Gastrointestinal Exam Flashcards
Symptoms of Gastroesophageal Reflux
- Dyspepsia
- Regurgitation, eructation, flatulence
- Hypersalivation
- Dysphagia and odynophagia
- Others manifestations—chronic cough, asthma, atypical chest pain, bloating, nausea and vomiting (rare)
Esophageal Reflux
- Most common GI disorder in the US
- Occurs as a result of the backward flow (reflux) of GI contents into the esophagus.
- Esophageal reflux occurs when gastric volume or intra-abdominal pressure is elevated or the sphincter tone of the lower esophageal sphincter is decreased or relaxed.
Drugs to treat reflux
- Three main types
- Antacids elevate the pH level of the gastric contents- deactivating pepsin.
- Histamine receptor antagonists decrease acid production.
- Proton pump inhibitors provide effective, long-acting inhibition of gastric acid secretion.
- Prokinetic drugs increase gastric emptying and improve lower esophageal sphincter pressure and esophageal peristalsis.
Hiatal Hernia
- Protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest
- Sliding hernia—most common, occurring when esophagogastric junction and a portion of the fundus of the stomach slide upward through the esophageal hiatus into the thorax
- http://www.youtube.com/watch?v=-KPsGUCzi68
•Rolling hernia—fundus rolls into the thorax beside the esophagus
Symptoms of hernias
- Sliding hernia: symptoms mainly associated with reflux, detailed history to differentiate angina from non-cardiac chest pain caused by reflux.
- Heartburn
- Regurgitation
- Pain
- Dysphagia
- Belching (eructation)
- Worsening symptoms after eating or when in recumbent position
- Rolling hernia: symptoms will relate to stretching or displacement of thoracic contents
- Feeling of fullness after eating
- Breathlessness or feeling of suffocation
- Chest pain associated with reflux
- Diagnostics: Barium swallow study, EGD
What is Achasalia ?
- Rare esophageal motility disorder that results from loss of nerve impulses to the smooth muscle of the esophagus characterized by chronic and progressive dysphagia
- Primary symptoms—dysphagia and regurgitation of solids, liquids, or both
Drug therapy for achasala
- Calcium channel blockers, Nitrates- used to decrease LES pressure
- Direct injection of Botox into the lower esophageal muscle
- Semisoft, warm foods and liquids
- Smaller meals more frequently
- Arching the back while swallowing- changes pressure to aid in food passage
- Avoiding restrictive clothing- increases esophageal pressure
Acute vs Chronic gastritis
- Acute gastritis- can heal after several months
- Causes: Long-term NSAIDs, alcohol, caffeine, corticosteroids, radiation therapy, ingestion of corrosive agents, emotional stress
- Chronic gastritis:
- Type A gastritis- nonerosive, inflammation of the glands, fundus and body
- Type B gastritis (most common)- affects glands of antrum, but may involve entire stomach, caused by H. pylori infection, chronic local irritation (alcohol, radiation, smoking, some surgical procedures)
- Atrophic gastritis- affects all layers of the stomach, total loss of fundal glands, minimal inflammation, thinning of mucosa, intestinal metaplasia. These changes can lead to PUD and gastric cancer, most common in older adults, caused by exposure to toxic substances, H. pylori infection, autoimmune factors
Symptoms of acute vs. chronic gastritis
- Acute Gastritis
- Abdominal tenderness
- Bloating
- Hematemesis
- Melena
- Intravascular depletion and shock
- Chronic Gastritis
- Vague report of epigastric pain that is relieved by food
- Anorexia
- Nausea or vomiting
- Intolerance of fatty and spicy foods
- Pernicious anemia
Treatment options for gastritis
- Drug therapy:
- H2-receptor antagonists
- Mucosal barrier fortifier (Sucralfate)
- Antacids
- Antisecretory agents
- Vitamin B12
- Treatment for Helicobacter pylori infection
- Diet therapy:
- Limit intake of foods and spices that cause distress (tea, coffee, cola, chocolate, mustard, paprika, cloves, pepper, and hot spices), as well as tobacco and alcohol
- Stress reduction
Peptic ulcer disease
•PUD is a mucosal lesion of the stomach or duodenum caused when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin.
- 3 Types of Ulcers
- Gastric, duodenal, stress ulcers.
- Acid, pepsin, and Helicobacter pylori infection play an important role in the development of gastric ulcers.
Duodenal Ulcers
- Most duodenal ulcers occur in the first portion of the duodenum.
