2.4 Gastrointestinal Flashcards
Diarrhea
Diarrhea Acute or Chronic Watery stools daily Can lead to dehydration Can lead to hypokalemia, hypomagnesemia and metabolic acidosis. Electrolyte loss Vascular collapse
Constipation
Constipation
Fewer than three bowel movements (BMs) per week. Hard stools, incomplete evacuation, or manual evacuation
Common in older adults
More common in women
Therapeutic Diets
Diarrhea
Diarrhea
Fluid replacement/glucose/balanced electrolyte solution.
Hold solid food 24 hours of acute diarrhea to rest the bowel.
BRAT diet (bananas, rice, applesauce, and toast)
Avoid Milk, raw fruits, vegetables, fried foods, bran, whole-grain cereals, condiments, spices, coffee, and alcohol
Therapeutic Diets
Constipation
Constipation
Foods that have high fiber
Raw fruits, vegetables and cereal bran. (apples)
Drink at least 6-8 glasses of fluid per day.
Diet history and fluid intake
Exercise
Constipation and the Older Adult
Slowed peristalsis, lowered activity levels, Reduced food and fluid intake, Decreased sensory perception Chronic Disease Mobility problems, Medications Constipation is not normal
Fecal Impaction
Significant constipation/long-term dependence on laxatives or enemas
Rock-hard or putty-like mass of feces in the rectum.
Abdominal fullness and cramping
Sensation of fullness in the rectal area
Constipation/Fecal Impaction Treatment
History and Physical Digital examination Education Diet modification Routine exercise Diagnostic examination
Clostridium difficile (CDI) gastroenteritis what is it?
Bacterial enterotoxins Loss of normal flora/Overgrowth of pathogens Severe infection of the colon Antibiotic-associated infection Affects food digestion Causes diarrhea
Clostridium difficile (CDI) gastroenteritis
Incubation
Pathogenesis
Manifestations
Incubation
1–2 weeks
Wash hands with soap and water
Pathogenesis
Antibiotic therapy interferes with normal protective bacteria in the colon. Switching antibiotics to one that is not resistant to C-Diff
Manifestations
Diarrhea, abdominal cramps, malaise, fever, anorexia
Clostridium difficile (CDI) gastroenteritis Management
Management
Cessation of the causative antibiotic; antibiotic therapy with metronidazole (specific forC. difficile)—possibly vancomycin for resistant strains
Assessment Of Pt. with Clostridium difficile
Health history
Health history:Duration and extent of diarrhea; associated manifestations; dietary intake; recent travel out of the country or to wilderness areas; previous history of diarrhea; chronic diseases; prescription and nonprescription medications
Assessment Of Pt. with Clostridium difficile
Physical assessment
Physical assessment:Vital signs (including orthostatic blood pressure); peripheral pulses; skin temperature, moisture, turgor; color and moisture of mucous membranes; abdominal contour and girth; bowel sounds; stool for obvious or occult blood, pus, mucus, orsteatorrhea(bulky, foul-smelling stool containing fat/grease).
Treatment of pt. with Clostridium difficile
Limit food intake if the diarrhea is acute, rest bowels
Promote balanced fluid and electrolyte status
Administer antidiarrheal medications as prescribed
Fecal microbiota transplant
Irritable Bowel Syndrome (IBS)
what is it
Motility disorder of the lower GI tract. Affects 10-15% of the adult population Young people most affected Higher in women than men Depression and anxiety linked to IBS
Signs and Symptoms (IBS)
IBS s/s Abdominal bloating, gas Nausea, vomiting, anorexia, fatigue Headache, depression, or anxiety Colicky, spasms, or dull and continuous pain Change in frequency Hard or lumpy, loose or watery Straining, urgency, or a sensation of incomplete evacuation Tender near the sigmoid colon
Inflammatory Bowel Disease (IBD)
Crohns Disease
Crohns Disease
Etiology Unknown
Chronic inflammatorydisorder affecting the gastrointestinal tract.
Can affect any portion of the GI tract from the mouth to the anus, but usually affects the terminal ileum and ascending colon.
