Bowel Obstruction

Adhesions

- are the most common cause of small bowel obstruction and are comprised of bands of scar tissue that surround organs after surgery or an inflammatory process; surgical lysis of adhesions may be required

Hirschsprung's Disease

- congenital defect also called Toxic Megacolon and is the most common cause of neonatal obstruction a. No ganglion cells in the gut that are responsible for motility b. Symptoms include no bowel sounds, lack of peristalsis, sever constipation, bowel distention, ischemia, enterocolitis c. Three times more common in males d. Has been associated with Down's syndrome e. May present acute or chronic in infancy or early childhood f. Infants may fail to pass meconium in the first 24-48 hours of life, are reluctant to take fluids, may have bile-stained vomitus, and abdominal distention Infancy Failure=re to thrive, constipation, abdominal distension, episodes of diarrhea and vomiting. Explosive watery stools, fever, malaise. Appear very ill. 80 % symptoms within first 6 wks of life. Childhood constipation, ribbon like foul smelling stool abdominal distension, visible peristalsis, poorly nourished anemia. g. Chronic disease signs may include constipation; ribbon-like, foul smelling stool; distention; visible peristaltic action; failure to thrive; anemia h. Long term outcome is good.

Meckel's Diverticulum

- most common congenital GI abnormality a. Begins during the embryonic stage during fetal development b. Symptomatic cases are usually seen the first 1-2 years of life c. Males have a higher incidence than females; males have a higher incidence of complications d. Symptoms may include: painless, tar-like stools, grossly bloody stools, abdominal pain, or signs of obstruction or appendicitis e. Complications may include: obstruction, diverticulum, ulceration, perforation, bleeding, inflammation, and intusseption f. Diagnosis confirmed with Nuclear Scan g. Treatment is surgical removal of the diverticulum

Intussusception

- one part of the bowel slips or telescopes into another part of the bowel a. Common cause of obstruction in infancy b. Usually occurs in children < 1 years of age(per the latest edition I have) c. Males have 2-3 times greater chance than females d. Often seen in conjunction with cystic fibrosis and celiac disease e. The intestinal walls press against each other causing inflammation, edema, decreased blood flow, necrosis, hemorrhage, perforation, and peritonitis f. Symptoms include acute intermittent abdominal pain in a healthy child (classic sign), child presents in a knee-chest position, vomiting typically followed by 1 normal brown stool, subsequent stools have the trademark sign appearing like red currant jelly g. Treatment may include an enema to push telescoped bowel back into original position; or surgical reduction and resection

Volvulus

- twisting of the bowel on itself causing obstruction and ischemia a. Complications: may result in necrosis, peritonitis, perforation, or death b. Symptoms may include bilious vomiting (classic sign), distention, abdominal pain, lower GI bleeding, or shock c. Treatment may include decompression tubes or surgery; may require an ostomy

Manifestations of Mechanical Obstruction

1. Abdominal pain - rhythmic waves 2. Distention 3. Visible peristalsis 4. High-pitched tinkling BS - borborygmi 5. Nausea/Vomiting (reverse peristalsis) 6. Constipation 7. Fluid and electrolyte imbalances 8. Auscultation: Proximal to the obstruction typically high pitched or hyperactive bowel sounds; Distal to obstruction typically hear hypoactive or absent bowel sounds

S/S of a non-mechanical Neurogenic Obstruction

1. Absence of bowel sounds 2. Absence of flatus 3. Abdominal distension 4. Abdominal pain

Non-Mechanical Obstruction

1. Also known as paralytic ileus and is the result of neuromuscular disturbance such as loss of innervation 2. Decreased or absent bowel sounds (peristalsis) 3. May be seen with CVA, spinal cord injuries, or interference with the blood supply to the area causing an infarction (intestinal ischemia) 4. May be caused by medications such as narcotics or anesthesia 5. May be caused by infectious processes 6. May occur after abdominal surgeries

Pseudo-obstruction

1. Apparent mechanical obstruction without radiological evidence 2. May be caused by: collagen vascular diseases, neurologic & endocrine disorders 3. Mostly found to be idiopathic but may be caused by collagen diseases (Lupus, scleroderma, rheumatoid arthritis, rheumatic fever, polymyositis and dermatomyositis) 4. May have a genetic factor or develop as an immunological response