- Duodenal ulcers present as deep, sharply demarcated lesions that penetrate through the mucosa and submucosa into the muscle layer.
Stress Ulcers
- Acute gastric mucosa lesions occurring after an acute medical crisis or trauma
- Associated with head injury, major surgery, burns, respiratory failure, shock, and sepsis
- Principal manifestation—bleeding caused by gastric erosion
Complications of Ulcers
- Hemorrhage—hematemesis
- Perforation—a surgical emergency
- Pyloric obstruction—manifested by vomiting caused by stasis and gastric dilation
- Intractable disease—the patient no longer responds to conservative management, or recurrences of symptoms interfere with ADLs
Livers function
Liver continually forms and secretes bile which aids in the break down of fats.
Liver stores many minerals and vitamins (iron, magnesium, fat-soluble vitamins- A, D, E, K)
Protective functions-phagocytic cells that engulf harmful bacteria and anemic red cells. Detoxifies potentially harmful compounds (drugs, chemicals, alcohol). Risk of liver toxicity increases with aging because of the decreased liver function.
Metabolism of proteins considered vital for human survival- breaks down amino acids to remove ammonia and converted to urea and excreted via kidneys. Synthesizes several plasma proteins- albumin, prothrombin, and fibrinogen. Liver also stores and releases glycogen as the body’s energy requirements change (carbohydrate metabolism). Also synthesizes, breaks down, and temporarily stores fatty acids and triglycerides.
True or false
pH of stomach acid is 1.5-2, where pH of distal esophagus is neutral at 6.0-7.0.
true
Diagnostics for GERD
24 hr ambulatory esophageal pH monitoring: placing a small catheter through the nose into the distal esophagus. Pt needs to keep a diary of activities and symptoms, and the pH is continuously monitored and recorded. Useful in diagnosing based on atypical symptoms.
EGD: useful in evaluating reflux esophagitis or monitoring complications such as Barrett’s esophagus. Tissue samples can be obtained for biopsy and strictures can be dilated.
Esophageal manometry: (motility testing) not very common, water filled catheters are inserted in the patient’s nose or mouth and slowly withdrawn while measurements of LES pressure and peristalsis are recorded. Not a good tool alone for diagnosis of GERD
true or false
LNF: gold standard for surgical management of GERD. Wraps a portion of the stomach fundus around the distal esophagus to anchor it and reinforce the LES
true
Rolling Hernia
Rolling hernia: paraesophageal hernias. Reflux is not usually present because the LES remains anchored below the diaphragm. Risk for volvulus (twisting), obstruction (blockage), and strangulation (stricture) are high. Thought to develop from an anatomic defect occurring when the stomach is not properly anchored below the diaphragm rather than from muscle weakness. Can also be caused by previous esophageal surgeries.
Barium swallow
Barium swallow: most specific for identifying. Rolling hernias are usually clearly visible, and sliding hernias can often be observed when the patient moves through a series of positions that increase intra-abdominal pressure
Peptic ulcer disease
When a break in the mucosal barrier occurs, hydrochloric acid injures the epithelium- ulcers develop as a result of back diffusion of acid or dysfunction of the pyloric sphincter. When the pyloric sphincter is not functioning, bile can reflux into the stomach which further impairs the integrity of the mucosal barrier and produce hydrogen ion back diffusion, causing mucosal inflammation and destruction of the gastric mucosa.
Complications of ulcers
Hemorrhage—hematemesis
Perforation—a surgical emergency
Pyloric obstruction—manifested by vomiting caused by stasis and gastric dilation
Intractable disease—the patient no longer responds to conservative management, or recurrences of symptoms interfere with ADLs
Signs of a GI bleed
Bright red or coffee-ground vomitus Tarry stools or frank blood in stools Melena (occult blood) Decreased blood pressure Increased weak and thready pulse Decreased hemoglobin and hematocrit Vertigo Acute confusion Dizziness Syncope
Drug therapy for GI bleed
Four primary goals for drug therapy: Provide pain relief Eradicate Helicobacter pylori infection Heal ulcerations Prevent recurrence
Drug therapy for GI bleed con…
H.pylori- triple therapy- PPI and 2 antibiotics for 7-14 days
PPIs- Prilosec, prevacid, aciphex, protonix, nexium
H2 receptor antagonists- Zantac, Pepcid, Axid
Prostaglandin analogues- cytotec (most commonly used to prevent NSAID induced ulcers) side effect is uterine contractions- makes menstrual cramps worse
Antacids- Mylanta, Maalox (aluminum hydroxide and magnesium hydroxide), can interact with certain drugs- Dilantin, tetracycline-interfering with effectiveness
Mucosal barrier fortifiers- Sucralfate (Carafate), does not inhibit acid secretion, but binds bile acids and pepsins, reducing injury from these substances. Used in conjunction with H2 receptor antagonists and antacids, but should not be administered within 1 hour of the antacid. Main side effect is constipation.
