Intestinal Problems Student Flashcards
IBS
chronic abdominal pain or discomfort and alteration of bowel patterns
- diarrhea or constipation
- no known organic cause
- psychologic stressors
- GI infection; adverse reactions to food (dietary intolerances)
IBS vs IBD
IBD = disease, destructive inflammation and permanent harm to the intestines, seen in diagnostic imaging, increased risk of colon cancer
IBS = syndrome (group of symptoms), does not cause inflammation, rarely requires hospitalization, no sign of disease or abnormality during exam of colon, no increased risk for colon cancer or IBD
IBS: Dietary Intolerances
gluten
FODMAPs: fermentable oligo-, di-, and monosaccharides and polyols
IBS: Dx
based solely on sx Rome IV criteria: - presence of abdominal pain and/or discomfort at least 1 day/wk for 3 months and associated w/: -change in stool frequency -change in stool form
look at:
- health hx including psychosocial factors
- family hx
- drug hx
- diet hx
- impact on activities/life
r/o other disorders
IBS: S/Sx
GI Sx:
- abdominal pain
- nausea
- flatulence
- mucus in stool
- sensation of incomplete evacuation
Non GI Sx:
- fatigue
- HA
- sleep problems
IBS: Tx
no single effective therapy
tx considerations:
- psychological support (CBT, stress management)
- dietary changes (FODMAP diet)
- drug to regulate stool and reduce pain (opioid agonists, antispasmodics, antidepressants, antidiarrheals, or laxatives)
Diverticulosis and Diverticulitis
diverticula: saccular dilations or out-pouchings of the mucosa in the colon
common in older adults
diverticulosis: multiple, noninflamed diverticula
diverticulitis: one or more inflamed diverticus
Diverticulosis and Diverticulitis: Complications
perforation, abscess, fistula, bleeding, erosion of bowel wall, peritonitis
Diverticulosis and Diverticulitis: Etiology and Pathophysiology
- common in left (descending, sigmoid) colon
- develop at weak points; blood vessels pass through muscle layer
- cause: genetic and environmental factors
- main factors: constipation and lack of dietary fiber
- other factors: obesity, inactivity, smoking, excess alcohol use and NSAID use
D&D: S/Sx
Diverticulosis: mostly asymptomatic
- abdominal pain, bloating, flatulence, changes in bowel habits
- serious: bleeding or diverticulitis
Diverticulitis: acute pain in LLQ
- distention, decreased or absent bowel sounds, n/v, systemic sx of infection
- older adults: afrebrile, normal WBC, possible abdominal tenderness
D&D: Dx
sigmoidoscopy or colonoscopy
preferred: CT scan w/ oral contrast
- occult blood
- CBC, urinalysis
- barium enema
- blood cultures
- abdominal x-ray or chest (to r/o other causes)
D&D: Intervention
prevention:
- high fiber diet, decrease fat and red meat
- physical activity
acute diverticulitis: goal = bowel rest to reduce inflammation
- clear liquids, bed rest, analgesia
- severe sx: systemic infection, comorbidities, hospitalization, NPO, NGT, bed rest, IV fluid and antibiotics, observe for signs of abscess, bleeding, and peritonitis; advance diet as tolerated.
