Lower GI key points - Med Surg, Lewis PDF

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Lower Gastrointestinal Disorders KEY POINTS

ACUTE ABDOMINAL PAIN  Acute abdominal pain is a new pain that may signal a problem requiring immediate surgery or other medical treatment.  Acute abdominal pain is a symptom of many different types of tissue injury and can arise from damage to abdominal or pelvic organs and blood vessels.  Pain is the most common symptom of abdominal and pelvic problems. Nausea, vomiting, diarrhea, fatigue, fever, and constipation may also be present.  Expected outcomes for the patient with acute abdominal pain include resolution of the cause of the acute abdominal pain, relief of abdominal pain, freedom from complications (especially hypovolemic shock and septicemia), and normal fluid, electrolyte, and nutritional status.  It is important to monitor patients frequently to detect deteriorations in their condition (e.g., fever, increased pulse and respirations, decreased BP, decreased oxygenation, altered mental status, poor skin perfusion, decreased urine output). CHRONIC ABDOMINAL PAIN  Common causes of chronic abdominal pain include irritable bowel syndrome (IBS), diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflammatory disease, and vascular insufficiency.  Treatment for chronic abdominal pain is comprehensive and directed toward palliation of symptoms using nonopioid analgesics and antiemetics, as well as nutritional, psychologic, or behavioral therapies. IRRITABLE BOWEL SYNDROME  Irritable bowel syndrome (IBS) is a chronic functional disorder characterized by intermittent and recurrent abdominal pain or discomfort and stool pattern irregularities (diarrhea, constipation, or both).  The cause is unknown and there are no specific findings. Treatment is directed at psychologic and dietary factors as well as medications to regulate output and reduce pain/discomfort. ABDOMINAL TRAUMA  Blunt abdominal trauma commonly occurs with motor vehicle accidents and falls and may not be obvious because it does not leave an open wound.  Penetrating trauma occurs with gunshot or knife wounds.  Common injuries of the abdomen include lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragm rupture, urinary bladder rupture, great vessel tears, renal injury, and stomach or intestine rupture.  Emergency management of abdominal trauma focuses on establishing a patent airway and adequate breathing, fluid replacement, and prevention of hypovolemic and septic shock.

INFLAMMATORY DISORDERS Appendicitis  Appendicitis is inflammation of the appendix. Obstruction results in distention, venous engorgement, and the accumulation of mucus and bacteria, which can lead to gangrene and perforation.  Appendicitis typically begins with periumbilical pain, followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney’s point.  The treatment is immediate surgical removal. Some patients need antibiotics and fluid resuscitation before surgery. Peritonitis  Peritonitis results from a localized or generalized inflammatory process of the peritoneum that occurs when organisms or chemicals enter the sterile peritoneal cavity. It can occur when sterility is inadequate during peritoneal dialysis and when an organ perforates, releasing its contents into the peritoneal cavity.  Common symptoms of peritoneal irritation include the cause of abdominal pain, hard abdomen, and tenderness over the involved area.  Major concerns are maintaining fluid and electrolyte balance and preventing septic shock. Surgery is usually indicated to drain purulent fluid and repair damage. Other care includes antibiotics, nasogastric suction, analgesics, and IV fluid administration. Gastroenteritis  Gastroenteritis is an inflammation of the mucosa of the stomach and small intestine.  Clinical manifestations include nausea, vomiting, diarrhea, fever, and abdominal cramping. Most cases are self-limiting and do not require hospitalization.  If the causative agent is identified, appropriate antibiotic and antimicrobial drugs are given. Nursing care is focused on maintaining adequate hydration and relief of nausea, vomiting, and diarrhea. Inflammatory Bowel Disease  Crohn’s disease and ulcerative colitis are immunologically related disorders that are referred to as inflammatory bowel disease (IBD).  IBD is characterized by an overactive, inappropriate, sustained immune response to substances that are normally tolerated.  Patients suffer mild to severe acute exacerbations that occur at unpredictable intervals over their lifetimes.  Ulcerative colitis affects the mucosal layer of the rectum and colon, but some patients do have mild inflammation in the terminal ileum. The primary symptoms are bloody diarrhea and abdominal pain. Medications are used to achieve and maintain remission.  Crohn’s disease can occur anywhere in the GI tract from the mouth to the anus but occurs most commonly in the terminal ileum and colon. The inflammation involves all layers of the bowel wall with segments of normal bowel occurring between diseased portions—the so-called skip lesions.

