GI Disorders: Peritonitis to Pancreatitis

GI Disorders Overview

• Includes peritonitis, bowel obstruction, ostomy, pancreatitis and biliary tract diseases.

Learning Objectives

• Explain the interprofessional care of Peritonitis and the associated nursing management.
• Differentiate between small and large bowel obstructions, causes, manifestations, care, and management.
• Determine nursing interventions for patients post bowel resection and ostomy surgery.
• Describe the underlying mechanisms, signs and symptoms, complications, and management for acute pancreatitis.
• Explain the underlying mechanisms gallbladder disorders, the clinical manifestations, and interprofessional care.
• Clarify the nursing management required for patients undergoing surgical treatments for cholecystitis and cholelithiasis.

Key Terms

• Acute Pancreatitis
• Bowel Obstruction
• Cholecystitis
• Cholelithiasis
• Chronic Pancreatitis
• ERCP
• Fistula
• Jaundice
• Lapchole
• Ostomy
• Paralytic Ileus
• Peritonitis

Peritonitis

• Inflammation of the peritoneum caused by bacteria or irritating chemicals contaminating the peritoneal cavity.
• Primary peritonitis stems from blood-borne organisms.
• Secondary peritonitis results from organ perforation, spilling contents into the cavity

Peritonitis: Pathophysiology

• Initial chemical peritonitis advances to bacterial form.
• This progression results in fluid shifts and adhesions.

Peritonitis: Clinical Manifestations

• Severe, continuous abdominal pain is most common.
• Tenderness is a universal sign.
• Rebound tenderness, rigidity, and spasm are common due to peritoneal irritation.
• Shallow breathing, abdominal distention, fever, tachycardia, nausea, vomiting, decreased appetite, and altered bowel habits can occur.
• Potential complications include hypovolemic shock, sepsis, intraabdominal abscess, paralytic ileus, and ARDS.

Peritonitis: Diagnosis

• Diagnosis using history and physical examination (H&P).
• Complete blood count can be performed including WBC and hemoglobin (H&H).
• CMP will measure electrolytes, organ function
• Peritoneal aspiration.
• Abdominal x-ray.
• Ultrasound.
• CT scan.
• Peritoneoscopy is also performed.

Peritonitis: Interprofessional Care

• Preoperative care involves NPO status, nasogastric suction, IV fluids, antibiotics, analgesia, and antiemetics particularly in mild cases or with poor surgical risk.
• Surgery involves locating the source, draining purulent fluid, and repairing the damaged organ.
• Postoperative care includes NPO, IV fluids, nasogastric suction, blood transfusions, parenteral nutrition, antibiotics, sedatives, opioids, and antiemetics.

Peritonitis: Implementation

• Implementation starts with IV access for fluids and antibiotics.
• Pain management includes analgesia and positioning with knees flexed.
• Anxiety must be reduced with sedatives, and rest should be promoted.
• Monitor vital signs, intake and output, and oxygen levels.
• Administer antiemetics for nausea and vomiting.
• Maintain NPO status and low intermittent nasogastric suction as needed.
• Drains require appropriate care.

Intestinal Obstruction - Mechanical and Nonmechanical

• Intestinal Obstruction: Contents are unable to pass through intestines.
• Obstructions can be small bowel (SBO) or large bowel (LBO) obstructions.
• Obstructions can be partial where contents can get through
• Obstructions can be complete and require surgery
• A simple obstruction leaves the blood supply intact.
• A strangulated obstruction does not have blood supply.
• Two main types: mechanical or nonmechanical.

Bowel Obstruction: Mechanical

• Most obstructions occur in the small intestine.
• SBO is often caused by surgical adhesions.
• SBO can also stem from hernias, cancer, strictures from Crohn's disease, and intussusception,
• LBO is from colorectal cancer or diverticular disease.
• LBO also linked to adhesions, ischemia, volvulus, and Crohn's disease

Bowel Obstruction: Nonmechanical

• Absent peristalsis due to altered neuromuscular parasympathetic innervation.
• Paralytic ileus is a subtype marked by lack of peristalsis and bowel sounds.
• Paralytic Ileus is the most common form of nonmechanical obstruction; usually affects both intestines.
• Paralytic ileus causes are abdominal surgery, peritonitis, inflammatory disorders, electrolyte imbalances, along with thoracic/lumbar spinal fractures.