reoccurring diverticulitis or complications:
-surgical resection w/ anastomosis or temporary colostomy
D&D: Pt Ed
- explain condition and prescribed regimen
- high fiber diet
- fluids (at least 2 L/day)
- avoid increased intraabdominal pressure
Intestinal Obstruction
contents can’t pass through intestines
can be:
- small bowel (SBO) or large bowel (LBO)
- partial (some contents can get through)
- complete (total occlusion, needs surgery)
- simple (intact blood supply)
- strangulated (no blood supply)
Intestinal Obstruction: Types
Mechanical: physical
- SBO: surgical adhesions, hernias, cancer, strictures from Crohn’s disease, intussusception
- LBO: colorectal cancer, diverticular disease
- other: adhesions, ischemia, vovulus, Crohn’s
Non-mechanical: reduced or absent peristalsis d/t altered neuromuscular parasympathetic innervation
-paralytic ileus: abdominal surgery, peritonitis, inflammatory disordes, electrolyte imbalances, thoracic, or lumbar spinal fractures
Intestinal Obstruction: Ischemia
inadequate blood flow to bowel
ischemia results in necrosis and perforation
blood flow stops, resulting in edema and cyanosis which results in gangrene (intestinal strangulation or infarction)
requires immediate tx to avoid infection, septic shock and death
Intestinal Obstruction: Location of Obstruction
location of obstruction determines fluid and electrolyte and acid-base imbalances
high (upper duodenum): decreased HCl acid results in metabolic alkalosis
small intestine: dehydration occurs quickly
large intestine (below proximal colon): solid fecal material accumulates causing discomfort
Intestinal Obstruction: S/Sx
four hallmark:
- abdominal pain
- n/v
- distention - LBO
- constipation
order and degree depend on cause, location, and type of obstruction
Intestinal Obstruction: Dx
- imaging: abdominal x-rays, CT scan, contrast enema
- sigmoidoscopy or colonoscopy
- blood tests: CBC, blood chemistries
- increased WBC-strangulation or perforation
- increased Hct - hemoconcentration
- decreased Hgb and Hct - bleeding
- Serum electrolytes, BUN, creatinine - hydration
- metabolic alkalosis - vomiting
Intestinal Obstruction: Tx
depends on cause
- emergency surgery: strangulation or perforation
- resection of obstructed segment w/ anastomosis
- partial or total colectomy or ileostomy - obstruction or necrosis
- colonoscopy: remove polyps, dilate strictures, laser destruction and removal of tumors
monitor I&O
NGT
postop surgery similar to laparotomy
Polyps of Large Intestine
colonic polyps: arise from mucosal surface and project into lumen
- sessile: flat, broad-based, attached to wall
- pedunculated: attached to wall by thin stalk
- increase incidence with age; especially proximal colon
- commonly asymptomatic (occult blood & bleeding)
Types of Polyps
hyperplastic: non-cancerous; less than 5mm
- no symptoms
- other benign: inflammatory, lipomas, juvenile
adenomatous: neoplastic
- removal decreases risk of cancer
Familial Adenomatous Polyposis (FAP)
- autosomal dominant and recessive; DNA testing
- colorectal screening at puberty and annually age 16
may have hundreds or thousands of polyps that will become cancerous by age 40
requires removal of colon and rectum by age 25 (proctocolectomy w/ IPAA or ileostomy)
risk for other cancer (lifetime surveillance required)
Polyps: Dx
colonoscopy sigmoidoscopy barium enema virtual colonoscopy (CT or MRI) all polyps are abnormal and removed (polypectomy)
Colorectal Cancer
third leading cause of cancer related deaths
Hereditary Nonpolyposis Colorectal Cancer (HNPCC) or Lynch Syndrome:
- autosomal dominant disorder
- DNA testing available to detect gene mutations
- increased risk of other organ cancers
- need annual colonoscopy
CRC: Risk Factors
no single risk factor
highest risk: first degree relatives w/ CRC and people with IBD
-family hx of CRC or familial adenomatous polyposis (FAP)
-hereditary form
-Abnormal KRAS gene (oncogene)
other: obesity, smoking, more than 7 servings red meat/wk, more than 4 alcohol drinks/wk, diabetes
CRC: S/Sx
sx do not usually appear until disease is in advanced stages
- common: iron-deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits
- early: none or nonspecific; fatigue, weight loss
- advanced: abdominal tenderness, palpable mass, hepatomegaly ascites