With Crohn’s disease, diarrhea and colicky abdominal pain are common symptoms. If the small intestine is involved, weight loss and nutritional problems are common because of malabsorption. Patients may have systemic symptoms such as fever.  Treatment goals for IBD include bowel rest, control of inflammation and infection, improved nutrition, alleviation of stress, symptomatic relief, and improved quality of life.  Five major classes of medications are used to treat IBD: aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, and biologic and targeted therapy.  Ulcerative colitis can be cured with a total colectomy, since the colon and rectum are not necessary for survival. Surgery is a last resort for Crohn ’s disease because of high recurrence rates and the risk for developing short bowel syndrome.  Surgery is indicated if the patient with IBD fails to respond to treatment; exacerbations are frequent and debilitating; massive bleeding, perforation, strictures, and/or obstruction occur; tissue changes suggest that dysplasia is occurring; or carcinoma develops.  During an acute exacerbation of IBD, nursing care is focused on hemodynamic stability, pain control, fluid and electrolyte balance, and nutritional support.  Nurses and other team members can assist patients to accept the chronicity of IBD and learn strategies to cope with its recurrent, unpredictable nature. 

INTESTINAL OBSTRUCTION  Intestinal obstruction occurs in either the small or large intestine. It can be partial or complete, simple or strangulated. Partial obstructions usually resolve with conservative treatment and complete obstructions usually require surgery.  A simple obstruction has an intact blood supply, and a strangulated one does not.  Physical (mechanical) obstructions are visible, but obstructions caused by impaired neuromuscular function or a poor blood supply to the intestines cannot be seen.  An obstructed bowel leads to retention of fluid in the intestine and eventually the peritoneal cavity, which can result in a severe reduction in circulating blood volume followed by hypotension and hypovolemic shock.  Clinical manifestations of intestinal obstruction vary, depending on the location of the obstruction, and include nausea, vomiting, abdominal pain, abdominal distention, inability to pass flatus, obstipation, and signs and symptoms of hypovolemia.  If the obstruction is strangulated, tissue death leads to necrosis and sepsis, and emergency surgery is necessary for survival.  Nursing care for the patient revolves around the nursing diagnoses of acute pain, deficient fluid volume, and imbalanced nutrition, as well as close monitoring to detect impending hypovolemic or septic shock. POLYPS OF THE LARGE INTESTINE  Adenomatous polyps are characterized by neoplastic changes in the epithelium and are closely linked to colorectal adenocarcinoma.  Familial adenomatous polyposis (FAP) is the most common hereditary polyp disease.

COLORECTAL CANCER  Major risk factors for colorectal cancer (CRC) include increasing age, a family or personal history of CRC, colorectal polyps, and IBD. Lifestyle factors associated with CRC include obesity, smoking, alcohol, and diet.  Symptoms do not appear until the advanced stages and include rectal bleeding, abdominal pain, and/or changes in bowel habits. Symptoms appear earlier with left-sided cancer as compared to right-sided cancer.  Most CRC arises from adenomatous polyps. Therefore early detection and removal of precancerous polyps can prevent most CRC.  Beginning at age 50, both men and women at average risk for developing CRC should have screening tests done to detect both polyps and cancer or tests that primarily detect cancer. Colonoscopy is the gold standard for CRC screening.  CRC prognosis and treatment correlate with stage of the disease. Treatments include endoscopic removal, surgical removal alone, surgical removal plus chemotherapy, or palliative chemotherapy for nonresectable CRC.  The goals for the patient with CRC include normal bowel elimination patterns, quality of life appropriate to disease progression, relief of pain, and feelings of comfort and wellbeing.  Psychologic support for the patient with CRC and family is important. The recovery period is long, and the cancer could return.  Bowel surgery can disrupt nerve and vascular supply to the genitals. Radiation therapy, chemotherapy, and medications can also alter sexual function. OSTOMY SURGERY  An ostomy is the surgical creation of an opening called a stoma that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen. An ostomy is used when the normal elimination route is no longer possible.  The two major aspects of nursing care for the patient undergoing ostomy surgery are emotional support as the patient copes with a radical change in body image and patient teaching about the many aspects of stoma care and the ostomy.  Postoperative nursing care includes assessment of the stoma and provision of an appropriate pouching system that protects the skin and contains drainage and odor.  The patient should be able to perform a pouch change, provide appropriate skin care, control odor, care for the stoma, and identify signs and symptoms of complications.  The patient with an ileostomy should be observed for signs and symptoms of fluid and electrolyte imbalance, particularly potassium, sodium, and fluid deficits.  With time and proper support, people learn to manage the stoma and resume work, social, and sexual activities. Accurate information, emotional support and mastering basic skills will help patients learn to live a full life with an ostomy and accept their change in body appearance and function. FISTULAS  A fistula, an abnormal tract between two hollow organs or a hollow organ and the skin, is named by the track it takes.

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Fistulas are classified as simple or complex and by the amount of output. Fever and abdominal pain are early indicators of a fistula. Other manifestations vary depending on the type of fistula. Nursing care involves maintaining fluid and electrolyte balance, controlling infection, protecting the surrounding skin, managing output, and providing nutritional support. Most fistulas heal spontaneously. Surgery may be necessary to address complications.