Functions of the Digestive Tract

1. Breakdown of food for digestion 2. Absorption of nutrients produced by digestion into the bloodstream 3. Elimination of undigested foodstuffs and other waste products 4. Extends from mouth to anus

Surgical Options

1. Conventional Colostomy/ Ileostomy (End) 2. Abdominal Perineal Resection 3. Hartmann's I and II 4. Kock Pouch 5. Ileoanal Anastomosis - Distal ileum is brought down to anus and sutured in place 6. Permanent colostomy 7. Colectomy with preservation of the rectum & most importantly the sphincter muscle 8. Appliances a. Appliances-2 piece b. Appliances - 1 Piece

Non-Mechanical obstruction Vascular Factors

1. Interference with blood supply to intestine 2. Most common causes are emboli and atherosclerosis of the mesenteric arteries 3. Complete occlusion (mesenteric infarction) 4. Partial Occlusion (abdominal angina)

Intestinal Obstruction

1. Intestinal contents cannot pass through GI tract 2. Requires prompt treatment 3. Partial or complete 4. Mechanical or non-mechanical 5. May have pain after eating, weight loss or change in bowel patterns

Causes of Intestinal Obstruction

1. Mechanical 2. Non-Mechanical a.Neurogenic/Neuromuscular b.Vascular (intestinal ischemia)

Mechanical Obstruction

1. Most in small intestine- ileum 2. Account for 90% of all obstructions 3. Carcinoma, diverticulitis most common cause > 65 y.o. 4. Usually caused by something within the body that is blocking movement of bowel material 5. Regardless of age, adhesions 60% 6. Hernias 15% 7. Neoplasms (tumors) 15% 8. Fecal impaction 9. Intusseption 10. Volvulus 11. Endometriosis 12. Vascular disorders (emboli or arteriosclerotic narrowing of the mesenteric vessels

Major Enzymes and Secretions

1. Mouth: saliva, salivary amylase (breakdown starch) 2. Stomach: hydrochloric acid (food breakdown and kills bacteria), pepsin (protein breakdown), intrinsic factor (gastric secretion that helps B12 be absorbed) 3. Small intestine: amylase, lipase, trypsin, bile 4. Large intestine: bacteria (normal flora)

Nursing Care S/P Hernia Surgery

1. Observe for difficulty voiding 2. Strict I & O, watch for bladder distention 3. Ice packs for pain and edema 4. Scrotal support prn 5. Encourage deep breathing and turning 6. Splint incision if need to cough/sneeze 7. May be restricted from lifting heavy objects for 6-8 weeks

Assessment

1. Patient history: Include all information related to GI function 2. Assess psychosocial, spiritual, and cultural factors 3. Assess knowledge and identify any need for patient education 4. Physical assessment: Assess presence of abdominal pain, dyspepsia, nausea and vomiting, constipation, diarrhea, fecal incontinence, changes in bowel patterns, hiccups, stool characteristics, presence of jaundice, appetite and eating patterns, teeth, and overall nutritional assessment.

Colostomy Irrigation

1. Regulates bowel function 2. Evacuates bowel of stool (prep for OR/colonoscopy) 3. Eliminates the need for a pouch 4. Treats constipation

Hernias

1.Reducible, irreducible, or strangulated (emergency); strangulated symptoms include fever, tachycardia, nausea and vomiting, crampy pain, distention, may see or feel a protrusion 2.Causes may include trauma, prior surgery, aging, pregnancy, obesity, or heavy lifting

answer 6

A - A colostomy stoma that is moist and dark pink without any drainage on the first postoperative day has a normal appearance. These findings should be documented in the client's medical record. The items in the other answer options (2, 3, and 4) are not necessary because the assessment of the colostomy stoma is normal.

Question 4

A nurse is assessing a client with a diagnosed inguinal hernia at a scheduled clinic visit. The nurse suspects that the client's hernia may be strangulated when which finding is noted on assessment? a. Shortness of breath b. Intense abdominal pain c. Constipation d. Hyperactive bowel sound

Answer 4

B. When a hernia is irreducible and intestinal flow and blood supply are obstructed, the hernia is strangulated. Lack of blood supply causes severe pain in the strangulated area.

Adhesion

Band of scar tissue between or around organs that develops naturally after surgery as part of the healing process. Can also develop form infection or any inflammatory process. May kink a loop of bowel Most common cause of small bowel obstruction. Treatment decompression tube surgical lysis of adhesions.