CRC: Dx
regular screening for polyps and cancer from ages 45-75 years of age by one of the following exams:
- flexible sigmoidoscopy every 5 years
- colonoscopy every 10 years
- double-contrast barium enema every 5 years
- CT colonography every 5 years
annual screening primarily for cancer
- high sensitivity fecal occult blood test (FOBT) or
- fecal immunochemical test (FIT): test for blood in the stool, must be done frequently to catch intermittent bleeding common with tumors
stool DNA every 3 years - DNA mutations
colonoscopy = gold standard
- entire colon is examine; biopsy specimens
- polyps removed and sent to lab
- every 10 years starting at 45
- every 5 years starting at 40 if higher risk (1º relative w/ CRC) or 10 years earlier than when youngest relative diagnosed
CRC: Tx
correlates w/ pathologic staging of disease
surgery:
- resect tumor
- remove lymph nodes that drain that area
non-resectable tumors or metastasis:
- surgery is palliative, relieves obstruction or controls bleeding
- chemo and radiation, control the spread and provide pain relief
Bowel Resection and Ostomy Surgery: Indications
- remove cancer
- repair perforation, fistula, or traumatic injury
- relieve obstruction or stricture
- treat an abscess, inflammatory disease (Diverticulitis) or hemorrhage
Types of Bowel Surgeries
- total proctocolectomy with IPAA
- proctocolectomy w/ permanent ileostomy
- right or left hemicolectomy
- anterior rectosigmoid resection
- abdominal-perineal resection
- low anterior resection
Ostomy
surgically created opening (stoma) on the abdomen for fecal elimination
named for location ileum-ileostomy (involuntary drainage)
-may be temporary or permanent
Permanent Ostomy: Traditional
End stoma:
- distal bowel removed (permanent stoma)
- distal bowel oversewn (possible reanastomosis and stoma closed)
Loop stoma (usually temporary): - loop of bowel to abdominal surface; anterior wall opened for fecal diversion; distal opening to drain mucus; plastic rod in place 7 to 10 days
Double-barrel stoma:
- bowel divided; two stomas created; both proximal and distal ends though abdominal wall
- proximal: fecal diversion
- distal: mucus fistula
- usually temporary
Bowel Resection and Ostomy Surgery: Complications
delayed wound healing
hemorrhage
fistulas
infection
normal ostomy: pink-red, mild swelling, small amount of blood
Bowel Resection and Ostomy Surgery: Postoperative Care
Colostomy function:
- record volume, color, consistency of drainage
- excess gas common for 2 weeks (temporary)
Ileostomy function:
- 24-48 hours - minmal
- peristalsis returns - 1500-1800 ml/day
- monitor fluid and electrolyte (Na+, K+) balance
- bowels adapts and increases absorption - feces thickens and volume decreases to 500ml/day
IPAA:
- 4-6 stools/day
- adapt in 3-6 months
- anal sphincter controls defecation
Anal canal:
- transient incontinence of mucus
- kegel exercise after 4 weeks
- perianal skin care
- phantom rectal pain
Colostomy Care
diet: balanced w/ adequate fluids; avoid odor, gas, and diarrhea-producing foods
resume ADLs 4 to 6 weeks
empty when 1/3 full to prevent pulling and leaks
change failed pouch immediately
charcoal filters - deodorize and release flatus
Ileostomy Care
secure pouching - stool is caustic to skin
best pouch = open ended and drainable
fluid intake = at least 2-3 L/day
- teach about fluid and electrolyte imbalance; esp Na+
- increased risk of obstruction: narrowed lumen
- chew thoroughly; especially nuts, raisins, popcorn, coconut, mushrooms, olives, stringy vegetables, foods with skins, dried fruis, and meats with casings
Diarrhea
passage of 3 or more loose stools/day
- acute: 14 days or less
- persistent: more than 14 days
- chronic: more than 30 days
primary cause: infectious organisms alter intestines by
- alter secretions and/or absorption of enterocytes in small intestines; no inflammation
- impair absorption by destroying cells, causing inflammation in the colon, and producing toxins
Diarrhea: RF
- age (older adults more susceptible)
- gastric acidity (proton pump inhibitors decrease stomach acid; organisms survive)
- intestinal microflora (microbial barrier altered by antibiotics)
- immune status (immunocompromised d/t disease or jejunal enteral feedings)
Diarrhea: S/Sx
