GI - UC, Crohns and GI Bleeds

What is the treatment for peritonitis?

-NPO with NG to suction (decompression) -IV fluids and electrolytes -IV antibiotics (the strong ones!) -Analgesics (Morphine, meperidine (Demerol)) -Antiemetics -Surgical closure of perforation

What is a major symptom of chronic pancreatitis?

A.Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting Chronic pancreatitis has recurrent attacks of severe upper abdominal and back pain accompanied by vomiting. Acute pancreatitis presents with fever, jaundice, confusion, agitation, ecchymosis in the flank or umbilical area, and abdominal guarding

What is pancreatitis?

Auto digestion of the Pancreas

What are the tx for pancreatitis?

Control Pain Control fluid/blood loss Biliary drains (severe) Nutrition ◦Keep patient NPO ◦Low calorie diet Monitor for complications

What are the complications for pancreatitis?

Fluid & electrolyte disturbances Pancreatic necrosis Shock MODS

What is peritonitis?

Inflammation of the lining of the abdominal cavity

What is referred to as spastic colon, mucous colon, or nervous colon?

Irritable bowl syndrome

What is toxic colon?

Tons of inflammation (wide spread abd. pain and extension), colon cannot work.

Peritonitis can lead to sepsis (t/f).

True. It's emergent!

What causes peritonitis?

Typically caused by bacterial infection either via the blood or after rupture of an abdominal organ.

What are the two most common inflammatory bowel diseases?

Ulcerative Colitis Crohn's Disease Do not confuse the IBD's with IBS (irritable bowel syndrome)

Can skip lesions seen on an x-ray?

Yes

Crohn's disease has recurrent with remissions and exacerbations?

Yes

Irritable bowel syndrome is the most common digestive disorder?

Yes

Is Crohn's disease slowly progressive and unpredictable?

Yes

What are the s/s of peritonitis?

ab pain - severe ridigitdy, distension increased temp and leukocytosis, increased pulse, increased BP, decreased bowel sounds, rebound tenderness, N&V, anorexia

What is chronic pancreatitis?

progressive inflammatory disorder with destruction of the pancreas; cells are replaced by fibrous tissue; pressure within the pancreas increases, obstructing the pancreatic and common bile ducts

What is acute pancreatitis?

pancreatic duct becomes obstructed (gallstone), and enzymes back up, causing autodigestion and inflammation of the pancreas. Can also be from acute intoxication

What is the cause of Crohn's disease?

unknown

What is the cause of IBS?

unknown

What is the cause of ulcerative colitis?

unknown

What are the history assessment questions for IBS?

•Ask about weight changes, fatigue, malaise, abdominal pain •Ask about changes in bowel patterns (constipation, diarrhea, or an alternating pattern of both; consistency, color, and odor of stools) •Ask about any GI infections •Gather information on nutritional history (caffeinated beverages, alcohol) •Ask about other triggers (stress, anxiety, food intolerances)

What are the s/s for IBS?

•Abdominal pain relieved by defecation (LLQ) •Nausea associated with mealtimes and defecation •Fatigue and malaise •Erratic bowel patterns (alternating b/w diarrhea and constipation or mix of both) •Abdominal distention •Mucus present in stool •Colicky abdomen and tenderness (LLQ) •Weight loss (not usual with IBS) •Belching, gas

What are the complementary tx for IBS?

•Acupuncture •Herbs (peppermint oil, caraway, artichoke leaf) •Stress management •Meditation •Yoga

What are the medications for ulcerative colitis?

•Aminosalicylates - decrease inflammation (TX mild to moderate UC) •Sulfasalazine (Azulfidine) - check for sulfa allergy •Mesalamine (Asacol) - better tolerated •Corticosteroids (TX during exacerbations) •Prednisone (Deltasone) •Antidiarrheals (monitor for toxic megacolon) •Atropine Sulfate (Lomotil); Loperamide (Imodium) •Immune system suppressors •Infliximab (Remicade); Adalimumab (Humira)

What are the risk factors for a GI bleed?

•Bleeding disorders (some more than other) •Excessive alcohol use •Long-term use of steroids, blood-thinning medication, nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin •Smoking •Prior GI or vascular surgery •History of gastrointestinal disease or bleeding •History of ulcers •History of bacterial infections, such as Helicobacter pylori

What are the s/s of an upper GI bleed?

•Bright red (undigested blood) or coffee-ground vomit (hematemesis) •Dark, black, tarry stools •Melena (occult blood) •Decreased B/P •Increased weak, thready pulse •Decreased H & H •Vertigo •Dizziness (orthostatic hypotension) •Syncope

What are the IBS medications?

•Bulk-forming agents (Metamucil) •Antidiarrheal agents (Imodium) •Antibiotic for bloating/distention (Xifaxan) - NOT YET FDA APPROVED FOR IBS •Tricyclic antidepressants for pain (Amitriptyline) •SSRIs (slow GI transit time) ◦Probiotics ◦Antispasmodics ◦*Lubiprostone: chloride channel blocker (for constipation sx) ◦*Alosetron (Lotronex): for diarrhea sx *newer drugs

What are the diagnostic assessments for ulcerative colitis?