Colon/Bowel Cancer

Bowel Cancer Treatment a. Surgical resection b. Chemotherapy (primary) c. Radiation (may be used for palliation) d. Bowel Resection e. Medications 1) Antiflatulents 2) Antidiarrheals 3) Laxatives 4) Emollients / Stool Softeners 5) Lubricants 6) Saline / Osmotics 7) Irritants / Stimulants 8) Anticholinergics 9) Antibiotics (Aminoglycosides, Erythromycins, Cephalosporins) f. Positioning for comfort g. Colostomy

Diagnostic Labs

CBC, CMP, and PT, PTT, LFTS are commonly drawn

Diagnosis

CT with contrast, GI series, Barium Enema, Colonoscopy, ultrasound, CBC, fecal occult blood test *Acute diverticulitis or any perforation or obstruction no barium or colonoscopy secondary to worsening, peritonitis.*

S/S Diverticulosis

Chronic constipation or no symptoms, most have no symptoms. Crampy abd. Pain in LLQ relieved by flatus or BM. H/o alternating constipation/diarrhea. Occasional tenderness on palpation.

Paralytic Ileus

Classic sign is the absence of bowel sounds

answer 1

False • Lipase is an enzyme that aids in the digestion of fats. • Trypsin is an enzyme that aids in the digestion of protein.

answer 5

False - Regular bowel habits can NOT be established for a patient with an ileostomy.

Answer 3

False - The most common site for diverticulitis is not the ileum. The most common site for diverticulitis is the sigmoid.

Diverticular disease

Increase incidence with age Fecalith may cause perforation Bowel narrowing form fibrotic structure = obstruction Associated with deficient dietary fiber Prevalent in Western Diets

Ingestion

Ingestion occurs when food is taken into the GI tract via the mouth and esophagus.

S/S of complete occlusion r/t embolus

Intense abdominal pain form ischemic tissue Passage of stool with blood or mucous Fever, leukocytosis shock secondary to ischemia

Question 1

Is the following statement True or False? Lipase is an enzyme that aids in the digestion of protein.

Question 3

Is the following statement True or False? The most common site for diverticulitis is the ileum.

question 5

Is the following statement True or False? a. Regular bowel habits can be established for a patient with an ileostomy

S/S Diverticulitis

Mild or sever pain in LLQ, nausea, vomiting, fever, chills, and leukocytosis. Fever chills nausea and anorexia. Elderly frequently afebrile, normal WBC, little abdominal tenderness. Complications are perforation, peritonitis, abscess, bowel obstruction, bleeding.

Inguinal hernia

Most common type a. Direct - protrusion through a weak point in the abdominal wall b. Indirect - protrusion through the inguinal ring following the spermatic cord or round ligament (common type in infants or males > age 50)

question 6

On the first postoperative day the nurse assesses a client's colostomy stoma and notes that it is moist and dark pink with no obvious drainage. Which action should the nurse consider taking? a. Document the normal findings. b. Consult the enterostomal therapist. c. Irrigate the ostomy with normal saline. d. Palpate the abdomen around the stoma.

CEA (carcinoembryonic antigen):

Protein used to determine extent of disease and prognosis in patients with cancer, particularly breast and intestinal cancers

Hernia Truss

Support garment

Umbilical hernia

Umbilical ring opening fails to close after birth and requires surgical repair if does not close spontaneously by age 5; more common in children and preemies

Colonosopy/Proctoscopy/Sigmoidoscopy

Warn of urge to defecate with Sigmoidoscopy. Preop clears 1-2 days, Go lytely afternoon before, fleets enema morning of. Lots of different protocols physician dependent. Watch for bleeding, sharp abdominal pain= bowel perforation.

