GIT Disorders

NURSING MANAGEMENT

OF GIT PROBLEMS

COMMON MANIFESTATIONS OF DIGESTIVE SYSTEM DISORDERS:

Changes in bowel habits – a signal of colon diseasea.Diarrhea – abnormal increase in frequency and liquidity of the stool

or daily stool weight or volume.

- Occurs when contents move so rapidly through the intestine and colon with inadequate time for absorption of GI contents.

- Sometimes associated with abdominal pain or cramping and nausea and vomiting

CONSTITUENTS OF AN AVERAGE STOOL:

1. 1/3 unabsorbed food

2. Remainder made up of:

- cast – off intestinal epithelial cells

- microbes

- partially dried secretions

150 – 200 grams daily

100 – 150ml of water lost in the stools

MECHANISMS OF DIARRHEA:

• 1. Accumulation of EXCESSIVE FLUID VOLUME within the gut;

• - distends the gut wall and thus initiates strong propulsive movements

• 2. INCREASE PROPULSIVE MOTILITY - due to local reflex stimulation or generalized neural or Humoral stimulation of the intestines

- less time for water to be absorbed in the small intestines

DIARRHEA: Pathophysiology

• Types of diarrhea: secretory, osmotic and mixed diarrhea.

• Secretory diarrhea is usually high-volume diarrhea caused by increased production and secretion of water and electrolytes by the intestinal mucosa into the intestinal lumen.

• Osmotic diarrhea occurs when water is pulled into the intestines by the osmotic pressure of unabsorbed particles, slowing the reabsorption of water.

DIARRHEA: Pathophysiology

• Mixed diarrhea is caused by increased peristalsis (usually from IBD) and a combination of increased secretion and decreased absorption in the bowel.

CLASSIFICATION OF DIARRHEA:

A. According to ONSET and DURATION

1. ACUTE DIARRHEA – sudden and short duration

causes: infectious agent

toxins

poisons

drugs

2. CHRONIC DIARRHEA – Insiduous onset long duration( three weeks)

• B. SITE OF THE LESION• 1. Small bowel diarrhea• 2. Large bowel diarrhea

Small bowelSmall bowel Large bowelLarge bowel

1. Vol of stool1. Vol of stool largelarge smallsmall

2. frequency2. frequency 1-2x daily1-2x daily 6-10x daily6-10x daily

3. Urgency or 3. Urgency or tenesmustenesmus

absentabsent presentpresent

4. Blood or 4. Blood or mucusmucus

absentabsent presentpresent

5.Abdominal 5.Abdominal pain or pain or discomfortdiscomfort

Worse after Worse after meals or just meals or just before bowel before bowel movmentmovment

Relieved by Relieved by defecation or defecation or passage of passage of flatusflatus

DIARRHEA: Clinical Manifestations

• Increased frequency and fluid content of stools

• Abdominal cramps and distention• Intestinal rumbling• Anorexia and thirst• Painful spasmodic contractions of the anus and ineffectual straining (tenesmus)

• Watery stools are characteristic of small bowel disease.

• Loose, semisolid stools are associated more often with disorders of the colon.

DIARRHEA: Clinical Manifestations

• Voluminous, greasy stools suggest intestinal malabsorption.

• Presence of mucus and pus suggests inflammatory enteritis or colitis.

DIARRHEA: Assessment and Diagnostic Findings

• Complete blood count• Chemical profile• Urinalysis• Routine stool examination• Stool examinations for parasitic or infectious organisms, bacterial toxins, blood, fat and electrolytes.

• Barium enema may assist in identifying the cause.

DIARRHEA: Complications

• Fluid and electrolyte imbalance (cardiac dysrhythmias)

• Renal failure• Multiorgan failure and death

DIARRHEA: Medical Management

• Primary management is directed at controlling symptoms, preventing complications, and eliminating or treating the underlying disease.

• Certain medications may reduce the severity of the diarrhea and treat the underlying disease.

DIARRHEA: Nursing Management

• Assess and monitor the characteristics and pattern of diarrhea.

• Encourage bed rest and intake of fluids and food low in bulk until the acute attack subsides.

• When food intake is tolerated, recommend a bland diet of semisolid and solid food.

• Avoid caffeine, carbonated beverages and very hot and very cold food.

• Restrict milk products, fat, whole-grain products, fresh fruits and vegetables for several days.


• Administer antidiarrheal medications such as diphenoxylate (Lomotil) and loperamide (Imodium) as prescribed.

• IV therapy for rapid rehydration especially for the elderly and those with preexisting GI conditions.

• Monitor serum electrolyte levels• Report immediately clinical evidence of dysrhythmias or a change in the level of consciousness.


• The perianal area may be excoriated because diarrheal stool contains digestive enzymes that can irritate the skin. The patient should follow a perianal skin care routine to decrease irritation and excoriation.

• Use skin sealants and moisture barriers as needed.

b. Constipation – decrease in the frequency of stool or stools that are hard, dry and smaller volume than normal.

