Lower Gastrointestinal Problems

Zoya MinasyanRN, MSN-Edu

Colorectal Cancer

• Third most common form of cancer• More common in men• Risk factors

– Family or personal history of colorectal cancer– Increased age – Colorectal polyps– Lifestyle factors

• Obesity• Smoking• Alcohol• Large amounts of red meat

Etiology and PathophysiologyTumors spread through the walls of the colon into musculature and into the lymphatic and

vascular system.

Etiology and Pathophysiology

• Most common sites of metastasis– Regional lymph nodes– Liver– Lungs– Bones– Brain

• Usually nonspecific, do not appear until advanced.

Diagnostic Studies• Colonoscopy

– Entire colon is examined.– Biopsies can be obtained.– Polyps can be immediately removed and sent to the laboratory for

examination.• Colonoscopy and tissue biopsies confirm diagnosis.• Additional laboratory studies must be done.

– CBC– Liver function tests

• CT scan or MRI in detecting • Liver metastases• Depth of penetration of tumor in bowel wall

• Surgical therapy– Surgery is the only cure.

Inflammatory Bowel Disease

• Characterized by chronic, recurrent inflammation of the intestinal tract– Periods of remission interspersed and

exacerbation • Ulcerative colitis: Inflammation and ulceration

of the colon and rectum• Crohn’s disease: Inflammation of segments of

the GI tract

Acute Ulcerative Colitis

Comparison of distribution patterns of Crohn’s disease and ulcerative colitis, as well as different conformations of ulcers and wall thickenings.

Ulcerative ColitisEtiology and Pathophysiology

• Multiple abscesses develop in the intestinal glands.• Abscesses break through into the submucosa,

leaving ulcerations. • Ulcerations destroy the mucosal epithelium,

causing bleeding and diarrhea. • Fluid and electrolyte losses• Protein loss

Crohn’s Disease Description

• A chronic, nonspecific inflammatory bowel disorder of unknown origin • Can affect any part of the GI tract from the mouth to the anus• Most often seen in the terminal ileum and colon• Inflammation involves all layers of the bowel wall. • Segments of normal bowel occurring between diseased portions• Ulcerations are deep and longitudinal.• Ulcerations penetrate between islands of inflamed edematous mucosa,

causing the classic cobblestone appearance. • Narrowing of the lumen with stricture development

– May cause bowel obstruction• Microscopic leaks can allow bowel contents into peritoneal cavity. Peritonitis

may develop.• Abscesses or fistulous tracts that communicate with other loops of bowel,

skin, bladder, rectum, or vagina may occur.

Inflammatory Bowel DiseaseClinical Manifestations

• Chronic disorder with mild to severe acute exacerbations • May occur at unpredictable intervals over many years• Nonspecific complaints

– Diarrhea– Bloody stool– Fatigue– Abdominal pain– Weight loss– Fever

• Major symptoms– Bloody diarrhea – Abdominal pain

Crohn’s DiseaseClinical Manifestations

• Main manifestations– Diarrhea– abdominal pain

• Weight loss may occur if small intestine is involved.

Inflammatory Bowel Disease Complications

• Complications may be classified as– Intestinal (localized to GI tract)– Extraintestinal (systemic)

Ulcerative Colitis: Complications

• GI complications – Hemorrhage– Strictures– Perforation (with possible peritonitis)– Fistulae– Toxic megacolon

• Dilation and paralysis of the colon• Associated with perforation• May need emergency colectomy

Crohn’s Disease: Complications

• Extraintestinal– Thromboembolism– Arthritis– Eye inflammation– Kidney stones– Gallstones– Skin lesions

Diagnostic Studies• History and physical examination• Blood studies

– CBC– Serum electrolyte levels– Serum protein levels

• Stool cultures– Pus– Blood– Mucus

• Sigmoidoscopy and colonoscopy– Biopsy specimens

• Double-contrast barium enema• Capsule endoscopy

Collaborative Care• Goals of treatment

– Rest the bowel.– Control inflammation.– Combat infection.– Correct malnutrition. – Alleviate stress.– Relieve symptoms.– Improve quality of life.

