Chapter 47 Sections on irritable bowel syndrome, appendicitis, diverticular Disease, and inflammatory bowel disease [recorded the rest of IBD]

Clinical manifestations of appendicitis

Vague periumbilical pain [visceral pain that is dull and poorly localized] with anorexia progresses to right lower quadrant pain[ie parietal pain that is sharp, discrete, and well localized, and nausea Low grade fever may be present Local tenderness may be elicited at McBurney point when pressure is applied Rebound tenderness may be present Rovsign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt on the right lower quadrant If the appendix has ruptured, the pain becomes consistent with peritonitis, abdominal distention develops as a result of paralytic ileus, and the patient's condition worsens

Immediate surgical intervention is necessary if complications

[perforation, peritonitis, hemorrhage, obstruction] occur ***Hinchey stage III or IV are considered surgical candidates

Diverticular Disease

A diverticulum is a saclike herniation of the lining of the bowel that extends through a defect in the muscle layer Diverticula may occur anywhere in the GI tract, from the esophagus to the colon, but most commonly in the colon, particularly in the sigmoid colon ***Asians may develop diverticula in the right colon probably because of genetic differences

Probiotics that include Lactobacillus and Bifidobacterium can be given to help decrease

Abdominal bloating and gas

Bentyl (dicyclomine) is used in all types of IBS to relieve

Abdominal pain

Antidepressants used to treat the underlying anxiety and depression

Antidepressants may affect serotonin levels, thus modulating intestinal transit time and improving abdominal discomfort

A complex interplay of genetic, environmental, and psychosocial factors

Are thought to be associated with the onset of irritable bowel syndrome Results from a functional disorder of intestinal motility The change in motility may be related to neuroendocrine dysregulation, especially changes in serotonin signaling, infection, or a vascular or metabolic disturbance

Medical management of appendicitis

immediate surgery is often indicated conservative nonsurgical medical management for uncomplicated appendicitis [absence of gangrene or perforation of the appendix, empyema or abscess formation, or peritonitis] IV fluids and antibiotics are given until surgery is performed Appendectomy is performed as soon as possible to decrease risk of peritonitis by laparoscopy or laparatomy For complicated appendicitis the patient is treated with a 3 to 5 day course of antibiotics postoperatively In patients with abscess formation that involves the cecum and or terminal ileum, appendectomy is deferred until the mass is drained and no evidence of infection is present

Hartmann's procedure

1. proximal colostomy 2. distal stapled-off colon or rectum that is left in peritoneal cavity

Nursing management [diverticulitis]

2 liters per day of fluid intake unless contraindicated [renal or cardiac issues] Soft foods that are high in fiber [prepared cereals or soft cooked vegetables An individualized exercise program to improve abdominal muscle tone Daily intake of bulk laxatives such as psyllium, which help propel feces from through the colon Avoid trigger foods such as popcorn or nuts

Types of foods than can act as irritants include

Beans, caffeinated products, dairy lactose, wheat, fried foods, alcohol, spicy foods, aspartame

Recording the quality and quantity of bowel movements in a stool diary such as

Bristol stool form scale can be useful in determining the category of IBS

Laboratory tests that assist in diagnosis of diverticulitis include a

CBC [elevated WBC] Hemoglobin level if frank blood is present in stool Urinalysis and urine cultures if colovesicular fistula is suspected Abdominal CT scan with contrast Abdominal x-rays The Hinchey classification is used as a guide to determine treatment

The following triggers are believed to either herald the onset of IBS or exacerbate symptoms

Chronic stress Sleep deprivation Surgery Infections Diverticulitis Some foods [eggs, milk, yeast products and wheat products

Diverticulosis is typically diagnosed by

Colonoscopy

The main symptom is an alteration in bowel patterns

Constipation [IBS-C] Diarrhea [IBS-D] Both [IBS-M] for mixed

The goal of management for IBS are to relieve

Diarrhea and constipation ***lifestyle modification including stress reduction, ensuring adequate sleep, and instituting a workout regimen can result in symptom improvement

Peppermint oil has been proven effective in

Diminishing abdominal pain [IBS]

Assessment and diagnostic findings [appendicitis]

Elevated WBC with an elevated of neutrophils C-reactive protein [CRP] elevated CT scan may reveal a right lower quadrant density, or localized distention of the bowel Enlargement of the appendix by at least 6 mm ***a pregnancy test in women to rule out ectopic pregnancy Urinalysis to rule out UTI Laparoscopy to rule out acute appendicitis in equivocal cases

IBS occurs concomitant with other disorders including

GERD, chronic fatigue syndrome, chronic pelvic pain, fibromyalgia, interstitial cystitis, migraine headaches, anxiety, and depression

Complications of appendicitis

Gangrene or perforation of the appendix, which can lead to peritonitis, abscess formation, or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines ***Perforation generally occurs within 6 to 24 hrs after the onset of pain and leads to peritonitis

Nursing management of appendicitis

Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, preventing or treating surgical site infection, preventing atelectasis, maintaining skin integrity, and attaining optimal nutrition After surgery the patient is placed in a high Fowler position to reduce the tension on the incision and abdominal organs, helping to reduce pain; it also promotes thoracic expansion, diminishing the work of breathing, and decreasing the likelihood of atelectasis [use of incentive spirometer every 2 hrs while awake] Parenteral opioids [eg Morphine] for pain until the patient is able to tolerate oral fluids and food Auscultation for bowel sounds and passage of flatus before food is offered on the day of surgery [post] Urine output is monitored The patient is encouraged to ambulate on the day of surgery to reduce risks of VTE and atelectasis Removal of wound and removal of sutures in 1 to 2 weeks Patients with surgery done by laparoscopy may be discharged on the day of surgery if no complications are present Secondary abscesses may form in the pelvis, under the diaphragm or in the liver causing elevation of the temperature, pulse rate and white blood cell count

