Hiatal Hernia: Types, Symptoms, and Management

Hiatal Hernia

• Two types: sliding and paraesophageal/rolling.
• Sliding Hiatal Hernia involves the esophagogastric junction protruding into the thoracic cavity and back, related to position changes.
• Primary cause of sliding hiatal hernia is muscle weakness in the esophageal hiatus.
• Paraesophageal Hiatal Hernia or rolling Hernia involves the fundus of the stomach and greater curvature protruding into the thorax next to the esophagus while the gastric junction remains below the diaphragm.

Clinical Manifestations of Hiatal Hernia

• Heartburns due to gastroesophageal reflux
• Dysphagia, odynophagia from esophagus compression
• Dyspnea from lung compression
• Abdominal pain from protruding stomach portion compression
• Nausea and vomiting from sensitive structure stimulation
• Gastric distention, belching, flatulence due to gas accumulation caused by impaired motility

Medical Management of Hiatal Hernia

• Antacids relieve heartburns
• Antiemetics relieve nausea and vomiting, examples include:
  • Vontrol (Diphenidol HCI)
  • Anzemet (Dolasetron)
  • Marinol (Dronabinol)
  • Kytril (Granisetron)
  • Atarax (Hydroxyzine HCI)
  • Antivert (Meclizine HCI)
  • Vistaril (Hydroxyzine Pamoate)
  • Reglan (Metoclopramide)
  • Zofran (Ondansentron)
  • Compazine (Prochlorperazine)
  • Phenergan (Promethazine HCI)
  • Transderm- Scop (Scopolamine Transdermal)
  • Torecan (Thiethylperazine Maleate)
  • Tigan (Trimethobenzamide HCI)
• Histamine H2 Receptor Antagonists suppress gastric acid secretion:
  • Tagamet (Cimetidine)
  • Zantac (Ranitidine)
  • Axid (Nizatidine)
  • Pepcid (Famotidine)
• Proton Pump Inhibitors suppress gastric acid secretion:
  • Nexium (Esomeprazole)
  • Prevacid (Lansoprazole)
  • Prilosec (Omeprazole)
  • Protonix (Pantaprazole)
  • Aciphex (Rabeprazole)
• Clients should avoid drugs that lower LES pressure to prevent gastroesophageal reflux, including anticholinergics, xanthine derivatives, calcium channel blockers, and diazepam.

Nursing Interventions for Hiatal Hernia

• Relieve pain by administering antacids
• Modify diet:
  • High protein diet enhances LES pressure and prevents esophageal reflux
  • Small frequent feedings prevent gastric distention and stomach protrusion into the thoracic cavity
• Instruct the client to eat slowly and chew food properly to reduce gastric motility
• Clients should avoid foods and beverages that decrease LES pressure like fatty foods, cold beverages, coffee, tea, chocolate, and alcohol
• Assume an upright position before and after eating for 1 to 2 hours to prevent stomach protrusion into the thoracic cavity
• Avoid eating at least 3 hours before bedtime to prevent nighttime reflux
• Avoid evening snacks
• Advise the client to reduce weight if obese
• Promote lifestyle change by elevating the head of the bed 6 to 12 inches for sleep
• Avoid factors that increase abdominal pressure, such as constrictive clothing, straining at stool, heavy lifting, bending, stooping, vigorous coughing
• Avoid cigarette smoking, which causes a significant drop in LES pressure
• Surgical intervention is Nissen Fundoplication or gastric wrap-around

Abdominal Hernia

• Protrusion of an organ or structure through a weakened abdominal muscle, either congenital or acquired.

Causes of Abdominal Hernia

• Congenital or acquired muscle weakness.
• Increased abdominal pressure due to heavy lifting, obesity, or pregnancy.

Types of Abdominal Hernia

• Reducible hernia- can be returned by manipulation
• Irreducible hernia- requires surgery
• Inguinal Hernia- common among males
  • Indirect inguinal hernia- protrusion through the inguinal ring
  • Direct inguinal hernia- protrusion through the inguinal wall
• Umbilical hernia- common among infants
• Femoral hernia- common among females
• Incisional hernia- common after surgery
• Incarcerated hernia- bowel obstruction
• Strangulated hernia- compromised blood flow

Clinical Manifestations of Abdominal Hernia

• Lump in the groin, around the umbilicus, or from an old surgical incision
• Sensation of heaviness in the area, with vague discomfort
• Nausea, vomiting, distention, and pain indicate strangulated hernia

Surgical Management of Abdominal Hernia

• Herniorrhaphy (Hernioplasty)

Pre-Operative Care for Abdominal Hernia Surgery

• Assess for respiratory tract infection

Post-Operative Care for Abdominal Hernia Surgery

• Encourage deep breathing exercises
• Increase fluid intake
• Monitor for bladder distention
• Elevate the scrotum with a rolled small towel, apply an ice bag over the scrotum
• Monitor for discharge teachings

Gastric Cancer

• More common among middle-aged males.