GI bleed solutions
Endoscopic therapy can assist in achieving hemostasis- EGD to cauterize vessels
Acid-suppressive agents are used to stabilize the clot by raising the pH level of gastric contents and prevent rebleeding
Upper GI bleeding may require the health care provider to insert nasogastric tube.
Saline lavage requires the insertion of a large-bore nasogastric tube.
What is the mos common cause of GERD?
Excessive relaxation of lower esophageal sphincer
true or false
Noninflammatory problems tend to cause rectal/lower GI bleeding
true
Common symptom of IBS
Most common symptom is pain in the left lower quadrant
Nausea with meals and defecation
Crampy abdominal patterns are accompanied by constipation and diarrhea
Interventions of IBS
Interventions include health teaching, drug therapy, and stress management
Keep a symptom diary- record potential triggers and bowel habits for a period of time can assist in identifying new triggers.
5-HT4 antagonists- last resort in women with diarrhea predominant symptoms
M3-receptor antagonists- inhibit intestinal motility
Tricyclic antidepressants- used in patients with pain as the predominant symptom
Kinds of Hernias
Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes
Types of hernia include:
Indirect inguinal-sac formed from the peritoneum that contains a portion of the intestine or omentum, pushes down into the inguinal canal
Direct inguinal- pass through a weak point in the abdominal wall
Femoral- protrude through the femoral ring, plug of fat enlarges and pulls the peritoneum and often the bladder into the sac
Umbilical- congenital (infancy) or acquired (direct result from increased intra-abdominal pressure
Incisional or ventral- at the site of a previous surgical incision, result of inadequate healing (post-op infection, inadequate nutrition, obesity)
Classification of Hernias
Reducible- when contents of the hernial sac can be placed back into the abdominal cavity by gentle pressure
Irreducible (incarcerated)- cannot be reduced and requires immediate surgical evaluation
Strangulated- blood supply to herniated segment of the bowel is cut off by pressure from the hernial ring, there is ischemia and obstruction of bowel loop
Signs of strangulation hernia
Signs of strangulation- abdominal distension, nausea, vomiting, pain fever and tachycardia
Different Signs
Ecchymosis- may indicate internal bleeding
Turner’s- may be a sign of retroperitoneal bleeding into abdominal wall
Ballance’s- indicated ruptured spleen
Kehr’s- splenic injury
true or false
Almost all colorectal cancers develop from an adenoma
true
Kinds of polyps
Sessile: broad based (villous adenomas- greater cancer risk)
Pedunculated: stalk-like (tubular adenomas)
What is appendicitis/?
Acute inflammation of the vermiform appendix—the blind pouch attached to the cecum of the colon
Symptom of appendicitis
Abdominal pain in the epigastric or periumbilical area is the initial symptom of classic appendicitis
McBurney’s point- localized tenderness during later stages of appendicitis
Perforation- abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis
Peritonitis
Life-threatening acute inflammation of visceral/parietal peritoneum and endothelial lining of abdominal cavity, or peritoneum
Caused by contamination by bacteria or chemicals
Less common- perforating tumors, leakage or contamination during surgery, peritoneal dialysis patients
Signs of peritonitis
Rigid, boardlike abdomen, abdominal pain, distended abdomen, high fever, tachycardia, dehydration, low urine output, hiccups, compromised respiratory status, nausea and vomiting, anorexia, diminishing bowel sounds, inability to pass flatus or feces, rebound tenderness
Gastroenteritis
Increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract (small bowel)
Bacterial form—Campylobacter, Shigella, Escherichia coli
Viral form—Norwalk virus
Signs of gastroenteritis
Vomiting , loss of appetite, nausea , bloating
Crohns disease
Inflammatory disease of the small intestine and the colon, or both.
It can affect the GI tract from mouth to anus but mostly the terminal ileum.
Transmural inflammation causing thickening of the bowel wall with strictures and deep ulcerations with bowel fistulas commonly developing.
