*Appendicitis*Gastroenteritis

*Peritonitis*Ulcerative Colitis*Crohn’s Disease

*Diverticular Disease*Gallbladder Disease

Acute and Chronic Inflammatory Bowel Disorders and Bowel

Diseases

Appendicitis

Acute inflammation of vermiform appendix

Most common cause of RLQ pain

Lumen (opening) of appendix is blocked by fecaliths (hard feces, composed of calcium phosphate rich mucus and inorganic salts)

Appendicitis Cont.

Other causes:malignant tumorsHelminthesOther infections

Appendicitis Cont.

The lumen gets blocked the mucosa secretes fluid internal pressure increases causing pain

Slow process may develop abscess Rapid process may result in

peritonitis Gangrene can occur in 24-36 hours Life threating Emergency surgery

Perforation may develop

Assessment

Abdominal pain followed by N/V Cramp like pain in in epigastric or

periumbilical area Anorexia Initally pain can be anywhere in the

abdomen or flank area Pain becomes severe and shifts to

the RJQ (McBurney’s point) Between anterior iliac crest and

umbilicus

Assessment Cont.

Pain that increases with cough or movement suggest perforation and peritonitis

Observe for: Muscle rigidity Guarding on palpation Rebound tenderness

Lab findings: Incresed WBC’s with a shift to the left

Assessment Cont.

Other tests: Ultrasound-may show enlarged appendix CT scan- may reveal a fecalith

Nonsurgical Management

IV fluids NPO Semi-fowlers position to facilitate

abdominal drainage Analgesics Antibiotics DO NOT:

Apply heat-increases inflammation and perforation

Give laxatives or enemas-may cause perforation

Surgical management

Appendectomy-removal of appendix Laparoscopy-minimally invasive Natural orifice transluminal endoscopic

surgery (NOTES)-endoscope is placed in vagina or other orifice and makes small incision into peritoneal space

Laparotomy- open surgical approach

Gastroenteritis

Diarrhea and/or vomiting caused by inflammation of the mucous membranes of stomach and intestinal tract

Small bowel affected

Viral or bacterial

Gastroenteritis

Viral: Epidemic viral:▪ parvovirus-type organism ▪ transmitted fecal-oral in food and water. ▪ Incubation period 10-51 hours. ▪ Communicable during acute illness.

Rotavirus and Norwalk virus:▪ transmitted fecal-oral and possibly resp. route.▪ Incubation 48 hours. ▪ Common in infants and young children.▪ Norwalk virus affects young children and adults

Gastroenteritis Cont.

Bactreial: Campylobactor enteritis:▪ Transmitted fecal-oral or contact with infected animals or

infants ▪ Incubation period 1-10 days▪ Communicable 2-7 weeks

Escherichia coli diarrhea:▪ Transmitted by fecal contamination of food or water

Shigellosis:▪ Transmitted by direct or indirect fecal-oral routes▪ Incubation period 1-7 days▪ Communicable during acute illness and up to 4 weeks after▪ Humans possibly carries for months

Assessment

Obtain history of recent travel especially tropical regions

N/V Diarrhea Myalgia HA Malaise Weakness Cardiac dysrhythmias due to hypokalemia Hyrotension Dry mucous membranes Poor skin turgor

Assessment Cont.

Lab assessment: Gram stain stool:▪ Many WBC’s suggest shigellosis▪ WBC’s and RBC’s indicate Campylobacter

gasteroenteritis

Interventions

Fluid replacement: Oral IV- may need potassium added if excessive diarrhea

Drug therapy: Imodium if deemed necessary Antibiotics if bacterial infection

▪ Cipro▪ Levaquin▪ Zithromax▪ Septra DS

Skin care Avoid toilet paper and harsh soap Gently clean with warm water or absorbent material followed by

gentle drying Apply cream, oils, gel or barrier cream sitz baths for 10 minutes 2-3 times a day

Peritonitis

acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity.

LIFE THREATENING Body begins an

inflammatory reaction to create a “wall” to stop the spread of bacteria

When the wall fails the bacteria spreads resulting in peritonitis.

Peritonitis

Causes: Bacteria or chemicals contaminating the

peritoneal cavity ▪ Escherichia coli▪ Streptococcus▪ Staphylococcus▪ Pneumococcus▪ Gonococcus▪ Bile▪ Pancreatic enzymes▪ Gastric acid

Peritonitis Cont.

