2. Objectives
By the end of this session, students will be able to:
• Define the following conditions.
Irritable bowel syndrome (IBS)
Appendicitis, peritonitis
ulcerative colitis
Chron’s diseases
Colorectal cancer
• Discuss the etiology, pathophysiology and clinical
manifestations of above disorders.
• Explain the Medical, surgical and nursing
management.
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3. 2
IBS is defined as “abdominal pain or discomfort that occurs
in association with altered bowel habits over a periods of at
least three months.”
• Probably the most challenging of all functional GI
disorders
• IBS is a chronic condition that you'll need to manage
long term.
What is IBS?
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4. • IBS is functional disorder of motility in the
intestine.
• No anatomic abnormality
• Also called spastic colitis, irritable colon,
spastic colitis.
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5. Etiology and risk factors
• Idiopathic
• Abnormality in communication btw the enteric
nervous system and the central nervous system
• Depression and anxiety
• Diet high in fat, gas producing, carbonated
beverages and caffeine, and alcohol
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6. PATHOPHYSIOLOGY
• Impairment in the motor or sensory function of the GI
tract Increased bowel activity in response to
food intake, hormones, stress
Increased sensations of chyme movement through gut
Hyper secretion of colonic mucus
Lower visceral pain threshold causing abdominal pain
and bloating with normal levels of gas
Some linkage of depression and anxiety
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7. 5
Symptoms
• Abdominal pain relieved by defecation; may be colicky,
occurring in spasms, dull or continuous
• Alternating Diarrhea and Constipation
• Altered bowel habits including frequency, hard or watery
stool, straining or urgency with stooling, incomplete
evacuation, passage of mucus; abdominal bloating,
excess gas
• Nausea, vomiting, anorexia, fatigue, headache, anxiety
• Tenderness over sigmoid colon upon palpation
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9. Diagnostic Tests:
• Stool examination for occult blood, ova and parasites,
culture
• CBC with differential, Erythrocyte Sedimentation Rate
(ESR): to determine if anemia, bacterial infection, or
inflammatory process
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10. Sigmoidoscopy or colonoscopy
Visualize bowel mucosa, measure intraluminal
pressures, obtain biopsies if indicated
Findings with IBS: normal appearance increased
mucus, intraluminal pressures, marked spasms.
Small bowel series (Upper GI series with small bowel-
follow through) and barium enema: examination of
entire GI tract;
• IBS: increased motility
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11. Medical Management
• Purpose: to manage symptoms
• Bulk-forming laxatives: reduce bowel spasm,
normalize bowel movement in number
• Anticholinergic drugs (dicyclomine (Bentyl),
hyoscyamine) to inhibit bowel motility and prevent
spasms; given before meals
• Antidiarrheal medications (loperamide (Imodium),
diphenoxylate (Lomotil): prevent diarrhea
prophylactically
• Antidepressant medications
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12. Dietary Management
• Often benefit from additional dietary fiber: adds bulk
and water content to stool reducing constipation
• Some benefit from elimination of lactose, fructose,
• Limiting intake of gas-forming foods, caffeinated
beverages
Nursing Care
• Contact in health environments outside acute care
• Home care focus on improving symptoms with
changes of diet, stress management, medications;
seek medical attention if serious changes occur
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13. APPENDICITIS
• The inflammation of the appendix
• Most common cause of emergency abdominal
surgery
• More common in adolescents and young adults
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14. Etiology and risk factors
• Fecalith
• Kinking of the appendix
• Swelling of the bowel wall
• Infection with Yersinia organisms up to 30% of cases
• Not preventable
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15. Pathophysiology
Appendix become kinked or blocked(hard stool, or
foreign body) becomes edematous and inflamed
the pressure inside the lumen increases progressively
cause severe pain in the whole abdomen especially in
the epigastric and RLQ area
• pressure leads to in venous drainage, thrombosis,
and bacterial invasion
• last appendix becomes filled with pus
• Rupture and fistula form (bladder, small intestine )
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16. Clinical Manifestations
• Vague epigastric or periumbilical pain progresses to
RLQ client often guard the area
• Low grade fever
• Constipation
• Nausea and Vomiting
• Mild leukemia
• Blumberg's sign, also referred to as rebound
tenderness, (It refers to pain upon removal of
pressure rather than application of pressure to the
abdomen).