Pseudo-obstruction

• Rare GI motility disorder mimicking mechanical obstruction but not visible on imaging.
• Usually affects large intestine only.
• Associated with neurologic conditions, drugs, endocrine and metabolic problems, lung disease, trauma, and burns.

Vascular Obstruction

• Emboli or thrombi alter blood supply to a part of the intestines.

Pathophysiology of Small and Large Bowel Obstructions (SBO and LBO)

• Fluid, gas, and intestinal contents back up proximally relative to the obstruction.
• This results in proximal bowel distention that reduces fluid absorption and stimulates intestinal secretion.
• The distal bowel empties and collapses.
• Increased pressure in the bowel lumen leads to increased capillary permeability.
• There is extravasation of fluids and electrolytes into the peritoneal cavity.
• Circulating blood volume decreases along with hypotension and hypovolemic shock.
• Intestinal muscle eventually fatigues and peristalsis stops from increasing distention.
• Blood flow to bowel is inadequate.
• Perforated bowel requires immediate treatment to avoid severe infection to avoid septic shock, and possible death.

SBO, LBO: Progression of Events

• Bowel becomes edematous, then ischemic.
• Prolonged ischemia leads to necrosis and gangrene.
• Gangrene leads to perforation.

Bowel Obstruction: Clinical Manifestations

• Hallmarks include abdominal pain, nausea/vomiting, distention, and constipation.
• The order and degree of these symptoms varies according to the cause, location, and type of obstruction.
• Bowel sounds may be high-pitched, absent in paralytic ileus, or hypoactive in LBO.

Manifestations by Location of Obstruction

• Small Bowel: Rapid onset; Frequent, copious vomiting (bile or stool) if proximal; Colicky, intermittent pain in mid to upper abdomen; may produce stool at first; minimal abdominal distention if proximal, more if distal.
• Large Bowel: Gradual onset; vomiting is rare; persistent crampy lower abdominal pain; no stool, "obstipation" (complete obstruction vs partial); abdominal distention more noticeable.

Bowel Obstruction: Diagnostics

• History and physical exam must be performed.
• Imaging includes abdominal x-rays, CT scans, and contrast enemas.
• For LBO: Sigmoidoscopy or colonoscopy.
• Blood tests: CBC and CMP
• Increased WBC indicates strangulation or perforation.
• Increased Hct indicates hemoconcentration.
• Decreased Hemoglobin and Hct indicate bleeding.
• Serum electrolytes, blood urea nitrogen (BUN), and creatinine reveal hydration status.
• Metabolic alkalosis indicates vomiting.

Bowel Obstruction Interprofessional Care

• Treatment goal is to regain intestinal patency which depends on cause.
• Emergency surgery is required for strangulation or perforation.
• Resection of obstructed segment with anastomosis.
• Partial or total colostomy or ileostomy for obstruction, necrosis, or perforation.
• Colonoscopy to remove polyps, dilate strictures, laser destruction, and removal of tumors.

Bowel Obstruction Interprofessional Care: Conservative Management

• Preferred if indicated, and paralytic ileus and adhesion related obstructions often resolve without surgical intervention.
• NG decompression is a hallmark treatment that reduces bowel distention reducing the risk of edema, necrosis, and perforation.
• Connect the NG tube to wall suction and monitor output.
• IV hydration.
• PVN if obstruction period is prolonged.
• Blood work must monitor for signs and symptoms of fluid, electrolyte, and acid-base abnormalities.

Bowel Obstruction: Nursing Management

• Obstruction is potentially life-threatening.
• Early recognition of deterioration in condition is key.
• A H & P needs to be performed and should assess the characteristics of abdominal pain.
• Vomitus: onset, frequency, color, odor, and amount.
• Bowel function: flatus, bowel sounds and movements.
• Abdomen: check for scars, masses, distention, tenderness, rigidity, girth, muscle guarding/rebound pain.
• Strict Intake and Output monitoring must be completed.
• Acid-Base Imbalance: Metabolic alkalosis with high obstruction and Metabolic acidosis with low obstruction.

Bowel Resection

• Possible Indications: Remove cancer, repair perforation, fistula, or traumatic injury, relieve obstruction or stricture, and treat an abscess, inflammatory disease or hemorrhage
• Common Etiologies: CRC, IBD, necrotic bowel, perforated ulcer, diverticulitis, and trauma.

