PERITONITIS, APPENDICITIS, DIVERTICULAR DIEASE, BOWEL OBSTRUCTION

Medical Management of *Bowel Obstruction*

*(1)* MAINTAIN F & E BALANCE > presence of NG tube puts pt @ BIG risk of fluid imbalance > IV fluids, K+ replacement *(2)* NG tube -> decompression of bowel *(3)* Surgical Intervention - IF bowel is completely obstructed with strangulation - colonoscopy to untwist and decompress large bowel

Medical Management of *Peritonitis*?

*(1)* MAJOR FOCUS: fluid, colloid and electrolyte replacement > admin of isotonic solution *(2)* Pain & Antiemetics Medications *(3)* Oxygen Therapy > b/c pressure of fluid in abd cavity can restrict lung expansion *(4)* Antibiotic therapy *(5)* Drain fluid or abscess *(6)* NG suction

Clinical Manifestations of *Diverticulitis* Acute complications Chronic complications

*(1)* Mild to severe LLQ pain. *(2)* Change in Bowel Habits > constipation w/ nausea *(3)* Fever & Elevated WBC and sedimentation rate ACUTE COMPLICATIONS - abscess formation w/ palpable mass, fever - massive rectal bleeding (due to erosion) - peritonitis - Septicemia and shock if untreated. CHRONIC COMPLICATIONS - due to recurrent episodes of diverticulitis - fistula formation b/t colon and bladder

What are the surgical objectives for *peritonitis*? post op care and complications

*(1)* Removing infected material *(2)* Correcting cause like perforation *POST-OP CARE* - monitor and record amount and character of drainage - monitor incision *COMPLICATIONS* - abscess formation - *Wound Dehiscence*: sutured wound opens up > feels like something just gave way > sudden serosanguineous wound drainage

Assessment & Diagnostic Findings for *Diverticulosis & Diverticulitis*

*DIVERTICULOSIS* - diagnosed by colonscopy - lab test assist like CBC *DIVERTICULITIS* - abd CT scan w/ contrast agent is TEST OF CHOICE - can reveal perforation and abscesses

Assessment and Diagnostic Findings of *Small Bowel Obstruction* hx assessment diagnostics

*HISTORY* •recent abd surgery • bowel hx *PHYSICAL ASSESSMENT* •Bowel sounds absent •Abd tenderness •Distention *DIAGNOSTICS* •X-ray •CT - find abnormal quantities of gas or fluid

Mechanical vs functional intestinal obstruction cause

*MECHANICAL* - GI contents cannot pass because lumen is blocked - due to pressure on intestinal walls - CAUSE: > adhesions after surgery > hernias > tumors > carcinoma > volvulus > foreign bodies *FUNCTIONAL* -result from an inability of the intestinal musculature to move the contents through the bowel - can lead to paralytic ileus - CAUSE: > abd surgery > peritonitis > diabetes

Explain peritonits categorization Primary Secondary Teritary

*PRIMARY* - spontaneous bacterial peritonitis (SBP) - occurs as spontaneous bacterial infection of ascitic fluid *SECONDARY* - perforation of abd organs with spillage -> infects serous peritoneum - mostly due to perforated peptic ulcer, appendix, or sigmoid *TERTIARY* -results of a suprainfection in a patient who is immunocompromised

What is *diverticular disease*? diverticulum (common in) diverticulosis (risk factor) diverticulitis

- *Diverticulum*: saclike pouch of mucosa and submucosa that protrudes through the muscular layer of the colon > commonly in colon - *Diverticulosis*: presence of multiple diverticula w/o inflammation or symptoms - RISK FACTOR: > low intake of dietary fiber > obesity, smoking, NSAID - *Diverticulitis*: diverticulum becomes inflamed -> perforation and potential complications (obstruction, peritonitis, hemorrhage)

Pathophysiology of *Diverticular Disease* why does diverticula form? how can it lead to inflammation? how does perforation occurs?

- DIVERTICULA form under > high intraluminal pressure > low volume in colon > decreased colon muscle strength - when bowel contents accumulate in diverticulum -> decompose -> inflammation and infection - diverticulum also become obstructed - weakened colonic wall of the diverticulum can cause it to perforate -> diverticulitis - abscess may develop -> peritonitis and erosion of arterial blood vessels

Treatment of *Appendicitis* post op place patient in ____ monitor patient discharge if

- IMMEDIATE SURGICAL REMOVAL - abx and IV fluids given while surgery performed *POST-OP* - place patient in HIGH FOWLER - educate patient on use of incentive spirometer - provide parenteral opioid - montor bowel sounds and urine output - educate patient to avoid heavy lifting -patient may be discharged on the day of surgery if the temp is within normal limits

Clinical Manifestations of *Small Bowel Obstruction*

- INITIAL: crampy pain that is wave like and cockily - peristalsis waves assume a reverse direction -> VOMITING - first vomit stomach contents -> then bile stained contents of duodenum - UNABLE to pass flatus - dehydration with s/s > thirst > drowsiness > aching > parched tongue - abdomen distended - more distended as obstruction gets lower in GI tract - vomiting -> dehydration can lead to hypovolemic shock -> acidosis - CAN CAUSE SERIOUS COMPLICATIONS -> perforation