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19. Complications
• Rupture of appendix
• It leads to peritonitis or an abscess
• Rupture occur generally after 24 hrs of onset of pain.
Symptoms include
– Fever of 100 F or more
– Continuous abdominal pain
– Tenderness
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20. Medical Management
• To prevent electrolyte imbalance and dehydration IV
fluid is administered
• To prevent infection antibiotics are used
• Analgesics are used to relieve pain after surgery
• Appendectomy
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21. Nursing Intervention
• Prepare the patient for surgery
• Administer IV fluids
• Administer antibiotics
• Do not administer enema
• Place the patient in semi fowler position after surgery
• Administer the opioid analgesic( morphine sulfate)
prescribed after surgery
• Teach about the discharge teaching
• Teach that normal activity can be resumed with in 2-4
weeks
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22. Peritonitis
• Inflammation of peritoneum, lining that covers wall
(parietal peritoneum) and organs (visceral
peritoneum) of abdominal cavity
• Enteric bacteria enter the peritoneal cavity through a
break of intact GI tract (e.g. perforated ulcer, ruptured
appendix)
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24. 24
Pathophysiology
Inflammation
Shifts fluid volume from
IVC to peritoneal space
Peristalsis Free Air pressure
fluid accumulation
circulating volume
O² requirements
pressure on
diaphragm
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25. Manifestations
• Depends on severity and extent of infection, age and
health of client and vary according to cause
• Presents with “acute abdomen”
1.Abrupt onset of diffuse, severe abdominal pain
2.Pain may localize near site of infection (may
have rebound tenderness)
3.Intensifies with movement
• Entire abdomen is tender with board like guarding or
rigidity of abdominal muscle .
• Fever, malaise, tachycardia and tachypnea,
restlessness, disorientation, oliguria with dehydration
and shock
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26. Diagnostic Tests
• Elevated WBC
• Serum electrolytes
• Abdominal x rays: detect intestinal distension, air-
fluid levels, free air under diaphragm (sign of GI
perforation)
• Diagnostic Paracentesis
• Blood cultures: identify bacteria in blood
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27. Complications
• May be life-threatening; mortality rate overall 40%
• Abscess
• Septicemia, septic shock; fluid loss into abdominal
cavity leads to hypovolemic shock
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28. Medical Management
• IV fluids and electrolytes to maintain vascular
volume and electrolyte balance
• Bed rest in Fowler’s position to localize infection and
promote lung ventilation
• Intestinal decompression with nasogastric tube or
intestinal tube connected to suction
• NPO with intravenous fluids while having nasogastric
suction
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29. • Medications
• Broad-spectrum before definitive culture results
identifying specific organism(s) causing infection
• Specific antibiotic(s) treating causative pathogens
• Analgesics
• Antiemetics
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30. Surgical Management
• Laparotomy: to treat cause (close perforation,
removed inflamed tissue)
• Peritoneal Lavage: washing out peritoneal cavity with
copious amounts of warm isotonic fluid during
surgery to dilute residual bacterial and remove gross
contaminants
• Often have drain in place and/or incision left
unsutured to continue drainage
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31. Nursing Management
• Assessment of pain, GI function and electrolytes
• Administer analgesics
• Position the patient( lying in side with flexed knees)
• Record I/O, closely monitor IV fluids
• Gradually increase fluid and food and decrease
parenteral fluid
• Take care of drain postoperatively
• Wound care
• Discharge teaching
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32. Inflammatory Bowel Disease ( IBD)
• Umbrella term used to describe two chronic
inflammatory disorders
1. Crohn’s Disease (Regional Enteritis)
2. Ulcerative Colitis
• Etiology is unknown but runs in families; may be
related to infectious agent and altered immune
responses, pesticides, tobacco etc.
• Idiopathic
• Genetic predisposing factors
• Chronic disease with recurrent exacerbations
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34. Ulcerative Colitis (UC)
• UC is an inflammatory bowel disease that spans the
entire length of the colon and involves only mucosa
and sub mucosa.