Ostomy

• Surgically created opening on the abdomen for fecal elimination.
• Stoma is the outermost visible part of the ostomy.
• Large or small bowel brought to outside of abdomen and sutured in place.
• Ostomies are named according to location and type.
• The more distal the ostomy, the more likely contents will resemble normal feces.

Ostomy Types Cont.

• Ostomies can be temporary or permanent.
• A “Takedown” procedure corresponds to a reversal of ostomy.
• Output management is either traditional or continent.

Traditional Ostomy

• Includes End Stoma, Loop Stoma, Double-barrel Stoma

End Stoma

• Distal bowel removed and functions as permanent stoma.
• Distal bowel oversewn for possible reanastomosis with stoma closure called Hartmann's pouch.

Loop Stoma

• It is generally temporary.
• A loop of bowel to abdominal surface with anterior wall opened for fecal diversion.
• The distal opening allows to drain mucus and a plastic rod is placed in place for 7 to 10 days.

Double-Barrel Stoma

• Bowel divided, two stomas created; both proximal and distal ends through abdominal wall.
• Proximal provides fecal diversion.
• Distal serves as the mucus fistula and is usually temporary.

Continent Ileostomy

• Terminal ileum made into internal pouch with nipple valve and abdominal stoma.
• This incudes a Kock Pouch or Barnett Continent lleal Reservoir.
• Patient manually drains stool by insertion of a catheter.
• It must follow low-residue diet to keep stool more fluid.

Preoperative Care for Ostomy

• Includes psychological preparation and emotional support.
• Involves WOCN consult and education.
• Stoma site selection and considerations include ensuring it occurs within the rectus muscle to decrease risk of hernia.
• Flat surface offers better seal to reduce leaking , and the site should be easily accessible.

Postoperative Care for Ostomy

• Assess integrity of incision and skin around stoma.
• Monitor for complications such as delayed wound healing, hemorrhage, fistulas, and infection.
• Monitor for infection should include edema, redness, drainage, fever, and high WBC count.
• Keep area around surgical drains clean and dry, and Monitor dressings and change if saturated.
• Assess ostomy characteristics, it should be pink-red with mild swelling and small amount of blood.
• Maintain a clear pouch system and assess stoma every four hours.

Assessment of Colostomy/ Ileostomy Functioning

• Colostomy: Output typically occurs after peristalsis returns, or up to 2 days after the patient resumes a diet.
• Colostomy: Record volume, color, and consistency of drainage.
• Ileostomy: Excess gas is common for 2 weeks.
• Ileostomy: First 24 to 48 hours post-op show minimal drainage.
• Peristalsis returns to up to 1500 to 1800 mL/day with an ileostomy.
• The bowel gradually adapts and increases water absorption, which thickens feces, and volume decreases to approximately 500mL/day.

Postoperative Care after Bowel Resection and Ostomy

• Anal Canal: Transient incontinence of mucus occur.
• Kegel exercises should be commenced after 4 weeks.
• Perianal skin care is needed to prevent breakdown and infection.
• Phantom rectal pain.
• Sensation like needing to stool is a possibility.

Ostomy Care: Pouching System

• Includes adhesive skin barrier and pouch.
• Empty when one-third full to prevent pulling and leaks.
• Transparent pouch may be used to visualize stoma
• Pouch change necessary when assessing skin.
• Replace the pouch when failed.
• Use Charcoal filters to deodorize/release flatus.
• Irrigation for regulation of distal colon ostomy.
• Bathing, showering, and swimming won’t harm the stoma.

Ostomy Care: Patient and Caregiver Education

• Includes ostomy management skills.
• Diet must be balanced with adequate fluids and electrolytes.
• Diet should avoid odor, gas, and diarrhea-producing foods.
• Give the contact info for for resources for problems or home care, WOCN.
• Reassure that Patients can resume ADLs within 6-8 weeks of ostomy, and should avoid heavy lifting.

