NURSING MANAGEMENT-GASTROINTESTINAL TRACT DYSFUNCTION

NURSING
MANAGEMENT OF
PATIENT WITH
GASTROINTESTINAL
TRACT
DYSFUNCTION
BY: ROMMEL
LUIS C. ISRAEL
III
1
BY: ROMMEL LUIS C. ISRAEL III

Disorders in the oral
cavity
Achalasia, Hiatal
Hernia(GERD)
Intestinal obstruction
Appendicitis, Peritonitis
Hemorrhoids
Peptic ulcer disease,
Gastritis
Gall bladder disorder
pancreatitis
2

Disorders
in the
oral
cavity
⚫DENTAL PLAQUE AND CARIES
⚫Tooth decay:- is an erosive
process that begins with the
action of bacteria on fermentable
carbohydrates in the mouth,
which produces acids that
dissolve tooth enamel.
*
3
BY: ROMMEL LUIS C. ISRAEL III 3

It is the most common problem
affecting the teeth.
Plague formation is the most
important factor in tooth decay, but
familial tendency, poor oral
hygiene, poor health and perhaps
a diet high in simple or refined
sugars also play a role.
*
4 BY: ROMMEL LUIS C. ISRAEL III 4

Disorders
in the oral
cavity…
⚫The extent of damage to the
teeth depends on
�The presence of dental plaque
�The strength of the acids
�The ability of the saliva to
neutralize the acids
�The length of time the acids are
in contact with the teeth
�The susceptibility of the teeth to
decay
*
5

Disorders
in the oral
cavity …
⚫When the blood and lymph
vessels, and nerves are
exposed, they become infected
⚫An abscess may form, either
within the tooth or at the tip of
the root.
⚫Soreness and pain usually occur
with an abscess.
⚫As infection continues the
patient’s face may swell, and
there may be pulsating pain.
*
6

Disorders
in the oral
cavity…
⚫The extent of damage
and the type of treatment
is determined by X-ray.
⚫Treatment
�Fillings
�Dental implants and
�Extractions.
*
7

Disorders
in the
oral
cavity…
⚫Prevention
⚫Measures used to prevent and
control dental caries include
Practicing effective mouth
care
Reducing the intake of
starches and sugars (refined
carbohydrates)
Applying fluoride to the teeth
or drinking fluoridated water,
Refraining from smoking
Controlling diabetes
*
8

Periodontal
disease
Periodontitis
⚫The periodontium is the tissue
that surrounds and supports
the teeth, disease of the
prriontium is the most
common cause of tooth loss in
adults after ae 50.
Cause
⚫Bacterial plaque
⚫Dental malocyusion
⚫Caries
⚫Dietary deficiencies
⚫And systemic diseases such as
diabetes may also play a role.
*
9

⚫Gingivitis, the earliest form of periodontal
disease
⚫Gingivitis – inflammation of gums
reddened gums
Swelling
Easy bleeding
managment
⚫Usually no pain treatment
Removal of decayed tooth, structures and
their replacement with restorative barriers
⚫Tooth extraction and the fitting of
dentures
⚫
*

PREVENTION
Good hygiene with frequent brushing
and regular flushing
Correct techniques , regular checkups
and intervention
Restricting the amount of simple sugar
in the diet.
Adequate or supplemental vitamin to
reduce plague
Oral health.
*

Stomatitis
Stomatitis is an inflammatory response of the oral tissues that
most often develops with in 3 to 14 days following the
administration of certain chemotherapeutic agents.
i.e It may be also occur with irradiation to the head and neck
area.
It is characterized by C/F
mild redness
edema or
*

If severe
Painful ulceration ulceration
Bleeding
Secondary infection
pain interfere with nutritional in take, communication and
willingness to maintain oral hygiene
*

MANAGEMENT:
Oral hygiene
Avoid foods that are difficult to chew or too hot or too spicy to reduce
further trauma
Lips are lubricated
Topical antifungal and anesthetic to promote healing and minimize
discomfort
Analgesics
Maintain adequate fluid and food intake
Antibiotics
*

Parotitis
Parotid glands are the saliva producing
glands buried within each cheek
• saliva comes out usually at the level of the upper back teeth
• Parotitis is an inflammation of one or both parotid glands
Etiology:
Staphylococcus aureus, except in mumps
(viral)
Acute bacterial parotitis
Is an acute inflammatory response to bacterial infection which
cause redness, pain , swelling and tenderness over the gland on
the side of the cheek. *

Rx
Correction of fluids
Antibiotics
Analgesics
Chronic recurrent parotitis
Refers to repeated episodes of discomfort and swelling of the parotid
gland often after eating It is treated conservatively
Gland massage
Stimulate flow of saliva (lemonjuice)
Antibiotics
Surgery –remove the gland
*

Viral parotitis
The commonest viral cause of parotitisis is mumps. It
usually affected 4 to 10 years old and causes painful
swelling of both parotid glands.
Recurrent parotitis inchidren
It though to be distention of the duct and if result in
the same symptoms as acute bacterial parotitis in
this case it is self limiting.
*

Disorders of the
Esophagus
DYSPHAGIA
It is a difficulty of swallowing and is the most common
symptom of esophageal disease.
This symptom may vary from an uncomfortable feeling in the
upper esophagus to acute pain on swallowing
(odynophagia).
Obstruction of food and even liquids may occur anywhere
along the esophagus.
*

Disorders
of the
Esophagus
…
❖Often the patient can indicate
where the problem is located
in the esophagus.
❖Pathologic conditions of the
esophagus, includes
Motility disorders (achalasia,
diffuse spasm)
Gastro esophageal reflux
Hiatal hernias
Diverticulation
Perforation
Foreign bodies
Chemical burns
Benign tumors and carcinoma.
*
19
19

Disorders of the
Esophagus…
⚫ ACHALASIA
✀Achalasia is absent or ineffective peristalsis
of the distal esophagus,
✀It is accompanied by failure of the
esophageal sphincter to relax in response to
swallowing.
✀Achalasia may progress slowly and occurs
most often in people 40 years of age or
older. *

Disorders of the
Esophagus…
❖Cause include the following:
⮚Primary (idiopathic)
⮚Degeneration and loss of ganglion
cells cause a defect in the
innervations of the esophagus
⮚Resulting absence of complete LES
relaxation and absence of peristalsis
*

Disorders of the
Esophagus…
⚫ Clinical manifestation
⮚Difficulty in swallowing both liquids and
solids.
⮚Sensation of food sticking in the lower
portion of the esophagus.
⮚Food regurgitation( commonly in advanced
stage).
⮚Weight loss can be a late manifestation.
*

Disorders of the
Esophagus…
⚫Chest pain and heartburn (pyrosis).
⚫Pain may or may not be associated with
eating.
⚫There may be secondary pulmonary
complications from aspiration of gastric
contents.
*

Disorders of the
Esophagus…
⚫ Treatment
⮚There is no curative treatment for achalasia
⮚The aim is to decrease the LES pressure
either chemically(medications) or
mechanically (by forceful stretching) .
⮚Smooth muscle relaxants such as
▪ Calcium channel blockers and
▪ Nitrates, have been used with limited
success.
*