- May be associated with anal discomfort and rectal bleeding

Stool characteristics

Normally light to dark brown Indigestion of certain foods and

medications can change the appearance of stool.

Causes of Constipation:• 1. Inadequate dietary fibers• 2. inadequate fluid intake• 3. failure to respond to the defecation reflex because of pain or inconvenient timing

• 4. muscle weakness and inactivity• 5. neurologic disorders• 6.drugs (opiates,antacids, iron medications• 7. obstructions caused by tumors and strictures

CONSTIPATION: Pathophysiology

• Poorly understood.• Interference with mucosal transport, myoelectric activity, or processes of defecation.

CONSTIPATION:Clinical Manifestations

• Abdominal distention• Borborygmus• Pain and pressure• Decreased appetite• Headache, fatigue• Indigestion• Sensation of incomplete emptying• Passage of scybala

CONSTIPATION: Assessment and Diagnosis

• Chronic constipation is usually considered idiopathic, but secondary causes should be eliminated.

• Diagnosis is based on results of the patient’s history, physical examination, possibly a barium enema or sigmoidoscopy, and stool testing for occult blood.

CONSTIPATION: Complications

• Hypertension• Fecal impaction• Hemorrhoids and fissures• Megacolon

CONSTIPATION: Medical Management

• Treatment is aimed at the underlying cause of constipation and includes education, bowel habit training, increased fiber and fluid intake, and judicious use of laxatives.

• Enemas and rectal suppositories are generally not recommended for constipation and should be reserved for the treatment of impaction or for preparing the bowel for surgery or diagnostic procedures.

CONSTIPATION: Medical Management

• Further studies are being carried out on cholinergic agents (e.g., bethanechol), cholinesterase inhibitors (e.g., neostigmine), and prokinetic agents (e.g., metoclopramide) to determine the role of these agents in treating constipation.

CONSTIPATION: Nursing Management

• Elicit information about the onset and duration of constipation, past and present elimination patterns, the patient’s expectation of normal bowel elimination, and lifestyle information during health history review.

• Past medical and surgical history, current medications, and laxative and enema use are important, as is information about the sensation of rectal fullness or pressure, abdominal pain, excessive straining at defecation and flatulence.

CONSTIPATION: Nursing Management

• Patient education and health promotion• Restoring and maintaining a regular pattern of elimination

• Ensuring adequate intake of fluids and high-fiber foods

• Teach methods to avoid constipation• Relieve anxiety about bowel elimination patterns

• Avoid complications

treatment• Increasing intestinal bulk by increasing dietary fiber

content

NURSING MANAGEMENT

OF GIT PROBLEMS

Esophageal disorders

The GIT ANATOMY

The Esophagus•A hollow collapsible tube•Length- 10 inches•Made up of stratified squamous epithelium

The GIT ANATOMY

The Esophagus• The upper third contains skeletal muscles• The middle third contains mixed skeletal and

smooth muscles• The lower third contains smooth muscles and the

esophago-gastric/ cardiac sphincter is found here

The GIT PHYSIOLOGY

The EsophagusFunctions to carry or propel foods from the

oropharynx to the stomach

Three Phases of Deglutition:

1. voluntary phase

2. pharyngeal phase

3. esophageal phase

NERVOUS CONTROL OF THE GIT

The GIT Physiology

SYMPATHETIC• Generally INHIBITORY!• Decreased gastric

secretions• Decreased GIT motility

• But: Increased sphincteric tone and constriction of blood vessels

PARASYMPATHETIC• Generally EXCITATORY!• Increased gastric

secretions• Increased gastric

motility

• But: Decreased sphincteric tone and dilation of blood vessels

DISORDERS OF THE ESOPHAGUS: Dysphagia

• The most common symptom of esophageal disease.

• Ranges from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing (odynophagia).

DISORDERS OF THE ESOPHAGUS: Achalasia• Absent or ineffective peristalsis of the distal

esophagus, accompanied by failure of the esophageal sphincter to relax in response to swallowing.

• Primary symptoms: - is difficulty of swallowing both liquids and solids, - regurgitation of food either spontaneously or

intentionally, - chest pain and heart burn (pyrosis), - Nocturnal cough - and secondary pulmonary complications from

aspiration of gastric contents.

AchalasiaEpidemiology: 1:100.000 in US

equally in both sexes

Age of Onset: 20 and 40 years

Pathogenesis:

1. Primary achalasia: decreased ganglion cells, with fibrosis and scarring in Myenteric (Auerbach’s) plexus.

2. Secondary achalasia:

e.g Chagas disease, polio

Diabetic autonomic neuropathy

DISORDERS OF THE ESOPHAGUS: Achalasia

• X-rays show esophageal dilatation above the narrowing at the gastroesophageal junction.

• Manometry

1. aperistalsis

2. Elevated LES pressure

3. Partial or incomplete relaxation of LES

DISORDERS OF THE ESOPHAGUS: Achalasia

DISORDERS OF THE ESOPHAGUS: AchalasiaManagement:

- Eat slowly and drink fluids with mealsCalcium channel blockers and nitrates

- Pneumatic or forceful dilation or surgical separation of the muscle fibers.