Ostomy Care

• Emotional support should be available, and concerns like grief, anger, depression, anxiety and fear can be discussed.
• Emotions may alter participation in care.
• Discuss body image and self-esteem, as well as identify coping strategies and support systems as necessary.
• Offer support sites like www.wocn.org or www.ostomy.org.
• Explain about hospital visitor programs and available support groups.
• Ostomy Education: Explain the purpose of ostomy function.
• Demonstrate and observe the patient/caregiver practice the following:
  • Removing old skin barrier then cleanse the skin, and correctly apply new skin barrier
  • Applying, emptying, cleaning, and remove the pouch
  • Emptying the pouch once it reaches one-third full.
• Educate on How to obtain ostomy supplies

Ostomy Education

• Emphasize how to recognize problems which includes fever, diarrhea, skin irritation, stomal problems, dehydration, and electrolyte imbalance.
• Consider impact to sexual function for the patient.
• Teach patient the effects from abdominal surgery and possible nerve/vascular disruption to genitalia.
• Address Males can be concerned with erection and ejaculation which may be temporary for 3 to 12 months.
• Recognize Females can have vaginal dryness and can fear rejection with this new change.
• Arousal and orgasm concerns are common.
• Acknowledge that pregnancy after ostomy is still possible.
• Teach about alternatives for pouching/security.

Ostomy - Foods to Limit/Avoid

• Asparagus, broccoli, cabbage, eggs, fish, garlic or onions can produce odor.
• Beans, beer, cabbage family, carbonated beverages, cheeses or onions can produce gas.
• Alcohol, beer, cabbage family, coffee, raw fruits or vegetables can produce diarrhea.
• To prevent obstruction: Chew thoroughly, especially any nuts, raisins, popcorn, coconut, mushrooms, olives, stringy vegetables, fruits with skins, dried fruits, or meats with casings.

Acute Pancreatitis

• Acute inflammation of the pancreas.
• Spillage of pancreatic enzymes into surrounding pancreatic tissue causes autodigestion resulting in severe pain, this may be mild to severe.
• Ranges from edema to hemorrhagic necrosis.

Acute Pancreatitis: Etiology

• Gallbladder disease stems from women.
• Reflux of digestive enzymes back into the pancreas from obstructive gallstones.
• Chronic alcohol use is linked to hypertriglyceridemia.
• Alcohol exact mechanism is unknown.
• Alcohol may increase production of pancreatic enzymes in men.
• Hypertriglyceridemia level is greater than 1000 mg/dL.
• Other less common causes stem from drug reactions and pancreatic cancer.

Acute Pancreatitis: Autodigestion & Severity

• Caused by autodigestion of pancreas through injury to cells and activation of pancreatic enzymes.
• Leads to activation of trypsinogen to trypsin creating bleeding.
• Mild pancreatitis correlates with edematous or interstitial presentation.
• Severe Necrotizing pancreatitis is correlated with long-lasting endocrine and exocrine dysfunction, can cause organ failure, sepsis, and overall has a 9% fatality rate.

Acute Pancreatitis: Clinical Manifestations

• Hallmark is abdominal pain that is predominantly epigastric and can radiate to the back.
• Sudden onset with sharp piercing that is consistent.
• Eating and laying down worsens pain.
• Guarding is also indicative of acute pancreatitis.
• There is no relief of abdominal pain, even with emesis.

Acute Pancreatitis: Symptoms Elsewhere In Body

• Cyanosis, dyspnea, crackles linked to the respiratory system.
• Nausea and vomiting may correlate with deceased or absence bowel function along with distention in the gastrointestinal system, when ileus is present.
• Immune system: Flushing, low-grade fever, leukocytosis.
• For the cardiovascular system it will affect tachycardia, hypotension, and shock.
• The skin should be observed for jaundice.
• If elevated bilirubin, or abdominal skin discoloration is observed check for Grey Turner's spots/ Cullen sign.

Acute Pancreatitis: Complications

• Pancreatic Pseudocyst can occur, composed of fluid, pancreatic enzymes, debris, and exudates, all surrounded by a wall.
• S/s: abdominal pain, palpable mass, nausea/vomiting, anorexia, resolves spontaneously or may perforate and cause peritonitis, requiring surgical, percutaneous, or endoscopic drainage.
• Pancreatic Abscess: Results from infected pseudocyst/extensive necrosis, or may rupture or perforate needing surgical drainage which should include upper abdominal pain, mass, high fever, and leukocytosis.

Acute Pancreatitis: Potential Systemic Complications

• Potential Systemic Complications: Pleural effusion, Atelectasis, Pneumonia, ARDS, Systemic Involvement, Hypotension and shock will all need further assessment and intervention.
• Thrombi, pulmonary embolism, and DIC, Hypocalcemia tetany, and Abdominal compartment syndrome can correlate to higher levels of acute manifestations.