Disorders of the
Esophagus…
• Ex. Nifedipine, 10–20 mg, or isosorbide
dinitrate, 5–10 mg solution
• Forceful dilation of the LES using balloons,
pneumatic (forceful) dilation
• Pneumatic dilation has a high success rate
• Is effective in 85%cases , with 3–5% risk of
perforation or bleeding.
*

*

Nursing care of pt’s
with achalasia
The patient should be instructed to eat slowly and to drink
fluids with meals
Semisoft ,warm foods are better tolerated than cold, hard
foods ,the client should avoid hot, iced foods as well as
alcohol and tobacco
All foods should be chewed thoroughly to add saliva to
mixture, providing lubrication and allowing the bolus to pass
more easily
To prevent nocturnal reflux of food the client should sleep
with head of the bed elevated.
*

HIATAL HERNIA
Some times also
known as a
diaphragmatic or
esophageal hernia.
A part of the
stomach protrudes
up through the
diaphragm near
the esophagus into
the chest.
Patients may be
asymptomatic or
have daily
symptoms of gastro
esophageal reflux
disease (GERD).
*

HIATAL HERNIA…
⚫ The hernia may be
⮚A sliding hiatal hernia:- is known as type
I hernia.
⮚Accounts about 90% of total hiatal hernia
⮚Allows movement of the upper portion of the
stomach including the lower esophageal
sphincter up and down through the
diaphragm.
⮚These patients typically have symptoms of
GERD.
*

*

HIATAL HERNIA …
Etiology. The actual cause
of sliding hernia is unknown
Predisposing factors
Structural changes, such as
weakening of the muscles in the
diaphragm around the
esophagogastric opening
Factors that increase
intraabdominal pressure:
e.g Obesity, pregnancy, ascites,
tumors, tight corsets, intense
physical exertion and heavy lifting
on a continual basis
0*

HIATAL HERNIA …
❖ Other predisposing factors are
⮚Increased age
⮚Trauma
⮚Poor nutrition and
⮚A forced recumbent position
* 32 BY: ROMMEL LUIS C. ISRAEL III 32

Hiatal Hernia …
⚫ Clinical manifestation
✔In sliding hernia 50% patients are
asymptomatic
✔Heart burn, Regurgitation
✔Dysphagia, symptoms of reflux
✔Substernal pain, burning, non radiating,
position dependent epigastric pain,
substernal tightness
✔Symptoms may be exacerbated by gastric
irritants(alcohol, tobacco, caffeine)

HIATAL HERNIA…
⚫A rolling hernia:- known as
Paraesophageal (type II) hernia.
⮚Portion of the stomach protrudes up through
the diaphragm, but the lower esophageal
sphincter area remains below the level of
the diaphragm.
⮚These patients do not generally suffer from
reflux.
*

Hernia …
⮚ Type II(paraesophageal hernia),Rolling hernia
accounts 10% of the total hernia
⮚ Depending on the extent of herniation,
Paraesophageal hernia is further classified as
types II, III, or IV(which has the greatest
herniation)
⮚ Gastro esophageal junction is blow the
diaphragm

Hiatal Hernia …

Hernia …
Clinical Manifestations
• A sense of fullness after eating
• Does not have symptoms of reflux
• Chest pain
• Reflux usually does not occur, because the
gastroesophageal sphincter is intact.
Complication for both (type I and II)
• Hemorrhage, obstruction, and strangulation can
occur with any type of hernia.

Hernia …
⚫ Nursing Management
⮚Frequent, small feedings that can pass easily
through the esophagus.
⮚No food intake several hours before bed
⮚Weight reduction
⮚Sleep with head at 300
⮚Avoid gastric irritants, alcohol, tobacco and
caffeine
⮚Regular use of anti acids

Hernia …
The patient is advised not to recline for 1 hour after
eating, to prevent reflux or movement of the hernia,
Elevate the head of the bed 10- to 20-cm blocks to
prevent the hernia from sliding upward.
Avoid lifting and straining
If overweight, the patient should be encourage to
lose weight

Intestinal
Obstruction
⮚Partial or complete impairment of the
forward flow of intestinal contents.
⮚Two types of processes can impede this
flow.
⮚Mechanical Obstruction:
❑ Is an intra luminal obstruction or a mural
obstruction from pressure of the intestinal
walls.

Intestinal
obstruction …
Mechanical causes of intestinal obstruction
Adhesion
Most common causes of small bowel obstruction (60%).
Mostly occur after abdominal operation.
Loops of intestine may become adherent to these area.
Results- kinking of an intestinal loop.

Intestinal
obstruction …
Functional Obstruction
The intestinal musculature cannot propel the contents along the
bowel
Causes:
Manipulation of the bowel
Neurologic disorder.
Endocrine disorders. E.g diabetes mellitus
Metabolic. E.g. Electrolyte imbalance, Hypokalemia
Inflammatory condition Ex. Peritonitis.
Spinal fracture

Intestinal
obstruction …
⮚ Incidence:
⮚Most bowel obstructions occur in the
small intestine (85%).
⮚About 15% in large bowel
obstruction.(most of these are found
in sigmoid colon)

Intestinal
obstruction …
⚫ Intussusceptions:
⮚One part of intestine slips into another part
located below it.
⮚Is prolapsing or invaginating of bowel.
⮚Is a telescoping of the bowel on itself or
⮚Is the tube with in a tube

Intestinal
obstruction
…
* 45

Intestinal
obstruction …
⚫Volvulus:
⮚Bowel twists and turns on itself.
⮚Results- intestinal lumen becomes
obstructed, gas and fluid accumulate in the
trapped bowel.
⮚Volvulus can be sometimes corrected
without surgical intervention

Intestinal
obstruction
…
*
47
47

HERNIA
⮚Hernia-
⮚protrusion of intestine through
a weakened area in the
abdomen muscle or wall.
* 48
48

Intestinal
obstruction …
Tumor –
That exist within the wall of
intestine or outside the intestinal
causes pressure on the wall of
intestine.
Is the most common causes of
large bowel obstruction.
Can result partially obstructed if
the tumor is not removed
Worms
E.g, Ascariasis bolus

Intestinal
obstruction
…
Pathophysiology of small
bowel obstruction
❖Intestinal contents, fluid and gas
accumulate above the obstruction site.
❖The abdominal distention and retention
of fluid reduce the absorption of fluids
and stimulate more gastric secretion.
❖With increasing distention, pressure
within the intestinal lumen increases,
causing a decrease in venous and
arteriolar capillary pressure.
* 50
50

Intestinal
obstruction …
This causes edema,
congestion, necrosis
and eventual rupture
or perforation of the
intestinal wall, with
resultant peritonitis.
Reflux vomiting may
be caused by
abdominal
distention.
Dehydration and
acidosis develop
from loss of water
and sodium.
With acute fluid
losses, hypovolemic
shock may occur

Intestinal
obstruction …
Pathophysiology of Large bowel obstruction
⮚ As in small bowel obstruction, large bowel
obstruction results in an accumulation of
intestinal contents, fluid and gas proximal to
the obstruction.
⮚ Obstruction in the large bowel can lead to
severe distention and perforation unless some
gas and fluid can flow back through the ileal
valve.
⮚ If the blood supply is cut off, however,
intestinal strangulation and necrosis (ie, tissue
death) occur; this condition is life threatening.