In acute cases of diverticulitis with significant symptoms

Hospitalization is required [also indicated for the older, the immunocompromised or those taking corticosteroids] Oral intake is withheld, IV fluids and institution of NG suctioning if vomiting or distention occurs [used to rest the bowel] Broad spectrum antibiotics [Unasyn, Timentin] are prescribed Opioids or other analgesics for pain Increase oral intake as symptoms subside A low fiber diet until signs of infection decrease

Results of CBC and C-reactive protein or fecal calprotein are used to differentiate

IBS from IBD

Antidiarrheals [eg Imodium] may be used in patients with

IBS- D to control diarrhea and fecal urgency

Amitiza (Lubiprostone) may be prescribed for

IBS-C

The patients who do not fit the above classifications are classified as

IBS-U for unknown

Irritable bowel syndrome [IBS]

Is a chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation or both

Irritable bowel syndrome [IBS] [Maternity]

Is a functional bowel disorder that typically causes symptoms of abdominal pain and altered bowel habits with no underlying organic cause It may be either constipation or diarrhea predominant or there may be a mixed picture The onset of loose stool can follow an infection and may be due to an alteration in the intestinal flora Other studies have looked at intestinal bacterial overgrowth, food sensitivities, visceral hyperalgesia [heightened sensitivity to bowel distention], and psychosocial factors Antidepressants, anticholinergics, and antibiotics that work to reduce bacteria in the gut such as rifaximin may be prescribed to treat the symptoms of IBS

Inflammatory bowel disease

Is a group of chronic disorders: Crohn's disease [regional enteritis] and Ulcerative colitis [results in inflammation or ulceration or both of the bowel Family history predisposes people to IBD Being a Caucasian of Ashkenazi Jewish descent, living in a northern climate, living in an urban area Men -higher risk for ulcerative colitis Women -higher risk for Crohn's disease Current smokers -at risk for Crohn's disease Non smokers and ex smokers - Ulcerative colitis

Diverticulosis

Is defined by the presence of multiple diverticula without inflammation or symptoms Most common pathological incidental finding on colonoscopy A low intake of dietary fiber , obesity, a history of cigarette smoking, regular use of NSAIDs and acetaminophen, positive family history are risk factors Chronic constipation precedes development of diverticulosis by many years Mild or no problematic signs and symptoms with diverticulosis

Treatment for patients with uncomplicated diverticulitis or with Hinchey stage 1 diverticulitis

Is on outpatient basis with diet and medication Rest, oral fluids and medications are recommended Clear liquid diet until inflammation subsides; the a low fat, high fiber diet [helps increase stool volume, decrease colonic transit time, and reduce intraluminal pressure Antibiotics for 7 to 10 [no evidence of improved outcomes]

Severe IBS-D may be treated with

Lotronex [slows colonic motility] Xifaxan Viberzi, Allegan

When a patient develops symptoms of diverticulitis

Microperforation of the colon has occurred

Diverticulitis

Occurs when a diverticulum becomes inflamed, causing perforation and potential complications such as obstruction, abscess, fistula [abnormal tract] formation, peritonitis, and hemorrhage Acute onset of mild to severe pain in the left lower quadrant, may be accompanied by constipation, with nausea, fever, and leukocytosis Acute complications of diverticulitis may include abscess formation [tenderness, palpable mass, fever, and leukocytosis], bleeding and peritonitis Inflamed diverticula may erode areas adjacent to arterial branches, causing massive rectal bleeding; may perforate causing pain over the involved colon segment usually the sigmoid, local abscess or peritonitis follows Recurrent episodes of diverticulitis may cause fistula formation including colovesicular fistulas [between the colon and the bladder] and in women colovaginal fistula; colon may narrow with scar tissue and fibrotic strictures leading to narrow stools, increased constipation or intestinal obstruction

Two types of surgery either to treat acute complications or prevent further episodes of inflammation

One stage resection, in which the inflamed area is removed and a primary end to end anastomosis is completed Multi-stage procedures for complications such as obstruction or perforation [Hartmann procedure]

Symptoms of IBS include

Pain, bloating, abdominal distention, changes in bowel pattern ***abdominal pain is precipitated by eating and relieved by defecation

Hinchey classification

Stage I - Localized pericolic or mesenteric abscess Stage II - Walled-off pelvic abscess Stage III - Generalized purulent peritonitis Stage IV - Generalized fecal peritonitis I and II: preopp bowel reg then primary anastomosis is performed. III and IV: primary anastomosis is contraindicated. The preferred surgical treatment is a Hartmann's procedure with end colostomy

Appendicitis

The appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith [ie hardened mass of stool]; lymphoid hyperplasia [secondary to inflammation or infection] or rarely foreign bodies [fruit seeds] or tumors The inflammatory process increases intraluminal pressure, causing edema and obstruction of the orifice; once obstructed the appendix becomes ischemic, bacterial overgrowth occurs, and eventually gangrene or perforation occurs

Gerontological considerations [appendicitis]

The incidence of complications is higher in older adults because many of these patients do not seek healthcare as quickly as younger patients