Disorders of Small and Large Intestine

Lec: 09
BY
Asif Ali Magsi
Nursing Lecturer
BCON,SMBBMU Lrk 1
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Irritable Bowel Syndrome (IBS)

 Irritable bowel syndrome (IBS) is called a functional
disorder it is not considered a disease as such because there
are no organic abnormalities or physical changes when the
colon is examined.

 Understanding IBS is important because it is often confused

with other similar digestive disorders, such as inflammatory
bowel diseases.

 It occurs more commonly in women

than in men(Smeltzer., Bare., Hinkle. & Cheever. 2010).

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Cont…
 The bowel is the part of the digestive system that makes and
stores stool.

 The word syndrome means a group of symptoms. IBS is a

syndrome because it can cause several symptoms. For
example, IBS causes cramping, bloating, gas, diarrhea, and
constipation.

 Irritable bowel syndrome (IBS) is a chronic gastrointestinal

disorder of unknown cause.
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Cont…
 It is not contagious, inherited, or cancerous. However, it often
disrupts daily living activities

 Also known as spastic colon, nervous bowel, irritable colon

and mucous colitis.

 However, IBS is not a true “colitis.” The term colitis refers to

a separate condition known as inflammatory bowel disease
(IBD).
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Symptoms of IBS…
 The primary symptom is an alteration in bowel patterns—
constipation, diarrhea, or a combination of both.

 Pain, bloating, and abdominal distention often accompany

this change in bowel pattern.

 The abdominal pain is sometimes precipitated by eating and

is frequently relieved by defecation.
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Causes
 The exact cause of IBS is not known.

 Factors are associated with the syndrome:

 Psychological stress, depression and anxiety,

 Diet high in fat and stimulating or irritating foods,

 Alcohol consumption, and smoking.

 Sensitive and reactive colon

 Family history of IBS

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Other Contributing Factors

 Lactose intolerance

 Inflammatory bowel disease (IBD) ulcerative colitis crohn’s

disease
 Celiac disease

 Diverticulitis

 Abuse of laxatives

 Tumors of the digestive system

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Diagnostic Findings
 A definite diagnosis of IBS requires tests that prove the
absence of structural or other disorders.

 Stool test

 Contrast x-ray

 Proctoscopy may be performed

 Barium enema and

 Colonoscopy
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Assessment
 Specific diagnostic criteria established through international
consensus conferences have led to improve diagnosis of IBS.
Criteria include:
 Recurrent pain or discomfort for at least 3 days a month in the
past 3 months, including 2 or more of the following:
1. Improvement with defecation
2. Onset associated with change in frequency of stool.
3. Onset associated with change in appearance (form) of stool.
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Red Flag Indicators

 Unintentional and unexplained weight loss

 Rectal bleeding

 A family history of bowel or ovarian cancer

A change in bowel habit to looser and/or more frequent

stool persisting for more than 6 weeks in a person over the
age of 60 years
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Cont...
 Anaemia

 Abdominal masses

 Rectal masses

 Inflammatory markers for inflammatory bowel disease

 Ifthere is significant concern that symptoms may suggest

ovarian cancer then a pelvic examination should be considered
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Medical Management
 Antidiarrheal

 Antidepressants (citalopram (Celexa) Paroxetine)

 Anticholinergics ( Benztropine)
 Calcium channel blockers decrease smooth muscle spasm,
decreasing cramping and constipation. Nifidpine
verapamal
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Nursing Management (Diet)

 Restriction and then gradual reintroduction of foods that are
possibly irritating.
 Encouraged to keep a food diary looking for trigger foods and
variants that may help determine what types of food are acting
as irritants (e.g. beans, caffeinated products, fried foods,
alcohol, spicy foods).
 A healthy, high-fiber diet is prescribed to help control the
diarrhea and constipation.
 Drink at least 8 cups of fluid per day, especially water or non
caffeinated drinks.
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Psychological Treatment
 Controversial and complex

 Anxiety and depression are common in patients with IBS

 Patients report a close relationship between stress and gut

symptoms providing a pragmatic rationale for psychological
therapy including:
 Relaxation training, cognitive behavioural therapy,
psychodynamic interpersonal therapy and hypnotherapy
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Hernias
 A hernia occurs when an organ or fatty tissue squeezes
through a weak spot in a surrounding muscle or connective
tissue called fascia.

 Hernias that do not return to the abdominal cavity with rest or

manipulation and cause complete bowel obstruction are said
to be incarcerated.

 If the blood supply to the hernia is cut off, the hernia is said to
be strangulated.
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Types
The most common types of hernia
are:
 Inguinal (inner groin)

 Incision (resulting from an

incision)
 Femoral (outer groin)

 Umbilical (belly button), and

 Hiatal (upper stomach).

