominal muscle or
wall.
• Tumor
Intestinal Obstruction
• Nonmechanical obstruction = results from
neurological or vascular disorder
– Paralytic ileus = lack of intestinal peristalsis
and the no presence of bowel sounds, is the
most common form of nonmechanical
obstruction.
• May be due to postoperative abdominal
surgeries.
– Mesenteric infarction
Intestinal Obstruction
Clinical Small intestinal Large intestinal
manifestation obstruction obstruction
s
Onset rapid Gradual
Vomiting Frequent and Rare
copious
Pain Colicky, Low-grade,
cramplike, cramping abdominal
intermittent pain
Bowel Feces for a Absolute constipation
movement short time
Abdominal Greatly Increased
distention increased
Intestinal Obstruction
• Diagnostics:
– Abdominal x-rays = most useful diagnostic
aids. Will show the presence of gas and fluid
in the intestine.
– Barium enemas = used to locate large
intestinal obstructions
– UGIS
– CBC = increased WBC may indicate
strangulation or perforation.
Intestinal Obstruction
• Surgical management:
• Partial or total colectomy, colonoscopy, or
ileostomy = only done in cases of extensive
obstruction or necrosis
• Medical managements:
• The goals of treatment are relief of the
obstruction and correction and
maintenance of F&E balance.
Intestinal Obstruction
• NPO status, IVF (NSS or D5LR)
• Insertion of an NG tube to decompress
bowel and relieve abdominal distention.
• Analgesics
Intestinal Obstruction
• Nursing managements:
• Auscultating bowel sounds.
• Measure abdominal girth for signs of
abdominal distention
• Assess passage of stool or flatus
• F&E balance by monitoring I&O = monitor
signs of dehydration
Intestinal Obstruction
• Check NGT q 4 hours
–Provide mouth care, encourage the
patient to brush teeth, and provide
petroleum jelly or water-soluble
lubricant.
• Provide comfort measures and promote
restful environment.
• Keep distractions and visitors at a
minimum.
MANAGEMENT OF CLIENTS WITH ANORECTAL
DISORDERS
Hemorrhoids
• are dilated hemorrhoidal veins.
• Types:
– Internal = occurring above the internal
sphincter.
– External = occurring outside the external
sphincter. Most obvious and visible.
Hemorrhoids
Hemorrhoids
Hemorrhoids
• Causes:
– Result of straining at defecation, venules
become dilated.
• Precipitating factors:
– Pregnancy
– Prolonged constipation
– Heavy lifting
Hemorrhoids
– Prolonged standing and sitting
– Portal hypertension as found in cirrhosis
• Clinical manifestations:
– Internal hemorrhoids may be asymptomatic.
– Rectal bleeding
– Pruritus
– Prolapsed
– Anal pain
Hemorrhoids
• Diagnostics:
– DRE, anoscopy and sigmoidoscopy = used to
diagnose internal hemorrhoids
– Visual inspection and DRE = used to diagnose
external hemorrhoids.
Hemorrhoids
• Surgical therapy:
– Rubber band ligation = an anoscope is
inserted to visualize hemorrhoids and then
ligated with a rubber band. The rubber band
around the hemorrhoid constricts
circulation, tissue becomes necrotic,
separates, and sloughs off.
• Most widely used technique.
Hemorrhoids
• No anesthetic is required. Aspirin or
acetaminophen is given
– Cryotherapy = involves rapid freezing of the
hemorrhoid.
• Used less often because it can result in
acute pain.
– Hemorrhoidectomy = is the surgical excision
of hemorrhoids.
Hemorrhoids
• Nursing managements:
– Prevent constipation
• Stool softeners (Docusate [Colace])
• Increase fluid intake and high-fiber diet
– Reduce pain in the area
• Sitz bath 15 – 20 mins two to three times a
day for 7 – 10 days.
• Nupercainal ointment
Hemorrhoids
– Hydrocortisone cream = should be limited to
1 week or less to prevent side effects:
• Contact dermatitis
• Mucosal atrophy
• Anesthetics (Benzocaine)
Hemorrhoids
• Postoperatively:
– Nitroglycerine topical to reduce pain.
– Assess for rectal bleeding. Packing may be
inserted into the rectum to absorb drainage.
Anal Fissure
• is a skin ulcer or a crack in the lining of the anal
wall that is caused by trauma, local infection, or
inflammation.
• Cause:
– Primary fissures = occur as a result of local
trauma associated with defecation or forced
trauma such as rape.
Anal Fissure
• Secondary fissures = due to IBD, prior anal
surgery, infection (syphilis, TB, Chlamydia,
gonorrhea, herpes simplex virus and HIV)
• Manifestations:
– Anal pain severe during and after defecation.
– Slight and bright red anal bleeding.
– Constipation due to fear of pain associated
with bowel movement.
Anal Fissure
• Diagnosis:
– physical examination
• Managements:
– Local injection of botulin toxin (botox)
– Topical NTG, calcium channel blockers = are
used to decrease rectal anal pressure.
– Aesthetic suppository (Anusol)
Anal Fissure
– Stool softeners
– Fiber supplement, adequate fluid intake and
hot sitz bath

• Surgical management:
– Internal sphincterotomy = excision of the
fissure
Anorectal abscess
• collection of perianal pus.
• Cause:
– E. coli, staphylococci, and streptococci =
most common cause
– Secondary to anal fissures, IBD, and trauma
Anorectal abscess
• Clinical manifestations:
– Local pain and swelling
– Foul-smelling drainage
– Tenderness
– Elevated temp
Anorectal abscess
– Diagnostic: DRE
– Surgical management:
• Drainage of the abscess and anal packing
– Nursing management:
• Changing of anal packing when soiled with
urine and feces.
• Moist and hot compress applied to the area
• Low-fiber diet
Anal Fistula
• is an abnormal tunneling leading from the anus
or rectum extending to the outside of the skin,
vagina, or buttocks and often precedes an
abscess.
• Cause:
– complication of Crohn’s disease
Anal Fistula
• Manifestations:
– Persistent, blood-strained, purulent
discharge or stool leakage from the fistula.
Anal Fistula
• Surgical management:
– Fistulotomy = fistula is opened, and healthy
tissue is allowed to granulate.
– Fistulectomy = excision of the entire
fistulous tract. Gauze packing is inserted.
– Nursing management: same as hemorrhoids
• Nursing managements:
– Prevent constipation
• Stool softeners (Docusate [Colace])
• Increase fluid intake and high-fiber diet
– Reduce pain in the area
• Sitz bath 15 – 20 mins two to three times a
day for 7 – 10 days.
• Nupercainal ointment
– Hydrocortisone cream = should be limited to
1 week or less to prevent side effects:
• Contact dermatitis
• Mucosal atrophy
• Anesthetics (Benzocaine)
• Postoperatively:
– Nitroglycerine topical to reduce pain.
– Assess for rectal bleeding. Packing may be
inserted into the rectum to absorb drainage.