• Drug therapy– Aminosalicylates– Antimicrobials– Corticosteroids– Immunosuppressants– Biologic and targeted therapies

Irritable Bowel Syndrome (IBS)Description

• Characterized by intermittent and recurrent abdominal pain and stool pattern irregularities

• Symptoms– Alternating diarrhea/constipation– Abdominal distention– Excessive flatulence– Bloating– Continual defecation urge, urgency – Sensation of incomplete evacuation– Fatigue– Sleep disturbances

• Common in patients with IBS– Anxiety, panic disorder– Depression– Posttraumatic stress disorder– Abuse history

Treatments

•Education and reassurance •Relaxation•Stress management techniques•Alternative therapies •Eliminate gas-producing foods.

– Brown beans– Brussel sprouts, cabbage, cauliflower, raw onions– Grapes, plums, raisins– Determine if lactose intolerant.

Drug Therapy: Antispasmodics• Anticholinergics

– Dicyclomine (Bentyl)– Reduce colonic motility after meals.– Take before meals.– Side effects

• Dry mouth, urinary retention, tachycardia • Loperamide (Imodium)

– Decreases intestinal transit– Enhances intestinal water absorption and sphincter tone

• 5-HT3 receptor blockers – ↓ Urgency, pain, and diarrhea in diarrhea-prominent women– Alosetron (Lotronex)

• FDA approved for women only• Must be monitored because of potential side effects

Diarrhea

• Diarrhea is the passage of at least three loose or liquid stools per day. It may be acute or chronic, and is chronic if it lasts longer than 4 weeks

• Some organisms such as E. coli, Rotavirus, Clostridium difficile, can impair the absorption, damage the intestines directly or produce toxins.

Constipation

• Normal BM frequency varies from 3 BM daily to BM every 3 days

• Constipation is decrease in frequency of BM from what is normal for the individual

• Common cause– Insufficient diet fiber– Inadequate fluid intake– Decreased physical activity– Ignoring the defecation urge

Constipation and Diarrhea• Constipation – bowel movements that are infrequent, hard or dry, and

difficult to pass.• Diarrhea – increased number of loose liquid stools.• Causes of Constipation: - Frequent use of Laxatives - Advance age - Inadequate fluid intake - Inadequate fiber intake - Immobilization due to injury - A sedentary lifestyle• Causes of Diarrhea: - Viral Gastroenteritis - Overuse of laxatives/laxative abuse - Use of certain antibiotics - Inflammatory bowel disease (Cronh’s disease – subacute, chronic

inflammation extending throughout the entire intestinal mucosa (Terminal Ileum).

Diagnostic Procedures • Fecal Occult Blood Test ( OB) – fecal sample is obtained using

a medical aseptic technique and wearing disposable gloves. e.g. Hemoccult slide test and record result.

Certain food like red meat, raw vegetable and medication (aspirin, NSAIDS) can cause false positive. Bleeding can be a sign of CANCER (others include anal fissures, hemorrhoids, inflammatory bowel disease, malignant tumor, peptic ulcer) which can be contributing factor to constipation.

An early sign of colon cancer is rectal bleeding. Encourage client

50 years of age and older and those with increased risk factor to be screen with FOBT yearly and Routine Colonoscopy at 50.

Clinical Manifestation of GI Bleeding• Pallor: conjunctiva, mucous membranes, nail beds, Dark tarry stools ( Peptic Ulcer due to mixture of gastric acid and the blood) Macroscopic Bright –red (constipation, bleeding from anal fissure or sigmoid area). Abdominal mass or bruit Decreased BP, rapid pulse, cool ext. (s/s of shock)• Stress can cause or exacerbate ULCERS. Teach client on

stress-reduction methods and encourage those with family of ULCERS to obtain medical survillance for ulcer formation.

Diagnostic Procedures• Digital Rectal Examination – Checks for

impaction. Client position on the left side with knee flex. Client V/S and response should be monitored.

• Stool Cultures – obtaining fecal samples using a medical aseptic technique. Specimen should be labeled promptly sent to the laboratory. Intestinal bacteria can be a contributing factor for diarrhea.