•CBC (high, slightly elevated WBC = inflammatory disease) •H&H (may be low d/t chronic blood loss) •CRP or ESR (high = inflammatory disease) •BMET (Na, K+, Ch may be low d/t frequent diarrheal stools and malabsorption - how dehydrated are they determines) •Albumin (low in patients with extensive disease) •CT, barium enemas •Stool cultures •Colonoscopy is the most definitive test for UC

What is irritable bowl syndrome?

•Chronic disorder with recurrent diarrhea, constipation and/or abdominal pain and bloating.

What is Crohn's disease?

•Chronic inflammatory disease affecting the entire intestinal mucosa (cobblestone appearance d/t strictures and deep ulcerations) - causes thickened bowel wall

What are the physical assessment for Crohn's disease?

•Clinical presentation varies greatly from person to person •Perform thorough abdominal assessment (looking for distention, masses, visible peristalsis) •Perform inspection of perianal area (looking for ulcerations, fissures, or fistulas) •Auscultate bowel sounds (may be decreased or absent with severe inflammation/obstruction); (high-pitched or rushing sounds may be present over areas of narrowed bowel loops)

What does Crohn's disease effect?

•GI tract from the mouth to the anus; most common in terminal ileum

What are the diagnostics for GI bleeds?

•Digital rectal exam •Guaiac test (check for occult blood) •Endoscopy (upper GI bleed) •Colonoscopy (lower GI bleed) •Angiography (x-ray of the blood vessels)

What causes lower GI Bleeds?

•Diverticular disease •Gastrointestinal cancers •Inflammatory bowel diseases (IBD) •Infectious diarrhea •Angiodysplasia (abnormal growth of blood vessels in the intestines) •Polyps •Hemorrhoids and anal fissures

What are the IBS nursing interventions?

•Encourage diet high in fiber •Encourage regular exercise (walking/yoga) •Teach stress reduction •Teach regular meal times •Importance of fluid intake but to limit fluids with meals •Patient education is very important •Provide emotional support

What are the contributing factors for irritable bowel syndrome (IBS)?

•Environmental - high fat foods, caffeine, dairy products, smoking, NSAID use •Immunologic - bacterial growth and infection •Genetic - family history •Hormonal - females are 2x as likely to have IBS •Stress - mental or behavioral illness (anxiety, depression)

What are the contributing factors for ulcerative colitis?

•Family history (twins) •Autoimmune dysfunction •Epithelial antibodies in IgG class •Jewish (unknown why) •Middle and older age (30-40 and 55-65y/o) - women are more affected in younger years •Caucasian (unknown why more common)

What are the contributing factors for Crohn's disease?

•Family hx - 10-20% of pts. have + family hx •Jewish ancestry (reason unknown) •Bacterial infection •Tobacco use (reason unknown) •Age 15-40 - diagnosed d/t being symptomatic •Living in urban areas (reason unknown)

What are the history assessment questions for ulcerative colitis?

•Gather all information regarding previous and current flare-ups, precipitating and relieving factors •Nutritional history - intolerance of milk, fried foods, spicy foods •Ask about usual bowel elimination patterns and if there have been changes •Note a relationship between alteration in elimination and timing of meals, emotional distress, activity •Ask about antibiotic exposure (past 2-3 months) •Ask about recent travel to tropical locations

What are the history assessments used for Crohn's disease?

•Gather all information regarding previous and current flare-ups, precipitating and relieving factors •Nutritional history - unintentional weight loss (more common with Crohn's than colitis) •Ask about usual bowel elimination patterns and if there have been changes •Ask about recent bacterial infections

What are GI bleed treatments?

•IV fluids •Blood transfusions •Endoscopic cauterization •Endoscopic band ligation (hemorrhoids & esophageal varices) •Proton pump inhibitors •Vasoconstrictors (reduce bleeding) •Antibiotics if infection is cause •Surgery if necessary

What are the nutritional therapies for ulcerative colitis?

•NPO - ensures bowel rest •TPN - used for severally ill and malnourished pts. •Supplements (protein shakes) •Complementary and alternative therapies (including physical therapy, chiropractor) • Herbs •Biofeedback (for helping with stress) •Hypnosis - High protein, high calorie diets (poor absorption issues) - May need iron supplements - No offensive foods

What are the treatments for IBS?

•Keep a symptom diary •Dietitian consult

What are the s/s of ulcerative colitis (acute)?

•Liquid stools (10-20 per day); contains blood and mucus •Low grade fever (found in more severe cases) •LLQ pain (colicky in nature and relieved with defecation) •Abdominal distention along colon •Anorexia, weight loss, and malaise •Vomiting and dehydration •Sensation of urgent need to defecate (tenesmus) •Hypokalemia, anemia •Associated arthritis, conjunctivitis, skin lesions and/or liver problems •Psychosocial concerns (anxiety, depression) •Rebound tenderness indicates perforation

What are the s/s of a lower GI bleed?

•Maroon stools •Bright red blood per rectum •Melena •Low B/P •Low H & H

What are the nutritional therapy for Crohn's disease?