Inflammatory Bowel Disease (IBD)
Ulcerative Colitis
Ulcerative Colitis
Etiology Unknown
Chronicinflammatorydisorder that affects the mucosa and submucosa of the colon andrectum.
Onset is usually insidious,
Attacks that last 1 to 3 months occurring at intervals of months to years.
Inflammatory Bowel Disease (IBD)
Crohns Disease
Crohns Disease
Age at onset 15–30/60–80 years
Disease: Slowly progressive, relapsing
Diarrhea: Less severe than colitis, no blood or mucus in stool
Pain: Cramping right lower quadrant
Nutrition: anemia, weight loss, multiple vitamin and mineral deficits
Bowel Involved: terminal ileum and ascending colon
Inflammatory Bowel Disease (IBD)
Ulcerative Colitis
Ulcerative Colitis
Age at onset 15–30/60–80 years
Disease: Chronic and intermittent
Diarrhea: 5–30 stools per day with blood and mucus
Pain: Cramping in left lower quadrant; relieved by defecation
Nutrition: anemia, hypoalbuminemia, and weight loss
Bowel Involved:rectum and sigmoid colon
Diverticular Disease
what is it
Diverticulaare small (0.5- to 1.0-cm) outpouchings of the colon that occur in rows Increases with age Diet plays a factor Lifestyle choices Men and women are equally affected
Diverticular disease forms when high pressure causes mucosa to herniate through the muscle wall, forming a diverticulum. A diverticula begins to form when there is increased pressure.
A diverticulum forms from high pressure goes through 3 layers
Diverticular Disease
Diverticulosis
Diverticulosis
Presence of diverticula Asymptomatic but Pain (usually left-sided), Constipation, and diarrhea occur, Complication is hemorrhage/diverticulitis
However as the disease progress the patient will experience narrow stools, abdominal cramping, increased constipation, bleeding in stools, weakness, and fatigue
Diverticular Disease
Diverticulitis
Diverticulitis
Inflammation in and around the diverticular saccausing pain.
Usually affects 1 diverticulum
Sigmoid colon
Undigested food/bacteria forms hard masses.
Low grade temp/ abdomen tenderness
undigested food and bacteria to cause a decrease in blood flow potentially causing a perforation
Malabsorption Syndromes (3 common) Celiac disease
Celiac disease
chronic T-cell-mediated autoimmune genetic disorder of the small intestine in which the absorption of nutrients, particularly fats, is impaired.
Malabsorption Syndromes (3 common) Lactose intolerance
Lactose intolerance
Lactase deficiency is usually genetic in origin, but also occurs secondarily to celiac disease, Crohn disease, and other disorders affecting the mucosa of the small intestine.
Malabsorption Syndromes (3 common) Short bowelsyndrome
Short bowelsyndrome
Resected small bowel due to tumors, infarction of bowel mucosa, incarcerated hernias, Crohn disease, bariatric surgery, trauma, and enteropathy resulting from radiation therapy
Colorectal Cancer
what is it/info
Cancer of the colon or rectum
Cause unknown
3rd most common cancer diagnosed in the United States.
Higher among African Americans
Occurs most frequently after age 50
Colorectal Cancer
Risk Factors
Risk Factors
Age over 50 years
Polyps of the colon and/or rectum
Family history of colorectal cancer
Personal history of colorectal, ovarian, endometrial, or breast cancer
Inflammatory bowel disease
Exposure to radiation
Diet: High animal fat and kilocalorie intake
Obesity, smoking, and alcohol use.
Colorectal Cancer Complications
(1) Bowel obstruction due to narrowing of the bowel lumen by the lesion
(2) perforation of the bowel wall by the tumor, allowing contamination of the peritoneal cavity by bowel content
(3) Direct extension of the tumor to involve surrounding organs.
Colorectal Cancer Screening
Screening
Yearly fecal occult blood test (FOBT) or fecal immunochemical test (FIT) or stool DNA test (sDNA)
Flexible sigmoidoscopy every 5 years,or Double-contrast barium enema every 5 years,or CT colonography (virtual colonoscopy) every 5 years,or Colonoscopy every 10 years.