Acute Pancreatitis: Lab Tests

• Serum amylase level, though most sensitive, not specified.
• Levels can elevate within 12 hrs.
• Normalization in blood may take up to five days to normal, useful for diagnostics.
• Serum lipase level is specified as primary diagnostic and elevate within 24-48 hours.
• Elevated elevations (normal is 5-10x norm).
• A bilirubin and liver value can be elevated in blood.
• Glucose levels may decrease depending on calcium levels.

Acute Pancreatitis: Diagnostics

• Abdominal ultrasound, X-ray, Contrast-enhanced CT scan, Magnetic resonance cholangiopancreatography (MRCP)
• Percutaneous aspiration should be done w/ cultures.
• Endoscopic and surgical evaluation need review.
  • Endoscopic retrograde cholangiopancreatography (ERCP)
  • Endoscopic ultrasonography (EUS)
  • Angiography.

Acute Pancreatitis: Interprofessional Care

• Focus on aggressive hydration through IV LR or NS.
• Management of metabolic complications by monitoring SpO2 if less that 95%.
• NPO status, NG suction, and meds to decrease acid secretion.
• The patient may need to be put on antibiotics along with CT for cultures and diagnosis.
• Administer Analgesics along with frequent position changes.

Interventions for Acute Pancreatitis

• Minimized position changes when needed, maintain abdominal comfort.
• Flex the trunk and draw knee to abdomen and side-lying are optimal interventions.
• Use a head of the bed in conjunction at least 45 degrees.
• Oral and nasal care should be considered.

Acute Pancreatitis: Drug Therapy

• Aggressive IV Hydration through LR or NS.
• The drug regimen include manage include IV Opioids (Morphine, Hydromorphone).
• Antipasmodics with Anticholinergics, such as Ex. atropine, dicyclomine (Bentyl), hyoscyamine, scopolamine.
• Carbonic anhydrase inhibitors, such as ex. acetazolamide, can be implemented for acute care.
• Antacids are an option.
• Proton pump inhibitors ("-prazoles").

Acute Pancreatitis: Surgical Therapy

• The need for Gallstone/Obstructive Pancreatitis is vital with ERCP along with evaluation for laparoscopic cholecystectomy.
• Drainage can be needed if there is fluid or necrotic collection/abscess/pseudocyst,
• Plasmapheresis can be introduced for this disorder.

Acute Pancreatitis: Recovery

• Use alcohol and smoking cessation programs.
• High-carbohydrate snacks is key in nutrition strategy.
• Low food consumption high in fat consumption can lead to a variety of systemic disorders.
• Be sure to get adequate vitamin consumption and diagnosis with biliary treatments.

Biliary Tract Disease: Cholelithiasis and Cholecystitis

• Cholelithiasis is the most common biliary system disorder with stones in the gallbladder.
• Cholecystitis is an inflammation of the gallbladder associated with gallstones or sludge and may be acute or chronic.

Biliary: Risk Factors

• Are female, multiparous and on estrogen therapy.
• Typically Age are older than 40 years, sedentary lifestyle, obesity, or have a familial tendency.
• Have are native american ancestry.

Cholelithiasis: Causes

• Exact cause is unknown.
• Stones develop from precipation of cholesterol, bile salts, bilirubin, calcium or protein deposits in bile.
• Bile secreted can be supersaturated with lithogenic bile with a change in bile.

Cholidocholithiasis

• Can lead to a variety of systemic conditions like obstructive jaundice,
• Can cause LFT increase the possibility of pancreatitis.
• Gallstone obstructed with the common bile duct.

Cholecystitis: Pathophysiology

• Acalculous cholecystitis can cause disorders from older patients or critical situations.
• Is often linked to prolonged fasting, immobility or cancer among other causes.
• Mucus can become edematous or hyperemic and is typically infected distention after cystic duct was excluded.

Gallbladder: Clinical Manifestations

• Biliary colic occurs 3-6 hours after a meal and is steady pain.
• Tachycardia diaphoresis will occur with radiated shoulder pain.

Biliary: Possible Complication

• Cholangitis will lead gallbladder damage and a possible increase in the pancreas.

Biliary Diagnostic Strategies

• Abdominal is diagnosed for gallstones.
• ERCP can send samples of common hepatic and will lead to possible biliary diagnosis.

Biliary: Surgical Therapy

• Laprascopic cholecystectomy leads to a few complications while leading to symptom relief.
• Incisons of T-tube allow for excess drainage.
• Drains decrease bile flow along with decrease fluid control.