- Endoscopic injection of botulinum toxin- Surgical treatment by esophagomyotomy (Heller myotomy) in which the esophageal muscle fibers are separated to relieve the lower esophageal stricture.

• Patients with achalasia have a slightly higher incidence of esophageal cancer.

CONDITION OF THE ESOPHAGUSHIATAL HERNIA

• Protrusion of the esophagus into the diaphragm thru an opening

• Two types: 1. Sliding hiatal hernia or axial - 95% of cases 2. Nonaxial or paraesophageal hiatal herniaOccurs most often in women than in men

Etiology• Causes is UNKOWN• 40-70 year old• Congenital weakening of the muscles in the diaphragm

around the esophagogastric opening• Increase intra abdominal pressure

- obesity, pregnancy, ascites, trauma

CONDITION OF THE ESOPHAGUSASSESSMENT Findings in Hiatal hernia• 1. Heartburn• 2. Regurgitation and dysphagia• 3. Fullness after eating• 4. 50%- without symptoms

Complications: both types may ulcerate, causing bleeding and perforation

Paraesophageal hernias – strangulation and obtruction

MEDICAL MANAGEMENT:

1. Drug therapy: antacids to reduce acidity and relieve discomfort

2. Modification of diet: elimination of spicy foods and caffeine

3. Surgery, reduction of hiatal hernia via abdominal or thoracic approach.

CONDITION OF THE ESOPHAGUS

DIAGNOSTIC TESTBarium swallow And fluoroscopy/endoscopy


NURSING INTERVENTIONS• 1. Provide small frequent feedings• 2. AVOID supine position for 1 hour after eating• 3. Elevate the head of the bed on 4-8-inch block• 4. Provide pre-op and post-op care• 5. Provide client teaching and discharge planning.

CONDITIONS OF THE GIT

UPPER GI system

DISORDERS OF THE ESOPHAGUS: Perforation• The esophagus is not an uncommon site of injuryResult from:• stab or bullet wounds of the neck or chest• trauma from motor vehicle crash • caustic injury from a chemical burn puncture by surgical instrumentationSpontaneous perforation –Boerhaaves syndrome - violent retchingClinical Manifestations:

Persistent pain followed by dysphagiaInfection, fever, leukocytosis and severe hypotensionSigns of pneumothorax

* subcutaneous emphysemaDiagnosis: Endoscopy

DISORDERS OF THE ESOPHAGUS: Perforation

• Management:

Broad-spectrum antibiotic therapy

Suction by NGT insertion to reduce amount of gastric juice.

NPO; parenteral nutrition

Surgery may be necessary to close the wound

Post-operative nursing management

DISORDERS OF THE ESOPHAGUS: Foreign Bodies

• Glucagon may be injected intramuscularly.• Endoscopy to remove the impacting food or object

from the esophagus.• Sodium bicarbonate + tartaric acid may be used to

increase intraluminal pressure by the formation of gas. Caution must be used because of the risk of perforation.

DISORDERS OF THE ESOPHAGUS: Chemical Burns

• May be caused by undissolved medications in the esophagus, or by ingestion of caustic agents like strong acids and bases.

• May be intentional or accidental.• Patient is usually emotionally distraught as well

as in acute physical pain.• The patient may be profoundly toxic, febrile,

and in shock.• Esophagoscopy and barium swallow are

performed as soon as possible.


• Vomiting and gastric lavage are avoided to prevent further exposure of the esophagus to the caustic agent.

• Corticosteroids?• Antibiotics?• Nutritional support via enteral or parenteral

feeding• Prevent or manage strictures of the

esophagus.


• Surgical management for strictures that do not respond to dilation.

• Reconstruction may be accomplished by esophagectomy and colon interposition to replace the portion of esophagus removed.

CONDITION OF THE ESOPHAGUSEsophageal Varices•Dilation and tortuosity of the submucosal veins in the distal esophagus

•ETIOLOGY: commonly caused by PORTAL hypertension secondary to liver cirrhosis

•This is an Emergency condition!


ASSESSMENT findings for EV•1. Hematemesis•2. Melena•3. Ascites•4. jaundice•5.hepatomegaly/splenomegaly


ASSESSMENT findings for EV•Signs of Shock- tachycardia, hypotension, tachypnea, cold clammy skin, narrowed pulse pressure


DIAGNOSTIC PROCEDURE•Esophagoscopy


NURSING INTERVENTIONS FOR EV

•1. Monitor VS strictly. Note for signs of shock

•2. Monitor for LOC•3. Maintain NPO

CONDITION OF THE ESOPHAGUSNURSING INTERVENTIONS FOR EV

•4. Monitor blood studies•5. Administer O2•6. prepare for blood transfusion

CONDITION OF THE ESOPHAGUSINTERVENTIONS FOR EV•7. prepare to administer Vasopressin and Nitroglycerin

