abdominal / intestinal disorders

Outline for Abdominal Intestinal Disorders

 

I.) Appendicitis- Appendix is a tube like pouch attached to the cecum just below the ileocecal valve. Regularly fills with and empties digested food. Appendicitis- occurs at any age but most commonly in adolescents and young adults.

 

             Pathophysiology of the possible cause-the obstruction usually occurs at the proximal lumen of the appendix. The obstruction can occur for no apparent reason.

             Obstruction can be caused by:

 

                            a.) Fecalith

 

              b.) Calculus

 

              c.) Foreign body

 

              d.) Inflammation

 

              e.) Tumor

 

              f.) Parasites (pinworms)

 

              g.) Edema of lymphoid tissue or intramural thickening of lymphoid tissue

 

            Pathophysiology after the obstruction occurs: Once the obstruction occurs then the appendix becomes distended with fluid produced by its mucosa. There is an increase in the amount of pressure in the lumen of the appendix and limited blood supply resulting in: inflammation, edema, ulceration, and infection. Purulent exudate forms causing an increase in distention. Tissue necrosis and gangrene can result usually within 24-36 hrs of purulent drainage if not treated perforation can occur.

 

            Classified as:

1. Simple appendicitis-pain, RLQ, swollen, inflamed, intact, not ruptured

2. Gangrenous appendicitis: infection, tissue necrosis, microscopic perforations, getting ready to rupture

3. Perforated appendicitis: has ruptured, systemic infection, peritoneum area infiltration

 

            Signs and Symptoms:

1. initial Pain, periumbilical, vague epigastric pain,
2. RLQ pain, Mcburney's point halfway between umbilicus and anterior ischial spine, tenderness, rebound tenderness, fever, increased WBC's, nausea and vomiting, loss of appetite, Rovsing's (push on left have pain on right), not as much pain with simple as with perforated. Sudden relief of pain is when it ruptured. 

 

 

      *Older adult's pain may not be as intense or may have less pain or may be absent, if not know you have pain, can rupture faster

        *Pregnant women may have RLQ pain, periumbilical, substernal (due to displacement of appendix by baby)

 

   Complications: if rupture get sepsis, expect decreased pain initially after rupture, then constant pain generalized, possibly severe bleeding. Infection get fever, can cause abscess if stay in one place, if not in one place get peritonitis, higher risk in very young and old

Interdisciplinary care

II.) Peritonitis-is an inflammation of the peritoneum.

            Pathophysiology: The fluid becomes "contaminated" which is caused by bacteria such as Klebsiella, Escherichia Coli, Proteus, pseudomonas which normally inherits the bowel but enter the perioneal cavity. Peritonitis can also be caused by a chemical irritant from trauma or rupture of an organ such as: perforated ulcer, ruptured appendix, perforated diverticulum, necrotic bowel, abdominal surgery, or peritoneal dialysis. Chemical peritonitis is usually seen first and followed by bacteria peritonitis. Inflammatory and immune responses are activated. If there are only small amounts of bacteria then the body can eliminate it but massive amounts the body is unable to eliminate it. Continued contamination results in generalized inflammation of the peritoneal space.

 

            Signs and Symptoms of Peritonitis (note we are going to break them down into two sections) s&sx worse = severity of infection, not being treated, if contained to small area or spread out over larger area, young & old worse effects, hx of lots of problems (without hx of problems has better prognosis),

            Abdominal symptoms: pain, diffuse or localized, rebound tenderness, abdomen swollen, rigid, distention, no bowel sounds or absent sounds, nausea and vomiting

 

            Systemic Symptoms: fever, increased WBC's, tachycardia, tachypnea, hypoxia, cyanosis, confusion, disorientation, restless, anxious, overall malaise,  kidneys low urine output = oliguria,

 

            If you do not have bowel sounds then you would expect what?

Paralytic illeus possible, (blockage due to paralysis) inflammation will stop peristalsis, heat can increase symptoms (increase risk of rupture),

770-773 diagnostic studies

III.) Diverticulitis disease

            Diverticulum- is a saccular dilation or outpouching of the mucosa through the circular smooth muscle of the intestinal wall. That may occur anywhere along the GI tract some authors say it is more common in  the sigmoid colon.

There are two forms of diverticular disease: Diverticulosis-multiple non-inflamed diverticula are present most often do not have any symptoms and risk increases with age.

            Diverticulitis-inflammation of the diverticula. Cause is unknown but is contributed to a low fiber diet.

            Pathophysiology- increased pressure in the bowel lumen, low volume in the colon (fiber poor diet), and decreased muscle strength (hypertrophy of the colon from hardened fecal masses) causes bowl mucosa to become herniated through defects in the colon wall. Undigested food and bacteria can be trapped in the diverticula causing inflammation and infection, which can lead to ischemia of the diverticula, which results in perforation.

