Colorectal Cancer

• To teach patients being discharged from the hospital, advise them to avoid:
• High-fat foods
• Heavy meals
• Alcohol
• Give verbal and written instructions about the signs, symptoms, and possible complications of acute pancreatitis.
• Patients should know to report any issues to their primary provider promptly.

Pancreatitis

• Pancreatitis involves inflammation of the pancreas.
• Acute pancreatitis symptoms include severe epigastric abdominal pain that may radiate to the back, and pain that is experienced after eating heavy or spicy meals.
• Alcohol ingestion may stimulate an episode of pancreatitis.
• Tachycardia, fever, extreme malaise, mottled or cold skin, restlessness, and ecchymosis may occur.
• Signs of acute pancreatitis that suggest peritonitis include a rigid board-like abdomen, decreased or absent breath sounds, crackles at the bases, left plural effusion, abdominal guarding, and respiratory distress.
• Chronic manifestations include dull discomfort to severe upper abdominal and back pain, along with vomiting.
• Diagnostic testing includes evaluation of amylase, lipase, calcium, glucose, and hematocrit levels, all of which are elevated, except for calcium.

Pancreatitis Diagnostics

• Testing includes abdominal x-ray, ultrasound, CT scan, ERCP, and glucose tolerance test.
• Medical management may include IV fluids, morphine for pain management (avoid demerol), NPO.
• TPN management may be required.
• Diet should be high in carbs and low in protein and fats, and avoid caffeine and smoking

Hepatic Encephalopathy

• A life-threatening complication of liver disease that occurs with profound liver failure.
• It affects the brain due to the seriousness of the liver disease.
• It is the neuropsychiatric manifestation of hepatic failure associated with portal hypertension and the shunting of blood from the portal venous system into the systemic circulation
• Ammonia is the major etiologic factor in the development of encephalopathy.
• Asterixis (“liver flap”) may occur, where the patient is asked to hold arm out with the hand held upward (dorsiflexed).
• The hand falls forward involuntarily and quickly returns to the dorsiflexed position.
• Early symptoms include; mental status changes, motor disturbances, and alterations in mood and sleep patterns; patients tend to sleep during the day and experience restlessness and insomnia at night.
• For diagnostics: use ECG.
• Lactulose reduces serum ammonia levels; monitor patients receiving lactulose for watery diarrhea stools, which indicate medication overdose.
• Lactulose can be put in fruit juice to mask the taste.
• Discontinue sedatives, tranquilizers, and analgesic medications. Keep daily protein intake between 1.2 and 1.5 g/kg body weight per day.
• Provide small, frequent meals and 3 small snacks per day in addition to a late-night snack before bed.
• Respiratory compromise is great given depressed neurologic status.

Hepatitis A

• Hepatitis A is a viral infection that causes inflammation.
• Symptoms: fatigue, nausea, vomiting, abdominal pain, diarrhea, fever, and jaundice.
• Causes: Consumption of contaminated food or water or close contact with a contaminated person.

Hepatitis B

• A viral infection transmitted primarily through blood (percutaneous and permucosal routes).
• Symptoms: fatigue, jaundice, dark urine, clay-colored stools, nausea and vomiting, and abdominal pain.
• Found in blood, saliva, semen, and vaginal secretions.
• Can be transmitted through mucous membranes and breaks in the skin.
• HBV is also transferred from carrier mothers to their infants, especially in areas with a high incidence.

