Diarrhea and Fecal Incontinence

Diarrhea

• Diarrhea is defined as passing at least 3 loose or liquid stools daily and can be acute, persistent or chronic
• Can result from changes in GI motility, increased secretion or decreased absorption
• The primary cause is ingesting infectious organisms
• Acute diarrhea cases all need to be considered infectious until proven otherwise, and require infection control precautions
• Most infectious diarrhea is self-limiting and does not need hospitalization
• Patients on antibiotics are susceptible to Clostridioides difficile (C. difficile), a serious bacterial infection
• C. difficile infections are treated with antibiotic therapy or fecal microbiota transplant
• Diagnosis and management requires a thorough history, physical assessment, and laboratory testing
• Treatment is dependent on the cause
• Overall goals involve a return to normal bowel habits, fluid and electrolyte balance, nutritional status and no perianal skin breakdown

Fecal Incontinence

• Fecal incontinence is the involuntary passage of stool when normal continence-maintaining structures are disrupted
• Risk factors are constipation, diarrhea, obstetric/surgical trauma, neurologic problems, anorectal surgery, radiation therapy and fecal impaction
• Prevention and treatment rely on a comprehensive bowel training program and maintaining perineal skin integrity

Constipation

• Constipation involves having < 3 stools per week
• It is often accompanied by straining, a feeling of incomplete evacuation, a need for digital assistance to pass stool, bloating, and hard stools
• Clinical presentation varies with cause from chronic discomfort to an acute event
• It can be prevented with increased dietary fiber, fluid intake and exercise
• Laxatives are an option
• A key nursing role is teaching the importance of dietary and activity measures

Acute Abdominal Pain

• It is a new pain that may signal a problem requiring immediate surgery or other medical treatment
• The pain is a symptom of tissue injury and can arise from damage to abdominal or pelvic organs and blood vessels
• Pain is the most common symptom of abdominal and pelvic problems
• Nausea, vomiting, diarrhea, fatigue, fever, and constipation may be present
• Expected outcomes include resolution of the cause, pain relief, freedom from complications like hypovolemic shock/sepsis and normal nutrition
• Monitor patients frequently to detect deterioration in their condition, like fever, increased pulse/respirations, decreased BP/oxygenation, altered mental status, poor skin perfusion, or decreased urine output

Abdominal Trauma

• Blunt abdominal trauma occurs with motor vehicle accidents, direct blows, and falls
• Penetrating trauma occurs with gunshot or knife wounds
• Injuries include lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragm/urinary bladder rupture, great vessel tears, renal injury, and stomach/intestine rupture
• Management focuses on establishing a patent airway and adequate breathing, fluid replacement, and prevention of hypovolemic/septic shock

Chronic Abdominal Pain

• Common diseases that cause this type of pain include irritable bowel syndrome (IBS), diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflammatory disease, and vascular insufficiency
• Treatment depends on the cause

Irritable Bowel Syndrome (IBS)

• IBS is a disorder characterized by chronic abdominal pain and altered bowel patterns (diarrhea, constipation, or both)
• The cause is unknown, diagnosis is based solely on symptoms
• Treatment focuses on psychological, lifestyle, and dietary changes, along with medications to regulate output and reduce pain/discomfort

Appendicitis

• Appendicitis is inflammation of the appendix
• Obstruction results in distention, venous engorgement, and accumulation of mucus/bacteria, leading to gangrene and perforation
• The condition typically begins with periumbilical pain, followed by anorexia, nausea, and vomiting
• Pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney's point
• Standard treatment is immediate surgical removal, with antibiotics and fluid resuscitation sometimes needed before surgery

Peritonitis

• Peritonitis is inflammation of the peritoneum, resulting from contamination of the peritoneal cavity with bacteria or irritating chemicals
• Secondary peritonitis is most common, which happens when organs perforate or rupture
• Common symptoms are abdominal pain, hard abdomen, and tenderness over the involved area
• Major concerns are maintaining fluid/electrolyte balance and preventing septic shock
• Surgery drains purulent fluid and repair damage, as well as nasogastric suction, antibiotics, analgesics and IV fluids