• The disease usually starts
in the rectum and distal colon,
involves sigmoid ,
descending colon and spread
upward to the entire colon
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35. Pathophysiology
Ulceration of the superficial mucosa of the colon
Multiple continuous inflammations
Wet desquamation
Shedding of epithelial layer of colon
Rectal bleeding
Recurrent episodes lead to hypertrophy and fat deposition
Malignant changes to cancer
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36. Manifestation
• Diarrhea with stool containing blood and mucus; 5 –
10 stools per day leading to anemia, hypovolemia,
malnutrition
• Fatigue, anorexia, weakness, weight loss
• Severe watery diarrhea (20 or more per day)
• Tenesmus (Painful spasm of the anal sphincter )
• Lower left quadrant pain
• Rebound tenderness to right lower quadrant
• Hypokalemia
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37. Complications
• Hemorrhage: can be massive with severe attacks
• Toxic megacolon: usually involves transverse colon
which dilates and lacks peristalsis (manifestations:
fever, tachycardia, hypotension, dehydration, change
in stools, abdominal cramping)
• Colon perforation: rare but leads to peritonitis and
15% mortality rate
• Increased risk for colorectal cancer (20 – 30 times);
need yearly colonoscopies
• Abcess, fistula formation
• Bowel obstruction
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38. Diagnosis and Assessment
• Stool examination + blood
• CBC : low Hb and Hct , elevated WBC
• Blood chemistry: low albumin, electrolytes
• Sigmoidoscopy and barium enema
differentiate mucosal irregularities, short colon and
dilation of bowel
• Endoscopy : inflammed mucosa, exudation and
ulceration
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39. Crohn's disease or Regional enteritis
• Is an inflammatory disease of the intestines
• A chronic relapsing disease
• May develop discontinuously in any segment
• The most common location is terminal ileum
• Involves the entire thickness of bowel wall
• Rectum is frequently not involved
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40. Pathophysiology
• Lesions develop in several segments of bowel
• Enlarged lymph nodes appear in sub mucosa and
peyers patches on intestinal mucosa
• Small superficial ulceration with granulomas and
fissures
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41. • Fissures may completely penetrate the bowel wall
leading to fistulas and abscesses
• Intestinal wall become thickened and the lumen
narrows
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44. Complications
• Intestinal obstruction: caused by repeated
inflammation and scarring causing fibrosis and
stricture
• Fistulas lead to abscess formation; recurrent urinary
tract infection if bladder involved
• Perforation of bowel may occur with peritonitis
• Massive hemorrhage
• Increased risk of bowel cancer (5 – 6 times)
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45. Diagnostic Tests
• Colonoscopy, sigmoidoscopy: determine area and
pattern of involvement, tissue biopsies; small risk of
perforation
• Upper GI series with small bowel follow-through,
barium enema
• Stool examination and stool cultures to rule out
infections
• CBC: shows anemia, leukocytosis from inflammation
and abscess formation
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46. Management
Nutritional Therapy:
• Oral fluid, high protein and high caloric diet with
vitamin therapy
• IV therapy ; restore electrolyte imbalance
• TPN may be recommended
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47. Pharmacologic Therapy:
• Sedative, anti diarrheal and anti peristalsis
– Sulphoenamid, sulfisoxazol
• Antibiotics for secondary infection, abscess
• Corticosteroids
• Immunosuppressive agent (cyclosporine) prevent
relapses
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48. Surgical Management
• Strictureplasty : widened the blocked narrow section
of bowel
• Surgical removal of small bowel and anastomosis
• Total colectomy with iliostomy
• Segmental colectomy with anastomosis
• Sub total colectomy – ileorectal ananstomosis
• Total colectomy with an ileal pouch-anal anastomosis
(initially has temporary ileostomy)
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49. Ostomy
• Surgically created opening between intestine and
abdominal wall that allows passage of fecal material
• Name of ostomy depends on location of stoma
• Ileostomy: opening in ileum; may be permanent with
total proctocolectomy or temporary (loop ileostomy)
• Ileostomies: always have liquid stool which can be
corrosive to skin since contains digestive enzymes
• Continent (or Kock’s) ileostomy: has intra-abdominal
reservoir with nipple valve formation to allow
catheter insertion to drain out stool