Gastritis

• Gastritis is the swelling and inflammation of the stomach, either erosive or non-erosive.
• Acute gastritis symptoms include epigastric pain/discomfort, dyspepsia, indigestion, anorexia, nausea, and vomiting.
• Management includes avoiding spicy foods, opting for bland meals, and consuming plenty of fluids.
• Antibiotics are treatment option for conditions caused by H. Pylori.
• Medications used - Antacids, PPI’s, and H2 blockers.
• Can develop when patient has a major trauma injury, burns, server infection, and lack of perfusion to the stomach lining or major surgery.
• It's often referred to as stress gastritis or ulcer.
• Symptoms of chronic gastritis: fatigue, pyrosis after eating, belching, sour taste, halitosis, feeling fullness, anorexia, nausea/vomiting.
• Management: modifying diet, rest, reduce stress, stop drinking and smoking.
• Medications like NSAIDs or coffee are to be avoided entirely.
• Erosive gastritis may cause bleeding, blood in vomitting, black tarry stool(melena), bright red stool(hematochezia)
• Causes include, NSAIDS (aspirin, ibuprofen, naproxen) and Corticosteroids: hydrocortisone, prednisone, etc
• In Non-erosive gastritis - disruption of the mucosal barrier that normally protects the stomach tissue from digestive juices.
• Can be caused by H.Pylori, autoimmune d/o, alcohol, and smoking
• Definitive diagnostic is endoscopy and histologic exam of specimen obtained by bx

GERD (gastroesophageal reflux disease)

• A common disorder marked by the backflow of gastric or duodenal contents into the esophagus, causing troublesome symptoms and/or mucosal injury.
• Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder.
• GERD increases with aging and is seen in patients with irritable bowel syndrome and obstructive airway disorder exacerbations associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori.
• Pyrosis (heartburn) and regurgitation are the hallmark symptoms, but patients may also experience dyspepsia (indigestion), dysphagia, hypersalivation, and esophagitis.
• GERD can result in dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications.
• Diagnostic testing may include ambulatory pH monitoring, which is the gold standard.
• Lifestyle modifications include tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet.
• Surgical management involves an open or laparoscopic Nissen fundoplication, which involves wrapping of a portion of the gastric fundus around the sphincter area of the esophagus.

Colon Cancer

• Cancer of the colon and rectum is predominantly (95%) adenocarcinoma
• Genetic mutations are associated with the transformation of a benign polyp to invasive adenocarcinoma, which invades and destroys normal tissues and extends into surrounding structures.
• Cancer cells may migrate away from the primary tumor and spread to other parts of the body, most often to the liver, peritoneum, and lungs. Risk factors: smoking, family hx, alcohol, high fat high protein diet, type 2 diabetes, age, history of IBD, male gender, obesity, black or Jewish
• The most common presenting symptom is a change in bowel habits; the passage of blood in or on the stools is the second most common symptom.
• Symptoms associated with right-sided lesions (i.e., more proximal tumors) are dull abdominal pain and melena (i.e., black, tarry stools).
• Patients with right-sided tumors have poorer outcomes than those with left-sided tumors.
• Symptoms associated with left-sided lesions are a change in bowel habits or those associated with obstruction (i.e., abdominal pain and cramping, narrowing stools, constipation, distention), as well as hematochezia (i.e., bright red blood in the stool).
• Symptoms associated with rectal lesions are tenesmus, rectal pain, the feeling of incomplete evacuation after a bowel movement, alternating constipation and diarrhea, and bloody stool
• Screening colonoscopies can reduce mortality by decreasing incidence and increasing survival rates.
• Surgery is the mainstay of initial treatment; the goal is removal of the primary tumor with clean margins, including lymph nodes
• Postoperative infection is a major cause of morbidity and mortality following colorectal surgery.
• Monitor vital signs for increased temperature, pulse, and respirations and for decreased blood pressure
• Frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction and report bleeding immediately as it indicated hemorrhage.

Ascites

• 3rd space fluid accumulated in the peritoneal and pleural space, resulting from volume disturbances such as hypervolemia, liver disease, heart failure, and kidney injury.
• Common reports of SHORTNESS OF BREATH AND SENSE OF PRESSURE.
• It is a consequence of portal hypertension, capillary pressure and obstruction of venous blood flow through the damaged liver, and is albumin rich fluid.
• Increased abdominal girth and rapid weight gain are common presenting signs, assessed by percussion of abdomen.
• Treatments - LOW SODIUM DIET, diuretics, Spironolactone, or bed rest in the upright position; surgical paracentesis
• Nursing care includes assessment and documentation of intake and output (I&O), abdominal girth, and daily weight to assess fluid status; the nurse also closely monitors the respiratory status.
• The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of hepatic encephalopathy.