Gastroenteritis

• Gastroenteritis is inflammation of the mucosa of the stomach and small intestine
• Clinical manifestations are sudden diarrhea with nausea, vomiting, fever, and abdominal cramping
• Most cases are self-limiting and do not need hospitalization
• Appropriate antibiotic and antimicrobial drugs are given if the causative agent is identified
• Nursing care focuses on maintaining adequate hydration and relief of nausea, vomiting, and diarrhea

Inflammatory Bowel Disease (IBD)

• Crohn’s disease and ulcerative colitis are immunologically related disorders referred to as IBD
• IBD is characterized by an overactive, inappropriate, sustained immune response to normally tolerated substances
• Patients have mild to severe acute exacerbations at unpredictable intervals
• Ulcerative colitis affects the mucosal layer of the rectum and colon, but some patients have mild inflammation in the terminal ileum
• Primary symptoms are bloody diarrhea and abdominal pain
• Crohn’s disease can occur anywhere in the GI tract from the mouth to the anus but occurs most often in the terminal ileum and colon
• Inflammation involves all layers of the bowel wall with segments of normal bowel occurring between diseased portions, hence the name "skip lesions."
• Diarrhea and colicky abdominal pain are common symptoms for Crohn's disease
• Small intestine involvement causes weight loss and nutritional problems from malabsorption and systemic symptoms
• Treatment goals for IBD include bowel rest, control of inflammation, improve nutrition, symptomatic relief, and improved quality of life
• Medications are used to achieve and maintain remission, with five major classes of drugs: aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, and biologic therapy
• Ulcerative colitis can be cured with a total colectomy, since the colon and rectum are not needed for survival
• Surgery is a last resort for Crohn’s disease due to high recurrence rates and the risk for developing short bowel syndrome
• Surgery is needed if the patient with IBD does not respond to treatment, experiences frequent and debilitating exacerbations, massive bleeding, perforation, strictures, obstruction or has tissue changes suggesting dysplasia/cancer
• Nursing during an acute exacerbation of IBD is focused on hemodynamic stability, pain control, fluid and electrolyte balance, and nutritional support
• Nurses and other team members can help patients to accept the chronicity of IBD and learn ways to cope with its recurrent, unpredictable nature.

Bowel Obstruction

• Bowel obstruction can be partial or complete, simple or strangulated, and occurs in either the small or large intestine
• Partial obstructions usually resolve with conservative treatment, complete obstructions usually need surgery
• A simple obstruction has an intact blood supply, while a strangulated one does not
• Physical (mechanical) obstructions are visible
• Obstructions that are caused by impaired neuromuscular function or a poor blood supply to the intestines cannot be seen
• An obstructed bowel causes retention of fluid in the intestine and eventually the peritoneal cavity, a condition that which lead to reduced circulating blood volume followed by hypotension and hypovolemic shock
• Clinical manifestations vary with location and include nausea, vomiting, abdominal pain, abdominal distention, inability to pass flatus, obstipation, and symptoms of hypovolemia
• Strangulation leads to tissue death and emergency surgery is needed for survival
• Nursing care revolves around managing acute pain, maintaining fluid volume, promoting nutrition, and close monitoring for impending hypovolemic or septic shock

Polyps of the Large Intestine

• Adenomatous polyps are characterized by neoplastic changes in the epithelium and are closely linked to colorectal cancer
• Familial adenomatous polyposis (FAP) is the most common hereditary polyp disease
• Polyps are easily removed during colonoscopy or sigmoidoscopy

Colorectal Cancer (CRC)

