Lower Gastrointestinal Problems

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Biological Sciences
Stephen Reid

Chapter 43: Lower Gastrointestinal Problems Diarrhea  Diarrhea is most commonly defined as an increase in stool frequency or volume, and an increase in the looseness of stool.  Diarrhea can result from alterations in gastrointestinal motility, increased secretion, and decreased absorption.  All cases of acute diarrhea should be considered infectious until the cause is known.  Patients receiving antibiotics (e.g., clindamycin [Cleocin], ampicillin, amoxicillin, cephalosporin) are susceptible to Clostridium difficile (C. difficile), which is a serious bacterial infection. Fecal Incontinence  Fecal incontinence, the involuntary passage of stool, occurs when the normal structures that maintain continence are disrupted.  Risk factors include constipation, diarrhea, obstetric trauma, and fecal impaction.  Prevention and treatment of fecal incontinence may be managed by implementing a bowel training program. CONSTIPATION  Constipation can be defined as a decrease in the frequency of bowel movements from what is “normal” for the individual; hard, difficult-to-pass stools; a decrease in stool volume; and/or retention of feces in the rectum.  The overall goals are that the patient with constipation is to increase dietary intake of fiber and fluids; increase physical activity; have the passage of soft, formed stools; and not have any complications, such as bleeding hemorrhoids.  An important role of the nurse is teaching the patient the importance of dietary measures to prevent constipation. Abdominal Pain, Trauma, and Inflammatory Disorders  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 an acute abdominal problem.  The goal of management of the patient with acute abdominal pain is to identify and treat the cause and monitor and treat complications, especially shock.  Bowel sounds that are diminished or absent in a quadrant may indicate a complete bowel obstruction, acute peritonitis, or paralytic ileus.  Expected outcomes for the patient with acute abdominal pain include resolution of the cause of the acute abdominal pain; relief of abdominal pain and discomfort; freedom from complications (especially hypovolemic shock and septicemia); and normal fluid, electrolyte, and nutritional status.  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.  The abdominal pain or discomfort associated with IBS is most likely due to increased visceral sensitivity. Abdominal Trauma  Blunt trauma commonly occurs with motor vehicle accidents and falls and may not be obvious because it does not leave an open wound.  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. Appendicitis  Appendicitis 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.  Until a health care provider sees the patient, nothing should be taken by mouth (NPO) to ensure that the stomach is empty in the event that surgery is needed. Peritonitis  Peritonitis results from a localized or generalized inflammatory process of the peritoneum.  Assessment of the patient’s abdominal pain, including the location, is important and may help in determining the cause of peritonitis. Gastroenteritis  Gastroenteritis is an inflammation of the mucosa of the stomach and small intestine.  Clinical manifestations include nausea, vomiting, diarrhea, abdominal cramping, and distention. Most cases are self-limiting and do not require hospitalization.  If the causative agent is identified, appropriate antibiotic and antimicrobial drugs are given.  Symptomatic nursing care is given for 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 mild to severe acute exacerbations that occur at unpredictable intervals over many years.  Ulcerative colitis usually starts in the rectum and moves in a continual fashion toward the cecum. Although there is sometimes mild inflammation in the terminal ileum, ulcerative colitis is a disease of the colon and rectum.  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 occurs due to malabsorption. In addition, patients may have systemic symptoms such as fever. The primary symptoms of ulcerative colitis are bloody diarrhea and abdominal pain.  The goals of treatment for IBD include rest the bowel, control the inflammation, combat infection, correct malnutrition, alleviate stress, provide symptomatic relief, and improve quality of life.  Nutritional problems are especially common with Crohn’s disease when the terminal ileum is involved.  The following five major classes of medications are used to treat IBD: o Aminosalicylates o Antimicrobials o Corticosteroids o Immunosuppressants o Biologic therapy  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  The causes of intestinal obstruction can be classified as mechanical or nonmechanical.  Intestinal obstruction can be a life-threatening problem.  Cancer is the most common cause of large bowel obstruction, followed by volvulus and diverticular disease.  Emergency surgery is performed if the bowel is strangulated, but many bowel obstructions resolve with conservative treatment.  With a bowel obstruction, there is retention of fluid in the intestine and peritoneal cavity, which can result in a severe reduction
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