Protonix (pantoprazole)

• Proton pump inhibitor that decreases the amount of acid produced in the stomach.
• Used to treat erosive esophagitis caused by GERD or gastroesophageal reflux.
• NOT USED FOR IMMEDIATE RELIEF OF HEARTBURN SYMPTOMS.
• Can cause kidney problems
• More likely to break a bone
• Do not take with medicine that contains dipivefrine

Lactulose (Constulose)

• Laxitive
• Should not take if on a low galactose (milk sugar) diet

Gastrectomy

• A type of bariatric surgical procedure, and is most commonly performed involving removal of part of the stomach.
• Patients getting sugar-free fluids are preferred because high sugar levels may cause dumping syndrome.
• After bowel sounds have returned and oral intake is resumed, six small feedings consisting of a total of 600 to 800 calories per day are provided.
• Consumption of fluids between meals is encouraged to prevent dehydration.
• Common dietary deficiencies in patients who have had bariatric surgery include malabsorption of organic iron and B12
• Assume a low Fowler position during mealtime and then remain in that position for 20 to 30 minutes after mealtime
• Avoid drinking fluid with meals; instead, consume fluids up to 30 minutes before a meal and 60 minutes after mealtime.
• Gastrectomy for stomach cancer:
  • The entire stomach is removed along with the duodenum, the lower portion of the esophagus, supporting mesentery, and lymph nodes.
  • Reconstruction of the GI tract is performed by anastomosing the end of the jejunum to the end of the esophagus, a procedure called an esophagojejunostomy
• A radical partial (subtotal) gastrectomy is performed for a respectable tumor in the middle and distal portions of the stomach.
• The Billroth I involves a limited resection and offers a lower cure rate than the Billroth II, a wider resection ( approximately 75% of the stomach) that decreases the possibility of lymph node spread or metastatic recurrence.
• A proximal partial (subtotal) gastrectomy may be performed for a resectable tumor located in the proximal portion of the stomach or cardia.
• A total gastrectomy or an esophagogastrectomy is usually performed in place of this procedure to achieve a more extensive resection.
• Complications: Hemorrhage, dumping syndrome, bile reflux, and gastric outlet obstruction.
• Postoperative bleeding from the surgical site is a common complication.

Esophagogastroduodenoscopy (EGD)

• Fibroscopy of the upper GI tract allows direct visualization of the esophageal, gastric, and duodenal mucosa through a lighted endoscope. It is valuable when esophageal, gastric, or duodenal disorders or inflammatory, neoplastic, or infectious processes are suspected.
• This procedure also can be used to evaluate esophageal and gastric motility and to collect secretions and tissue specimens for further analysis
• Therapeutic endoscopy can be used to remove common bile duct stones, dilate strictures, and treat gastric bleeding and esophageal varices.
• The use of topical anesthetic agents and moderate sedation makes it important to monitor and maintain the patient's oral airway during and after the procedure.
• Fingertip or ear oximeters are used to monitor oxygen during and after the procedure.
• NPO for at least 8 hours prior to the examination, it's important to give Midazolam, a sedative that provides moderate sedation with loss of the gag reflex and relieves anxiety during the procedure
• Atropine may be given to reduce secretions, and glucagon may be given to relax smooth muscle.
• Position patient in the left lateral position to facilitate clearance of pulmonary secretions and provide smooth entry of the scope.