Intestinal
obstruction …
In the large intestine,
dehydration occurs more
slowly than in the small intestine
Because the colon can absorb
its fluid contents and can
distend to a size considerably
beyond its normal full capacity

Intestinal
obstruction …
C/m:
Cramp pain that is wave like and colicky.
Initially the peristaltic waves increase
Patient may pass blood and mucus but no fecal
matter and no flatus.
Vomiting
If obstruction is in the ileum, fecal vomiting takes
place

Intestinal
obstruction …
Abdominal
distention.
Dehydration
and electrolyte
imbalance.
Hypovolemic
shock
In large bowel
Obstruction :
On set of c/m is
gradual
Vomiting is rare
Pain ,low- grade,
cramping abdominal
pain
Dehydration occurs
more slowly than in
the small intestine.
Symptoms develop
and progress
relatively slow

Intestinal
obstruction …
On History and P/E suggests the
obstruction and the site of obstruction
X- ray finding, abnormal quantities of
gas or fluid or both in the bowel
supports the data
Blood chemistry shows dehydration

Intestinal
obstruction …
Medical Management
Decompression of the bowel through a nasogastric or small
bowel tube.
Intravenous therapy is necessary to replace the depleted
water, sodium, chloride and potassium.
When the bowel is completely obstructed, the possibility of
strangulation warrants surgical intervention.
The surgical treatment of intestinal obstruction depends
largely on the cause of the obstruction.

Intestinal
obstruction …
If hernia and adhesions, the surgical
procedure involves repairing the
hernia or dividing the adhesion to
which the intestine is attached.
In some instances, the portion of
affected bowel may be removed and
an anastomosis can performed.

Intestinal
obstruction …
⚫Nursing Care:
⮚Maintaining the function of the naso-gastric
tube.
⮚Assessing for fluid and electrolyte
imbalance.
⮚Monitoring nutritional status.
⮚Assessing improvement.
⮚Wound care and routine post operative
nursing care

Appendicitis
When appendix empties
inefficiently and its lumen is
small, it is prone to obstruction
and is particularly vulnerable
to infection (ie, appendicitis)
Is an inflammation of a narrow,
blind protrusion located at the
tip of the cecum (appendix).

Appendicitis …
⚫ Incidence:
❖Can occur at any age.
❖More common in 10-30years.
❖It is not common in adult but when it does
occur, rupture is more common
❖Is the most common reason for emergency
abdominal surgery.

Appendicitis …
About 7% of the population will have appendicitis
at some time in their lives
Males are affected more than females.
Etiology:
•A fecal mass (fecallith- hardened mass of stool).
•Tumor or foreign body.
•Kinking of the appendix
•External occlusion of the bowel by adhesions

Appendicitis …
⚫ Pathophysiology:
⮚when the appendix become obstructed, the
intraluminal pressure increase leading to
decrease Venus drainage, thrombosis,
edema and bacterial invasion of the bowel
wall.
⮚Will continue obstruction, perforation will
result and the inflamed appendix fills will
pus

Appendicitis …
⚫ C/M:
✔Vague epigastric or periumblical pain
progresses to right lower quadrant.
✔Fever (37.7°C/100°F) or higher
✔Anorexia, nausea and sometimes vomiting
✔Local tenderness is elicited at MC-burney’s
point when pressure is applied.
✔Rebound tenderness may present (i.e.
production of pain when pressure is
released)

Appendicitis …
Rovsing sign 🡪 May be elicited by palpating the
left lower quadrants, causes pain in right lower
quadrant.
Pain becomes steady rather than intermittent
The client often guards the area by lying still and
drawing the legs up to relieve tension on
abdominal muscles.
Psoas sign 🡪 Pain on extension of the right hip
Obturatory sign 🡪 Pain on internal or external
rotation of the hip

Appendicitis …

Appendicitis …
Example
If its tip in the pelvis, these
signs may be elicited by
only on rectal examination.
Pain on defecation suggests
that the tip of the appendix
is resting against the rectum.
The extent of tenderness
depends on the location of the
inflamed appendix.

Appendicitis …
Pain on urination suggests that the tip is near
the bladder.
If ruptured, pain becomes more diffuse,
abdominal distension, patients’ condition
worsens
Diagnostic Assessment
History and physical
examination
Laboratory examination
Complete blood count-
elevated WBC count.

Appendicitis …
⚫ On laboratory findings.
⮚The CBC reveals WBC >10,000 cells/mm3,
⮚The neutrophil count >75%.
⮚Abdominal x-ray films, ultrasound studies,
and CT scans may reveal a right lower
quadrant density or localized distention of
the bowel

Appendicitis …
⚫ Complications
⮚Perforation of the appendix
⮚This leads to peritonitis or an abscess.
⮚The incidence of perforation is 10% - 32%.
⮚Perforation occurs 24 hrs after the onset of
pain.

Appendicitis …
Management
No medical treatment as
such for appendicitis.
Surgical
Management
Appendectomy (removing
the appendix).
Intravenous fluid (to correct
electrolyte and fluid).
Antibiotics to prevent
infection.

Appendicitis …
⮚ Nursing Management
❑ If appendicitis is suspected.
⮚ Prepare the patient for surgery.
⮚ IV infusion (to replace fluid loss).
⮚ Antibiotic therapy (to prevent infection).
⮚ Pain medication should be with held until
diagnosis is confirmed.
⮚ Never give enema or a laxative or apply heat
(because it can lead to perforation).
⮚ NPO(Nothing per OS)

Appendicitis …
⚫ After Appendectomy
⮚Place the patient in a semi fowler’s position.
⮚Monitor vital sign, intake and output.
⮚Give analgesic as ordered.
⮚Encourage the patient to cough, deep
breath, and turn frequently to prevent
pulmonary complication
⮚Document bowel sounds.
⮚Watch closely for possible surgical
complications.

Peritonitis
Is an inflammation of the peritoneum.
Caused by bacterial or chemical
contamination of the peritoneal cavity.
Can be primary or secondary peritonitis.
Classified as: acute or chronic peritonitis.
Localize or generalized peritonitis

Peritonitis …
They enter the sterile peritoneal cavity usually this is a result
of
Perforated
appendix.
Perforated
peptic ulcer
disease.
Strangulated
bowel /bowel
perforation.
Perforation of a
diverticulum
The most common organism E. colil, streptococci.
Normal bacterial flora of the intestine becomes a source of
infection.

Peritonitis …
Septic abortion
Pancreatitis
Cholecystitis
Typhoid perforation…..etc.

Peritonitis …
⚫ C/M
⮚Sharp abdominal pain which worsen with
movement
⮚Abdominal distention.
⮚Increased pulse rate.
⮚Abdomen becomes rigid (muscle guarding).
⮚Leucocytosis and fever may develop.
⮚Decreased or absent bowel sounds.
⮚Tenderness/localized or generalized.
⮚Respirations may be shallow and rapid.
⮚Nausea and vomiting.

Peritonitis …
⚫ Diagnosis is based on the findings of
⮚History and physical Examination.
⮚Lab- elevated white blood cells
⮚WBC 20,000 mm3
⮚Abdominal X- ray Studies are performed
show dilation and edema of the intestine.