•8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade

CONDITION OF THE ESOPHAGUSNURSING INTERVENTIONS FOR EV

•9. Prepare to assist in surgical management:•Endoscopic sclerotherapy•Variceal ligation•Shunt procedures

Conditions of the Esophagus

Gastro-esophageal reflux•Backflow of gastric contents into the esophagus

Conditions of the EsophagusGastro-esophageal refluxFACTORS•Usually due to incompetent lower esophageal sphincter , pyloric stenosis or motility disorder

•Symptoms may mimic ANGINA or MI


Gastro-esophageal reflux: Pathophysioincompetent lower esophageal sphincter

regurgitation of acidic contents

Erosion of esophageal mucosa

Pain


ASSESSMENT ( for GERD)•Heartburn•Dysphagia•Dyspepsia•Regurgitation•Epigastric pain•Ptyalism

Conditions of the EsophagusDiagnostic test• Endoscopy or barium swallow• Gastric ambulatory pH analysis

• Note for the pH of the esophagus, usually done for 24 hours

• The pH probe is located 5 inches above the lower esophageal sphincter

• The machine registers the different pH of the refluxed material into the esophagus

DISORDERS OF THE ESOPHAGUS: GERD


NURSING INTERVENTIONS• 1. Instruct the patient to AVOID stimulus that increases

stomach pressure and decreases GES pressure• 2. Instruct to avoid alcohol , spices, coffee, tobacco

and carbonated drinks• 3. Instruct to eat LOW-FAT, HIGH-FIBER diet, BLAND

DIET


NURSING INTERVENTIONS•4. Avoid foods and drinks TWO hours before bedtime

•5. Elevate the head of the bed with an approximately 8-inch block


NURSING INTERVENTIONS•6. Administer prescribed H2-blockers, PPI and prokinetic meds like cisapride, metochlopromide

•7. Advise proper weight reduction

DISORDERS OF THE ESOPHAGUS: GERD

• Management:

Proton-pump inhibitors

Prokinetic drugs (urecholine, domperidone, metoclopramide)

Surgical intervention (fundoplication)

Disorders of the Esophagus: Barrett’s Esophagus

• Believed to result from long-standing untreated GERD.

• Identified as a precancerous condition that, if left untreated, can result in adenocarcinoma of the esophagus.

• Patients complain of symptoms of GERD.• EGD is performed revealing an esophageal

lining that is red rather than pink. On biopsy, cells obtained from the esophagus resemble those of the intestine.


• Monitoring varies depending on the amount of cell changes.

• EGD should be done every 6 to 12 months if there are minor cell changes.

CANCERS OF THE ESOPHAGUS

• Carcinoma of the esophagus occurs more than three times as often in men as in women. (4:1) 50-70yr old

• Often in middle and lower portion• Chronic irritation is a risk factor.• Associated with ingestion of alcohol and

with the use of tobacco.• Vitamin deficiency – Vit A & C• Usually of the squamous cell epidermoid

type, but the incidence of adenocarcinoma is increasing.

CANCERS OF THE ESOPHAGUS

• Clinical Manifestations:

Dysphagia, initially with solid foods and eventually with liquids

Sensation of mass in the throat

Odynophagia

Substernal pain or fullness

Regurgitation of undigested food with foul breath and singultus.

• Diagnosis is confirmed most often by EGD with biopsy and brushings.

CANCERS OF THE ESOPHAGUS• Medical Management:

Early stage: cure; Late stage: palliationSurgery, irradiation, chemotherapy or a

combination

• Nursing Management:Improving the patient’s nutritional and

physical condition in preparation for surgery, radiation therapy or chemotherapy

Immediate postoperative care is similar to that provided for patients undergoing thoracic

surgery.

Conditions of the Stomach

PEPTIC ULCER DISEASE•An ulceration of the gastric and duodenal lining

•May be referred as to location as Gastric ulcer in the stomach, or Duodenal ulcer in the duodenum