Colorectal Cancer Diagnosis
Diagnosis
sigmoidoscopy or colonoscopy as the primary diagnostic test used to detect and visualize tumors
Colorectal Cancer Surgery
Surgery
Surgical resection of the tumor, adjacent colon, and regional lymph nodes is the treatment of choice for colorectal cancer
Caring for the pt. with a Colostomy
Assess the stoma, monitoring the output
Provide stoma and dietary teaching
keep the stoma free from irritants
Empty a drainable pouch or replace the colostomy bag as needed
Provide stoma and skin care
No rectal suppositories, rectal temperatures, or enemas if had abdominoperineal resection
Adjunct Therapy (Colorectal Cancer) Radiation Therapy
Radiation Therapy
Not primary treatment/used with surgical resection( rectal tumors)
Preoperatively to shrink large rectal tumors to surgically able t remove it
**Together radiation therapy, chemotherapy reduces the rate of tumor recurrence and prolongs survival for patients with stage II and stage III rectal tumors.
Adjunct Therapy (Colorectal Cancer) Chemotherapy
Chemotherapy
used to reduce its spread to the liver and prevent recurrence.
Used postoperatively as adjunctive therapy
**Together radiation therapy, chemotherapy reduces the rate of tumor recurrence and prolongs survival for patients with stage II and stage III rectal tumors.
Preventative measure of Colon Cancer
Consuming a diet high in fruits and vegetables and low in saturated fat and red meat, regular exercise, maintaining a healthy weight, limiting alcohol consumption, and quitting smoking. Consuming fiber supplements, minerals such as calcium, vitamins, and NSAIDs may help preventcolorectalcancer(ACS, 2018).
Although considered safe, these measures are the subject of further research to demonstrate conclusive proof of effectiveness.
Constipation/Fecal Impaction Treatment
Laxatives
Laxatives should not be given if a patient has an undiagnosed intestinal obstruction, abdominal pain,fecalimpaction, rectal fissures, ulcerated hemorrhoids, Crohn disease, ulcerative colitis, or chronic inflammatory bowel disease.
When the bowel is obstructed, laxatives or cathartics may cause serious mechanical damage and perforate the bowel.
Irritable Bowel Syndrome (IBS)
Diagnosis
The goal is to rule out other causes of abdominal pain and altered fecal elimination.
An occult stool may be examined for blood, ova and parasites, and lab test to identify white blood cells (WBCs). Which if elevated could indicate a bacterial infection
A sigmoidoscopy, colonoscopy, and/or a small-bowelseries (upper GI series with small-bowelfollow-through) and barium enema may be performed to look the bowelmucosa.
May need a biopsy if there are any lesions. Laboratory tests include a complete blood count (CBC) including WBC to rule out bacterial infection.
Irritable Bowel Syndrome (IBS)
Medications
Antispasmodic agents are sometimes used for treatment of acute episodes characterized by significant pain or bloating.
Loperamide may be used for patients with diarrhea and oral osmotic laxatives may be used for patients experiencing constipation
Antidepressant drugs, including tricyclics and selective serotonin reuptake inhibitors (SSRIs), may help relieve abdominal pain associated with IBS
Irritable Bowel Syndrome (IBS)
Nutrition
Foods rich in dietary fiber. Example bran adds bulk and water to the stool, decreasing loose and hard stools.
The patient has to learn what triggers their IBS.
For lactose, fructose, or
sorbitol may irritate the bowel. Gas forming foods like beans, cabbage, apple andgrape juices, nuts, and raisins, Caffeinated drinks, such as coffee, tea, and soft drinks, act as gastrointestinal stimulants; limiting intake of these fluids may prove beneficial.
Irritable Bowel Syndrome (IBS)
Integrative Therapies
Herbal preparations may provide some benefit for patients with IBS. Herbs with an antispasmodic effect, such as anise, chamomile, peppermint, and sage, may be used to reduce the manifestations of IBS.
Ginger root can be consumed as a tea or capsule to assist with reduction of gas, bloating, and diarrhea and to improve the functioning of the stomach.