Peritonitis …
⚫ Complications
⮚Generalized sepsis.
⮚Shock- may results from septicemia or
hypovolemia.
⮚Inflammatory process may cause
intestinal obstruction

Peritonitis …
⚫ TREATMENT
�Intravenous fluids.
�Administer broad-spectrum antibiotics.
�Surgical intervention may be necessary to
correct cause of peritonitis.
�Pain management postoperatively
*

Peritonitis …
⚫ NURSING INTERVENTION
�Controlling the patient weigh daily.
�Monitor vital signs
�Monitor intake and output.
�NPO to avoid irritation of intestinal tract
�Position for comfort, head of bed elevated.
�Teach patient about home care:
�Pain management.
�Wound care, drains, etc.
�Monitor for signs of infection
*

Peptic Ulcer Disease
⚫ An ulcer develops when there is erosion of a
portion of the mucosal layer of either the
stomach or duodenum.
⮚Stomach ulcer (gastric ulcer) or
⮚The duodenum ulcer (duodenal ulcer).
⮚Gastric ulcers favor the lesser curvature of
the stomach.
*

Peptic Ulcer Disease …
Duodenal ulcers tend to be
deeper, penetrating
through the mucosa to the
muscular layer.
Helicobacter pylori
infection has been
associated with duodenal
ulcers.
*

Peptic ulcer disease …
⚫ Complications
⮚Bleeding or perforation
⮚Peritonitis
⮚Paralytic ileus
⮚Septicemia
*

C/M
• Worse just after eating as acid increases with
gastric ulcer
• Worse when stomach is empty (with
duodenal ulcer); may awaken during the
night due to pain
• Weight changes
• Loss with gastric ulcer
• Gain with duodenal ulcer
Epigastric area pain:
*

Bleeding from ulcer
causes:
Hematemesis 🡪 more
likely with gastric ulcer
Coffee-ground emesis
(partially digested
blood)
Melena (tarry stool) 🡪
more likely with
duodenal ulcer
Perforation of ulcer
causes:
Sudden, sharp pain
Tender, rigid, board-like
abdomen
Knee-chest position
reduces pain
Hypovolemic shock
*

*
87
•Anemia due to bleeding.
•Stool for occult blood positive due to
bleeding.
•H. pylori testing positive.
Lab finding shows
•Areas of ulceration(not done if perforation
suspected).
Upper GI or barium swallow
shows
•Abdominal x-rays show free air in
perforation.
Upper endoscopy shows ulcer.

*
88
TREATMENT
Administer antacids
•Famotidine, ranitidine, nizatidine, cimetidine
Administer histamine-2 blockers
•Sucralfate
Administer mucosal barrier fortifiers:
•Misoprostol
Administer prostaglandin analogue:
Adjust diet.
Treat H. pylori infection

⚫ NURSING INTERVENTION
�Monitor vital signs
�Monitor intake and output
�Assess abdomen for bowel sounds,
tenderness, rigidity, rebound pain,
guarding.
�Monitor stool for change in color,
consistency, blood.
*

⚫ Teach patient about home care:
⮚Diet modification to avoid acidic foods,
caffeine, alcohol.
⮚Eat more frequent, small meals.
⮚Avoid nonsteroidal anti-inflammatory
medication.
⮚Stop smoking.
*

Gastroenteritis
An acute inflammation of the gastric and
intestinal mucosa
It is most commonly due to bacterial,
viral, protozoa or parasitic infection.
It may also be caused by irritation due to
chemical or toxin exposure or allergic
response.
*

Gastroenteritis…
Symptoms may be self-limiting or may
need prescription medication to
resolve the illness.
Older or debilitated patients may have
more severe symptoms or require
hospitalization due to dehydration.
*

Gastroenteritis…
❖C/M
¯ Anorexia, Malaise, Nausea &
vomiting
¯ Diarrhea—watery, soft, may be
mixed with mucous or blood
¯ Abdominal pain
¯ Abdominal distention
¯ Fever due to infection
¯ Headache due to viral illness
¯ Signs of dehydration
*

Gastroenteritis…
❖ Lab finding
ø CBC may show leukocytosis or eosinophilia
(parasites).
ø Electrolytes show imbalance due to GI loss.
ø BUN and creatinine elevated due to
dehydration.
ø Stool for ova and parasites show positive with
parasitic infection.
*

Gastroenteritis…
⚫ Medical management
⮚Monitor intake and output.
⮚Replace fluids lost.
⮚ Administer antiemetic medication for
symptom relief:
⮚Prochlorperazine
⮚Trimethobenzamide
*

Gastroenteritis…
⚫ Administer anti diarrheal medications for
symptom relief:
⮚Loperamide
⮚Diphenoxylate
⮚Kaolin-pectin
⮚Bismuth subsalicylate
⚫ Need to allow organism one way out of
gastrointestinal system (either antiemetic or
ant diarrheal).
*

Gastroenteritis…
⚫ Administer antimicrobials for infectious cause:
⮚ciprofloxacin
⮚Metronidazole
⚫ Intravenous fluids to correct dehydration
*

NURSING INTERVENTION
Monitor vital signs for changes.
Monitor
Monitor intake and output.
Monitor
Assess skin and mucous membranes for signs of
dehydration.
Assess
Assess abdomen for bowel sounds, tenderness
Assess
Teach the patient about the risks of
communicability
Teach
*

Hepatitis
Hepatitis is an inflammation of the liver
cells.
This is most commonly due to a viral
cause which may be either an acute
illness or become chronic.
It can be prevented by vaccine. a
and b
It can be prevented by vaccine
*

Food borne
hepatitis
Hepatitis A &
B virus
Ingestion of
contaminated food
or drink; direct
contact with carrier
Blood borne
hepatitis
Hepatitis B,
C, D&G virus
Sexual, perinatal
and percutaneous
*
10
0
✔Hepatitis A and B are vaccine preventable
✔Hepatitis C, D E and G have no vaccination

Hepatitis may occur as an acute infection (viral type A,
E) or become a chronic state.
The patient with chronic disease may be unaware of the
illness until testing of liver function shows abnormalities
and further testing reveals presence of hepatitis.
The chronic (viral type B, C) disease state creates the
potential development of progressive liver disease.
Liver cancer may develop in those with chronic disease
states.
*

Sign and symptoms
⚫ Acute hepatitis:
⚫Malaise
⚫Nausea and vomiting
⚫Diarrhea or constipation
⚫Low-grade fever
⚫Dark urine due to change in liver function
⚫Jaundice due to liver compromise
⚫Tenderness in right upper quadrant of abdomen
⚫Hepatomegaly
⚫Arthritis, glomerulonephritis, polyarteritis nodosa
in hepatitis B
*

Sign and symptoms …
Chronic hepatitis:
⮚Asymptomatic with elevated liver enzymes
⮚Symptoms as acute hepatitis
⮚Cirrhosis due to altered liver function
⮚Ascites due to decrease in liver function,
increased portal hypertension
⮚Bleeding from esophageal varices
⮚Encephalopathy due to diminished liver
function
⮚Bleeding due to clotting disorders
⮚Enlargement of spleen
*

Medical management
Avoid medications metabolized in the liver.
Avoid alcohol.
Remove or discontinue causative agent if drug-
induced or toxic hepatitis.
Intravenous hydration if vomiting during acute hepatitis.
Activity as tolerated.
*

High-calorie diet; breakfast is usually the
best tolerated meal.
Administer interferon or lamivudine for
chronic hepatitis B.
Administer interferon and ribavirin for
hepatitis C.
Administer prednisone in autoimmune
hepatitis.
Liver transplantation.
*