•Most common Peptic ulceration: anterior part of the upper duodenum

Acids, bile salts, NSAID’s Alcohol, ischemia, H. pylori

Destruction of mucosal barrier

Acid back diffusion into the mucosa

Destruction of mucosal cells

Inc. Acid and Pepsin in mucosa

Further mucosal erosionsDestruction of blood vessels

Bleeding

Histamine

Inc. VasodilationInc. capillary permeability

Loss of plasma protein into gastric lumen

Mucosal edemaUlceration

GASTRIC AND DUODENAL ULCERS

H. pylori, gastritis, alcohol, smoking, NSAIDs, stress

H. pylori, alcohol, smoking, cirrhosis, stress

RISK FACTORS

OccasionallyRareMALIGNANCY

Less commonMore commonPERFORATION

More common, hematemesisLess common, melenaHEMORRHAGE

Common (relieves pain)UncommonVOMITING

½ - 1 hr post-meal, rarely occurs at night; food intake aggravates pain

2-3 hrs post-meal, early morning awakenings, relieved by food intake

EPIGASTRIC PAIN

Weight lossNormal or weight gainBODY WEIGHT

Normal or hyposecretionHypersecretionSTOMACH ACID

15% of peptic ulcers80% of peptic ulcersINCIDENCE

1:12-3:1MALE:FEMALE RATIO

Usually 50 and over30 – 60 yearsAGE

GASTRIC ULCERDUODENAL ULCER

Pathogenesis1. Social Factors – tobacco smoking, drugs, alcohol

2. Physiologic factors – Gastric acid

3. Genetic Factors

4. Infectious etiology – H. pylori

5. Associated dse – e.g. Antral atropic gastritis

6. Psychosomatic factors – chronic anxiety, Type A personality

Stress ulcers:• Cushing’s ulcers are common in patients with

trauma to the brain. They may occur in the esophagus, stomach or duodenum and are usually deeper and more penetrating than stress ulcers.

• Curling’s ulcers are frequently observed about 72 hours after extensive burns and involves the antrum of the stomach or the duodenum.


DIAGNOSTIC PROCEDURES• 1. EGD to visualize the ulceration• 2. Urea breath test for H. pylori infection• 3. Biopsy- to rule out gastric cancer• 4. Barium swallow• 5. Gastric analysis

GASTRIC AND DUODENAL ULCERS: Assessment• Endoscopy is the preferred diagnostic

procedure because it allows direct visualization of inflammatory changes, ulcers and lesions.

• Stools may be tested periodically until they are negative for occult blood.

• H. pylori infection may be determined by biopsy and histology with culture, as well as a breath test and serologic test for H. pylori antibodies.


NURSING INTERVENTIONS•1. Give BLAND diet, small frequent meals during the active phase of the disease

•2. Administer prescribed medications- H2 blockers, PPI, mucosal barrier protectants and antacids


NURSING INTERVENTIONS•3. Monitor for complications of bleeding, perforation and intractable pain

•4. Provide teaching about stress reduction and relaxation techniques


NURSING INTERVENTIONS FOR BLEEDING

•1. Maintain on NPO •2. Administer IVF and medications

•3. Monitor hydration status, hematocrit and hemoglobin


NURSING INTERVENTIONS FOR BLEEDING

•4. Assist with iced SALINE lavage

•5. Insert NGT for decompression and lavage

Conditions of the StomachNURSING INTERVENTIONS FOR BLEEDING

•6. Prepare to administer blood transfusion

•7. Prepare to give VASOPRESSIN to induce vasoconstriction to reduce bleeding

•8. Prepare patient for SURGERY if warranted


SURGICAL PROCEDURES FOR PUD

•Total gastrectomy, vagotomy, gastric resection, Billroth I and II, pyloroplasty

1.Vagotomy – severing of part of the vagus nerve innervating the stomach to decrease gastric acid secretion.

2. Antrectomy – removal of the antrum of the stomach to eliminate the gastgric phase of digestion

3. Pyloroplasty – enlargement of the pyloric sphincter with acceleration of gastric emptying

4. Gastroduodenostomy (Billroth I) removal of the lower portion of the stomach with anastomosis of the remaining portion of the duodenum.

5. GAstrojejunostomy (Billroth II): removal of the antrum and the distal portion of the stomach and duodenum with anastomosis of the remaining portion of the stomach in the jejunum.

6. Gastrectomy: removal of 60% to 80% of the stomach.

7. Esophagojejunostomy (total gastrectomy): removal of the entire stomach with a loop jejunum anastomosed to the esophagus


SURGICAL PROCEDURES FOR PUD

Post-operative Nursing management• 1. Monitor VS• 2. Post-op position: FOWLER’S• 3. NPO until peristalsis returns• 4. Monitor for bowel sounds• 5. Monitor for complications of surgery


Post-operative Nursing management•6. Monitor I and O, IVF•7. Maintain NGT•8. Diet progress: clear liquid full liquid six bland meals

•9. Manage DUMPING SYNDROME

DUMPING SYNDROME:• Control of gastric emptying is lost, following

gastric resection• Ingested food are rapidly “dumped” into the

intestine

Signs and Symptoms:

1. Abdominal cramps

2. Nausea and diarrhea

3. Hypovolemia – dizziness, weakness, rapid pulse and sweating

4. Hypoglycemia – 2 to 3 hrs after meal

Management:

1. Dietary changes – small frequent feeding high protein low carbohydrates

2. Fluids should be taken between meals

3. Medication to decreased intestinal motility

1. Food intake

2. Gastric resectionDecresed gastric capacity and loss of pyloric sphincter

3. Large amt of undiluted chyme is dumped in small intestine

4.Fluid shifts fromm blood into small intestinesTo dilute hypertonic chyme

5. Hypovolemia:-decreased blood pressure

-faint,weak pulse, dizzy-tachycardia

- pallor, diaphoresis

6. Distended intestine-pain,cramps

- nausea and vomitin

7. Rapid digestion and absorption of food intake

8. Hyperglycemia and inc. insulin secretions9. Hypoglycemia-weak, confused

-Tachycardia-Pallor, diaphoresis

Follow-Up Care

• Recurrence within a year may be prevented with the prophylactic use of H2-receptor antagonists given at a reduced dose. Not all patients require maintenance therapy.