Rarely, cancer of the small bowel and colon develop.
Malabsorption of vitamins and nutrients characteristic of Crohn’s.
Fistula formation is very common.
Divericular Disease
Diverticulosis is the presence of many abnormal pouch- like herniations in the wall of the intestine.
Diverticulitis is inflammation of one or more of the diverticula
Typically in the sigmoid colon. Muscle of the colon hypertrophies, thickens, and becomes rigid and herniation of the mucosa and submucosa through the colon wall is seen. Occur at points of weakness, often at areas where blood vessels interrupt the muscle layer (result of aging or lack of fiber in diet)
Undigested food or bacteria get stuck in the diverticula- blood supply is decreased, bacteria invade diverticulum, resulting in infection- can lead to perforate and develop abscess
true or false
An anorectal abscess is Most often the result of obstruction of the ducts of glands in the anorectal region
true
Causes of an anal fissure
Straining to pass stool, Crohn’s, tuberculosis, leukemia, neoplasm, trauma (foreign body, anal sex, perirectal surgery)
true or false
Most anal fistulas result from anorectal abscesses
true
Helminthic infestation
Wormlike animals that are often parasitic and capable of causing infectious disease (roundworms, flukes, tapeworms)
Enterobiasis (pinworm)
Most common helminth infection in US
Oral intake of contaminated food or drink
Trichinosis
Transmitted through eating under-cooked pork
Hookworms
Enter through the skin
Tapeworms
5 types can infect humans- tapeworms found in cattle, fish, dogs, pigs, rodents
Transmitted through consumption of under-cooked beef, raw fish, or other contaminated food or water or accidentally swallows infected lice or fleas from dogs
Acute cholecystitis
Acute cholecystitis is the inflammation of the gallbladder.
Calculous cholecystitis
Calculous cholecystitis
Most common
Cholelithiasis (gallstones) cause irritation and inflammation that can obstruct the cystic duct, gallbladder neck, or common bile duct
Trapped bile is reabsorbed and becomes chemical irritant
Decreased circulation, edema, and distension leads to ischemia and infection and gallbladder can become necrotic
Acalculous cholecystitis
Acalculous cholecystitis inflammation can occur in the absence of gallstones
Typically associated with biliary stasis
Conditions that can cause acalculous cholecystitis
Sepsis, severe trauma or burns, long-term TPN, multisystem organ failure, major surgery, hypovolemia.
Chronic cholecystitis
Repeated episodes of cystic duct obstruction result in chronic inflammation
Pancreatitis, cholangitis occur as complications of cholecystitis
Jaundice/icterus- most common in chronic vs. acute
Obstructive jaundice- occurs when flow of bile is impeded by stones or compression of duct
Pruritus- accumulation of excess bile salts in the skin
Stool may be clay colored as bilirubin does not make it to the large intestine
Urine becomes dark and foamy as kidneys try to clear excess bilirubin
Manifestations of chronic cholecystitis
Gas, indigestion, belching, anorexia, nausea and vomiting, abdominal pain, fever, jaundice Biliary colic Severe pain caused by obstructed cystic duct and tissue spasm Murphy’s sign Pain with deep inspiration Blumberg’s sign Rebound tenderness Steatorrhea Fatty stools
true or false
Acute pain only when the cystic or common bile duct becomes obstructed in chronic chol…
true
Managing chronic cholecystitis
Nutrition therapy
low-fat diet, fat-soluble vitamins, bile salts
Drug therapy
opioid analgesic such as morphine or hydromorphone, anticholinergic drugs (relax smooth muscle and decrease ductal tone/spasm), antiemetic
Extracorporeal shock wave lithotripsy
Used for patients who are not surgical candidates
Only for patients who are normal weight, good gallbladder function
Percutaneous transhepatic biliary catheter
Opens blocked ducts
Can be internal, external, internal/external
Internal diverts bile from liver, past stricture to duodenum
External connected to drainage bag on the outside of body
Internal/External- part of bile empties into a drainage bag, other part empties into the duodenum
Acute Pancreatitis
Serious and possibly life-threatening inflammatory process of the pancreas
Premature activation of excessive pancreatic enzymes that destroy ductal tissue and pancreatic cells
Necrotizing hemorrhagic pancreatitis
Diffusely bleeding pancreatic tissue with fibrosis and tissue death
Acute- 4 main processes:
Lipolysis- fatty acids combine with ionized calcium, hypocalcemia
Proteolysis- splitting proteins, thrombosis, gangrene