Nursing management
⚫Monitor vital signs.
⚫Assess abdomen for bowel sounds,
tenderness, ascites.
⚫Plan appropriate rest for patient in acute
phase.
⚫Monitor intake and output.
⚫Assess mental status for changes due to
encephalopathy.
*

Assist patient to:
Assist
Plan palatable meals; remember
that breakfast is generally the best
tolerated meal.
Plan
Avoid smoking areas—intolerance
to smoking.
Avoid
*

Pancreatitis
Pancreatitis is an inflammation of
the pancreas which causes
destructive cellular changes.
Acute pancreatitis:- involves auto
digestion of the pancreas by
pancreatic enzymes and
development of fibrosis.
*
10
8

Pancreatitis …
❖ Chronic pancreatitis:- results from recurrent
episodes of exacerbation, leading to fibrosis
and a decrease in pancreatic function.
⮚Presence of gallstones blocking a pancreatic
duct
⮚Chronic use of alcohol
⮚Post abdominal trauma or surgery or
⮚Elevated cholesterol are associated with an
increased risk of pancreatitis.
*

Pancreatitis
⚫ Acute pancreatitis may be life-
threatening.
⚫ Complication
❖Pleural effusion
❖Pneumonia common in older patients.
❖Disseminated intravascular
coagulation
*

CLINICAL
MANIFESTATION
Epigastric pain due to inflammation and
stretching of pancreatic duct
Boring abdominal pain may radiate to back or
left shoulder in acute pancreatitis
Gnawing continuous abdominal pain with acute
exacerbations in chronic pancreatitis
Patient in knee-chest position for comfort—
reduces tension on abdomen
Nausea and vomiting
*

C/M…
Bluish-gray discoloration of periumbilical area and
abdomen (Cullen’s sign)
Bluish-gray discoloration of flank areas (Turner’s sign)
Ascites
Weight loss
Blood glucose elevation
Fatigue
*

⚫ Diagnostic finding
✔Elevated serum amylase.
✔Elevated serum lipase.
✔Elevated white blood cell count (WBC)
due to inflammation.
✔Elevated cholesterol.
✔Elevated glucose due to labile effect on
glucose control.
✔Elevated bilirubin.
✔CT scan shows inflammation.
✔Chest x-ray may show pleural effusion
*

Medical management
NPO during acute stage to reduce release of pancreatic enzymes.
Intravenous fluids for hydration.
Administer vitamin supplementation.
Pain management with narcotics during acute stage.
Avoid morphine that may increase pain due to spasm of the
sphincter of Oddi at the opening to the small intestine from the
common bile duct.
*

Medical management …
Intravenous, patient-controlled analgesia or trans dermal delivery preferable to
intramuscular.
Acute:
NG tube connected to suction if vomiting.
Surgical intervention for abscess or pseudo cyst.
Chronic:
Blood glucose control with insulin.
Administer pancreatic enzymes with meals.
Surgical intervention for pain control, abscess.
*

Nursing management
Assess vital signs for elevated temperature, elevated pulse, and
changes in blood pressure.
Assess pain level.
Monitor intake and output.
Assess abdomen for bowel sounds, tenderness, masses, ascites.
Monitor fingerstick blood glucose.
Assess lung sounds for bilateral equality.
Frequent oral care for NPO patients.
*

⚫ Teach patient about home care:
❖Avoid alcohol and caffeine.
❖Bland, low-fat, high-protein, high-calorie,
small, frequent meals.
❖Use of blood glucose meter.
❖Medication management, schedule, side
effects.
❖Plan rest periods until strength returns.
*

ACUTE
ABDOMEN

CONTENTS
@ Definition
@ Introduction
@ Causes/ DDx
@ Diagnosis
@ History
@ Physical examination
@ Investigation
@ Treatment
@ Reference
BY:
ROMMEL
LUIS
C.
ISRAEL
III
119

DEFINITION
Acute abdomen= is the term
used for an episode of severe
abdominal pain with an acute
onset ( <8hrs) that lasts for
several hours or longer and
requires medical attention.
BY:
ROMMEL
LUIS
C.
ISRAEL
III
120

…..DEFINITION
BY:
ROMMEL
LUIS
C.
ISRAEL
III
121
‘Acute abdomen’ is a term used to encompass a
spectrum of surgical, medical and gynecological
conditions, ranging from the trivial to the life-
threatening, which require hospital admission,
investigation and treatment.
The acute abdomen may be defined generally
as an intra-abdominal process causing severe
pain requiring admission to hospital, and which
has not been previously investigated or treated
and may need surgical intervention.

INTRODUCTION
BY:
ROMMEL
LUIS
C.
ISRAEL
III
122
Is the most common presenting
surgical emergency.
The aim is to differentiate serious
causes from less serious causes of
acute abdominal pain.

INTRODUCTION
�The mortality rate varies with
age, being the highest at the
extremes of age.
�The highest mortality rates are
associated with laparotomy for
unresectable cancer, ruptured
abdominal aortic aneurysm and
perforated peptic ulcer.
BY:
ROMMEL
LUIS
C.
ISRAEL
III
123

;;;;;;;;;;
o -Most common causes in any
population will vary according to
age .sex and race,as well as
genetic and environmental
factors.
BY:
ROMMEL
LUIS
C.
ISRAEL
III
124

BY:
ROMMEL
LUIS
C.
ISRAEL
III
125

BY:
ROMMEL
LUIS
C.
ISRAEL
III
126

BY:
ROMMEL
LUIS
C.
ISRAEL
III
127

THINK BROAD CATEGORIES FOR
DDX
BY:
ROMMEL
LUIS
C.
ISRAEL
III
128
Inflammation
Obstruction
Ischemia
Perforation (any of above
can end here)
Offended organ becomes
distended
Lymphatic/venous obstrux due
to ↑pressure
Arterial pressure exceeded →
ischemia
Prolonged ischemia →
perforation

CAUSES-
A. Gastrointestinal-
1-Gut
Acute appendicitis
Intest obstruction(SB,LB)
Perforated peptic ulcer
Inflammatory bowel disease
Acute exacerbation of peptic
ulcer
Gastroenteritis
Meckel’s diverticulitis
Intussusception
obstructed hernia
Hirschsprungs d/se
2-Liver and biliary tract
cholecystitis/lithiasis
cholangitis
Hepatitis
3-Pancreas
Acute pancreatitis
4-Spleen
Splenic infarct and
spontaneous rupture
BY:
ROMMEL
LUIS
C.
ISRAEL
III
129

BY:
ROMMEL
LUIS
C.
ISRAEL
III
130

BY:
ROMMEL
LUIS
C.
ISRAEL
III
131

BY:
ROMMEL
LUIS
C.
ISRAEL
III
132

BY:
ROMMEL
LUIS
C.
ISRAEL
III
133

BY:
ROMMEL
LUIS
C.
ISRAEL
III
134

Ileo-sigmoid
knotting
(compound volvulus)
✔ Dramatic
presentstion with
shock & gangrene of
bowl
✔ 4th decade
Intussusception
✔ Commonest site -
ileocaecal junction
Sigmoid volvulus
Small Intestinal volvulus
BY:
ROMMEL
LUIS
C.
ISRAEL
III
135