 

            Signs and Symptoms:

1.)    Diverticulosis- know quadrants,  pockets, may not have symptoms, symptoms may have cramping, abdominal pain, diarrhea between constipation (alternate), cramping goes away with bowel mvm or flatus, stools are narrow with blood, can become weak, fatigued,

 

What complications would you expect to find with diverticula?

         2.) Diverticulitis- hemorrhage of pockets, can bleed whether inflamed or not due to erosion by a fecalith, infection

What complications would you expect to find with diverticulits?

Fever, chills, increase WBC's low, appetite, malaise, peristalsis slows down, constipation, pain in LLQ especially with palpation over area, *bowel obstruction* due to inflamed tissue can adhere to bowel wall, fistula formation between sigmoid colon to bladder most common can open to peritoneum, go to uterus, vagina, ureter, perineum, nausea, vomiting, hemorrhage, scars, adhesions, fibrosis, size of colon decreases due to inflammation, scaring, adhesions,

Read pgs 816 -818 diverticulosis/itis. Lemone

 

IV.) Bowel Obstructions-can be partial or complete

            Pathophysiology: They can occur from any condition that prevents the flow of intestinal contents through the intestinal lumen can be partial or complete and can occur in the small or large bowel. It can be broken down into two different types:

1. Mechanical: is classified as problems outside or inside the intestines.

2. Functional occurs when peristalsis can not occur either due to neurogenic or muscular impairment and there is not a mechanical obstruction. Ie spinal cord injury

 

            Causes of obstructions:

1. Hernia- protrusion of the intestinal wall through a weak area in the abdominal muscle or the inguinal ring. mechanical

2. Intususseption- telescoping of one part of the intestine into another. More common in infants 10-15 months of age. It usually causes strangulation of the blood vessels. mechanical

3. Volvulus- twisting of the intestinal wall. Causes occlusion of the blood flow. Occurs most often in the middle age to older men. mechanical

4. Diverticulosis: mechanical inside/outside. 

5. Tumor-adenocarcinoma is the most common, mechanical

6. Paralytic illeus- Fibrous adhesions- irritation from surgery or trauma leads to formation of fibirin and adhesions that attach to the intestine. Functional

7. fibrous adhesions:  mechanical

Functional causes: hemorrhage, peritonitis, spinal cord injury, electrolyte imbalance K+ hypokalemia, drugs: narcotics, antidiarretic, anticholinergic (dries you up),

Read patho book pg 989

 

            Pathophysiology continued: When the intestine is obstructed, gas and fluid accumulate close and within the obstructed segment causing the bowel to distend. Water and NA are drawn into the bowel lumen contributing to the bowel distention, vascular fluid losses, and fluid accumulation. The increase in pressure in the lumen decreases capillary blood flow to the bowel, which can lead to necrosis and bacterial peritonitis.

 

Intestinal s/sx see 989

 

V.) Polyp-Pathophysiology-mass of tissue that arises from the bowel wall and protrudes into the lumen. Can appear anywhere in the intestine and rectum. Some authors suggest they are more prominent in the sigmoid and rectum. Can be classified as neoplastic and non-neoplastic. Neoplastic-adenomatous and carcinomas are characterized by a disruption of the normal process of cell proliferation. The neoplastic are closely linked to colorectal adenocarcinoma. Non-neoplastic-originate from the epithelium. Types of non-neoplastic- hyperplastic (epithelial polyps), inflammatory (pseudopolyps), or submucosal (Lipomas). Increase in occurrence after age 40.

            Signs and symptoms: Pg 1015 -1016 (table), 1017 staging (know)

Know interdisciplinary care/ nursing care lemone 812-814

See 1016 pg patho book, pg 1015 patho book,

1. polyp – size, location, duration, how much pressure on intestinal wall, s/sx sometimes, symptoms: bleeding rectal bright red, tarry red (further up in colon), large polyp sx- constipation, pain, sx of obstruction, abdominal cramping

read 801 Lemone

 

VI.) Colorectal Cancer

            Risk Factors: Most frequently after age 50 but can occur at any age

            Polyps of the colon or rectum

            Family hx of colorectal cancer

            Inflammatory bowel disease

            Exposure to radiation

            Diet high in animal fat, (beef diet), high calorie, and limited intake of fiber

 

            Pathophysiology- Most arise from adenomatous polyps that become malignant. (They're called adenocarcinoma) Spread through intestine wall and into the lymphatic system or circulatory system. Can spread by direct extension to such as the liver, greater curvature of the stomach, duodenum, small intestine, pancreas, spleen, genitourinary tract, and abdominal wall. Metastases of the tumor commonly spreads to the liver (because the venous blood flow from the colorectal tumor is through the portal vein) can spread to lungs, brain, bones, and kidneys.