Necrosis of blood vessels- elastase activated by trypsin, dissolves elastic fibers of blood vessels
Inflammation
Secondary bacterial infection can lead to pus collection, fibrosis can occur and develop into a pseudocyst
Acute Pancreatitis
Primary exocrine function is secreting an inactive form of enzymes that breaks down starches, proteins, and fats (activated in small intestine)
Early activation causes inflammation
Hemorrhagic pancreatitis is life-threatening- can cause shock from extensive pancreatic damage
Complications of Acute Pancreatitis
Hypovolemia
Hemorrhage
Acute renal failure
Paralytic ileus
Hypovolemic or septic shock
Pleural effusion, respiratory distress syndrome, pneumonia
Amylase passes through transdiaphragmatic lymph channels
Multisystem organ failure (NHP)
Disseminated intravascular coagulation (DIC)
Release of necrotic tissue and enzymes into the blood stream
Hypercoagulation of blood, with consumption of clotting factors and development of microthrombi
Diabetes mellitus
Pancreatic infection
Clinical Manifestations of Acute Pancreatitis
Generalized jaundice Cullen’s sign Turner’s sign Bowel sounds Abdominal tenderness, rigidity, guarding Pancreatic ascites Significant changes in vital signs
Chronic Pancreatitis
Progressive destructive disease of the pancreas, characterized by remissions and exacerbations
Typically develops after several episodes of alcohol induced acute pancreatitis
Chronic obstruction of CBD
Pancreatic insufficiency causes loss of exocrine and endocrine function
Manifestations may differ from acute pancreatitis (chart 62-2)
Nonsurgical management includes:
Drug therapy
Analgesic administration
H2 Blockers, PPIs
Insulin therapy
Nutrition therapy
Enzyme replacement (chart 62-3)
TPN
Low- fat, high protein, carbohydrates
Most serious complication of pancreatitis; always fatal if untreated
Pancreatic Abscess
Most serious complication of pancreatitis; always fatal if untreated
Results from extensive inflammatory necrosis of the pancreas that is invaded by bacteria
High fever
Blood cultures
Determine infectious organism
Drainage via the percutaneous method or laparoscopy to prevent sepsis
May need to be repeated
Antibiotic treatment alone does not resolve abscess
Hiatal hernias
- Hiatal hernias, also called diaphragmatic hernias, involve the protrusion of a portion of the stomach through the esophageal hiatus of the diaphragm into the chest.
- Most patients with hiatal hernias are asymptomatic, but some may have daily symptoms similar to those with GERD.
- Patients with hiatal hernias may be managed either medically or surgically based on the severity of symptoms and the risk of serious complications.
- The primary focus of care after conventional surgery is the prevention of respiratory complications.
Esophageal tumors
- Although esophageal tumors can be benign, they are most often malignant
- Esophageal tumors grow rapidly because there is no serosal layer to limit their extension and spread to the lymph nodes occurs early.
- The diagnosis of esophageal cancer causes high patient anxiety, as it is accompanied by distressing symptoms and is often terminal.
- Medical and surgical treatment is based on the extent and location of the tumor.
- Respiratory care is the highest postoperative priority for patients having an esophagectomy.
- Before beginning oral feedings postoperatively, a cine-esophagram study is performed to detect the presence of anastomotic leaks, strictures, or signs of aspiration.
- When discharged, teach patients about the signs of anastomosis leakage and the importance of reporting them to the health care provider immediately.
- Teach the patient and family members to report the presence of fever and a swollen, painful neck incision, which could indicate an anastomotic leak.
ESOPHAGEAL DIVERTICULA
- Diverticula are sacs that may develop anywhere along the length of the esophagus, resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue.
- Zenker’s diverticula is the most common form and occurs most often in older adults.
- Patients complain of dysphagia, regurgitation, nocturnal cough, and halitosis, and may be at risk for perforation because the mucosa is without the protection of the normal esophageal muscle layer.
- Esophageal diverticula are diagnosed by barium swallow and esophagogastroduodenoscopy.
- Surgical management is aimed at removing the diverticula.
Colorecal cancer
• Colorectal cancer is cancer of the colon or rectum and is one of the most prevalent malignancies, utilizing a significant proportion of health care dollars.
• Most are adenocarcinomas, arising from the glandular epithelial tissue of the colon.