CAUSES-
B. Urinary tract
Cystitis
Acute pyelonephritis
Ureteric colic
Acute retention
C. Vascular
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous
thrombosis
Ischemic colitis
Acute aortic dissection
D. Abdominal wall
conditions
Rectus sheath haematoma
E. Peritoneum
Primary peritonitis
Secondary peritonitis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
136

CAUSES-
F. Retroperitoneal
Hemorrhage e.g anticoagulants
G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Salpingitis
Pelvic endometriosis
Severe dysmenorrhea
Endometriosis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
137

CAUSES-
H. Extra-abdominal causes
Lobar pneumonia
Pleurisy –infl of pleura.
MI
Sickle cell crisis
Uremia –excess of urea & nitrogenous waste cpd
in bld.
Hypercalcemia
DKA
Addison’s disease
Acute intermitent porphyria
BY:
ROMMEL
LUIS
C.
ISRAEL
III
138

NON-SURGICAL CAUSES BY SYSTEMS
System Disease System Disease
Cardiac Myocardial infarction
Acute pericarditis
Endocrine Diab ketoacidosis
Addisonian crisis
Pulmonary Pneumonia
Pulmonary infarction
PE
Metabolic Acute porphyria
Mediterranean fever
Hyperlipidemia
GI Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculo-
skeletal
Rectus muscle
hematoma
GU Pyelonephritis CNS
PNS
Tabes dorsalis (syph)
Nerve root
compression
Vascular Aortic dissection Heme Sickle cell crisis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
139

RELATION OF PAIN TO EMBRYOLOGY
BY:
ROMMEL
LUIS
C.
ISRAEL
III
140
Intestine and its outgrowths (the liver, biliary system and pancreas)->
midline.
Irritation of foregut structures
(oesophagus to the second part of the duodenum)
->epigastric area.
Midgut structures
(the second part of the duodenum to the splenic
flexure) ->umbilicus.
Hindgut structures (the splenic flexure to the rectum)->
hypogastrium.

DIAGNOSIS
BY:
ROMMEL
LUIS
C.
ISRAEL
III
141
History
Physical examination
Laboratory
Radiology
History-
• Biodata
• Age:
• Mesenteric adenitis in children
• Diverticulitis in elderly
• Gender

BY:
ROMMEL
LUIS
C.
ISRAEL
III
142
Characteristics of abdominal pain
Site
Time and mode of onset
Severity
Nature/Character
Progression
Radiation
Duration
Cessation
Exacerbating/relieving factors
Associated symptoms

CLINICAL DIAGNOSIS
� Location of pain by
organ
� RUQ
⚫ Gallbladder
� Epigastrum
⚫ Stomach
⚫ Pancreas
� Mid abdomen
⚫ Small intestine
� Lower abdomen
⚫ Colon, GYN pathology
BY: ROMMEL LUIS C.
ISRAEL III
143

SITE-PAIN
Whole abdomen
Peritonitis or mesentric infarction
Right upper quadrant
Acute cholycystitis
Cholangitis
Hepatitis
Peptic ulceration
Left upper quadrant
Peptic ulceration
Pancreatitis
Splenic infarct
BY:
ROMMEL
LUIS
C.
ISRAEL
III
144

Right lower quadrant
Appendicitis
Ovarian cyst
Ectopic pregnancy
PID
Right ureteric colic
Left lower quadrant
Sigmoid diverticular disease
Ovarian cyst
Ectopic pregnancy
PID
Left ureteric colic
BY:
ROMMEL
LUIS
C.
ISRAEL
III
145

SYMPTOMS--PAIN
Onset
sudden: perforation of bowel, smooth muscle colic
slow insidious onset: inflammation of visceral
peritoneum
Severity
Patient asked to rate pain from 1-10
Ureteric colic is one of worst pains
Character
Aching-dull pain poorly localised
Burning- peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal
obstruction worse by movement ; wringing of cloth
BY:
ROMMEL
LUIS
C.
ISRAEL
III
146

SYMPTOMS--PAIN
Progression
-Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric colic)
or tens of minutes (gallbladder
-may change character completely from dull poorly
localized pain to sharp pain indicates involvement
of parietal peritoneum e.g.appendicitis
Radiation of the pain
Back: duodenal ulcer, pancreatitis, aortic
aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion
BY:
ROMMEL
LUIS
C.
ISRAEL
III
147

Epigastric-periumbli-RLQ=Acute appt
Localized pain – diffuse=diffuse
peritonitis
Exacerbating/relieving factors-
Movement/Rest-inflammatory
conditions
Food- peptic ulcers
BY:
ROMMEL
LUIS
C.
ISRAEL
III
148

History
BY:
ROMMEL
LUIS
C.
ISRAEL
III
149

HISTORY
Past history
previous surgery
trauma
any medical diseases
Drug history
corticosteroid: mask pain
anti-coagulant: intra-mural hematoma
NSAIDS: gastritis, peptic ulcer
Family history
colon cancer
IBD
BY:
ROMMEL
LUIS
C.
ISRAEL
III
150

Physical Examination
BY:
ROMMEL
LUIS
C.
ISRAEL
III
151
• -Patient is lying motionless
• acute appendicitis, peritonitis
• -Rolling in bed
• ureteric colic, intestinal colic
• -Bending forward
• chronic pancreatitis
General
appearance

Vital signs
Temp.
low grade: appendicitis, acute cholycystitis
high grade: abscess
Pulse, BP, Resp.rate
General examination-
Conjuctival pallor
cyanosis
jaundice
Signs of dehydation
Cervical lymphadenopathy
-mesentric adenitis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
152

BY:
ROMMEL
LUIS
C.
ISRAEL
III
153
Cardio-pulmonary examination
-MI
-basal pneumonia
-pleural effusion

Abdomen
*Inspection
*Palpation
*Percussion
*Auscultation
Inspection
-movement with respiration
-distension, peristalsis, mass, scars
and any obvious cough impulse at
hernia site
BY:
ROMMEL
LUIS
C.
ISRAEL
III
154

Palpation
*superficial palpation
-tenderness, rebound tenderness, guarding,
rigidity, masses, hernial orifices
*deep palpation
-organomegaly
Percussion
-tympanic note: intestinal obstruction
-dullness over bladder: acute retention
BY:
ROMMEL
LUIS
C.
ISRAEL
III
155

Auscultation
-silent abdomen: peritonitis
-increase bowel sound: intestinal
obstruction
**Don’t forget to examine rectum for
tenderness, mass, blood and vaginal
examination for discharge, tenderness( PID).
BY:
ROMMEL
LUIS
C.
ISRAEL
III
156

SIGNS , DESCRIPTION AND
DIAGNOSIS
SIGN DESCRIPTION
DIAGNOSIS/CONDITIO
N
1. Aaron sign Pain or pressure in
epigastrium or anterior
chest with persistent firm
pressure applied to
McBurney's point
Acute appendicitis
2. Bassler sign Sharp pain created by
compressing appendix
between abdominal wall
and iliacus
Chronic appendicitis
3. Blumberg's sign Transient abdominal wall
rebound tenderness
Peritoneal inflammation
BY:
ROMMEL
LUIS
C.
ISRAEL
III
157