Predisposing Factors for Gastric Cancer

• Diet high in carbohydrates, grains, salt, smoked foods, and low in fresh produce.
• Smoking and alcohol ingestion
• Use of nitrates and nitrites as food preservatives
• Overheated fat products
• Helicobacter pylori infection, chronic atrophic gastritis, pernicious anemia, and history of gastric ulcers.

Clinical Manifestations of Gastric Cancer

• Progressive loss of appetite
• Gastric fullness
• Dyspepsia or indigestion
• Positive guiac stool exam
• Hematemesis (vomiting blood)
• Melena (black, tarry stool)
• Weight loss, anemia, and fatigue
• Pain induced by eating, relieved by vomiting
• Palpable abdominal mass

Medical Management of Gastric Cancer

• Chemotherapy and radiation therapy
• Surgery- Total Gastrectomy: the esophagus is anastomosed to the jejunum, leaving the duodenum for bile transport

Peptic Ulcer Diesease

• Impairment of the mucosa and deeper structures of the esophagus, stomach, and duodenum.
• Helicobacter Pylori

Predisposing Factors for Peptic Ulcer Disease

• Stress, cigarette smoking, alcohol, caffeine
• Drugs- ASA
• Gastritis and Zollinger Ellison Syndrome
• Irregular hurried meals
• Fatty, spicy, and highly acidic foods
• Type A personality
• Type O blood
• Genetics

Gastric Ulcer

• Poor man's/laborer's ulcer
• 20% incidence rate
• 50 years old and above
• Malnourished
• Normal gastric emptying and HCl secretion
• Pain radiates to the left side of the abdomen, experienced 0.5 to 2 hours after eating
• Dully, aching, gnawing epigastric pain
• Not relieved by food intake
• Nausea, vomiting, and hematemesis.
• Potential for hemorrhage, perforation, peritonitis

Duodenal Ulcer

• Executive's ulcer
• 80% incidence rate
• 25 to 50 years of age
• Well-nourished
• Pain radiates to the right side of the abdomen, experienced 3 to 4 hours after eating
• Described as dull, aching, gnawing epigastric pain
• Relieved by food intake
• Melena, hemorrhage, perforation, peritonitis, and obstruction may occur

Medical Management of Peptic Ulcer

• Antacids- neutralize HCl, best administered 1 to 2 hours after eating.
• Histamine (H2) Receptor Antagonists- reduce HCl secretion, best taken in the morning and at bedtime.
• Cytoprotective drugs- coats the ulcers and enhances prostaglandin synthesis.
• Prostaglandin Analogue- replaces gastric prostaglandin and suppresses secretion of gastric acid.
• Proton Pump Inhibitors- suppress gastric acid secretion.
• Anticholinergics- reduce gastric motility
• Antimicrobials

Nursing Management of Peptic Ulcer

• Relieve pain by administering antacid as prescribed
• Encourage a healthy lifestyle and smoking cessation
• Enhance coping through stress therapy

Surgical Management of Peptic Ulcer

• Vagotomy- resection of the vagus nerve to decrease gastric motility and HCl secretion.
• Pyloroplasty- surgical dilatation of the pyloric sphincter to improve gastric emptying.
• Antrectomies- surgical resection of 50% of the distal part of the stomach followed by anastomosis with the duodenum or jejunum.
  • Billroth I (Gastroduodenostomy): anastomosis of the gastric stump with the duodenum
  • Billroth II (Gastrojejunostomy): anastomosis of the gastric stump with the jejunum
• Subtotal Gastrectomy- removal of 75% of the distal stomach with a Billroth I or II repair

Nursing Management for Gastric Surgery

• Pre-Operative Care: providing psychosocial support, teaching the cleint DBCT, providing nutritional support, and informing the client and family on postoperative measures

Post-Operative Care for Gastric Surgery

• Airway and ventilation, promote adequate nutrition, and prevent complications like bleeding and leakage from anastomosis

Dumping Syndrome

• Unpleasant vasomotor and GI symptoms caused by rapid emptying of gastric content into the jejunum, resulting in fluid shift and decreased blood volume leading to shock.
• Early signs/symptoms: weakness, tachycardia, dizziness, diaphoresis, pallor, feeling fullness or discomfort, nausea, abdominal cramps, and diarrhea. Occur 5-30 minutes after eating.
• Late signs/symptoms: hyperglycemia followed by increased insulin secretion, leading to hypoglycemia. Occurs 2-3 hours after eating

Management of Dumping Syndrome

• Client should eat in a lying position and place the client in left side-lying position after meals
• Small, frequent feedings of high-protein foods.
• Limit carbohydrates and simple sugars.
• Take fluids after or between meals, not with meals
• Teach client to avoid hot and cold foods and beverages
• Administer anticholinergics or antispasmodics 30 minutes before meals

Possible Conditions After Gastric Surgery

• Marginal ulcers- caused by gastric acids coming into contact with the area of anastomosis with the duodenum or jejunum
• Alkaline Reflux Gastritis- caused by reflux of duodenal contents
• Vitamin B12 Deficiency- due to loss of intrinsic factor, leading to pernicious anemia

Appendicitis

• Inflammation of the vermiform appendix.
• Common causes: obstruction by fecalith, foreign bodies, or infection.