• Colorectal cancer can metastasize by direct extension or through the blood or lymph.
• Most colorectal cancers have no known predisposing cause, although age, previous colorectal cancer, and family history are considered risk factors.
o The major risk factors for the development of colorectal cancer (CRC) include being older than 50 years, genetic predisposition, personal or family history of cancer, and/or diseases that predispose the patient to cancer such as familial adenomatous polyposis (FAP), Crohn’s disease, and ulcerative colitis.
o There is also strong evidence that long-term smoking, increased body fat, physical inactivity, and heavy alcohol consumption are risk factors for colorectal cancer
• People of average risk who are over 50 years of age, without a family history, should undergo regular screening, including fecal occult blood testing and colonoscopy every 10 years or double-contrast barium enema every 5 years.
• People who have a personal or family history of the disease should begin screening earlier and more frequently.
• A positive test result for occult blood in the stool indicates bleeding in the GI tract.
• CT or MRI of the chest, abdomen, pelvis, lungs, or liver helps confirm the existence of a mass, the extent of disease, and location of distant metastases.
• Colonoscopy is the definitive test for the diagnosis of colorectal cancer.
• CT-guided virtual colonoscopy is growing in popularity and may be more thorough than traditional colonoscopy. However, treatments or surgeries cannot be performed when a virtual colonoscopy is used.
• The type of therapy used is based on the pathologic staging of the disease.
• Preoperative radiation therapy may provide local or regional control of the disease.
• Postoperative radiation has not demonstrated any consistent improvement in survival or recurrence but is used palliatively to control pain, hemorrhage, bowel obstruction, or metastasis to the lung in advanced disease.
• Adjuvant chemotherapy after primary surgery is recommended in stage II or stage III.
• Surgical removal of the tumor with margins free of disease is the best method of ensuring removal of the cancer.
• If a colostomy is required, assess the characteristics of the stoma, which should be reddish pink and moist and immediately report abnormalities such as ischemia and necrosis or unusual bleeding to the surgeon.
Polyps
- Polyps are small growths covered with mucosa and attached to the surface of the intestine, which are usually benign, but may become malignant.
- Polyps are usually asymptomatic and are discovered during routine diagnostic testing, but may cause rectal bleeding, intestinal obstruction, or intussusceptions.
- Diagnostic studies involve a barium enema examination and sigmoidoscopy or colonoscopy.
- Biopsy specimens of polyps can be obtained and the entire polyp can be removed with the use of a snare that fits through the sigmoidoscope or colonoscope.
Hemorrhoids
- Hemorrhoids are unnaturally swollen or distended veins in the anorectal region.
- Internal hemorrhoids, which cannot be seen on inspection of the perineal area, lie above the anal sphincter.
- External hemorrhoids lie below the anal sphincter and can be seen on inspection of the anal region.
- Prolapsed hemorrhoids can become thrombosed or inflamed, or they can bleed.
- Prevention of constipation by increasing fiber in the diet and drinking plenty of water is the most important preventive measure.
- Local treatment and nutrition therapy are used when symptoms begin.
- The surgeon can perform several procedures for symptomatic internal hemorrhoids on an ambulatory care basis, including ultrasound coagulation, rubber band ligation, circular stapling, laser assisted or simple resection of the hemorrhoids.
Appendicitis
- Appendicitis is an acute inflammation which occurs when the lumen of the appendix is obstructed, leading to infection as bacteria invade the wall of the appendix.
- It affects individuals of all ages, but is usually more serious in older adults.
- The initial obstruction is usually a result of fecaliths, which are very hard pieces of feces, but less common causes are malignant tumors, worms, or other infections.
- An abscess may develop in slow onset, but a rapid process may result in peritonitis.
- All complications of peritonitis, such as gangrene and perforation, are serious.
- Laboratory findings do not establish the diagnosis, but often there is a moderate elevation of the white blood cell count with a “shift to the left.”
- A WBC elevation greater than 20,000/mm3 may indicate a perforated appendix.
- Keep the patient with suspected or known appendicitis NPO to prepare for the possibility of emergency surgery and to avoid making the inflammation worse.
- Surgery is required as soon as possible.
Peritonitis
- Peritonitis is a life threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity.
- The cardinal signs of peritonitis are abdominal pain and tenderness.
- Flat, upright and decubitus abdominal x-rays or abdominal sonogram can assess for free air or fluid in the abdominal cavity, indicating perforation.
- The physician may also perform a diagnostic peritoneal lavage.