4. Chandelier sign Extreme lower
abdominal and
pelvic pain with
movement of cervix
Pelvic inflammatory
disease
5. Charcot's sign Intermittent right
upper abdominal
pain, jaundice, and
fever
Choledocholithiasis
6. Claybrook sign Accentuation of
breath and cardiac
sounds through
abdominal wall
Ruptured abdominal
viscus
7. Courvoisier's sign Palpable gallbladder
in presence of
painless jaundice
Periampullary
tumor
BY:
ROMMEL
LUIS
C.
ISRAEL
III
158

8. Cullen's sign Periumbilical
bruising
Hemoperitoneum
9. Danforth sign Shoulder pain on
inspiration
Hemoperitoneum
BY:
ROMMEL
LUIS
C.
ISRAEL
III
159

10. Grey Turner's
sign
Local areas of
discoloration around
umbilicus and
flanks
Acute hemorrhagic
pancreatitis
11. Iliopsoas sign Elevation and
extension of leg
against resistance
creates pain
Appendicitis with
retrocecal abscess
12. Kehr's sign Left shoulder pain
when supine and
pressure placed on
left upper abdomen
Hemoperitoneum
(especially from
splenic origin)
BY:
ROMMEL
LUIS
C.
ISRAEL
III
160

13. Murphy's sign Pain caused by
inspiration while
applying pressure to
right upper
abdomen
Acute cholecystitis
14. Obturator sign Flexion and external
rotation of right
thigh while supine
creates hypogastric
pain
Pelvic abscess or
inflammatory mass
in pelvis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
161

15. Ransohoff sign Yellow discoloration
of umbilical region
Ruptured common
bile duct
16. Rovsing's sign Pain at McBurney's
point when
compressing the left
lower abdomen
Acute appendicitis
17. Ten Horn sign Pain caused by
gentle traction of
right testicle
Acute appendicitis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
162

LABS & IMAGING
Test Reason
CBC w diff Left shift can be
very telling
BMP N/V, lytes,
acidosis,
dehydration
Amylase Pancreatitis,
perf DU, bowel
ischemia
LFT Jaundice,hepati
tis
UA GU- UTI, stone,
hematuria
Beta-hCG Ectopic
Test Reason
KUB
Flat & Upright
SBO/LBO,
free air,
stones
Ultrasound Chol’y, jaundice
GYN pathology
CT scan
- Diagnostic
accuracy
Anatomic dx
Case not
straightforward
BY:
ROMMEL
LUIS
C.
ISRAEL
III
163

Investigation
• CBC with differential (infection and inflammation)
• Urea, electrolyte, creatinine, glucose (DKA)
• LFT
• Amylase ( high in acute pancreatitis)
• urinalysis
• CXR ( basal pneumonia, gas under diaphragm)
• AXR
-distended bowel with air fluid level
-stones
-calcified aorta
-air in biliary tree
BY:
ROMMEL
LUIS
C.
ISRAEL
III
164

Investigation
BY:
ROMMEL
LUIS
C.
ISRAEL
III
165
U/S (ovarian cyst, ectopic pregnancy)
IVU for stones
Angiography (mesentric embolus or thrombosis)
Sickling test
Pregnancy test

Treatment
1. Relieve the pain
2. IV fluids and nasogastric suction ,catheterization
3. Antibiotics and analgesics if indicated
4. Surgery if indicated
*Indication for surgery:
If patient has guarding or rigidity with peritoneal irritation
spreading tenderness
Progressive distension or generalized peritonitis
Shock with bleeding or sepsis
Free gas on x-ray
Mesentric occlusion on angiography
Blood, pus or bile on paracentesis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
166

REFERENCE
� 1. manipal surgery
� 2. bailey and loves
� 3. primary surgery
� 4. NMS 5th edition
BY:
ROMMEL
LUIS
C.
ISRAEL
III
167

INTESTINAL
OBSTRUCTION
BY:
ROMMEL
LUIS
C.
ISRAEL
III
168

INTESTINAL OBSTRUCTION
� One of the common
cause of acute
abdomen
� May lead to high
morbidity and
mortality if not
treated correctly
⮚ It can be classified
into two types:
Dynamic
(mechanical)
Adynamic
BY:
ROMMEL
LUIS
C.
ISRAEL
III
169

DYNAMIC
BY:
ROMMEL
LUIS
C.
ISRAEL
III
170
1.Intraluminal: impacted faeces,
foreign bodies, gallstones
2.Intramural: tumours, inflammatory
strictures, congenital atresia
3.Extramural: adhesion, hernias,
volvulus, intussusception, tumours

DYNAMIC
*also can be divided into:
1. Small bowel obstruction (SBO)
-high ->early perfuse vomiting
rapid dehydration
-low->predominant pain, and central
distention
Vomiting delayed
air-fluid levels seen on AXR
2. Large bowel obstruction (LBO)
early pronounced distension, mild pain
vomiting, dehydration late
e.g. -carcinoma
-diverticulitis or volvulus
BY:
ROMMEL
LUIS
C.
ISRAEL
III
171

ADYNAMIC
BY:
ROMMEL
LUIS
C.
ISRAEL
III
172
1.Paralytic ileus (peristalsis is absent)
2.Peristalsis is present in a non-
propulsive form e.g. mesentric vascular
occlusion

OBSTRUCTION CAN BE-
Simple: blockage without interfering with
vascular supply
Strangulation: significant impairment of blood
supply most commonly associated with
hernia, volvulus, intussusception and
vascular occlusion
-surgical emergency
Closed loop obstruction: bowel is obstructed
at both the proximal and distal end)
BY:
ROMMEL
LUIS
C.
ISRAEL
III
173

PATHOPHYSIOLOGY
Irrespective of etiology or acuteness of onset:
Proximal to obstruction
Increased fluid secretion 🡪 abdominal distention
Accumulation of gas 🡪 abdominal distention
Increased intraluminal pressure
Decreased reabsorption with time and flaccidity to prevent vascular
damage from high pressure
Vomiting
Dehydration
Dilatation of bowel
Reflex contraction of smooth muscle 🡪 colicky pain
Increased peristalsis to overcome obstruction 🡪 increased bowel sounds
If obstruction not overcome 🡪 bowel atony
Distal to obstruction: nothing is passed & bowel collapse 🡪
constipation
BY:
ROMMEL
LUIS
C.
ISRAEL
III
174

SYMPTOMS
The four cardinal features of intestinal
obstruction:
-abdominal pain
-vomiting
-distension
-constipation
Vary according to:-
location of obstruction
age of obstruction
underlying pathology
intestinal ischemia
BY:
ROMMEL
LUIS
C.
ISRAEL
III
175

SYMPTOMS
Abdominal pain
colicky in nature, around the umbilicus in SBO
while in the lower abdomen in LBO
if it becomes continuous, think about perforation
or strangulation
Vomiting
-starts early in SBO and late in LBO
-vomitus starts with clear color then becomes
thick, brown and foul ( faeculent)
-more with lower or complete obstruction
-diarrhea may be present with partial obstruction
Distension
-more with lower obstruction
BY:
ROMMEL
LUIS
C.
ISRAEL
III
176

SYMPTOMS
Constipation
-more with lower or complete obstruction
-diarrhea may be present with partial obstruction
-either absolute (no feces or flatus)<-cardinal in
absolute IO
or relative (flatus passed)
Distension
-more with lower obstruction
BY:
ROMMEL
LUIS
C.
ISRAEL
III
177