Ulcerative Colitis

• A chronic ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum, characterized by unpredictable periods of remission and exacerbation.
• Bouts of abdominal cramps and bloody or purulent diarrhea are common symptoms.
• Inflammatory changes typically begin in the rectum and progress proximally through the colon.
• Predominant symptoms include diarrhea, with passage of mucus, pus, or blood; left lower quadrant abdominal pain; and intermittent tenesmus.
• Bleeding may be mild or severe, with fatigue a very common symptom.
• Patients may have anorexia, weight loss, fever, vomiting, and dehydration, as well as cramping, and the passage of six or more liquid stools each day.
• Abdominal x-ray studies are useful for determining the cause of symptoms.
• In severe cases a colectomy might be needed.
• Patients with ulcerative colitis also have a significantly increased risk of osteoporotic fractures due to decreased bone mineral density; corticosteroid therapy may also contribute to the diminished bone density.
• Patients with ulcerative colitis are at increased risk for colon cancer, approximately 20 years post diagnosis.
• Aminosalicylates such as sulfasalazine are typically the first pharmacologic agents selected to induce and maintain remission of mild to moderate IBD
• Antibiotics include a combination therapy of both metronidazole and ciprofloxacin - these antibiotics are associated with adverse effects that include nausea and diarrhea, and increased risk of Clostridium difficile infection.
• Metronidazole can cause peripheral neuropathy that, if present, can warrant its discontinuance.
• Cold foods and smoking are avoided because both increase intestinal motility.
• Some patients may experience an improvement in symptoms if they follow the FODMAP diet

Bowel Obstruction

• Intestinal obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract.
• Mechanical obstruction: Intestinal obstruction exists from extrinsic lesions from outside the intestines or intrinsic lesions within the intestines
• Mechanical obstruction examples
  • Extrinsic lesions include adhesions, hernias, and abscesses
  • Intrinsic lesions include intestinal tumors (benign and cancerous), strictures (from prior surgery or radiation), or intraluminal lesions due to a defect in the bowel lumen (e.g., intussusception).
• Functional or paralytic obstruction: obstruction to the bowel due to the interruption of innervation or vascular supply to the bowel.
• Functional obstruction examples
  • Amyloidosis, muscular dystrophy, endocrine disorders such as diabetes, or neurologic disorders such as Parkinson's disease.
  • Blockage that is temporary and the result of the manipulation of the bowel during surgery (i.e., ileus).
• Obstruction can occur in the large or small intestine and can be partial or complete; severity depends on the region of bowel affected, the degree to which the lumen is occluded, and especially the degree to which the vascular supply to the bowel wall is disturbed.
• Most obstructions occur in the small intestine; adhesions, hernia, and tumor account for 90% of obstructions. Other causes of small bowel obstruction -Crohn's disease, intussusception, volvulus, and paralytic ileus.
• Most obstructions in the large intestines occur in the sigmoid colon, the most common causes are cancer (60%), diverticular disease (20%), and volvulus (5%).
• Mechanical causes of obstruction include: adhesions, intussusception, volvulus, hernia, and tumor.
• Intestinal contents, fluid, and gas accumulate proximal to the intestinal obstruction; with continued intestinal distention and edema, perfusion to the affected intestinal segment can be compromised, leading to ischemia, necrosis, and eventual rupture or perforation of the intestinal wall, with resultant peritonitis.
• Initial symptom is usually crampy pain that is wavelike and colicky due to persistent peristalsis both above and below the blockage.
• The patient may pass blood and mucus but no fecal matter and no flatus.
• Vomiting occurs; in the event of complete obstruction, the peristaltic waves initially become extremely vigorous.
• Vomiting results in loss of hydrogen ions and potassium from the stomach, leading to reduction of chloride and potassium in the blood and to metabolic alkalosis.
• Decompression of the bowel through insertion of an NG tube is necessary for all patients with small bowel obstruction.
• Maintain tube function and monitoring of NG output, as well as assessing for fluid and electrolyte imbalance and nutritional status.
• Maintaining fluid and electrolyte balance is a priority and will be carefully monitored given that presence of the NG tube in conjunction places the patient with the patient’s NPO status places the

Large Bowel Obstruction (LBO)