- IV fluids and broad-spectrum antibiotics are started immediately after diagnosis.
- Exploratory laparotomy is the usual surgical approach, followed by irrigation with antibiotic solutions and drain insertion before closing the abdominal cavity.
- For patients taking oral opioid analgesics such as oxycodone with acetaminophen (Tylox, Percocet, Endocet) for any length of time, a stool softener such as docusate sodium (Colace, Regulex) may be prescribed
Gastroenteritis
- Gastroenteritis is an increase in frequency and water content of stools or vomiting related to infection and inflammation of the mucous membranes of the stomach and intestinal tract, usually self-limiting unless complications occur.
- Some clinicians classify infectious disease of the intestine as bacterial, viral, or parasitic, without using the term gastroenteritis.
- Treatment with antibiotics may be needed if bacterial gastroenteritis.
- Weakness and cardiac dysrhythmias may be the result of loss of potassium (hypokalemia) from diarrhea.
Ulcerative colitis
- Ulcerative colitis creates widespread inflammation of mainly the rectum and rectosigmoid colon, associated with periodic remissions and exacerbations.
- The patient’s stool typically contains blood and mucus and patients report tenesmus, an unpleasant and urgent sensation to defecate, and lower abdominal colicky pain.
- A colonoscopy is the most definitive test for diagnosing ulcerative colitis.
- At the onset of treatment, activity is generally restricted because rest can reduce intestinal activity, provide comfort, and promote healing.
- In addition to dietary changes, complementary and alternative therapies may be used to supplement traditional management of ulcerative colitis.
- Some patients with ulcerative colitis require a surgical colon removal and ileostomy, including those with bowel perforation, toxic megacolon, hemorrhage, dysplastic biopsy results, failure of conventional treatment, and colon cancer.
- An ileostomy is a procedure in which a loop of the ileum is placed through the abdominal wall for drainage of fecal material into a pouching system.
- Having an ileostomy impacts the patient’s body image and self-esteem, therefore, assess for coping strategies and identify support systems.
Crohn’s disease
- Crohn’s disease is an inflammatory disease of the small intestine, the colon, or both.
- It is a slowly progressive, unpredictable, and recurrent disease with involvement of multiple regions of the intestine with normal sections in-between.
- Crohn’s disease results in severe diarrhea and malabsorption of vital nutrients.
- Anemia is common, usually from iron deficiency or malabsorption issues.
- Cause is not known, but may include genetic, immune, and environmental factors.
- X-rays show the common narrowing, ulcerations, strictures, and fistulas.
- Specific interventions vary with the severity of disease and the complications present.
- Fistulas are common with acute periods of Crohn’s disease.
- The patient with one or more fistulas often has complications such as systemic infections, skin problems, malnutrition, and fluid and electrolyte imbalances.
- Treatment of the patient with a fistula is complicated and includes nutrition and electrolyte therapy, skin care, and prevention of infection.
- Surgical resection of the diseased area is usually performed for those patients who have not improved with medical management, or with complications, perforation, massive hemorrhage, intestinal obstruction or strictures, abscesses, or cancer
Diverticula
- Diverticula are pouch-like herniations of the mucosa through the muscular wall of any portion of the gut, but most commonly in the colon.
- Diverticulosis is the presence of many abnormal pouch-like herniations.
- Diverticulitis is the inflammation of one or more diverticula.
- The patient with diverticulosis usually has no symptoms unless pain or bleeding develops, so it is often found incidentally on routine colonoscopy.
- The patient with diverticulitis usually does not undergo invasive procedures in the acute phase of the illness because of the risk for rupture.
- A computed tomography scan may be performed to diagnose an abscess or thickening of the bowel related to diverticulitis
true or false
• Ulcerative colitis and Crohn’s disease are the two most common inflammatory bowel diseases (IBDs) that affect adults
true
Anal disorders
- Anorectal abscess is a localized area of induration and pus caused by inflammation of the soft tissue near the rectum or anus from obstruction of the ducts of glands.
- Anorectal abscesses are managed by surgical incision and drainage.
- An anal fissure is a superficial tear in the anal lining causing discomfort and disability which resolves on its own or heals quickly with conservative treatment.
- Chronic fissures recur and surgical treatment may be needed.
- An anal fistula is an abnormal tract leading from the anal canal to the perianal skin, usually resulting from anorectal abscesses.
- A proctoscope is used to identify the source of symptoms and to locate the fistula.
