Acute and Chronic Inflammatory Bowel Disorders and Bowel Diseases

1. Acute and Chronic Inflammatory Bowel Disorders and Bowel Diseases *Appendicitis*Gastroenteritis*Peritonitis*Ulcerative Colitis*Crohn’s Disease*Diverticular Disease*Gallbladder Disease

2. 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)

3. Appendicitis Cont. • Other causes: • malignant tumors • Helminthes • Other infections

4. 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

5. 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

6. 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

7. Assessment Cont. • Other tests: • Ultrasound-may show enlarged appendix • CT scan- may reveal a fecalith

8. 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

9. 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

10. Gastroenteritis • Diarrhea and/or vomiting caused by inflammation of the mucous membranes of stomach and intestinal tract • Small bowel affected • Viral or bacterial

11. 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

12. 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

13. 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

14. Assessment Cont. • Lab assessment: • Gram stain stool: • Many WBC’s suggest shigellosis • WBC’s and RBC’s indicate Campylobacter gasteroenteritis

15. 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

16. 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.

17. Peritonitis • Causes: • Bacteria or chemicals contaminating the peritoneal cavity • Escherichia coli • Streptococcus • Staphylococcus • Pneumococcus • Gonococcus • Bile • Pancreatic enzymes • Gastric acid

18. 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.

19. 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)

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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)

34. 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)

35. 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

36. 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

37. 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

38. 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)

39. Diverticular Disease • Diverticula: pouchlikeherniations 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)

40. 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

41. 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.

42. 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

43. 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.

44. Gallstones • Formed by crystallized bile substances : • Excess cholesterol • Bile salts • calcium • Vary in size: • Can be as small as a grain of sand.

45. 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

46. Cholecystitis • Acute • Inflammation of the gall bladder from: • Irritation and inflammation from gallstones • stone blocking a passageway (cholelithiasis) • Chronic • Repeated episodes of duct obstruction

47. 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

48. Nonsurgical Management • Pain medication • Dilaudid • Morphine • Toradol • Antiemetics for N/V • IV antibiotics • Extracorporeal shock wave lithotripsy (ESWL) • Biliary catheters to open blocked ducts

49. 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

50. 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