• Results in an accumulation of intestinal contents, fluid, and gas proximal to the obstruction, and can lead to severe distention and perforation unless some gas and fluid can flow back through the ileocecal valve.
• LBO, even if complete, may be undramatic if the blood supply to the colon is not disturbed; however, if the blood supply is cut off, intestinal strangulation and necrosis occur, this condition is life threatening.
• In the large intestine, dehydration occurs more slowly than in the small intestine because the colon can absorb its fluid contents and can distend to a size considerably beyond its normal full capacity.
• Large or small bowel obstructions have similar complications include perforation, peritonitis, and sepsis.
• Large bowel obstruction differs clinically from small bowel obstruction in that the symptoms develop and progress relatively slowly.
• In patients with obstruction in the sigmoid colon or the rectum, constipation may be the only symptom for weeks.
• The shape of the stool is altered as it passes the obstruction that is gradually increasing in size.
• Blood loss in the stool may result in iron deficiency anemia; the patient may experience weakness, weight loss, and anorexia.
• Eventually, the abdomen becomes markedly distended, loops of large bowel become visibly outlined through the abdominal wall, and the patient has crampy lower abdominal pain

Peptic Ulcer Disease

• Peak onset between 30 and 60 years old.
• A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location.
• It is an excavation (hollowed-out area) that forms in the mucosa of the stomach, in the pylorus, in the duodenum, or in the esophagus - erosion of a circumscribed area of mucosa is the cause.
• Peptic ulcers are more likely to occur in the duodenum than in the stomach.
• Esophageal ulcers occur as a result of the backward flow of HCl from the stomach into the esophagus (gastroesophageal reflux disease [GERD]).
• Most peptic ulcers result from infection with H. pylori, or the use of NSAIDs, such as ibuprofen and aspirin, which represents a major risk factor.
• Peptic ulcer disease is associated with Zollinger-Ellison syndrome (ZES).
• Exposure of the mucosa to gastric acid (HCl), pepsin, and other irritating agents (e.g., NSAIDs or H. pylori) leads to inflammation, injury, and subsequent erosion of the mucosa.
• Patients with duodenal ulcers secrete more acid than normal, whereas patients with gastric ulcers tend to secrete normal or decreased levels of acid.
• The use of NSAIDs inhibits prostaglandin synthesis, which is associated with a disruption of the normally protective mucosal barrier; damage to the mucosal barrier also results in decreased resistance to bacteria.
• Stress ulcer is the term given to the acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events, such as burns, shock, sepsis, and multiple organ dysfunction syndrome most common in patients following significant burn injuries, traumatic brain injury, or who require mechanical ventilation.
• Curling is frequently observed after extensive burn injuries and often involves the antrum of the stomach or the duodenum.
• Cushing ulcer is common in patients with a traumatic head injury, stroke, brain tumor, or following intracranial surgery.
• The patient with an ulcer complains of dull, gnawing pain or a burning sensation in the mid epigastrium or the back; classically, the pain associated with gastric ulcers most commonly occurs immediately after eating, whereas the pain associated with duodenal ulcers most commonly occurs 2 to 3 hours after meals.
• Patients with duodenal ulcers are more likely to express relief of pain after eating or after taking an antacid than patients with gastric ulcers.
• Upper endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions.
• The most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and sometimes bismuth salts that suppress or eradicate H. pylori.
• Recommended combination drug therapy is typically prescribed for 10 to 14 days.

TPN

• Delivered intravenously to people who can't use their digestive systems at all.
• Essential when certain conditions impair the ability to process food, absorb nutrients through digestive tract, and avoid using digestive system for a while so it can heal.
• May include different amounts of any of the six essential nutrients that the body requires: water, carbohydrates, proteins, fats, vitamins and minerals and tailored to lab results.
• Method of providing nutrients to the body by an IV route.
• The nutrients are a complex admixture containing proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water in a single container.
• The goals are similar to enteral feedings; improve nutritional status, establish a positive nitrogen balance, maintain muscle mass, promote weight maintenance or gain, and enhance healing process indicated in adults who are malnourished, at risk for becoming malnourished, and who cannot tolerate receiving nutrition orally or by the enteral route
• Typically, a large, high-flow vein such as the superior vena cava is the preferred site
• A total of 1 to 3 L of solution is given over a 24-hour period, and the solution is verified by at least two identifiers and compared with the prescription
• Ideally, cyclic parenteral nutrition is infused over 10- to 14-hour period that continues through the night
• Possible complications: Pneumothorax, air embolism, clotted catheter line, catheter displacement, sepsis, hyperglycemia, fluid overload, rebound hyperglycemia.

