nurs 522 gi and universal preoperative care Flashcards
Colorectal Cancer: Modifiable Risks
+ fat/- fiber diet
- physical activity
Obesity
Colorectal Cancer: Non-modifiable Risks
50+ age
Family history of polyps or colorectal cancer
Hereditary Non-polyposis Colorectal Cancer
Lynch syndrome
Inflammatory Bowel Disease
Colorectal Cancer: Diagnosis
Biopsy w/ colonoscopy
Fecal occult blood test annually
Colonoscopy Q10 years
Colorectal Cancer: Sigmoid and Rectum
Change in bowel habits
Hematochezia
Colorectal Cancer: Proximal Colon
Subtle
Fecal occult blood (early)
Bowel obstruction symptoms (late)
Colorectal cancer (Adenocarcinoma): surgeries
Colectomy w/o stoma
Diversion w/o colon resection w/ perm. loop stoma
Low anterior resection w/ or w/o temp. stoma
Abdominoperineal resection w/ perm. sigmoid/descending colostomy
Low anterior resection (LAR)
If tumor mid/high rectum 0 use if tumor near anus/low rectum 2 stage procedure Temp ileostomy or transverse colostomy Anal canal and sphincters intact 0 perm colostomy
Abdominoperineal resection (APR): Mile’s Procedure
Low rectal tumors
Complete removal of rectum/anal sphincters
Perm. sigmoid/descending colostomy
Anal opening sewn closed
Wide resection of tissue/structures
Possible damage to pudendal nerve = sex. dysfunction
Posterior exenteration
Removal of sigmoid/descending colon, rectum, uterus, cervix, ovaries, fallopian tubes, vagina
Sigmoid colostomy
Anterior exenteration
Removal of urethra, uterus, cervix, vagina, bladder Urinary diversion (ileal conduit, colon conduit, Indiana pouch)
Total pelvic exenteration
Resection of all anterior and posterior pelvic structures
Advanced ovarian cancer not candidates 2nd to metastasis
Urinary and fecal diversions
Crohn’s Disease
Any portion of GI tract
Develops at terminal ileum
RLQ pan/cramping, fever, malaise, - weight, bleeding, extracolonic manifestations
Affects all layers of bowel wall
Skipped areas of ulceration = hallmark sign
Strictures, FISTULAS, abscess, bowel obstruction
0 surgical cure or continence diversions
Ulcerative Colitis
Confined to colon
Develops in rectum and moves proximally
Frank bleeding w/ diarrhea, TOXIC MEGACOLON
Ulcers in mucosa, continuous and circumferential
Seen on X-ray
Cured w/ removal of colon
May need ostomy
Total proctocolectomy
Rectum and anus removed
Familial Polyposis Coli
Hereditary
Premalignant polyps appear at puberty
Polyps progress to cancer w/i 10 years
Resection of colon and rectum - risk of cancer
Extra-intestinal manifestations (cysts, osteomas, duodenal tumors = Garder’s Syndrome)
Diverticulosis
Associated w/ diet
Disease of aging
Typically asymptomatic herniations of intestinal wall
Diverticulitis
Inflammations of intestinal wall herniations
0 evidence nuts/seeds obstruct
LLQ pain, rebound tenderness, fever, N/V, change in bowel habits, dysuria
Diverticular disease: medical management
Treat infection Bowel rest Liquid diet Tylenol Slow introduction of fiber
Diverticular disease: surgical management
Last resort
If recurrent/non-responsive diverticular disease, full perforation, fistula, obstruction
Percutaneous drainage of abscess
Resection of bowel, colorectal anastamosis w/o diverting colostomy or w/ temp. diverting ostomy (Hartmann’s pouch)
Radiation Enteritis
Iatrogenic damage = bowel mucosa damaged by radiation (diarrhea, incontinence, cramping, pain, bleeding)
Treat symptoms
Surgery to manage bowel obstruction, necrosis, strictures, perforation
Bowel resection required
Temp. stoma
Blunt GI trauma
Watch/wait over immediate surgery
Eval for organ damage
Medically manage if 0 organ damage/perforation
Penetrating GI trauma
If rectal or major colon injury, repair w/ protecting loop colostomy
Ischemic Colitis: Signs/symptoms
Left colon including splenic flexure and sigmoid colon
More common in elderly
Early: left ABD pain, distention, urgency, diarrhea
Late: hemorrhage w/ clots, frank blood
Young: acute, + bleeding, self-limiting
Diagnosis w/ s/s + endoscopy
Ischemic Colitis: treatment
Medical: 2/3 resolve w/ NPO; IV hydration; antibiotics; vitals monitoring; d/c estrogens, decongestants, crack cocaine
Surgical: if peritonitis, perforation, or co-existing co-morbidities = bowel resection w/ temp diverting stoma
Intestinal Obstruction
Partial or complete
High morbidity and death
Mechanical: volvulous, food bolus, adhesion, tumor
Non-mechanical: ileuss/s: altered bowel sounds/output, distention, discomfort
Intestinal Obstruction: Management
Medical: NPO, NG tube, hydration, avoid opiates
Surgical management: If + risk of perforation = bowel resection w/ diverting stoma
Antegrade Continent Enema (ACE) Procedure
Severe constipation (spina bifida)
Pt self-administers enema at cecum = BM
Appendix , ileum or colon connect bowel w/ skin
Complications: leakage of stool onto skin, perforation of bowel w/ catheter insertion
Inperforate Anus
Absence of opening
Co-existing anomalies (VACTERL)
VACTERL