 

 

 

 

 

            Signs and Symptoms-

Some authors say signs are non specific, can go on this way for 5-15 yrs.

s/sx, pressure at rectum, blood in stool (can be occult) stay away from red meat 24 hrs prior to exam, weight loss (late stage), change in bowel habits (ie. become constipated suddenly or diarrhea), anorexic, weakness, rectal mass that is palpable, pain (late stage), anemia due to blood loss (profuse or over time), read patho book evaluation and treatment 1017

high meat diet: anaerobic bacteria convert to carcinogens, longer to digest, stays in colon longer,

 

VII.) Hernias- can be classified by terms that reflect the degree of hernia obstruction. Sliding hernia-moves freely in and out of the hernia sac. If the protruding structure requires manipulation to return it to its proper position then it is considered reducible.

If the protruding structure can not be returned to its proper position then it is considered irreducible. When blood flow to the trapped segment is compromised by pressure from the surrounding muscle ring, the hernia is said to be strangulated. Intestinal obstruction occurs, and gangrene of the viscera can rapidly develop.

 

            Pathophysiology- Hernias typically form as a result of increased abdominal pressure, decreased resistance of the tissues of the abdominal wall and presence of spaces in the abdominal cavity. The major pathologic concern is strangulation and bowel obstruction.

 

            Signs and Symptoms-types: 809-10 Lemone

Hernia near umbilicus most common, inguinal – groin, hiatal upper GI, incision that is old (c-section), makes it weaker, can protrude with hernia,

s/sx pain, slides in/out = mild discomfort, as long as it is reducable, stricture – strangulated causes necrosis & severe pain, bowel obstruction can be caused by hernia,

inguinal hernia – pain in testicles, heavy feeling, dragging sensation,

irreducible – need surgery right away – emergency. rd 810-811 Lemone

 

 

VIII.) Anorectal disorders  www.hemorrhoid.net/anorectal_big.php   (website with info on diseases of intestine/rectum)

            A.) Anorectal abscess-

                                Pathophysiology- Invasion of the pararectal space by pathogenic bacteria can lead to an abscess. The abscess can appear small but contains a large amount of pus. Can occur as a result of anal fissures, trauma, regional enteritis, immunosuppressive, or inflammatory bowel disease. Most common causative organisms are E Coli, staphylococci, and streptococci.

                        Signs and Symptoms- swelling, local pain, fever, elevated WBC's, redness, abscess with pus, drainage, purulent, bad odor, tender to touch, could lead to sepsis,

 

 

 

 

            B.) Anal Fistula

                        Pathophysiology- an abnormal tunnel leading out from the anus or rectum. The tunnel has openings at both ends. The fistula can extend to the outside of the skin, vagina, or buttocks. It can be caused by Crohn's disease and often precedes an anorectal abscess.

                        Signs and Symptoms- discharge – constant or intermittent, odor, pain, itching, redness, swelling, feces coming out, (feces can come out through vagina), flatus, need to wear pads/briefs, bury personal dislikes, put Vaseline in nose, don't make ugly facial expressions, pt will not be open if you make bad comments or irritated face.  Be professional, pain on defecation

 

            C.) Anal Fissure-

 

                                Pathophysiology- a skin ulcer or crack in the lining of the anal wall that is caused by trauma, persistent tightening of the anal canal due to stress and anxiety, abuse of laxatives, local infections, or inflammation.

                        Signs and Symptoms- burning pain, constipation, minimal bright red blood, spasms,

            D.) Hemorrhoids-

                                Pathophysiology- dilated portion of veins in the anal canal. Occur when venous return from the anal canal is impaired. It may be caused by the following: pregnancy, prolonged constipation, straining on defecation, heavy lifting, prolonged standing and sitting, and portal hypertension (as found in cirrhosis). Can be internal occur above the internal sphincter or external occurring outside the external sphincter.

                        Signs and Symptoms:

1. Internal hemorrhoids- inside – above internal sphincter, painless unless thrombose, bleed, or prolapse (can have chronic, dull, aching, discomfort)

2. External hemorrhoids- burning, itching, blood when you defecate, thrombosed blood vessel (inflamed)

 

            E.) Pilonidal Cyst-

                        Pathophysiology- small tract under the skin between the buttocks in sacrococcygeal area . Thought to be caused by the penetration of hairs into the epithelium. Pilonidal = "a nest of hair

                        Signs and Symptoms: occur during puberty up to early adulthood, symptoms lacking unless infection present, could have pain, swelling at base of spine,

Lemone see pg 821 analrectal nursing care.

Read 982-983, 996 lactase deficiency* read patho book constipation/ diarrhea

Lemone pg 802 distribution of colon cancer