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Cont..
 Inguinal Hernia: The intestine or the bladder protrudes
through the abdominal wall or into the inguinal canal in the
groin.
 Incisional Hernia: The intestine pushes through the
abdominal wall at the site of previous abdominal surgery.
 Femoral Hernia: Occurs when the intestine enters the canal
carrying the femoral artery into the upper thigh.
 Umbilical Hernia: Part of the small intestine passes through
the abdominal wall near the navel.
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Causes
 Lifting heavy objects without stabilizing the abdominal
muscles.

 Diarrhea or constipation.

 Persistent coughing or sneezing.

 In addition, obesity, poor nutrition, and smoking, can all

weaken muscles and make hernias more likely.
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S/S
 The signs and symptoms of a hernia can range from noticing:

 The most common symptom of a hernia is a bulge or lump in

the affected area.

A painless lump to the severely painful, tender, swollen

protrusion of tissue that you are unable to push back into the
abdomen (an incarcerated strangulated hernia).
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Diagnosis
 Physical examination is often enough to diagnose a hernia.

 Ultrasound may be used to see a femoral hernia.

 Abdominal X-rays may be performed to identify a bowel

obstruction.
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Medical–Surgical Management
 Some hernias have no symptoms or minimal symptoms, so clients
may not be aware they have one or may learn to live with it by
reducing it when needed.
 Clients who are a poor surgical risk may use a truss, a device that
applies pressure to the hernia, thus keeping the intestine in the
abdominal cavity.
 Hernias are repaired with surgery called herniorrhaphy.
 The surgery is performed laparoscopically.
 Initially, the client will have an NG tube.
 The NG tube is removed 24 to 48 hours later and the diet gradually
progressed to a soft diet.
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Nursing Management
 Assess abdomen for bowel sounds and bulge in abdominal wall
every 4 hours.
 Encourage client with hernia to eat small, frequent meals and
avoid lying down for 2 hours after eating.
 Administer analgesics as ordered.
 Educate regarding signs of complications and when to notify
staff of symptoms.
 Insert NG tube to decrease abdominal distention as ordered .
 Administer IV hydration as ordered.
 Prepare client for surgery as ordered. Keep client NPO.
 Provide pre & post operative care
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Intestinal Obstruction
 Exists when there is obstruction in the normal flow of
intestinal contents through the intestinal tract.

 Mechanical obstruction: on the intestinal walls occurs due

to stenosis, strictures, adhesions, hernias, and abscesses.

 Functional obstruction: Intestinal musculature unable to

propel contents along the bowel due to muscular dystrophy,
endocrine disorders i.e. diabetes mellitus, or neurologic
disorders.

 May be partial or complete

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Causes
 SMALL BOWEL:

 Adhesions most common

 Intussusception

 Volvulus

 Paralytic ilieus

 Abdominal hernia
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Causes
 LARGE BOWEL:

 Carcinoma

 Diverticulitis

 Inflammatory bowel disorders

 Volvulus
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Small Bowel vs. Large Bowel

 Small:  Large:

 Symptoms develop slowly

 Abdominal pain

 Constipation
 Vomiting

 Distended abdomen
 Pass blood and mucous, no
stool, no gas  Crampy lower abdominal pain

 Over time signs of  Fecal vomiting

dehydration
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Assessment & Diagnostic Findings

 Large Bowel
 Small Bowel

 Based on symptoms
 Based on symptoms

 Abdominal x-ray (flat and

 Abdominal x-ray
upright)
 Electrolyte studies
 Electrolyte studies.

 Complete blood cell

count Note: Barium studies are
contraindicated.
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Medical Management
Small Bowel Large Bowel
 Decompression of the bowel  A colonoscopy may be

through a nasogastric or small performed to untwist and

bowel tube is successful in decompress the bowel.
most cases.  A cecostomy, in which a

 When the bowel is completely surgical opening is made

into the cecum, may be
obstructed, the possibility of
performed
strangulation warrants
surgical intervention.
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Nursing Management of Small Bowel

 Maintaining the function of the nasogastric tube.
 Assessing and measuring the nasogastric output.
 Assessing for fluid and electrolyte imbalance.
 Monitoring nutritional status.
 Assessing improvement (e.g. return of normal bowel sounds.
 Decreased abdominal distention.
 Subjective improvement in abdominal pain and tenderness,
passage of flatus or stool).
 Maintaining intake out put chart
 Pre & post operative care is same as other surgery.
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Nursing Management of Large Bowel

 Monitor the patient for symptoms that indicate that the
intestinal obstruction is worsening.
 Provide emotional support and comfort.
 Administers intravenous fluids and electrolytes as prescribed.
 If the patient’s condition does not respond to nonsurgical
treatment, the nurse prepares the patient for surgery.
 This preparation includes preoperative teaching as the
patient’s condition indicates.
 After surgery, general abdominal wound care and routine
postoperative nursing care are provided.
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Appendicitis
 Inflammation of the vermiform appendix is known as
appendicitis.