Appendicitis

• The most common reason for emergency abdominal surgery.
• The inflammatory process increases intraluminal pressure, causing edema and obstruction of the orifice. Once obstructed, becomes ischemic, bacterial overgrowth occurs, and gangrene or perforation eventually occur.
• Vague periumbilical pain (i.e., visceral pain that is dull and poorly localized) with anorexia progresses to right lower quadrant pain (i.e., parietal pain that is sharp, discrete, and well localized).
• Nausea in approximately 50% of patients with appendicitis.
• Rebound tenderness may be present, and a low-grade fever may also be present.
• WBC (>10,500) is helpful in determining diagnosis.
• Major complications: gangrene or perforation which can lead to peritonitis, abscess formation, or portal pylephlebitis, which is septic thromboembolism.

Colectomy (Colostomy)

• A surgical opening into the colon by means of a stoma to allow drainage of bowel contents; one type of fecal diversion
• Allows patient to empty colon of gas, mucus, and feces for social activities.
• A low-residue diet is followed for the first 6 to 8 weeks; strained fruits and vegetables are ingested
• Important sources of vitamins A and C
• There are few dietary restrictions, except for avoiding foods with hard-to-digest kernel and high in fiber.
• Peristomal skin irritation, which results from leakage of effluent, is the most common complication of an ileostomy; a drainable pouching system that does not fit well is often the cause.

Ileostomy

• Surgical opening in the small bowel (ileum) for those with IBD
• Cures the disease for people who have ulcerative colitis
• Drainage is liquid or unformed
• Indicated after a proctocolectomy or a total colectomy and is either temporary or permanent.
• For patients with severe ulcerative colitis, restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is the procedure of choice
• Typically indicated with Crohn's disease who must have total colectomy

Hiatal Hernia Repair

• The opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach moves into the lower portion of the thorax.
• Hiatal hernia occurs more often in women than in men.
• Two main types of hiatal hernias: sliding and paraoesophageal
• Sliding hiatal hernias are commonly associated with GERD, hemorrhage, obstruction, and volvulus -Occurs when the upper stomach and the gastroesophageal junction are displaced upward and slide in and out of the thorax
• Paraoesophageal hernias are further classified as types II, III, or IV, depending on the extent of herniation.
• Type IV has the greatest herniation, with other intra-abdominal viscera such as the colon, omentum, or small bowel present in the hernia sac that is displaced through the hiatus along with the stomach - occurs when all or part of the stomach pushes through the diaphragm beside the esophagus
• Can get strangulation with any type of hernia, but is more common with paraesophageal hernia
• Confirmed diagnosis by x-ray studies; barium swallow; esophagogastroduodenoscopy (EGD)
• Management includes frequent, small feedings that can pass easily through the esophagus; patient advised not to recline for 1 hour after eating and to elevate the head of the bed.
• 50% of patients may experience early postoperative dysphagia; the nurse advances the diet slowly from liquids to solids, while managing nausea and vomiting, tracking nutritional intake, and monitoring weight.
• Indicates need for medical revision if patients have belching, vomiting, gagging, abdominal distention, and epigastric chest pain.

Prevacid (Lansoprazole)

• Proton pump inhibitor
• Treats: stomach ulcers, damaged esophagus, GERD, high levels of stomach acid.
• DO NOT TAKE WITH ALCOHOL
• Potential risk of gastric acid suppression is the loss of protective flora and an increased risk of Clostridium difficile
• For a 2-min infusion (IVP), give the reconstituted vials (4 mg/mL) over at least 2 min -May inrease the risk of hip fractures
• Interferes with absorption of B12, iron, and magnesium.
• Interacts with diuretics and clopidogrel (Plavix)