Vertebral defects Anorectal anomalies Cardiovascular anomalies (ventricular septal defect) Tracheoesophageal defects (fistula) Esophageal atresia Renal defects (hydronephrosis) Limbs (webbed fingers, missing digits)
Necrotizing Enterocolitis (NEC)
Immature GI tract
Ischemia s/s: ABD distention, feeding intolerance, abnormal xray
Emergent surgery and temp ostomy
xray: air in bowel wall (halo sign)
Hirschprung’s Disease
Lack of ganglion cells and hypertrophic nerves to propel stool
s/s: distention, obstruction
tx: resection w/ pull-through, temp ostomy
Antegrade Continent Enema (ACE)
For severe constipation
Pt may self-administer enema at cecum = bowel contraction /evacuation
Use appendix, ileum, or colon to connect bowel w. skin
Complications: leakage, perforation
Intestinal or Multi-Organ Transplantation
For permanent intestinal failure w/ life-threatening TPN-related complications (recurring sepsis, impending loss of central access, liver failure)
Jejunostomy
RUQ or RLQ
2nd to Ischemic Bowel Disease, Crohn’s, trauma, NEC
Small bowel resection
Caustic effluent
Ileostomy
RLQ
2nd to Crohn’s, CUC, FAP, congenital anomalies, trauma, NEC, ischemic bowel cancer
Types: Total proctocolectomy (TPC), temp loop ileostomy, loop stoma, or bowel resection w/ temp loop ileostomy
Total Proctocolectomy (TPC)
Located in distal ileum
Traditional ileostomy
Transverse Colostomy
RUQ, LUQ 2nd to Diverticulitis, colon cancer, Crohn's, perforated bowel, obstructions, Hirschprungs, imperforate anus May include colectomy Temp loop stoma No active enzymes Semi-formed stool
Descending/Sigmoid Colostomy
LLQ
Colorectal cancer, trauma, bowel perforation, Crohn’s, ischemic bowel
Abdominoperineal resection w. perm colostomy (APR): rectum and anus removed or end colostomy w/ Hartmann’s procedure
Stool formed/semi-formed
IPAA - Ileal Pouch Anal Anastamosis (Ileoanal Reservoir)
RLQ
temp ileostomy
PELVIC internal pouch
CUC, FAP
IPAA - Ileal Pouch Anal Anastamosis (Ileoanal Reservoir)Stage I
Colon and most rectum removed Distal rectum and anus intact Pouch constructed from ileum Pouch anastomosed to distal rectum Temp loop ileostomy high in ileum May expel mucus
IPAA - Ileal Pouch Anal Anastamosis (Ileoanal Reservoir)Stage II
When suture lines healed, ileostomy takedown
Stool fills pouch
Evacuation via anus
ACE Procedure
RLQ at cecum or in umbilicus
Colonic inertia = severe constipation, neurologic disorder (spina bifida, ALS, MS, SCI)Used in addition to restorative procedures (Mitrofanoff)
Small opening made in umbilicus or appendix = stoma used for colon irrigation
Stool exits via anus
Kock Pouch
RLQ CUC, FAP Used if continent diversion needed but 0 rectum or anus 2nd to TPC Total proctocolectomy w/ ABD ileal pouch Perm stoma Nipple valve for continence
Risk of mucosal atrophy due to NPO
At villi
Villi connected to blood vessels
Atrophy reversible, but = diarrhea
Section of bowel w/ greatest bacteria
Distal colon
IPAA (ileoanal reservoir) indicated for:
Chronic Ulcerative Colitis (CUC)
Familial Adenomatous Polyposis (FAP)
Location for ileostomy
RLQ
Location for sigmoid colostomy
LLQ
Symptoms of CUC
Anemia
Bloody stool
Diarrhea
Symptoms of Crohn’s Disease
ABD pain/cramping
Fistulas
Stoma maturation
Bowel everted and sutured to ABD during surgery
Meds for management of Crohn’s
CorticosteroidsImmune suppressants
Antibiotics
Rectal cancer at dentate line =
Abdominoperineal resection (APR)
Removes diseased rectum
Wide resection of tissue and lymph nodes
Requires sigmoid colostomy
Low Anterior Resection (LAR)
Rectal cancer in middle of rectum
Total Proctocolectomy (TPC) and Ileal Pouch Anal Anastomosis (IPAA or IAR)
Removal of entire colon
Not indicated if disease limited to rectum
Pneumatosis Intestinalis
Halo sign
Indicator for impending bowel perforation
Seen in Necrotizing Enterocolitis (NEC)
Total Proctocolectomy and sexual function
Narrow resection of rectum
Low risk of damage to pudendal nerve
Erections still possible
Cause for abdominoperineal resection
Rectal cancer (Adenocarcinoma of colon/rectum)
Stoma w/ most corrosive effluent
Ileostomy
Most digestive enzymes in jejunum and ilium
Damage to inferior mesenteric artery
Provides blood supply to descending colon, sigmoid colon, proximal portion of rectum
Ileostomy may be needed
Stoma site location considerations
Through rectus muscle
Below belt line
Away from umbilicus, creases, scars
At apex of infraumbilical bulge
Treatment for carcinoma in upper and middle third of rectum
Low Anterior Recection (LAR)
Diverticulitis s/s
LLQ pain Fever N/V Change in bowel habits Palpable mass in LLQ
Complication of Diverticulitis requiring immediate surgery
Bowel perforation
Intussusception s/s
ABD pain
Vomiting
Palpable mass in RUQ
Bloody (red currant jelly) stool
Intussusception medical management
Air enema reductions (may re-expand bowel)
Surgery needed if reduction unsuccessful, bowel necrosis, perforation, peritonitis