How bacteria get in:▪ perforation (appendicitis, diverticulitis, PUD),▪ an external perforating wound▪ a gangrenous gallbladder▪ bowel obstruction▪ ascending infection through the genital tract.

Peritonitis Cont.

Hypovolemic shock results from a decrease in ECF and circulatory volume (this fluid migrates to the peritoneal cavity).

Hypovolemic shock insufficient perfusion to kidneys kidney failure with electrolyte imbalance

Peritoneal inflammation peristalsis slows or stops lumen of bowel becomes distended fluid accumulates in intestine (7-8 L DAILY)

Assessment

Respiratory problems caused by abdominal pressure on diaphragm

Rigid, board like abd. (classic) Pain Distention rebound tenderness N/V Anorexia diminished bowel sounds inability to “pass flatus” or poop High fever Tachycardia Dehydration decreased UO Hiccups possible compromised respiratory status

Assessment Cont.

Lab assessment Elevated WBC with high neutrophil count Blood culture studies to check for septicemia

(bacterial invasion of blood) Electrolytes BUN, CRT H&H O2

X-rays may be ordered to assess for air or fluid 

Nonsurgical Management

Administer IV fluids broad spectrum antibiotics Monitor daily weight I&O Place NG tube NPO O2

SPO2 and respiratory status checks Pain medications

Surgical Management

Laparotomy or Laparoscopy to remove or repair the inflamed or perforated organ

The focus is to control contamination and drain fluid

Catheters may be placed to drain the cavity and provide irrigation route

After surgery Maintain sterile technique during manual irrigation of

peritoneal wounds through a drain Assess for fluid retention during irrigation Place in semi-fowlers to promote drainage and

increase lung expansion

Surgical Management Cont.

After surgery Maintain sterile technique during manual irrigation of peritoneal

wounds through a drain Assess for fluid retention during irrigation Place in semi-fowlers to promote drainage and increase lung

expansion Assess ability of self-management

Teaching Provide written and oral instructions Discuss when to immediately call provider ( unusual/ foul-smelling

drainage, swelling, redness, warmth, bleeding from incision site, temperature higher than 101, abd pain)

Collaborate with case manager to ensure care will be provided at home if needed

Review medications Refrain from ANY lifting for AT LEAST 6 weeks

Ulcerative Colitis

Widespread inflammation of rectum and rectosigmoid colon, but may extend to entire colon when the disease is extensive

Associated with periodic remissions and exacerbations

Disease may remain constant for years

Ulcerative Colitis Cont.

Intestinal mucosa becomes hyperemic (increased blood flow), edematous, and reddened

In severe cases, the lining may bleed, causing small erosions, or ulcers, to occur

Abscesses form in ulcerative areas, resulting in tissue necrosis

Continued edema leads to narrowed colon, and possibly a bowel obstruction

Ulcerative Colitis Cont.

Patient’s stool contains blood and mucus

Patient reports tenesmus (unpleasant, urgent sensation to defecate), and lower abdominal pain which is relieved with defecation

Additional s/sx: malaise, anorexia, anemia, dehydration, fever, weight loss

Ulcerative Colitis Etiology/Risk

Affects about 1.4 million in U.S. Peak age of Dx: 30-40 y/o Women affected more than men in younger years; men

affected more in middle-older age Cause is unknown More prevalent among Jewish persons, and among whites

more than non-whites (Reason for this is unknown) Genetic/immunologic factors suspected Often found in families and twins Autoimmune dysfunction: epithelial antibodies IgG have

been found in the blood of some patients with Ulcerative Colitis

With long-term disease, risk for developing colon cancer increases

Ulcerative Colitis: Classification of Severity

Mild: <4 stools/day with/without blood Asymptomatic Lab values usually normal

Moderate: >4 stools/day with/without blood Minimal symptoms Mild abd pain Mild intermittent nausea Possible increased C-reactive protein or ESR (erythrocyte sedimentation rate)

Severe: >6 bloody stools/day Fever Tachycardia Anemia Abd pain Elevated C-reactive protein and/or ESR

Fulminant: >10 bloody stools/day Increasing symptoms Anemia may require transfusion Colonic distention on x-ray

Assessment

History Collect family hx data, nutrition hx, usual bowel patterns (color,

characteristic, consistency of stools) Inquire about recent antibiotic use (may suggest C-diff

infection) Inquire about travel to tropical areas Ask about use of NSAIDs (may cause flare-up)