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50. Nursing Process
• Assessment:
• COLDERRA of pain
• IBD family history
• Diarrhea and fecal urgency
• Inspection, Auscultation, Palpation,
• Regional enteritis ( pain in the Rt lower quadrant)
• Intermittent pain not relieved after defecation
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51. Nursing Diagnoses
• Diarrhea related to the inflammatory process
• Acute pain related to increased peristalsis and GI
inflammation
• Deficient fluid volume related to anorexia, nausea,
and diarrhea
• Imbalanced nutrition, less than body requirements,
related to dietary restrictions, nausea, and
malabsorption
• Activity intolerance related to fatigue
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52. Nursing Intervention
• Maintaining Normal elimination Patterns
• Relieving pain
• Maintaining fluid intake
• Maintaining optimal nutrition
• Promoting rest
• Reducing anxiety
• Enhancing coping measures
• Preventing skin breakdown
• Inflammatory bowel disease may also be referred to
as colitis, enteritis, ileitis, and proctitis
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54. Colorectal Cancer
Definition
• Most common cancer
• Affects sexes equally
• Five-year survival rate is 90%, with early diagnosis
and treatment
Risk Factors
• Family history
• Inflammatory bowel disease
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55. Pathophysiology
• Most malignancies begin as adenomatous polyps and
arise in rectum and sigmoid
• Spread by direct extension to involve entire bowel
circumference and adjacent organs
• Metastasize to regional lymph nodes via lymphatic and
circulatory systems to liver, lungs, brain, bones, and
kidneys
Manifestations
• No symptoms until it is advanced
• Presenting manifestation is bleeding; also change in
bowel habits (diarrhea or constipation); pain, anorexia,
weight loss, palpable abdominal or rectal mass; anemia
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56. Nursing Care
• Client teaching
Diet: decrease amount of fat, refined sugar, red meat;
increase amount of fiber; diet high in fruits and
vegetables, whole grains, legumes
Screening recommendations
Seek medical attention for bleeding and warning
signs of cancer
Risk may be lowered by aspirin or NSAID use
Nursing Diagnoses for post-operative colorectal
client
• Pain
• Imbalanced Nutrition: Less than body requirements
• Risk for infection
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57. Surgery
• Surgical resection of tumor, adjacent colon, and
regional lymph nodes is treatment of choice
• Whenever possible anal sphincter is preserved and
colostomy avoided; anastomosis of remaining bowel
is performed
• Tumors of rectum are treated with abdominoperineal
resection (A-P resection) in which sigmoid colon,
rectum, and anus are removed through abdominal and
perineal incisions and permanent colostomy created
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58. Colostomy
1. Ostomy made in colon if obstruction from tumor
• Temporary measure to promote healing of
anastomoses
• Permanent means for fecal evacuation if distal colon
and rectum removed
2. Named for area of colon is which formed
• Sigmoid colostomy:
• Double-barrel colostomy: 2 stomas: proximal for
feces diversion; distal is mucous fistula
• Transverse loop colostomy: emergency procedure;
loop suspended over a bridge; temporary
• Hartman procedure: Distal portion is left in place and
oversewn; only proximal colostomy is brought to
abdomen as stoma; temporary; colon reconnected at
later time when client ready for surgical repair
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59. • Post-op care
– Pain
– NG tube
– Wound management
• Stoma
–Should be pink and moist
–Dark red or black indicates ischemic
necrosis
–Look for excessive bleeding
–Observe for possible separation of suture
securing stoma to abdominal wall
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60. Radiation Therapy
• Used as adjunct with surgery; rectal cancer has high
rate of regional recurrence if tumor outside bowel
wall or in regional lymph nodes
• Used preoperatively to shrink tumor
• Provides local control of disease, does not improve
survival rates
Chemotherapy:
Used postoperatively with radiation therapy to reduce
rate of rectal tumor recurrence and prolong survival
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61. Home Care
• Referral for home care
• Referral to support groups for cancer or
ostomy
• Referral to hospice as needed for advanced
disease
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62. Your loud voice is not the proof of the
depth of your knowledge, for an empty
utensil makes more noise than a full
one
THNAKS
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