Signs and Symptoms/Nursing Assessments

• Constipation: - Abdominal bloating - Abdominal cramping - Straining at defecation• Diarrhea: - s/s of dehydration - Frequent loose stools - Abdominal crampingNursing Assessments:• PE of the abdomen for BS and tenderness (auscultate before palpation).• S/S of fluid deficit• Skin integrity around the anal area• Collection of detailed history of the client’s diet, exercise, and bowel

habits.

NANDA Nursing Diagnosis (Constipation and Diarrhea)

• Constipation• Diarrhea• Fluid Volume Deficit• Impaired skin integrity

Nursing Interventions (Constipation and Diarrhea)

• Closely monitor client fluid status (D)• Monitor for client s/s of dehydration (D)• Closely monitor elimination pattern ( C) and (D)• Observe and document the character of BM ( C) and (D)• Carefully check for blood or pus. If the client is experiencing

diarrhea, measure the volume of the stool. (D)• Administer laxatives or enemas as prescribed ( C)• Encourage adequate fluid intake ( C)• Monitor skin integrity ( D)• Suggest that client’s who are taking ATB to eat yogurt to help

re-establish an intestinal balance of beneficial bacteria.

Complications

• Constipation: - Fecal Impaction - Development of hemorrhoids and/or rectal fissure - Bradycardia, hypotension, and syncope associated with the Valsalva Maneuver (bearing down) stimulation of Vagus Nerve.. - Monitor constipation carefully and take measures to treat and prevent constipation - Removing fecal impaction. Break apart the impact slowly. Monitor V/S and response. Preceded by

application of glycerin or Bisacodyl (Dulcolax supp.)

Complications• Diarrhea: - Dehydration. Monitor for s/s of fluid and electrolyte imbalance. Monitor for metabolic

acidosis cause by excessive loss of bicarbonate. - Skin breakdown around the anal area. Carefully follow skin protocol. - Replace losses as prescribed.

Replacing Fluids and Electrolytes• Drinking fluids is important during bouts of diarrhea to prevent dehydration, which is the

loss of vital fluids and electrolytes (sodium and potassium). Proper hydration is especially important in children with diarrhea because they can die from dehydration within a couple of days.

• Although water is extremely important in preventing dehydration, it does not contain electrolytes.

• Good choices to help maintain electrolyte levels include broth or soups (which contain sodium) and certain fruit juices, soft fruits, or vegetables (which contain potassium).

• For children, often recommend a special rehydration solution that contains the nutrients they need. You can buy this solution without a prescription.

• Examples of rehydration solutions include Pedialyte®, CeraLyte®, and Infalyte®.

Older Adults• Older adults clients are more susceptible to developing

constipation as bowel tone decreases with age and more at risk for developing fecal impaction.

• Adequate fluid and fiber intake and exercise are important. Instruct proper diet.

Vegetables, fruits (especially dried fruits), and some cereals (whole wheat, bran, or oatmeal) are excellent sources of fiber. It is easy to remember that the harder a vegetable is (like celery), the more fiber it has. To reap the benefits of fiber, it is very important to drink an adequate amount of water to help with the passage of stool in the intestines.

Hemorrhoids• Hemorrhoids are dilated hemorrhoidal veins.

– Internal: occurring above the internal sphincter– External: occurring outside the external sphincterAre the most common reason for bleeding with defecation, can lead to

iron deficiency anemiaPrecipitated factors: pregnancy, constipation, prolonged standing and

sitting, portal HTN (ex: cirrhosis)Collaborative care: digital exam, anoscopy, sigmoidiscopy,Rubber band ligation is the most common technique. The rubber band

around the hemorrhoid constricts the circulation, tissue become necrotic, separates and sloughs off.

Cryotherapy-rapid freezing of the hemorrhoid. Less often used- b/c of acute pain.

A warm sitz bath provides comfort and keeps are cleanStool softner- docusate (Colace)

Ostomy

• An Ostomy is a surgical procedure that allows intestinal content to pass from the bowel through an opening in the skin on the abdomen.

• The intestinal contents will empty through the hole on the surface of the abdomen instead of the abdomen rather that being eliminated through the anus.

• Ileostomy, ascending, transverse and sigmoid colostomy ( Lewis, 8th edition, table 43-27, page 1040)

• Pre and post operative care and patient teaching ; ostomy self care.