What is *appendicitis*? cause patho

- appendix cannot empty efficiently with its small lumen -> prone to obstruction and infection - appendix fills with products of digestion and empties into cecum - common reason for emergency abd surgery *PATHO* - appendix becomes inflamed and edematous - increased intraluminal pressure -> edema and obstruction of orifice - once obstructed -> appendix can eventually become perforated or gangrene

Nursing Management of *Peritonitis*

- assess abdomen - placement of NG tube for gastric decompression - mouth and nose care - Strict I & O, daily weights - VS q 4 hours - nutritional support either NPO or TPN - change position to side with knees flex -> reduce tension -> reduce pain - abx per orders

What are the signs indicating that *peritonitis* is subsiding? then nurse would

- decrease in temp - decrease in pulse - softening of abdomen - return of peristalsis - bowel movements with passing o f flatus - nurse would then increase fluid and food intake gradually

Assessment and Diagnostic Findings of *Peritonitis*?

- elevated WBC - altered levels of K, NA, Cl - hypovolemia - abd X-ray may show air and fluid levels & distended bowl loops - ultrasound may reveal abscesses (localized collection of pus surrounded by inflamed tissues)

What are the major complications of *appendicitis*?

- gangrene - perforation of the appendix - can lead to peritonitis, abscess formation, or septic thrombosis of portal vein -

Medical Management of *Diverticular Disease* guided by tx of uncomplicated diverticulitis tx of complicated diverticulitis

- guided by the presence of complications - NO LAXATIVES *UNCOMPLICATED DIVERTICULITIS* - diet and medication in outpatient basis - rest, oral fluids, and analgesics recommended - initial, clear liquid diet till inflammation subsides - then high-fiber, low fat diet - abx prescribed for 7-10 days *COMPLICATED* - require hospitalization esp in those who are older, immunocompromised, use corticosteroids - NPO with IV fluid admin - NG suctioning - low-fiber diet may be needed until signs of infection decrease - fluid intake of 2L/day - refrain from any activity > can increases intra-abdominal pressure > this can result in the perforation of the diverticula

What is *peritonitis*? cause

- inflammation of the peritoneum, a serous membrane lining the abd cavity - result of bacterial infection usually due to E. coli - can also be due to external sources > abdominal surgery or trauma

Clinical Manifestations of *peritonitis*? Complications

- initially diffuse pain - then pain becomes severe, constant, localized, and more intense over disease progression - aggravated with movement. - rebound tenderness present & distention - paralytic ileus may be present. - diminished peristalsis - temp 100 to 101 Degrees F *COMPLICATIONS* - inflammatory process can obstruct intestine -> cause shock - sepsis

Pathophysiology of *Small Bowel Obstruction* how does obstruction occur distention

- intestinal contents, fluid, & gas buildup close to obstruction - the abd distention and retention of fluid in lumen -> decrease in absorption of fluid - pressure within lumen increases w/ increasing distension -> decrease venous and arteriolar prezsure - edema, congestion necrosis, and eventual rupture

What is the pathophysiology of *2ndary peritonitis*?

- leakage of contents from abd organs into abdominal cavity b/c of inflammation, infection, ischemia - fluid in peritoneal becomes clouded -> bacterial proliferation -> distended abdomen - IMMEDIATE RESPONSE is hypermobility - followed by paralytic ileus with buildup of air and fluid in bowel

What is *paralytic ileus*? cause assessment

- obstruction of the intestine due to paralysis of the intestinal muscles - muscle or nerve problems disrupt normal peristalsis -> stop movement of food and fluid throughout digestive system - lack of peristalsis -> paralysis -> functional blockage of the intestine - *CAUSE*: > surgery (most often) > use of narcotic pain meds > peritonitis (IMMEDIATE RESPONSE) - ABSENT BOWEL SOUNDS

Clinical Manifestations of *Paralytic Ileus*

- pain - N/V b/c fluids cannot go down GI tract -> come back up - Diarrhea first if lower obstruction - NO STOOL/FLATUS - absent bowel sounds - excess fluid and air in abdomen

Assess for S/S of Bowel perforation

- rectal bleeding - SUDDEN onset of abd pain -> worsen suddenly - cramping - abd distention - fever - rebound, RIGIDITY, guarding tenderness - ↑HR, ↓ BP

What is *Intestinal Obstruction*? common in in large intestine common in __ colon type

- when blockage prevents the normal flow of intestinal contents through the intestinal tract - can be partial or complete - occurs mainly in small intestine due to adhesions commonly - most large bowel obstruction occurs in sigmoid due to > adenocarcinoma > diverticulitis > IBS - mechanical and functional

Clinical Manifestations of *Appendicitis*

1. Rebound tenderness @ McBurney's point 2. N/V 3. Low grade fever 4. Periumbilical pain 5. Elevated WBC count 6. Constipation > DO NOT GIVE LAXATIVES

What is *Hinchey Classification*?

used as simple staging system to determine the severity of acute diverticulitis.