Probiotic therapies (such as yogurt with active bacterial cultures) have been shown to benefit patients with IBS
**no cure
Inflammatory Bowel Disease (IBD)
Crohndisease
Crohndisease, also known asregional enteritis, is a chronic, relapsinginflammatorydisorder affecting the gastrointestinal tract. Crohndiseasecan affect any portion of the GI tract from the mouth to the anus, but usually affects the terminal ileum and ascending colon. Only the smallbowelis involved in nearly 40% of patients with Crohndisease. Thediseaseis limited to the colon only in 30% of those affected. Both the small and large intestine are involved in the remaining 30% of patients
Inflammatory Bowel Disease (IBD)
Ulcerative colitis
Ulcerative colitisis a chronicinflammatoryboweldisorder that affects the mucosa and submucosa of the colon andrectum. Most people with ulcerative colitis have mild or moderatedisease, with six or fewer stools per day. Its onset is usually insidious, with attacks that last 1 to 3 months occurring at intervals of months to years. Typically, only the distal colon is affected, with few systemic manifestations of thedisease.
Diverticulosis/Diverticulitis
Diagnosis
Diagnosis
a colonoscopy may be done to detectdiverticulosis, assess for strictures or bleeding, and rule out tumor as the cause of the patient’s manifestations. CT scan will be done to confirm diagnosis, grade severity, detect abscess of fistula, and guide treatment
Hemoccult or guaiac to rule out the presence blood is done, and lab draw to check WBC to identify count, which may show leukocytosis with a left shift (an increased number of immature WBCs) due to inflammation in diverticulitis.
Diverticulosis/Diverticulitis
Medications
Medications
Systemic broad-spectrum antibiotics effective against usual bowel flora are prescribed to treat acute diverticulitis.
metronidazole (Flagyl) and ciprofloxacin (Cipro) or trimethoprim-sulfamethoxazole (Septra, Bactrim) may be prescribed if manifestations are mild.
If the attack is severe patient may need to be hospitalization and treated with an IV and antibiotics
Diverticulosis/Diverticulitis
Nutrition
Nutrition
A high-fiber diet is recommended; it increases stool bulk, decreases intraluminal pressures, and may reduce spasm
Bran is a low-cost fiber supplement that can be added to cereal, soups, salads, or other foods. Commercial bulk-forming products, such as psyllium
seed (Metamucil) or methylcellulose, also may be recommended, avoid foods with small seeds (such as popcorn, caraway seeds, figs, or berries),
which could obstruct diverticula, but these traditional dietary restrictions are not based on rigorous evidence-based research
Diverticulosis/Diverticulitis
Interprofessional Care
Interprofessional Care
Management of diverticular disease varies from no prescribed treatment to surgical resection of affected colon, depending on the severity of the disease and its complications.
Malabsorption Syndromes
what is it
Regardless of the cause,malabsorptioncause common manifestations resulting from impaired absorption of chyme and nutrients.
Results can include anorexia; abdominal bloating; diarrhea with loose, bulky, foul-smelling stools; and steatorrhea (fatty stools). Weight loss, weakness, general malaise, muscle cramps, bone pain, abnormal bleeding, and anemia are common systemic manifestations ofmalabsorption.
The cause is from malnutrition and fluid loss because of the inability to absorb.
Malabsorption Syndromes
Diagnosis
Diagnosis
Physical exam and laboratory and diagnostic testing are used to make the differential diagnosis for various causes ofmalabsorptionsyndromes and to determine the severity of nutrient deficiencies. Biopsy of the tissue is required for celiac disease
Malabsorption Syndromes
Medications
Medications
Patients with severe nutritional deficits may require vitamin and mineral supplements, as well as iron and folic acid to correct anemia. Vitamin K may be administered parenterally if the prothrombin time is prolonged. In patients whose disease fails to respond to dietary management, corticosteroids may be ordered to suppress the inflammatory response.
Malabsorption Syndromes
Nutrition
Nutrition
The patient with celiac disease is placed on a gluten-free diet. May be put on a diet high in calories and protein to correct nutrient deficits. Fat content may be restricted to decrease steatorrhea. The diet is usually restricted in lactose as well to compensate for the loss of lactase-containing microvilli. Foods containing lactose may be reintroduced once remission has occurred.