•NPO - complete bowel rest •TPN - used during severe exacerbations •Supplements (multivitamins, iron, protein shakes) •Avoid GI stimulants - caffeine and alcohol, smoking

What are the nursing interventions for acute ulcerative colitis?

•NPO during acute phases •Monitor fluid status (dry mucus membranes, poor skin turgor, weight loss) •Monitor electrolytes (could be low) •Dietary management (high calorie, high protein, low fiber) •MVI and supplemental FE •Report any s/s of infection, worsening symptoms

What are the causes of upper GI bleeds?

•Peptic ulcers •Gastritis •Esophageal varices •Mallory-Weiss tears - tear in the esophagus lining (violent vomiting) •Gastrointestinal cancers •Inflammation of the gastrointestinal lining from ingested materials

What are the nursing interventions for ulcerative colitis?

•Promote rest •Pain management •Monitor stools (color, volume, frequency, consistency, presence of blood) •Frequently cleanse and monitor skin around the perineal and perianal areas •Educate on ostomy care •Offer emotional support related to body image disturbances

What are the nursing interventions for Crohn's disease?

•Psychological and supportive care •Promote rest •Monitor stools (color, volume, frequency, consistency) •Monitor fluid I & O •Nutritional therapy (high calorie, high protein, low fiber, no dairy - dairy tends to be more of an issue in CD than colitis) •Monitor for complications (obstruction, perianal disease, fluid and electrolyte imbalances, malnutrition, fistulas)

What are the s/s of Crohn's disease?

•RLQ pain is constant; not relieved by BM; pain aggravated with eating • Low grade fever (common with fistulas, abscesses, and severe inflammation) •Diarrhea/steatorrhea (if occurs only in the ileum, diarrhea occurs 5-6 times per day with soft, loose stools, fatty stools) •Weight loss (d/t catabolism) •Fistula formation (common with CD but rare in UC) • Usually no rectal bleeding (rarely bloody stools) •Psychosocial issues (coping, support, depression, anxiety) •Accompanied by arthritis, conjunctivitis, and/or oral lesions

What is ulcerative colitis?

•Recurrent ulcerative and inflammatory disease of superficial mucosa of colon (only in large intestine/colon)

What are surgical treatments for ulcerative colitis?

•Restorative Proctocolectomy with Ileo Pouch-Anal Anastomosis (RPC-IPAA) - has become the gold standard treatment - can be done laparoscopically •Ileostomy placement - be aware of all nursing care involved with this type of treatment, location of ileostomy, complications, output expectations, nutritional considerations, and psychosocial concerns

What are the medications used for Crohn's disease?

•Steroids - use cautiously since they can mask s/s of infection •Anti-infectives •Metronidazole (Flagyl) •Aminosalicylates (turns urine orange, not to be concerned with that education) •Immune Suppressors •Azathiprine (Imuran) & Mercaptopurine (Purinethol) •Monoclonal Antibodies •Infliximab (Remicade), Adalimumab (Humira)

What are the diagnostic assessment for Crohn's disease?

•can indicate the extent and severity of the inflammation/complications •H & H (low d/t anemia = slow bleeding and/or poor nutrition) •BMET (low K+ & Mag. d/t severe diarrhea or fistula) •Folic acid & Vit. B (low d/t malabsorption) •Albumin (low d/t protein-losing enteropathy) •C- reactive protein & ESR (high d/t inflammation) •Urinalysis (WBC present d/t infection caused by ureteral obstruction or enterovesical fistula) •Abdominal x- ray (string sign d/t narrowing, ulcerations, strictures, or fistulas)

What are upper GI bleed origins?

•first part of the GI tract - the esophagus, stomach, or duodenum (first part of the small intestine)

What are the surgical interventions for Crohn's disease?

•not as successful with CD as with UC d/t extent of CD •Resection of the diseased area if a fistula exists •Resection if perforation, massive hemorrhage, intestinal obstruction, abscesses, or cancer exists •Stricturoplasty - increases the bowel diameter if stricture is present •Intestinal transplants - healthy stool is mixed with saline and is injected into the rectum

Where does lower GI bleeds originate?

•originates in the portions of the GI tract further down the digestive system - such as parts of the small intestine beyond the duodenum, large intestine, rectum, and anus

Where can a GI bleed originate?

•the upper or lower GI tract

What are the digestive enzymes in the pancreatic duct?

◦Amylase - breaks down carbs ◦Lipase - breaks down fats ◦Protease - breaks down proteins ◦Enzymes combine with bile and travel to intestine

What are the pancreatic hormones that are secreted?

◦Islets of Langerhans ◦Insulin ◦Glucagon - released with low BS ◦Somatostatin - inhibits glucagon

What are the diagnostic assessments for IBS?

◦Specific diagnostic criteria Recurrent abdominal pain for at least 3 days a month in past 3 months Plus two or more of the following: Improvement with defecation Onset associated with change in stool frequency Onset associated with change in stool appearance (form) •No definitive test, diagnosis is symptom based and by ruling out other conditions •Endoscopy •Colonoscopy •Chest and abdominal x-ray •Test for H. Pylori •Barium enema/colonoscopy may reveal spasm, distention or mucus accumulation in intestine