• Major risk factors for CRC include increasing age, a family/personal history of CRC, colorectal polyps, and IBD
• Lifestyle factors include obesity, smoking, alcohol, and diet
• Symptoms often do not appear until advanced stages and include rectal bleeding, abdominal pain, and/or changes in bowel habits
• Most CRC arises from adenomatous polyps. Early detection and removal of precancerous polyps can prevent most CRC
• Beginning at age 45, men and women at average risk should have screening tests to detect both polyps and cancer or tests that primarily detect cancer
• Colonoscopy is the gold standard for CRC screening
• Prognosis and treatment correlate with stage of the disease
• Treatments include removal of the tumor, removal plus chemotherapy, targeted therapy, or radiation; or palliative chemotherapy for nonresectable CRC
• Goals include normal bowel elimination patterns, quality of life appropriate to disease progression, relief of pain, and comfort/well-being
• Psychological support for the patient and family is important, given long recovery period and cancer recurrence risk

Surgical Bowel Resection

• Involves removing cancer, repairing a perforation, fistula, or traumatic injury, relieving an obstruction or stricture, and treating an abscess, inflammatory disease, or hemorrhage
• Depending on the problem, common procedures include:
  • A proctocolectomy with ileal pouch/anal anastomosis (IPAA), which consists of a 2 stage surgery, 8 to 12 weeks apart, and requires a temporary ileostomy
• A proctocolectomy with a permanent ileostomy: removal of the colon, rectum, and anus with closure of the anal opening
• Right hemicolectomy: involves removal of ascending colon and hepatic flexure with the ileum anastomosed to transverse colon
• Left hemicolectomy: involves the removal of splenic flexure, descending colon, and sigmoid colon
• Anterior rectosigmoid resection: involves removal of part of the descending colon, the sigmoid colon, and upper rectum
• Abdominal-perineal resection (APR): the entire rectum is removed with the creation of a permanent colostomy

Ostomy

• An ostomy is the surgical creation of an opening called a stoma that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen
• An ostomy is used when the normal elimination route is no longer possible
• Major nursing care aspects are emotional support during a radical change in body image and patient teaching about stoma care
• Pelvic surgery can disrupt nerve and vascular supplies to the genitalia, which can result in sexual dysfunction
• Postoperative nursing care includes wound care, monitoring for complications, promoting nutrition, assessing the stoma, and providing an appropriate pouching system
• The patient with an ileostomy should be observed for signs and symptoms of fluid and electrolyte imbalance, particularly potassium, sodium, and fluid deficits
• The patient should know to perform a pouch change, provide appropriate skin care, control odor, care for the stoma, and identify signs and symptoms of complications

Fistulas

• A fistula is an abnormal tract between 2 hollow organs or a hollow organ and the skin, and the name is based on the track it takes
• Fistulas are classified as simple or complex and also by the amount of output
• Fever and abdominal pain are early indicators of a fistula, but manifestations vary depending on the type of fistula
• Nursing care involves maintaining fluid and electrolyte balance, controlling infection, protecting the surrounding skin, managing output, and providing nutritional support, as well as complex wound care and surgery

Diverticulosis and Diverticulitis

• Diverticula are saccular dilations or outpouchings of the mucosa that develop in the colon
• Diverticulitis is inflammation of the diverticula, resulting in complications such as perforation, abscess, fistula formation, and bleeding
• The cause of diverticuli is unknown, but the contributing factors are diet and lifestyle
• Most patients with diverticular disease are asymptomatic, but those with symptoms will report abdominal pain, bloating, flatulence, and/or changes in bowel habits
• A high-fiber diet, mainly from fruits and vegetables, with decreased intake of fat and red meat are recommended for preventing exacerbations of diverticular disease

Hernias

• A hernia is a protrusion of a viscus through an abnormal opening or a weakened area in the wall of the cavity in which it is normally contained
• Types of hernias include inguinal, femoral, and ventral or incisional
• They are diagnosed based on history and physical assessment
• Surgery is the treatment of choice
• Strangulation causes severe pain and bowel obstruction symptoms (vomiting, cramping abdominal pain, and distention) that require emergency surgery