Malabsorption Syndromes
Interprofessional Care
Interprofessional Care
With any malabsorptive disorder, the initial focus of management is to identify the cause. Once this has been determined, specific therapy can be prescribed
Nursing priority of care is Diarrhea and malnutrition.
Irritable Bowel Disease
Diagnosis
Diagnosis
Diagnostic testing is used to establish the diagnosis of IBD, assess the extent of thedisease, and evaluate the effects of the disorder.
A sigmoidoscopy, colonoscopy, or a barium upper and lower x-ray series is performed to inspect thebowelmucosa for the characteristic changes of IBD.
Laboratory tests to differentiate IBD and to identify effects and complications of thediseaseinclude a stool examination for blood and mucus and stool cultures to rule out infectious causes ofbowelinflammation and diarrhea. CBC with hemoglobin and hematocrit shows anemia from chronic inflammation, blood loss, and malnutrition and leukocytosis due to inflammation and possible abscess formation. The sedimentation rate and levels of C-reactive protein are typically elevated during periods of acute inflammation. Serum albumin may be decreased because of malabsorption, malnutrition, protein loss through intestinal lesions, and chronic inflammation. Folic acid and serum levels of most vitamins—including A, B complex, C, and the fat-soluble vitamins—are often decreased due to malabsorption. Additional tests for renal and hepatic function may be done if the patient has significant systemic manifestations of thedisease.
Irritable Bowel Disease
Medications
Medications
The ultimate goal of care is to achieve and maintain remission of thediseaseand its symptoms.
Locally acting and systemic anti-inflammatorydrugs are the primary medications used to manage mild to moderate IBD.
Drugs to suppress the immune response may be used to treat patients with severedisease.
Sulfasalazine (Azulfidine) is a sulfonamide antibiotic and anti-inflammatorythat is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit theinflammatoryprocess. The active anti-inflammatoryingredient in sulfasalazine, 5-aminosalicylic acid (5-ASA), is also available in preparations that do not contain sulfa, such as olsalazine and mesalamine. They have the advantage of causing fewer adverse effects than sulfasalazine. Azo compounds, such as balsalazide and olsalazine, are 5-ASA compounds that are released in the colon and are especially useful for treating ulcerative colitis. Mesalamine (Asacol, Canasa, Rowasa) is an orally or rectally administered 5-ASA compound that provides topical anti-inflammatoryaction in the colon of patients with ulcerative colitis.
Irritable Bowel Disease
Nutrition
Nutrition
Antigens in the diet may stimulate the immune response in thebowel, exacerbating IBD.
Some patients benefit from eliminating all milk and milk products from the diet. Increased dietary fiber may help reduce diarrhea and relieve rectal manifestations, but is contraindicated for patients with intestinal strictures caused by repeated inflammation and scarring.
All food may be withheld to promotebowelrest during an acute exacerbation of Crohndisease. Nutritional status is maintained using enteral nutrition or TPN. An elemental diet such as Ensure, which contains all essential nutrients in a residue-free formula, may be prescribed. Elemental diets provide essential nutrients to the small intestine to support cell growth, but are not always palatable. TPN carries a higher risk of complications than does enteral nutrition.
Irritable Bowel Disease
Surgery
Surgery
Surgical interventions for IBD differ, depending on the primarydiseaseprocess and the portion of thebowelaffected. Generally, surgery is performed only when necessitated by complications of thediseaseor failure of conservative treatment measures.
Bowelobstruction is the leading indication for surgery in Crohndisease. Other complications that may require surgical intervention include perforation, internal or external fistula, abscess, and perianal complications. Resection of the affected portion ofbowelwith an end-to-end anastomosis to preserve as muchbowelas possible is the usual treatment. Thediseaseprocess tends to recur in other areas following removal of affectedbowelsegments. There is an increased risk of fistula formation following surgery.Bowelstrictures may be treated with a strictureplasty. In this procedure, longitudinal incisions are made in the narrowed segment to relieve the stricture while preservingbowel