DIVERTICULOSIS AND DIVERTICULITIS  Diverticula are saccular dilations or outpouchings of the mucosa that develop in the colon. Diverticulitis is inflammation of the diverticula, resulting in complications such as perforation, abscess, fistula formation, and bleeding.  The cause of diverticuli is unknown. The main factor contributing to the development of diverticuli is lack of dietary fiber. The majority of patients with diverticular disease are asymptomatic. Those with symptoms typically have abdominal pain, bloating, flatulence, and/or changes in bowel habits.  Patient and caregiver teaching regarding a high-fiber diet, mainly from fruits and vegetables, with decreased intake of fat and red meat are recommended for preventing exacerbations of diverticular disease. HERNIAS  A hernia is a protrusion of a viscus through an abnormal opening or a weakened area in the wall of the cavity in which it is normally contained.  Types of hernias include inguinal, femoral, and ventral or incisional. Diagnosis is based on the history and physical examination relative to the type of hernia.  Surgery is the treatment of choice for hernias.  If the hernia becomes strangulated, the patient will experience severe pain and symptoms of a bowel obstruction, such as vomiting, cramping abdominal pain, and distention. Emergency surgery is required to treat a strangulated hernia.

CELIAC DISEASE  Celiac disease is an autoimmune disease characterized by damage to the small intestinal mucosa from the ingestion of wheat, barley, and rye in genetically susceptible individuals.  Three factors necessary for the development of celiac disease (gluten intolerance) are genetic predisposition, gluten ingestion, and an immune-mediated response.  Classic signs of celiac disease include foul-smelling diarrhea, steatorrhea, flatulence, abdominal distention, and symptoms of malnutrition.  Early diagnosis and treatment of celiac disease can prevent complications such as cancer (e.g., intestinal lymphoma), osteoporosis, and chronic inflammation.  A gluten-free diet is the only effective treatment for celiac disease. Most patients need to maintain on a gluten-free diet for the rest of their lives. LACTASE DEFICIENCY  Lactase deficiency is a condition in which the lactase enzyme is deficient or absent.

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Symptoms include bloating, flatulence, cramping abdominal pain, and diarrhea, which usually occur within a half hour to several hours after ingesting a milk product. Treatment consists of eliminating lactose from the diet by avoiding milk and milk products and/or replacement of lactase with commercially available preparations.

SHORT BOWEL SYNDROME  Short bowel syndrome (SBS) results from surgical resection of too much small bowel, congenital defect, or disease-related loss of absorption. The length and portions of small bowel affected are associated with the number and severity of symptoms.  SBS is characterized by the inability to obtain adequate nutrients from a standard diet.  SBS is treated with dietary changes, supplements, and antidiarrheal medications.  In severe cases, patients need parenteral nutrition for survival or a small intestine organ transplant.

ANORECTAL PROBLEMS Hemorrhoids  Hemorrhoids are dilated hemorrhoidal veins. They may be internal (occurring above the internal sphincter) or external (occurring outside the external sphincter).  Classic symptoms include bleeding with defecation, anal pruritus, prolapse, and pain.  Surgery may be indicated when there is prolapse or excessive bleeding or pain.  Nursing management includes teaching patients to prevent constipation, avoid prolonged standing or sitting, properly use over-the-counter (OTC) drugs, and seek medical care for severe symptoms (e.g., excessive pain and bleeding, prolapsed hemorrhoids). Anal Fissure  An anal fissure is a skin ulcer or a crack in the lining of the anal wall that is caused by trauma, local infection, or inflammation.  The major symptoms are anal pain and bleeding.  Surgical repair is done if conservative treatment with medications is ineffective. Anorectal Abscess  Anorectal abscesses are collections of perianal pus resulting from an infection in the anal glands.  Manifestations include local pain and swelling, foul-smelling drainage, tenderness, and fever.  Treatment consists of drainage of the abscess. The patient must be taught afterward about wound care, sitz baths, and cleansing of the area after bowel movements. Anal Fistula  An anal fistula is an abnormal tunnel leading from the anus or rectum, often into the vagina, or outside skin. It is often accompanied by infection and incontinence.  Fistulas are closed by surgery or using fibrin glue. Postoperative nursing care is the same as for the patient after a hemorrhoidectomy.

Anal Cancer  Anal cancer is uncommon in the general population, but the incidence is increasing. Human papillomavirus (HPV) is associated with approximately 80% of anal cancer.  Risk factors include smoking, immunosuppression, men who have sex with men, women with cervical or vulvar cancer or precancerous lesions, and HIV infection.  Most frequently the initial symptom is rectal bleeding. Other symptoms include rectal pain and sensation of a rectal mass. Some patients have no symptoms, which leads to delayed diagnosis and treatment.  Two FDA-approved vaccines (Gardasil, Gardasil 9) are available to help prevent cervical, vulvar, vaginal, and anal cancers and associated precancerous lesions due to certain HPV types.  Treatment depends on the size and depth of the lesions. Treatment options include local ablation, chemotherapy and radiation, and surgical resection....