upper GI tract: large volume, water stools, cramping, periumbilical pain, preceding n/v, low grade or no fever
lower GI tract: small volume bloody diarrhea, fever
stool may contain leukocytes; blood, or mucus
severe diarrhea: dehydration (life-threatening), electrolyte imbalances (K+), and acid-base imbalances (metabolic acidosis)
Diarrhea: Dx
- stool cultures (blood, mucus, WBCs, infectious organisms)
- Blood cultures (sepsis or immunocompromised)
- WBCs
- Anemia from iron and folate deficiencies
- BUN, creatinine, electrolytes, pH, osmolality
- stool fat, protein
- GI hormones (polypeptide and gastrin may be elevated)
Diarrhea: Tx
depends on cause
prevent transmission
replace fluid and electrolytes (oral or IV)
protect the skin
antidiarrheals (CI: prolonged exposure; IBD can result in toxic megacolon)
antibiotics: fluoroquinolone and azithromycin
CDI
Clostridium difficile Infection
-health care associated infection
Tx: oral vancomycin or fidaxomicin for 10 days
-stop nonessential antibiotics, stool softeners, laxatives, and antidiarrheals
for recurrent: fecal microbiota transplantation (FMT)
- donor feces administered via enema, nasoenteral tube or colonoscopy
- concern = transmission of infection
Gastroenteritis (Stomach Flu)
inflammation of mucosa of stomach and small intestine
features: sudden diarrhea, n/v, fever, abdominal cramping
common foodborne cause (norovirus)
Dx: lab tet for virus
Tx: self-limiting
(oral or IV fluids)
Fecal Incontinence
involuntary passage of stool related to motor and/or sensory dysfunction
Fecal Incontinence: Dx
rectal exam
anorectal: manometry, u/s, or electromyography
Fecal Incontinence: Tx
depends on cause
- bowel management program (regular defecation, high-fiber diet, increased fluids, elimination 30 min after breakfast)
- if ineffective, administer bisacodyl, glycerin suppository, or small enema to stimulate anorectal reflex until pattern established. Digital stimulation, tap water irrigation.
- fiber supplements
- reduce irritating, diarrhea-producing foods
- remove fecal impaction
- antidiarrheal agents
- mild electrical stimulation
- dextranomer/hyaluronic gel (narrows anal canal)
- surgery (sphincter repair or colostomy)
Constipation
- difficult or infrequent bowel movements
- may require excessive exertion to defecate
- feeling of incomplete evacuation
- sx, not a disease
- acute = less than 1 week
- chronic = greater than 3 months
Constipation: RF
- low fiber diet
- decreased physical activity
- ignoring urge to defecate (prolonged retention desensitizes muscles and mucosa, stool dries as water absorbed > difficult to expel)
- emotions, anxiety, depression
- diseases that slow GI transit
- drug-induced (opiods)
- cathartic colon syndrome (chronic laxative use results in dilated, atonic colon)
Constipation: S/Sx
discomfort
absent or hard, dry stools (difficult to pass)
abdominal distention, bloating, increased flatulence, increased rectal pressure
hemorrhoids
rectal mucosal ulcers; diverticulosis
-obstipation, fecal impaction, perforation
Constipation: Dx
- exam of abdomen, perianal, and rectal areas
- sudden, persistent change in bowel habits (greater than 6 wks), rectal bleeding or bloody stool, anemia, weight loss, pain, personal or family hx of CR or IBD, and palpable mass
- abdominal x-rays
- barium enema
- colonoscopy or sigmoidoscopy
- anorectal manometry
- GI transit studies
- defecography
Constipation: Tx
increase dietary fiber, fluids, and exercise laxatives enemas dietary fiber: vegetables, fruits, and grains adequate fluid-2 L/day probiotics proper defecation position provide privacy
Peritonitis
inflammation of the peritoneum
causes:
- primary = blood-borne organisms
- secondary = perforation of organs that spill contents into peritoneal cavity
pathophysiology: initial chemical peritonitis progresses to bacterial causing fluid shifts and adhesion
Peritonitis: S/Sx
- abdominal pain - most common
- universal sign = tenderness over area involved
- rebound tenderness, muscular rigidity, and spasm -peritoneal irritation
- other: abdominal distention, fever, tachycardia, n/v, altered bowel habits
complications: hypovolemic shock, sepsis, intraabdominal abscess, paralytic ileus
Peritonitis: Dx
H&P CBC, electrolytes Peritoneal aspiration Abdominal x-ray, US, or CT scan Peritoneoscopy