SYMPTOMS
BY:
ROMMEL
LUIS
C.
ISRAEL
III
178
In strangulation:
severe constant abdominal pain
distended abdomen
fever
tachycardia
tender abdomen

CLINICAL EXAMINATION:
BY:
ROMMEL
LUIS
C.
ISRAEL
III
179
General examination-
• Vital signs
• Signs of dehydration –tachycardia, hypotension
dry mucus membrane, decreased skin turgor, decreased urine output
Inspection
• distension, scars, peristalsis, masses, hernial orifices
Palpation
• tenderness, masses, rigidity
Percussion tympanitic abdomen
Auscultation
high pitched bowel sound or silent abdomen
*Examine rectum for mass, blood, feces or it may be empty in case of complete
obstruction

INVESTIGATIONS
BY:
ROMMEL
LUIS
C.
ISRAEL
III
180
CBC- WBC (neutrophilia-strangulation)
Hb
U&E
Plain AXR
Sigmoidoscopy (carcinoma, volvulus)
Double Contrast x-ray ( complete or incomplete)
CT abdomen

NORMAL GAS PATTERN
AXR
BY:
ROMMEL
LUIS
C.
ISRAEL
III
181
• Always
Stomach
• Two or three loops of non-
distended bowel
• Normal diameter = 2.5 cm
Small
Bowel
• In rectum or sigmoid –
almost always
Large
Bowel

Gas in
stomach
Gas in a few
loops of
small bowel
Gas in
rectum or
sigmoid
Normal Gas Pattern
BY:
ROMMEL
LUIS
C.
ISRAEL
III
182

NORMAL FLUID LEVELS
BY:
ROMMEL
LUIS
C.
ISRAEL
III
183
Stomach
Always (except
supine film)
Small Bowel
Two or three levels
possible
Large Bowel None normally

Erect Abdomen
Always
air/fluid level
in stomach
A few
air/fluid
levels in
small bowel
BY:
ROMMEL
LUIS
C.
ISRAEL
III
184

Large vs. Small Bowel
∙ Large Bowel
♦ Peripheral
♦ Haustral markings don't
extend from wall to wall
∙ Small Bowel
♦ Central
♦ Valvulae extend across lumen
♦ Maximum diameter of 2"
BY:
ROMMEL
LUIS
C.
ISRAEL
III
185

Abnormal Gas Patterns
● Mechanical Obstruction
● SBO
● LBO
● Functional Ileus
● Localized (Sentinel Loops)
● Generalized adynamic ileus
BY:
ROMMEL
LUIS
C.
ISRAEL
III
186

Mechanical SBO
Key Features
● Dilated small bowel
● Fighting loops
● Little gas in colon, especially
rectum
● Key: disproportionate dilatation
of SB
BY:
ROMMEL
LUIS
C.
ISRAEL
III
187

SMALL BOWEL OBSTRUCTION
BY:
ROMMEL
LUIS
C.
ISRAEL
III
188

Mechanical LBO
Causes:-
● Tumor
● Volvulus
● Hernia
● Diverticulitis
● Intussusception
BY:
ROMMEL
LUIS
C.
ISRAEL
III
189

LBO
Supine Prone
BY:
ROMMEL
LUIS
C.
ISRAEL
III
190

Mechanical LBO
Pitfalls
● Incompetent ileocecal valve
● Large bowel decompresses
into small bowel
● May look like SBO
● Get BE or follow-up
BY:
ROMMEL
LUIS
C.
ISRAEL
III
191

Carcinoma of Sigmoid,LBO
Decompressed into SB
Prone
Supine
BY:
ROMMEL
LUIS
C.
ISRAEL
III
192

● One or two
persistently dilated
loops of large or
small bowel
● Gas in rectum or
sigmoid
Localized Ileus
Key Features
BY:
ROMMEL
LUIS
C.
ISRAEL
III
193

Localized Ileus
Pitfalls
● May resemble early
mechanical SBO
● Clinical course
● Get follow-up
BY:
ROMMEL
LUIS
C.
ISRAEL
III
194

● Gas in dilated small bowel and large
bowel to rectum
● Long air-fluid levels
● Only post-op patients have
generalized ileus
Generalized Ileus
Key Features
BY:
ROMMEL
LUIS
C.
ISRAEL
III
195

Generalized Adynamic Ileus
Supine Erect
BY:
ROMMEL
LUIS
C.
ISRAEL
III
196

BY:
ROMMEL
LUIS
C.
ISRAEL
III
197

TREATMENT
� Three main measures-
- GI drainage
� F&E replacement
- Relief of obstruction,
usually surgical
BY:
ROMMEL
LUIS
C.
ISRAEL
III
198

Treatment
Conservative:
-Nasogastric aspiration by Ryle or Salem tube
-IV fluids- volume varies depending on dehydration
-NPO
-urinary catheter
-check temp. and pulse 2 hourly
-abdominal examination 8 hourly
-Broad spectrum antibiotics initiated early-reduce
bacterial overgrowth
BY:
ROMMEL
LUIS
C.
ISRAEL
III
199

TREATMENT
BY:
ROMMEL
LUIS
C.
ISRAEL
III
200
Some cases will settle by using this conservative regimen, other
need surgical intervention.
Surgery should be delayed till resuscitation is complete unless
signs of strangulation and evidence of acute or closed-loop
obstruction.
Cases that show reasons for delay should be monitored
continuously for 72 hours in hope of spontaneous resolution e.g.
adhesions with radiological findings but no pain or tenderness
“The sun should not both rise and set” in cases of unrelieved
obstruction.

TREATMENT
Indication for surgery:
- failure of conservative management
- tender, irreducible hernia
-strangulation
Type of surgery depends upon the nature of the
cause.
Laprotomy is usually done
Decompression of obstruction ( by repair of hernia,
complete lysis of adhesion)
BY:
ROMMEL
LUIS
C.
ISRAEL
III
201

Surgical treatment
• Operative decompression required-
• if dilatation of bowel loops prevent exposure, if bowel
wall viability is compromised, or if subsequent closure
will be compromised.
Savage’s decompressor used within seromuscular
purse-string suture.
Or large-bore NG tube maybe used for milking intestinal
contents into stomach.
BY:
ROMMEL
LUIS
C.
ISRAEL
III
202

SURGICAL TREATMENT
*Once obstruction relieved, the bowel is inspected for
viability, and if non-viable, resection is required.
Indication of non-viability
1.absent peristalsis
2.loss of normal shine
3.loss of pulsation in mesentry
3.green or black color of bowel
BY:
ROMMEL
LUIS
C.
ISRAEL
III
203

SURGICAL TREATMENT
� If in doubt of viability, bowel is wrapped in hot
packs for 10 minutes with increased oxygen and
reassessed for viability.
� Sometimes a second look laprotomy is required in
24-48 hours e.g. multiple ischemic areas.
� Right sided large bowel lesion is treated by right
hemicolectomy with covering colostomy
BY:
ROMMEL
LUIS
C.
ISRAEL
III
204

Prognosis
BY:
ROMMEL
LUIS
C.
ISRAEL
III
205
Simple small bowel obstruction
has a very low mortality rate but
increases in case of strangulation
Reaches up to 15% in case of
large bowel obstruction mainly
due to perforation

NURSING MANAGEMENT-GASTROINTESTINAL TRACT DYSFUNCTION

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