Question 2

Which is the correct order to complete an abdominal assessment? a. Inspection, auscultation, percussion, palpation b. Auscultation, inspection palpation, percussion c. Percussion, palpation, inspection, auscultation d. Palpation, percussion, auscultation, inspection

look at acid/base balances

a. Acid-base may indicate high obstruction leading to metabolic alkalosis secondary to vomiting and acid loss b. Acid-base may indicate low obstruction leading to metabolic acidosis secondary to alkaline loss in the bowel due to diarrhea

Treatments asymptomatic disease Diverticulosis

a. Diet should include high fiber, low fat Raw vgetables, fruit with skin should be avoided if it triggers an attack. b. Prevent constipation - laxatives c. Increase fluid intake (not alcohol) d. Inspect stools e. Notify provider of any change in stool patterns, pain, fever, or urinary difficulties f. Decrease intra-abdominal pressure (no straining, lifting, bending, etc.) g. Lose weight (if warranted) h. Anticholinergic medication can relieve spasms (Donnatal)

CEA

a. Elevated CEA levels in peritoneal, pleural, and spinal fluid indicate metastatic cancer b. Cancer cells allow CEA to be released into connective tissue where it is absorbed c. Normal CEA values should be under 5 mcg/L; values greater than 10 indicate inflammation, and values greater than 12 may indicate presence of neoplasm

Symptoms

a. First symptoms are generally indicative of bowel obstruction b. Alternating constipation and diarrhea c. Narrow ribbon-like stools d. Rectal bleeding e. Passage of mucous f. Rectal or abdominal pain g. Feeling of fullness or incomplete evacuation h. Anemia and fatigue i. Unexplained weight loss

answer 2

a. Inspection, auscultation, percussion, palpation

Intestinal Obstruction Manifestations Small Intestine

a. Rapid onset b. Projectile vomiting c. Bile stained emesis d. Vomiting relieves some of the pain e. Minimal distention f. Abdominal discomfort or colicky, cramp like pain (may see peristaltic waves in the upper and middle abdomen) g. Electrolyte imbalances h. Possible metabolic alkalosis

Signs and Symptoms

a. Rigid board-like abdomen (classic sign) b. Abdominal pain that may be localized or referred pain to the shoulder or thorax c. Abdominal distention d. Nausea, vomiting, or diarrhea e. Decreased bowel sounds f. Inability to pass flatus or stool g. Rebound tenderness on palpation h. Fever, dehydration i. Tachycardia j. Hiccups k. Decreased urinary output l. Possible respiratory complications

Scope Procedures

a. Sigmoidoscopy b. Colonoscopy c. Proctoscopy • Pre-Operative care: Patients are to be on clear liquids, drink Go-Lytely the afternoon before, and have a Fleet's enema in the morning to clear the bowel. • Post-operative care: Patients should be monitored for complications such as bleeding, tachycardia, abdominal pain, malaise, fever, pallor, electrolyte imbalance, and a rigid or 'board-like' abdomen on inspection.

Acute care for symptomatic disease Diverticulitis

a. Typically on bedrest b. Refrain from coughing, straining, bending c. NPO with parenteral fluids to allow colon to rest d. Control inflammation possibly with steroids (Solumedrol) e. Antibiotics to reduce bacterial flora (Cipro or Flagyl) f. No laxatives or enemas g. Monitor WBC, S&S peritonitis (abdominal pain, rigid abdomen) h. Analgesics for pain i. Introduce fiber diet gradually j. Approximately 30% of patients will require surgery Potential complications perforation, peritonitis, abscess formation, bleeding

Intestinal Obstruction Manifestations Large Intestine

a. Vomiting without relief of pain b. Colicky, persistent pain c. Distention d. Symptoms develop and progress slowly

Both PTT and PT

are tests used for measuring the time taken for the blood to clot. The PT measures the extrinsic coagulation pathway by calculating the prothrombin ratio along with the INR.

Intrinsic pathway

arises if the endothelium is damaged (blood contacting collagen + platelets being damaged by cut edges of the vessel wall ultimately activates the pathway).

The pyloric sphincter

at the bottom portion of the stomach gives access for food to enter into the duodenum, followed by the jejunum, the ileum, and finally into the large intestine through the ileal cecal valve.

Commonly seen with

breast and ovarian cancers in women; can metastasize to the lymph nodes, bladder, liver, brain, and bone

Diverticulum

congenital or acquired pouch like herniation of the mucosa through the muscular intestinal wall. Caused by atrophy, weakness of bowel wall, increased intra-luminal pressure, obesity and chronic constipation. May occur anywhere in the intestine most common in the sigmoid colon

Stool

for occult blood

H & H (up) 2/2

hemoconcentration or (down) anemia

Digestion begins

in the mouth before food reaches the stomach. Smelling, tasting, or even thinking about a tasty meal triggers our salivary glands, which are located under the tongue and near the lower jaw, to begin producing saliva. Saliva contains the enzyme amylase which breaks down carbohydrates as we are chewing our food.