• Likelihood of recurrence is reduced if the patient avoids smoking, coffee and other caffeinated beverages, alcohol, and ulcerogenic medications.

CONDITIONS OF THE LOWER TRACTSmall and Large Intestine

INFLAMMATORY BOWEL DISEASE

• Refers to two chronic inflammatory GI disorders: regional enteritis (i.e., Crohn’s disease or granulomatous colitis) and ulcerative colitis.

• The cause is still unknown.• Researchers think it is triggered by

environmental agents such as pesticides, food additives, tobacco, and radiation.

• NSAIDs have been found to exacerbate IBD.• Allergies and immune disorders have also been

suggested as causes.


Almost 100%About 20%RECTAL INVOLVEMENT

SevereLess severeDIARRHEA

RareCommonFISTULAS

Rare – mild CommonPERIANAL INVOLVEMENT

Common – severe Usually not, but may occurBLEEDING

Rectum, left colonIleum, right colon (usually)LOCATION

Mucosal minute ulcerationsDeep, penetrating granulomas

LATE PATHOLOGY

Mucosal ulcerationTransmural thickeningEARLY PATHOLOGY

Exacerbations, remissionsProlonged, variableCOURSE

ULCERATIVE COLITISCROHN’S DISEASE


Friable mucosa with pseudopolyps or ulcers in the left colon.

Distinct ulcerations separated by relatively normal mucosa in the right colon

COLONOSCOPY

Abnormal inflamed mucosaMay be unremarkable unless accompanied by perianal fistulas

SIGMOIDOSCOPY

Diffuse involvement

No narrowing of colon

No mucosal edema

Stenosis rare

Shortening of colon

Abnormal inflamed mucosa

Regional, discontinuous lesions

Narrowing of colon

Thickening of bowel wall

Mucosal edema

Stenosis, fistulas

RADIOGRAPHY



Toxic megacolon, perforation, hemorrhage

Malignant neoplasms

Pyelonephritis

Nephrolithiasis

Cholangiocarcinoma

Small bowel obstruction

Right-sided hydronephrosis

Nephrolithiasis

Cholelithiasis

Arthritis, retinitis, iritis

Erythema nodosum

SYSTEMIC COMPLICATIONS

Corticosteroids, sulfonamides

Bulk hydrophilic agents

Antiobiotics

Proctocolectomy, with ielostomy

Rectum can be preserved in only a few patients “cured” by colectomy

Corticosteroids, sulfonamides

Antibiotics

Parenteral nutrition

Partial or complete colectomy, with ileostomy or anastomosis

Rectum can be preserved in some patients

THERAPEUTIC MANAGEMENT


CONDITIONS OF THE SMALL INTESTINE

CROHN’S DISEASE•Also called Regional Enteritis

•An inflammatory disease of the GIT affecting usually the small intestine

CONDITIONS OF THE SMALL INTESTINE

CROHN’S DISEASE•ETIOLOGY: unknown•The terminal ileum thickens, with scarring, ulcerations, abscess formation and narrowing of the lumen

CONDITIONS OF THE SMALL INTESTINEASSESSMENT findings for CD• 1. Fever• 2. Abdominal distention• 3. Diarrhea• 4. Colicky abdominal pain • 5. Anorexia/N/V• 6. Weight loss• 7. Anemia

Ulcerative Colitis

CONDITIONS OF THE LARGE INTESTINE

ULCERATIVE COLITIS• Ulcerative and inflammatory condition of the GIT

usually affecting the large intestine• The colon becomes edematous and develops

bleeding ulcerations• Scarring develops overtime with impaired water

absorption and loss of elasticity

CONDITIONS OF THE LARGE INTESTINEASSESSMENT findings for UC• 1. Anorexia• 2. Weight loss• 3. Fever• 4. SEVERE diarrhea with Rectal bleeding• 5. Anemia• 6. Dehydration• 7. Abdominal pain and cramping

INFLAMMATORY BOWEL DISEASE: Signs and Symptoms

Crohn’s DseCrohn’s Dse Ulcerative colitisUlcerative colitis

SYMTOMSSYMTOMS

DiarrheaDiarrhea ++++++ ++++++

Rectal BleedingRectal Bleeding ++ ++++++

TenesmusTenesmus 00 ++++++

Abdominal PainAbdominal Pain ++++++ ++

FeverFever ++++ ++

VomitingVomiting ++++++ 00

Weight lossWeight loss ++++++ ++

SIGNSSIGNS

Perianal diseasePerianal disease ++++++ 00

Abdominal massAbdominal mass ++++++ 00

MalnutritionMalnutrition ++++++ ++

NURSING INTERVENTIONS for CD and UC

•1. Maintain NPO during the active phase

•2. Monitor for complications like severe bleeding, dehydration, electrolyte imbalance