Physical Asessment Symptoms vary, VS are usually WNL in mild cases In severe cases, fever (99-100 F or 37.2-37.8 C) Note any abd distention Fever with tachycardia may indicate peritonitis, dehydration,

and bowel perforation Assess for complications such as inflamed joints and lesions in

the mouth

Assessment con’t

Psychosocial Assessment Inability to control bowel, specifically presence of diarrhea,

can be disruptive and stress-producing Explore: stress factors which cause flare-ups, family and

social support systems, genetic concerns Lab Assessment

H&H low due to blood loss (indicates anemia and a chronic disease state)

Elevated WBC, C-reactive protein, and/or ESR Serum Na, K, and Cl may be low due to diarrhea and

malabsorption from diseased bowel Decreased serum albumin due to loss of protein through stool

Other Diagnostic Assessment Colonoscopy is the most definitive test for diagnosing UC

Planning/Implementation

Priority problems: Diarrhea/incontinence r/t inflammation of bowel mucosa Pain r/t inflammation and ulceration of bowel mucosa

and skin irritation Potential for lower GI bleeding and resulting anemia

Nonsurgical management (Drug therapy) Aminosalicylates (anti-inflammatory effect by inhibiting

prostaglandins; effective in 2-4 wks)▪ Sulfasalizine, Mesalamine

Glucocorticoids (prescribed during exacerbations)▪ Prednisone – tapered dosing once improvement occurs

Immunomodulators (synergistic effect with prednisone)▪ Remicade, Humira

Planning/Implementation Cont. Nutrition therapy

Patients are kept NPO when symptoms are severe, to ensure bowel rest

TPN for severely ill/malnourished patients Diet is not a major factor, but ETOH and caffeine

may increase diarrhea and cramping For some patients, lactose and high-fiber foods

cause GI symptoms Rest

Activity is generally restricted to slow peristalsis Ensure access to bedpan, bedside commode, or

bathroom in case of tenesmus (urgency)

Planning/Implementation Cont. CAM therapies

Herbs (flaxseed), selenium, Vit. C, biofeedback, hypnosis, acupuncture, and ayurveda (a combination of diet, yoga, herbs, and breathing exercises)

Surgical management Temporary or permanent ileostomy Laparoscopic surgery Natural orifice transluminal endoscopic surgery

(NOTES) performed through anus or vagina Total proctolectomy with permanent ileostomy

(removal of anus, rectum, and colon)

Evaluation

Expected outcomes: Verbalizes decrease in pain Gain of control over bowel elimination No GI bleeding Self-management of ileostomy Maintains peristomal skin integrity Demonstrates behaviors that integrate

ostomy care into his or her lifestyle if a permanent ileostomy is performed

Crohn’s Disease

Inflammatory disease of the small intestine, colon, or both

Can affect GI tract from mouth to anus, but most commonly affects the terminal ileum

Progressive, unpredictable disease Like UC, this is recurrent with

remissions and exacerbations Unlike UC, Crohn’s causes a

thickened bowel wall with strictures and deep ulcerations that have a cobblestone appearance (these put the patient at risk for bowel fistulas)

Malabsorption of vital nutrients; anemia results

Horses and Zebras

Horses (Similarities between UC and CD) Inflammatory disease Periodic remissions and exacerbations Weight loss, frequent, bloody stools, fever, abd pain, abd distention, diarrhea No known cause; familial patterns; Jewish ethnicity Anemia Elevated WBCs, C-reactive protein, and ESR Decreased albumin Decreased electrolytes Complications: hemorrhage/perforation, abscess formation, toxic

megacolon, malabsorption, nonmechanical bowel obstruction, fistulas, colorectal cancer, extraintestinal complications (arthritis, oral and skin lesions), osteoporosis

Interventions are the same Drugs: Aminosalicylates, Remicade, Humira, glucocorticoids

(contraindication: fistulas) Need for TPN in malnourished patients

Horses and Zebras

Zebras: (Differences between UC and CD) Unlike UC, CD causes thickened bowel wall with

necrosis, strictures, and deep ulcerations Hemorrhage is more common in UC Fistula formation is common in CD (rare in UC) Malabsorption by small intestine is common in CD

because UC doesn’t significantly involve the small bowel Therefore, patients with CD tend to be more

malnourished Patients with CD at increased risk for sepsis Surgical management for CD: laparoscopic bowel

resection, or stricturoplasty (increasing the diameter of the bowel)

Diverticular Disease

Diverticula: pouchlike herniations of the mucosa through the muscular wall of any portion of the gut, usually the colon

Diverticulosis: presence of many abnormal diverticula in the wall of the intestine (without inflammation, this causes few problems)

Diverticulitis: inflammation of one or more diverticula (caused by trapping of undigested food or bacteria in diverticulum, resulting in reduced blood supply to that area)

Diverticular Disease Cont.