Bowel Obstruction: Diagnostic Tests Blood work

including stool for occult blood; may have false positives for occult blood if patient is on NSAIDS, aspirin, bromide, iodine, or from red meat consumption. Stool may have a false negative if patient has taken Vitamin C or Vitamin C containing foods. Stool may also be tested for parasites.

Diverticulitis

inflammation of one or more of the diverticula

Peritonitis

is an inflammation or bacterial infection that affects the lining of the abdominal cavity

The colon

is comprised of the ascending colon, the transverse colon which absorbs fluids and salts, and the descending colon which holds remaining waste.

Flat plate of abdomen / x-ray

is considered the most useful and indicates presence of gas and fluids in the intestine. If Intra-peritoneal air is present this may indicate a perforation. Do prior to giving any Barium

Barium enema

is not used as frequently, is not performed if a perforation or obstruction is suspected, and is useful in detecting polyps, tumors, or other abnormalities.

ERCP

is the combination of endoscopy and fluoroscopy to diagnose and treat certain problems of bile ducts, gallstones, inflammatory strictures (scar tissue), leaks (from trauma or surgery), and cancer.

Bowel cancer

known as the Silent Killer is the 2nd most common cause of cancer deaths in males and the 3rd most common in females in the U.S.; the highest incidence globally is in the North East (New England)

The food

leaves the stomach as a thick liquid substance known as chyme.

clotting factors

like I, II, V, VII and X are assessed in the prothrombin time.

LFT's

liver plays an important role in hemostasis. Not only is it the site of production of many of the coagulation factors (vitamin K-dependent factors, fibrinogen and factor VIII), but it is also responsible for clearance and degradation of factors.

Electrolytes

low Na, K, Cl possibly related to diarrhea, vomiting, NG suctioning

Upper GI series (Barium fluoroscopy)

may cause increase an obstruction pushes more contents into bowel

WBC (up)

may indicate strangulation, perforation, or abscess

Risk factors

over age 50, family history, inflammatory bowel disease, polyps, diet high in red meat (nitrates and fats), diet low in fiber, well-done foods, fried foods, or refined sugars

Anastomosis

part of the intestine is removed and the two remaining ends are sewn together

Elimination

phase of the digestive process that occurs after digestion and absorption, when waste products are eliminated from the body.

Digestion

phase of the digestive process that occurs when enzymes mix with ingested food and when proteins, fats, and sugars are broken down into their component molecules.

Absorption

phase of the digestive process that occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and into the bloodstream.

Diverticulosis

presence of multiple non inflamed out pouches. Often symptom free may have vague abdominal discomfort

Enzymes

produced by the pancreas, gallbladder, and liver, such as amylase, lipase and bile, continue the breakdown process.

The body

produces approximately 1.5 Liters of saliva per day.

Ventral/Incisional hernia

protrusion through a weakness in the abdominal wall at the site of a previous incision; common with multiple surgeries at the same incisional site, in obese patients, or from inadequate wound healing due to poor nutrition or infection

Femoral hernia

protrusion through the femoral ring into the femoral canal typically at the crease of the leg, more common in females, and can become easily strangulated

hernioplasty

reinforcement of weakened area with wire, fascia, or mesh

Bile

secreted by the liver aids in emulsifying fats making them easier to digest and absorb

herniorrhaphy

surgical repair of the hernia

PillCam - ESO

takes pictures of your esophagus and transmits wirelessly through a storage device; used to monitor abnormalities such as esophageal varices, Barrett's Esophagus, and esophageal cancers.

Food passes through

the pharynx when you swallow, goes into the esophagus and travels via contraction of smooth muscle entering into the stomach through the esophageal sphincter.

Bowel Resection

used if strangulation, gangrene, or necrosis is involved

cecostomy

used to decompress intestine when the patient is too sick for surgery, used to clear the bowel of feces, may be a drain connected to suction or gravity, may require irrigation

CT scan or abdominal ultrasound

used to detect gallstones, masses, or obstructions; cannot be given with contrast if patient allergic to Shellfish of Contrast Dye. Mucomyst and sodium bicarbonate may be administered before and after to protect from byproducts of contrast medium that can cause kidney and liver damage.

Abdominal ultrasound

uses sound waves to detect presence of gallstones, pancreatic masses, pelvic obstruction