- Because fistulas do not heal spontaneously, surgery is necessary.
- Instruct patients with anorectal disorders to use sitz baths, bulk-forming agents, and stool softeners to decrease pain.
Cholecystitis
- Cholecystitis is an inflammation of the gallbladder that affects many people in affluent countries.
- It may be either acute or chronic, although most patients have the acute type.
- Two types of acute cholecystitis are calculous and acalculous cholecystitis.
- The most common type is calculous cholecystitis, in which chemical irritation and inflammation results from gallstones that obstruct the cystic duct most commonly, gallbladder neck, or common bile duct.
- Acalculous cholecystitis, inflammation occurring without gallstones, is associated with biliary stasis caused by changes in the regular filling or emptying of the gallbladder.
- Chronic cholecystitis results when repeated episodes of cystic duct obstruction result in chronic inflammation, most often with calculi.
- Jaundice, seen as yellow discoloration of the skin and mucous membranes, and icterus, which is yellow discoloration of the sclera, can occur in patients with acute cholecystitis, but is most commonly observed with the chronic form of the disease.
- Women from 20 to 60 years of age are twice as likely to develop gallstones as men.
- Obesity, pregnancy, estrogen, birth control pills, and combinations of those factors are major risk factor for gallstone formation, especially in women.
- Teach patients to avoid losing weight too quickly and keep weight under control to help prevent gallbladder disease.
- Patients with acute cholecystitis present with abdominal pain, although clinical manifestations vary in intensity and frequency.
- There are no laboratory tests specific for gallbladder disease, so differential diagnosis rules out diseases causing similar symptoms, such pancreatitis.
- When the cause of cholecystitis or cholelithiasis is not known or the patient has manifestations of biliary obstruction, such as jaundice, an endoscopic retrograde cholangiopancreatography may be performed
Acute pancreatitis
- Acute pancreatitis is a serious and, at times, life-threatening inflammatory process.
- Pancreatitis can range from mild involvement evidenced by edema and inflammation to necrotizing hemorrhagic pancreatitis, which is characterized by diffusely bleeding pancreatic tissue with fibrosis and tissue death.
- The majority of deaths in patients with acute pancreatitis are from irreversible shock.
- Acute pancreatitis may result in severe, life-threatening complications such as jaundice from swelling of the head of the pancreas, calculi or pancreatic pseudocyst, transient hyperglycemia from release of glucagon, left lung pleural effusions, and total destruction of the pancreas, leading to type 1 diabetes.
- Multisystem organ failure may be caused by necrotizing hemorrhagic pancreatitis and the patient is at risk for acute respiratory distress syndrome (ARDS).
- The diagnosis of pancreatitis is made on the basis of the clinical presentation combined with the results of diagnostic studies.
- Clinical manifestations vary widely and depend on the severity of the inflammation, but usually involves severe pain in the mid-epigastric area or left upper quadrant
Chronic pancreatitis
- Chronic pancreatitis is a progressive, destructive disease which has remissions and exacerbations, usually developing after repeated episodes of alcohol-induced acute pancreatitis or associated with chronic obstruction of the common bile duct.
- Idiopathic and hereditary chronic pancreatitis may be associated with SPINK1 and CFTR gene mutations.
- The focus of caring for the patient with chronic pancreatitis is to manage pain, assist in maintaining a sufficient nutritional intake, and prevent recurrence.
- Surgery is not a primary intervention for treatment but may be used for intractable abdominal pain, incapacitating pain, or abscesses and pseudocysts.
Pancreatic abscesses
- Pancreatic abscesses are the most serious complication of acute necrotizing pancreatitis because if untreated, they are always fatal.
- Pancreatic abscesses occur after severe acute pancreatitis, exacerbations of chronic pancreatitis, or biliary tract surgery. should be performed as soon as possible to prevent sepsis since antibiotic treatment alone does not resolve it.
- Drainage via the percutaneous method or laparoscopy
Pancreatic pseudocyst
- Pancreatic pseudocysts, or false cysts, are so named because unlike true cysts they do not have an epithelial lining.
- Risk factors for pseudocysts are acute pancreatitis, abdominal trauma, and chronic pancreatitis.
- To provide external drainage, the surgeon inserts a sump drainage tube to remove pancreatic secretions and exudate.
- Pancreatic fistulas are common after surgery, and skin breakdown may occur from corrosive pancreatic enzymes in patients who have external drainage.