Peritonitis: Interventions
preoperative/mild cases or poor surgical risk:
-NPO, NG suction, IV fluids, antibiotics, analgesia, antiemetics
surgery - locate source, drain purulent fluid, repair damaged organ
postoperative care: NPO, IV fluid, NG suction, blood, parenteral nutrition, antibiotics, sedatives, opioids, antiemetics
Peritonitis: Nursing Implementation
- IV access: fluids and antibiotics
- Pain management: analgesia and positioning (knees flexed)
- relieve anxiety; promote rest: sedative
- monitor VS, I&O, O2
- antiemetics for n/v
- NPO; NG tube, if needed
- drain care
Fistulas
abnormal tract between two hollow organs or a hollow organ and the skin
- complication: increased morbidity and mortality, extended length of stay, and increased costs
- simple: 1 short direct tract
- complex: multiple organs, abscess, open into base of wound
- output: low less than 200 ml/day
- moderate: 200-500 ml/day
- high: greater than 500 ml/day
early signs = fever and abdominal pain
Fistula: Nursing Management
Fistula management:
- identify tract
- maintain fluid and electrolytes (IV replacement)
- control infection
- protect surrounding skin: WOCN consult
- manage output: monitor I&O drainage
- nutritional support: dietician; high-calorie, high-protein enteral or parenteral nutrition
most heal spontaneously, some require surgery
Hernias
protrusion of intestine through an opening or weakened area in the cavity wall
-most occur in abdomen
reducible - easy to return to abdominal cavity
irreducible or incarcerated - cannot be placed back into abdominal cavity; abdominal contents are trapped
- strangulated: blood supply compromised
- results in intestinal obstruction; gangrene and necrosis are concerns
Types of Hernias
inguinal
umbilical
femoral
incisional
Hernia: S/Sx
- pain, increases w/ activities that increase intraabdominal pressure
- may be visible
- strangulated: severe pain, vomiting, cramping, abdominal pain, distention
Hernia: Dx
H&P
imaging: u/s, CT, MRI
Hernia: Tx
- herniorrhaphy: surgical repair; laparoscopic
- hernioplasty: reinforce weak area w/ wire, fascia or mesh
- strangulated: emergency surgery; temporary colostomy
Hernia: Postoperative Care
- monitor voiding; I&O
- scrotal edema - ice and elevation
- encourage deep breathing
- splinting
- cough or sneeze w/ open mouth
- no heavy lifting (greater than 10 pounds) 6 to 8 weeks
Hemorrhoids
Dilated hemorrhoidal veins:
- internal - above internal sphincter
- external - outside external sphincter
Etiology and pathophysiology:
- increased anal pressure and weakened connective tissue results in downward displacement, which results in dilation
- RF: pregnancy, constipation, straining, diarrhea, heavy lifting, prolonged standing and sitting, obesity, and ascites
Hemorrhoids: S/Sx
internal: bleeding w/ defecation; pain, prolapse (pressure, protruding mass)
external: reddish blue color; itching, burning, edema
- thrombosis: bluish-purple, palpable; pain and inflammation; bleeding w/ defecation
Hemorrhoids: Dx
external: inspection and digital examination
internal: digital examination, anoscopy, sigmoidoscopy
Hemorrhoids: Tx
- high-fiber diet, increased fluids (prevent constipation and reduce straining)
- ointments, creams, suppositories, impregnated pads, astringents, anesthetics, stool softeners
external: conservative unless thrombosed
internal: rubber band ligation, infrared coagulation, sclerotherapy, laser treatment
Hemorrhoidectomy: surgical excision
-done w/ prolapse or thrombosis
Anorectal Abscess
perianal collection of pus d/t obstruction of anal glands results in infection which results in abscess
Anorectal Abscess: S/Sx
local severe pain and swelling, foul-smelling drainage, tenderness, fever; sepsis
Anorectal Abscess: Dx
rectal examination
Anorectal Abscess: Tx
surgical drainage; antibiotics
Anorectal Abscess: Nursing Care
moist heat, positioning, low-fiber diet
Education: wound care, perianal hygiene, follow-up care
Anal Fistula
abnormal tunnel from anus or rectum to skin, vagina, or buttocks
- precedes or d/t abscess or complication from Crohn’s disease
- drainage; bloody, purulent, or fecal
Tx: surgery (fistulotomy), complex (ligation of the intersphincteric fistula tract (LIFT), fibrin glue injections
