Adult Medical Surgical Nursing

1. Adult Medical Surgical Nursing Gastro-intestinal Module: Conditions of Malabsorption Inflammatory Bowel Disorder: Crohn’s Disease; Ulcerative Colitis

2. Conditions of Malabsorption • Malabsorption is the inability of the intestinal mucosa to absorb one or more of the major nutrients

3. Conditions of Malabsorption • Infection: gastro-enteritis, amoeba, giardia • Post-intestinal surgery (resection) • Specific nutrient disorders: lactose intolerance, cystic fibrosis, coeliac • Maldigestion of fats (also fat-soluble vitamins ADEK): related to obstruction of bile flow into the intestine • Inflammatory bowel disorder: Crohn’s Disease and Ulcerative Colitis

4. Conditions of Malabsorption: Clinical Manifestations • Diarrhoea, watery or with blood, mucus and/ or pus • Frequent loose bulky offensive stools • Pale, grey fatty stools • Abdominal distension/ flatulence • Weakness, muscle-wasting, weight loss • Malnutrition and loss of well-being, dehydration • Vitamin deficiency, anaemia, bruising tendency, osteoporosis, osteomalacia

5. Conditions of Malabsorption: Diagnostic Tests • History and physical examination • Blood: CBC, ESR, CRP, Urea, Electrolytes, LFTs, Plasma proteins • Stool: analysis, culture, parasites, 24-hour fat content, Guaic occult blood • Endoscopy • Colonoscopy • Barium or Gastrografin studies

6. Inflammatory Bowel Disorder • A chronic inflammatory condition which may relate to auto-immune disorder • There are two major conditions: • Crohn’s Disease (regional enteritis) • Ulcerative Colitis • Both conditions hold a risk for development of colon cancer

7. Crohn’s Disease

8. Crohn’s Disease: Pathophysiology • Sub-acute/ chronic inflammation of the distal ileum and ascending colon mainly • Mucosal ulceration in patches, separated by normal tissue • Ulceration may extend through all layers • Can cause perforation to the peritoneum • Inflammatory process leads to fibrosis, thickening the bowel wall and narrowing the lumen

9. Crohn’s Disease:Clinical Manifestations • Abdominal mild colicky pain (cramps from semi-obstruction) • Chronic diarrhoea (containing blood, mucus, pus): oedematous inflamed intestine with weeping irritating discharge • Weight loss, malnutrition, anaemia (chronic malabsorption), emaciation, dehydration • Fever and pain if abscesses • Acute severe pain/ shock if perforation • Remission and exacerbation

10. Crohn’s Disease: Diagnosis • Blood: • ↑ WCC, ESR, CRP (inflammation) • ↓ Hb, ↓ plasma proteins (albumen) • Electrolyte imbalance • Stool: blood, mucus, pus • Endoscopy/ colonoscopy: typical ulcerated patches seen • Barium or gastrografin studies: “string” sign, stricture/narrowing of intestinal lumen

11. Ulcerative Colitis

12. Ulcerative Colitis: Pathophysiology • Chronic inflammatory disease of the mucosa of the colon and rectum (10-15% will develop colon cancer) • Ulceration, desquamation and shedding of mucosa, bleeding, pus (severe protein loss) • Begins in rectum. May affect whole colon • Recurrent lesions, one after the other • Strictures and muscular hypertrophy

13. Ulcerative Colitis:Clinical Manifestations • Abdominal cramp-like pain (rebound tenderness right lower quadrant) • Diarrhoea (10-20 liquid stools daily with blood, mucus and pus in stool) • Rectal bleeding and urge to defaecate • Anorexia, severe weight loss, emaciation, muscle wasting, malnutrition, dehydration, anaemia, hypocalcaemia • Erythema, uveitis, arthritis (auto-immune)

14. Ulcerative Colitis: Diagnosis • Blood: • ↑ WCC, ESR, CRP (inflammation) • ↓ Hb, ↓ plasma proteins (serum albumen) • Electrolyte imbalance • Stool: frequent diarrhoea with pus, blood, mucus • Sigmoidoscopy: severe mucosal ulceration and shedding • Barium/ Gastrografin: shows shortening and dilatation of bowel (may perforate)

15. Inflammatory Bowel Disorder: (Crohn’s Disease and Ulcerative Colitis) Management

16. Inflammatory Bowel Disorder: Medical Treatment • Rest for the patient and for the bowel (to reduce inflammation and inappropriate immune response) • Nutrition and fluid replacement: • Encourage oral fluids • Intravenous infusion if electrolyte imbalance • Low-residue, high protein, high calorie diet as tolerated, with vitamin, minerals • Total Parenteral Nutrition (TPN)

17. Inflammatory Bowel Disorder: Medications • Medications: • Sedatives and antispasmodics to control bowel motility and pain: Diazepam, Codeine Phosphate, Imodium, Buscopan • Antibiotics (Sulphonamides) to control secondary infection/ abscesses • Corticosteroids (oral and by enema): anti-inflammatory; immunomodulators if severe- lower immune response (Imuran)

18. Inflammatory Bowel Disorder: Surgery • Where conservative treatment fails or complications occur • Resection of the affected part of the intestine and ileostomy is performed above as a faecal diversion • May be temporary or permanent stoma* • May involve pouch of ileum (Kock pouch) • Contents of ileostomy drainage are fluid, contain proteolytic enzymes and are irritant to the skin (extreme care needed)

19. Post-Surgery Complications • Diarrhoea leading to dehydration and electrolyte imbalance: excessive fluid loss through stoma • Stomal stenosis/ retraction • Peri-stomal irritation/ excoriation (poorly-fitting pouch; proteolytic enzymes in fluid) • Psychological/ social implications • Renal calculi (dehydration) • Gall-stones (change in absorption of bile acids)

20. Inflammatory Bowel Disorder:Nursing Considerations • Emotional support (patient is often depressed) • Teaching about fluids, diet, medications, rest • Monitoring progress, stool frequency, fluid balance, electrolytes, weight, skin turgor • Post-surgery stoma care: check that stoma is pink and moist, no stenosis • Skin care: anti-fungal powder or barrier cream • Accurate fitting (and avoid frequent changing) of stomahesive patches (proteolytic enzymes)