Diverticulitis: low-grade fever, N&V, abd pain (may be localized to LLQ), bleeding from rectum, chills, tachycardia

If pain is generalized, peritonitis has occurred Elevated WBCs, decreased H&H Stool test for occult blood Possible RBCs present in UA Most often diagnosed with colonoscopy CT to diagnose abscess or thickening Treated with wide-spectrum antimicrobials (Flagyl,

sulfa, cipro) Avoid laxatives and enemas which increase

motility

Gallbladder Disease (GBD)

The gallbladder is a small pear-shaped digestive organ located under the liver.

Bile is released from liver and stored in gallbladder.

Gallbladder Disease

IS More common in women than men Inflammation Infection Stones Obstruction of the gallbladder. Most common cause is gallstones

Symptoms vary widely from discomfort to severe pain Begins after eating

Severe Cases Jaundice nausea fever

Risk Factors

Heredity. More frequently in Mexican Americans and Native Americans but are also common in people of northern European stock.

Age. Gallbladder disease often strikes people over sixty years of age.

Gender. Excess estrogen may be implicated, since hormone replacement after menopause increases the likelihood of stones.

Diet. Most people know that there is an established link between fat intake and gallbladder disease, but many don't realize that there is also a significant correlation with high sugar intake as well. (Diabetes mellitus)

Obesity. In comparison with people of normal weight, the bile of obese people is supersaturated with cholesterol, predisposing them to the development of gallbladder illness.

Slow intestinal transit. Medical professionals have long known that constipation is common in patients who have gallbladder disease. Studies confirm that slow intestinal transit contributes to the formation of gallstones in women of normal weight.

Gallstones

Formed by crystallized bile substances : Excess cholesterol Bile salts calcium

Vary in size: Can be as small as a grain of sand.

Symptoms

N/V A bloated sensation in the abdomen Gassiness, with belching and passing of

intestinal gas Indigestion Clay-colored stools Jaundice Chills Sweating Fever

Cholecystitis

Acute Inflammation of the gall bladder from:▪ Irritation and inflammation from gallstones▪ stone blocking a passageway (cholelithiasis)

Chronic Repeated episodes of duct obstruction

Symptoms

Intense and sudden pain in the upper right part of the abdomen

recurrent painful attacks for several hours after meals

N/V Rigid abdominal muscles on right side Slight fever Chills Jaundice Itching Loose, light-colored bowel movements Abdominal bloating

Nonsurgical Management

Pain medication Dilaudid Morphine Toradol

Antiemetics for N/V IV antibiotics Extracorporeal shock wave

lithotripsy (ESWL) Biliary catheters to open blocked

ducts

Surgical Management

Cholecystectomy --surgical removal of the gallbladder Laparoscopic ▪ minimally invasive surgery (MIS)▪ Complications are not common▪ The death rate is very low▪ Bile duct injuries are rare▪ Patient recovery is quicker▪ Postoperative pain is less severe

Surgical ManagementCont.

Traditional Cholecystectomy Open surgical approach Used for severe biliary obstruction T-tube drain may be inserted into duct

for drainage JP drains my be placed in gallbladder

bed to prevent fluid accumulation

Post-0p Care

PCA Cough and deep breath Antiemetics Wound care Keep NPO until fully awake then advance

clear liquids red diet V/S LOC Assess surgical site for redness and

purulent drainage Ambulation

Patient Teaching

Teach signs of postcholecystectomy syndrome (PCS) Repeat abdominal pain Epigastric pain with vomiting that may

occur weeks to months after surgery

PCS

Causes Pseudocyst Common bile duct (CBD) leak CBD or pancreatic duct obstruction Sphincter dysfunction Retained or new gallstone Pancreatic or liver mass Diverticular compression

Presented by

Laura HendersonLindsey KinchIvette Nunez

Ronald PattersonDonna Wade

References

Ignatavicius, M. R., & Workman, P. R. (2013). Medical Surgical Nursing: Patient-Centered Collaborative Care. St. Louis: Elsevier Saunders.