•3. Monitor bowel sounds, stool and blood studies

NURSING INTERVENTIONS for CD and UC

•4. Restrict activities= rest and comfort

•5. Administer IVF, electrolytes and TPN if prescribed

•Monitor complications of diarrhea

NURSING INTERVENTIONS for CD and UC•6. Instruct the patient to AVOID gas-forming foods, MILK products and foods such as whole grains, nuts, RAW fruits and vegetables especially SPINACH, pepper, alcohol and caffeine

NURSING INTERVENTIONS for CD and UC•7. Diet progression- clear liquid LOW residue, high protein diet

•8. Administer drugs- anti-inflammatory, antibiotics, steroids, bulk-forming agents and vitamin/iron supplements

IRRITABLE BOWEL SYNDROMEOne of the most common GI problemsWomen > menCause is unknownFactors associated with the syndrome

Heredity, psychological stress or condition, high fat diet, stimulating or irritating foods, alcohol consumption and smoking

PathophysiologyFunctional disorder of intestinal motilityRelated to neurologic regulatory system, infection or

irritationVascular or metabolic disturbanceEvidence of inflammation or tissue changes in the

intestinal mucosa

Irritable Bowel Syndrome

• Due to stress and irritants

• R/t sensitivity to motor activity and distention

• CRAMPY LOWER ABDOMINAL PAIN

• Relieved by defecation

• Pain increases 1-2 hrs after meal

• Alternating C & D

Clinical ManifestationsAltered bowel patternsConstipation, diarrhea or combinationPain, bloating and abdominal distentionAbdominal pain sometimes preciipitated by eating and

frequently relieved by defecation.


DIVERTICULOSIS AND DIVERTICULITIS

Diverticulosis• Abnormal out-pouching of the intestinal mucosa

occurring in any part of the LI most commonly in the sigmoid

Diverticulitis• Inflammation of the diverticulosis

Diverticulitis

CONDITIONS OF THE LARGE INTESTINEPATHOPHYSIOLOGY• Increased intraluminal pressure, LOW volume in the

lumen and Decreased muscle strength in the colon wall herniation of the colonic mucosa

CONDITIONS OF THE LARGE INTESTINEASSESSMENT findings for D/D• 1. Left lower Quadrant pain• 2. Flatulence• 3. Bleeding per rectum• 4. nausea and vomiting• 5. Fever• 6. Palpable, tender rectal mass

CONDITIONS OF THE LARGE INTESTINE• DIAGNOSTIC STUDIES• 1. If no active inflammation, COLONOSCOPY and

Barium Enema• 2. CT scan is the procedure of choice!• 3. Abdominal X-ray

CONDITIONS OF THE LARGE INTESTINENURSING INTERVENTIONS• 1. Maintain NPO during acute phase• 2. Provide bed rest• 3. Administer antibiotics, analgesics like meperidine

(morphine is not used) and anti-spasmodics• 4. Monitor for potential complications like perforation,

hemorrhage and fistula• 5. Increase fluid intake


NURSING INTERVENTIONS• 6. Avoid gas-forming foods or HIGH-roughage

foods containing seeds, nuts to avoid trapping• 7. introduce soft, high fiber foods ONLY after the

inflammation subsides• 8. Instruct to avoid activities that increase intra-

abdominal pressure

BOWEL OBSTRUCTION

• - interference with the normal aboral transit of intestinal contents.

Extraluminal – e.g. adhesions

Intraluminal – bezoar, gallstones

Itramural - Crohn’s disease

Types of Obstruction:

A. Mechanical Obstruction

- actual physical barriers

B. Functional Obstruction

- ileus/ a functional failure of progressive intestinal transit

Mechanism of Intestinal Obstruction:A. MECHANICAL OBSTRUCTION:

a. Obturation of the lumen

-meconium

-intussusception

-gallstones

-impactions – fecal, barium, bezoar, worms

b. Lesions of Bowel

*Congenital

- atresia and stenosis

- Imperforate anus

- Duplications

*Traumatic

* Inflammatory

- regional enteritis

- Diverticulitis

- Chronic ulcerative colitis

*Neoplastic

*Miscellaneous

- K induced stricture

- Radiation stricture

- Endometriosis

• c. Lesions Extrinsic to the Bowel

- Adhesive Band constriction

- Hernia

- Extrinsic masses

d. Volvulus

B. INADEQUATE PROPULSIVE MOTILITY

a. Neuromascular defects

- Megacolon

- Paralytic ileus

Abdominal causes

-Intestinal distention

- Peritonitis

- Retroperitoneal lesions

Systemic causes

- Electrolyte imbalances

- Toxemias

Classification of Intestinal Obstruction:

1. Simple Obstruction- obstructed lumen with intact blood supply

2. Strangulated Obstruction- messenteric vessels are occluded

3. Closed loop Obstruction - both limbs of the loop are obstructed

Four CARDINAL symptoms and signs of Intestinal Obstruction:

1. Crampy abdominal pain

2. Vomiting

3. Obstipation

4. Abdominal distention

Bowel obstruction

•Signs and Symptoms• Abdominal pain• Abdominal rigidity• Increased BOWEL sound in early stage and ABSENT BOWEL sound in late stage

• Abdominal distention• Vomiting and fluid imbalance

HIRSCHSPRUNG’S DISEASE(Aganglionic Megacolon)

• Failure of the ganglion cells of the myenteric plexuses to migrate down the developing colon – lower portion of the sigmoid colon just above the anus.