Malabsorption Syndrome

• Malabsorption results from impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins
• Causes include biochemical or enzyme deficiencies, bacterial proliferation, disruption of small intestine mucosa, disturbed lymphatic and vascular circulation, and short bowel syndrome
• Treatment depends on the cause

Celiac Disease

• Celiac disease is an autoimmune disease characterized by damage to the small intestinal mucosa from the ingestion of wheat, barley, and rye in genetically susceptible persons with a genetic predisposition, where that individual ingests Gluten, resulting in an immune-mediated response
• Classic signs include foul-smelling diarrhea, abdominal pain, flatulence, and abdominal distention
• Malnutrition is common
• Early diagnosis/treatment can prevent complications like cancer, osteoporosis, and chronic inflammation
• The only effective treatment is a gluten-free diet for life

Lactase Deficiency

• Lactase deficiency is a condition in which the lactase enzyme is deficient or absent
• Symptoms are bloating, flatulence, cramping abdominal pain, and diarrhea, usually within a half hour to several hours after ingesting a milk product
• Treatment limits lactose by avoiding milk/milk products and/or using commercially available lactase preparations

Short Bowel Syndrome (SBS)

• SBS results from surgical resection of too much small bowel, congenital defect, or disease-related loss of absorption, with the length and portions of small bowel affected associated with the number and severity of symptoms
• SBS causes the inability to obtain adequate nutrients from a standard diet
• The syndrome is treated with dietary changes, supplements, and antidiarrheal medications
• Severe cases need parenteral nutrition for survival or a small intestine organ transplant

Gastrointestinal Stromal Tumors (GISTs)

• GISTs are a rare form of cancer originating in cells found in the wall of the GI tract
• They often metastasize even when surgically removed
• The discovery of specific effective gene mutations that are unresponsive to conventional chemotherapy has improved the prognosis of the disease

Hemorrhoids

• Hemorrhoids are dilated hemorrhoidal veins and can be internal (occurring above the internal sphincter) or external (occurring outside the external sphincter)
• Classic symptoms include bleeding with defecation, anal pruritus, prolapse, and pain
• Surgery may be needed when there is prolapse or excessive bleeding or pain
• Nursing teaches about preventing constipation, avoiding prolonged standing/sitting, safely using over-the-counter (OTC) drugs, and seeking medical care for severe symptoms

Anal Fissure

• An anal fissure is a linear tear in the anal mucosa that is caused by trauma, local infection, or inflammation
• Major symptoms are anal pain and bleeding
• Surgical repair is done if conservative treatment with fiber, fluids, sitz baths, and topical medications is ineffective

Anorectal Abscess

• Anorectal abscesses are collections of perianal pus resulting from an infection in the anal glands
• Manifestations are local pain and swelling, foul-smelling drainage, tenderness, and fever
• Treatment drains the abscess, and patient is taught about wound care, sitz baths, and cleansing after bowel movements

Anal Fistula

• An anal fistula is an abnormal tunnel leading from the anus/rectum to the vagina/outside skin and may be accompanied by infection and incontinence
• Fistulas may be closed by surgery or using fibrin glue
• Postoperative nursing care is the same as after a hemorrhoidectomy

Anal Cancer

• Anal cancer is uncommon but increasing in the general population
• Human papillomavirus (HPV) is associated with about 90% of cases
• High-risk groups are smokers, HIV-positive homosexual men, immunocompromised people, and women with cervical, vaginal, or vulvar cancer
• Rectal bleeding is often the first symptom, but other symptoms include rectal pain, itching, pressure, or a full feeling
• Treatment depends on the size and depth of the lesions and includes chemotherapy, radiation, and surgical resection

Pilonidal Sinus

• A pilonidal sinus is a small tract under the skin between the buttocks in the sacrococcygeal area
• Nursing care for a pilonidal cyst or abscess includes warm, moist heat applications and proper wound care