 Males are affected more than females, and teenagers more

than adults.

Causes
 Obstruction from stool, foreign body,
cancer, and infection
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S/S
 Abdominal pain begins periumbical and travels to right lower
quadrant.
 Fever due to infection
 Nausea, vomiting, loss of appetite

 Rebound tenderness

 Rigidity of the abdomen

 Right lower quadrant pain that improves with flexing the

right hip suggests perforation
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Assessment & Diagnostic

 Elevated white blood cell count (WBC).

 CT scan shows enlarged appendix or facility.

 Ultrasound may show enlarged appendix.

Complications
 Perforation leading to peritonitis or an abscess.
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Medical Management:
 Surgical removal of the appendix—appendectomy (may be done
via laparoscopy or open laparotomy).
 Intravenous fluids until diet resumed.

 Analgesics

 NPO—nothing by mouth to avoid further irritation of the

intestinal area, and prep for surgery.
 Preoperatively to maintain awareness of increase in pain due to
possible rupture of appendix.
 Antibiotics postoperatively if needed.
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Nursing Management
 Assess pain.
 Keep client NPO.
 Monitor intake and output.
 Monitor vital signs, especially temperature.
 Assess bowel sounds.
 Monitor the results of the CBC, especially WBC and
neutrophils.
 Postoperatively, encourage client to turn, cough, and deep
breathe every 2 hours.
 Monitor surgical site for appearance of wound, drainage.
 Encourage ambulation.
 Advance diet from liquid to regular as bowel function returns.
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Peritonitis
 Peritonitis is an acute inflammation of the peritoneum, the
serous membrane lining the abdominal cavity and covering the
organs.
 Peritonitis is a serious, life-threatening condition.

Causes:
 Peritonitis is caused by: Irritating substances such as feces,
gastric acids, bacteria, or blood in the abdominal cavity.
 A ruptured portion of the digestive system (such as the
appendix), a ruptured tubal pregnancy, or invasion of tumors
through the gastric wall can lead to peritonitis.
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S/S
 Abdominal pain or tenderness
 Bloating or a feeling of fullness (distention) in abdomen
 Fever
 Nausea and vomiting
 Loss of appetite
 Diarrhea
 Low urine output
 Thirst
 Inability to pass stool or gas
 Fatigue
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Tests and Diagnosis

 Peritoneal fluid analysis (for WBC count, bacteria, bile).

 Blood tests. (WBC Count, Blood cultures to identify

organisms.
 Imaging tests.

 Abdominal x-rays to show free air from perforation.

 Ultrasound to identify causative problem (appendicitis, etc.).
 CT scan to identify causative problem (appendicitis, salpingitis,
etc.).
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Cont..
Complications
 Adhesions (scar tissue), paralytic ileus, and pneumonia.

 A bloodstream infection (bacteremia).

 An infection throughout your body (sepsis). Sepsis is a rapidly

progressing, life-threatening condition that can cause shock
and organ failure.
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Medical & Surgical Treatments

 Antibiotics. Pre & post operatively.

 Analgesics: post operatively

 Other treatments. Depending on sign & symptoms.

 Surgery. Treatment is primarily surgical with repair of the

cause and irrigation of the abdominal cavity with saline and
antibiotic solutions.
 Drains are left in the abdomen for several days postoperatively
to allow any remaining fluid to drain.
 NG tube is placed to decompress the abdomen and relieve
nausea.
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Nursing Management
 Weigh daily.
 Monitor vital signs.
 Monitor intake and output.
 NPO to avoid irritation of intestinal tract, further stress on
abdominal organs.
 Position for comfort, head of bed elevated.
 Assess for return of bowel sounds postoperatively.
 Teach patient about home care:
 Pain management.
 Wound care, drains, etc.
 Monitor for signs of infection.
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Reference
 Smeltzer. S. C., Bare. B.G., Hinkle. J. L & Cheever. K. H. (2010).
Textbook of Medical – Surgical Nursing. Vol -I (12th Ed.). Lippincott
Williams & Williams. Tokyo.

 White.L., Duncan.D & Baulme.W. (2011). Foundations of Adult Health

Nursing. Cengage Learning. United States.

 DiGiulio. M., Jackson. D. & Keogh.J. (2007). Medical-Surgical Nursing

Demystified- A self Teaching Guide. McGraw-Hill. Toronto.
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Any questions?