• Abnormally innervated distal colon remains tonically contracted and obstructs the flow of feces

Assessment:• Chronic constipation or Ribbon-like stools• Abdominal distention, poor feeding habits, bilious vomiting • Failure to pass meconium within 24hrs• Requires rectal stimulation to induce bowel movement

Diagnostic:1. Digital Examination: (+) hard, caked stool2. Barium Enema: narrow, nerveless, distended bowel3. Biopsy: lack of innervation4. Anorectal manometry: decreased pressure in the sphincter

Hirschsprung’s Disease

Bowel obstruction• Diagnosis

: Abdominal x-ray

MANAGEMENT:

1. Fluid and electrolyte therapy

2. Decompression of the gastrointestinal tract.

3. Timely surgical interventions

HERNIAS• protrusion of an organ or part of an organ through the wall of the cavity

HERNIAS

FACTORS:

•caused by failure of certain normal openings to close during fetal development• increased intra-abdominal pressure

INGUINAL and FEMORAL HERNIA

Inguinal hernia -protrusion of peritoneum through a defect in the abdominal wall in the inguinal canal- account for 75% of all hernias Two Types: 1. Indirect Inguinal Hernia 2. Direct Inguinal Hernia

Indirect Inguinal Hernia• - due to persistence of the processus vaginalis• - occurs lateral to Hessebach’s Triangle• - protrude through the inguinal ring and may extend in the scrotum

• The herniated viscus or fat lies within the spermatic cord

• The hernia is directed by the spermatic cord toward the scrotum

• Inc. risk of strangulation and infarct• Much more common than direct inguinal hernia• Common in children 10% bilateral

Boundaries Of Inguinal Triangle (Hesselbach’s Triangle)

Lateral – inferior epigastric artery

Medial – lateral rectus abdominis

muscle border

Inferior – Inguinal ligament

Direct Inguinal Hernia- Are associated with tissue laxity (old age)- Factors that increases intra abdominal pressure:

a. obesityb. chronic coughc. straining with bowel movements or

micturition (BPH) - They protrude through the floor of the inguinal canal and Hasselbach’s triangle

- Herniated viscus or fat lies adjacent ( not within ) the spermatic cord

- Are always acquired

• Femoral hernia • – protrusion of peritoneum through the wall femoral

canal• more frequent in girls• mass at anterior surface of the thigh

Petit’s Triangle Hernia (Lumbar triangle)

- affects all age group

- males are frequently affected

- presents with a “lump near the buttocks”

Boundaries of lumbar Triangle:

Lateral : External oblique muscles

Superior : Latissimus dorsi muscles

Inferior : Iliac crest

Richter’s Hernia- Hernia in which one wall of intestine is trapped by

constricting ring of hernia- More common in femoral henia- Presents with a painful tender groin mass

Assessment:• history of intermittent appearance

of a mass in the groin

Complication: 1. Incarceration – (irreducibility

without vascular compromise) 2.Strangulation – ( ischemia and

necrosis )3.Intestinal obstruction with fluid

sequestration and electrolyte imbalance and damage to the urinary bladder or spermatic cord during surgical repair

Intervention:• surgery – as soon as diagnosis is made; rarely

close spontaneously• Acute incarceration or strangulation requires

emergent surgical repair• Elective herniorrhaphy

Nursing intervention:• if incarceration occurs – apply ice bag; elevate foot

of bed• post op: small dressing; encourage to ambulate;

resume activities gradually

“Hanggang…”

Sa mundong puno ng pakikipagsapalaran,Ang bawat tanong ay kung kailan…

Kailan matatapos ang dusa?Kailan hahantong ang wakas,

Nang bawat kabanatang ‘di tiyak ang tema?Kailan makikita ang tagumpay

Bunga ng matinding pagsusumikap?

… ang tanging sagot ay hanggang!Hanggang patuloy na tumatakbo ang orasan ng ating

buhay,Patuloy na pipintig ang bawat puso

Upang gisingin ang ating hangaring magtagumpay

… Hanggang may buhay, may mananatiling PAG-ASAOras-oras, araw- araw…bawat panahon.

• Arrow moves forward after pulling it backward• Bullet moves forward after pressing the trigger backward

• Every human being will get happy• Only after facing the difficulties in their life path…

• So do not be afraid to face difficulties.• They will push you forward

GIT Disorders

Documents

Transcript of GIT Disorders