Other Causes of Appendicitis

• Low fiber diet and high intake of refined carbohydrates

Clinical Manifestations of Appendicitis

• Begins in the epigastric or umbilical region, localizing to the right lower quadrant at McBurney's point
• Anorexia, nausea, and vomiting due to vagal stimulation
• Rigid abdomen and guarding as protective measures
• Rebound tenderness (Blumberg sign)
• Fever and leukocytosis, with WBC level of 20,000/cu.mm indicating peritonitis
• Psoas sign as a protective mechanism
• Decreased or absent bowel sounds

Management of Appendicitis

• Bed rest to reduce peristalsis
• Maintain NPO to observe pattern of abdominal pain
• Pain relief with cold application over the abdomen
• Avoid factors that increase peristalsis
• Intravenous therapy to maintain fluid and electrolyte balance.
• Antibiotic therapy to control infection
• Surgery: appendectomy

Appendectomy and Post-Operative Care

• If spinal anesthesia is administered position patient flat for 6 to 8 hours to prevent headaches
• Monitor the return of sensation in the lower extremities
• Maintain NPO until peristalsis returns
• Ambulate the client after 24 hours to prevent postop complication
• A Penrose drain is inserted to drain exudates when appendicitis is ruptured.
• Client should be placed in semi-Fowler's position to localized inflammation in the pelvic area
• Clean the insertion site of the penrose drain separately to prevent infection
• Mobilization of penrose drain involves pulling out 1 inch of the drain daily

Peritonitis

• Inflammation of the peritoneum related to ruptured appendicitis, perforated peptic ulcer, diverticulitis, etc

Inflammatory Process results in the following

• Adhesions, abscess formation, and intestinal obstruction
• Decreased peristalsis:
  • Fluid shifting into the abdominal cavity
  • Bowel distention with gas and fluid
  • Hypovolemia, electrolyte imbalances, dehydration and shock

Clinical Manifestations of Peritonitis

• Abdominal pain and tenderness
• Abdominal guarding and rigidity
• Abdominal distention
• Paralytic ileus
• Fever and elevated WBC
• Nausea and vomiting.
• Signs of early shock: restless, tachycardia, tachypnea, weakness, pallor, diaphoresis, oliguria

Management of Peritonitis

• Monitor vital signs and intake and output to assess fluid balance.
• NGT insertion to relieve abdominal distention.
• Bedrest in Semi-Fowler's position to localize inflammatory process in the pelvic cavity.
• Encourage deep breathing to prevent respiratory complications
• Peritoneal lavage removes exudates

Diverticulitis

• Acute inflammation and infection caused by trapped fecal material/bacteria in an outpouching of the mucosal lining of the colon
• Diverticulum is a single outpouching
• Diverticula: multiple outpouchings
• Commonly caused by a low-fiber diet which leads to increased muscular contractions of the colon to push feces, the muscular contracts of the colon weakens
• Scarring and abscess formation, bleeding, perforation, and peritonitis may occur

.Clinical Manifestations for Diverticulitis

• Crampy abdominal pain in the left, lower quadrant that worsens with movement, coughing, or straining
• Episodes of diarrhea
• Obstruction in the colon causes constipation
• Low grade fever due to inflammation and infection
• Nausea and vomiting due to vagal stimulation
• Abdominal distention and tenderness due to accumulation of gas

Management of Diverticulitis

• High fiber diet to increase bulk of the feces and promote peristalsis
• Liberal fluid intake of 2,500 to 3,000 ml/day to prevent constipation
• Avoid nuts and seeds as they can become trapped in diverticula
• Bulk-forming laxatives to promote peristalsis and defecation Examples: Metamucil, Fiberall, Konsyl, Serutan, Modane Bulk (Psyllium Hdrophillic Mucilloid)
• During an acute episode:
  • Bed rest to reduce peristalsis
  • NPO followed by clear liquid diets
  • Avoid high fiber foods

Management of Diverticulitis complications

• Intravenous fluids to replace fluid and electrolytes
• Antibiotics, antispasmodics/anticholinergics, and NGT insertion to relieve abdominal distention
• Weight reduction is obese

Inflammatory Bowel Disease (IBD)

• 2 Types: Crohn's & Ulcerative Colitis

Crohn's Disease

• Diarrhea & Transmural
• The ileum and transcending colon are commonly affected.
• Inflammation is discontinuous (regional)
• Stool is with pus and mucus + is common
• Age groups: 20-30’s and 40-60’s
• Fistula formation
• Abdominal pain, weight loss, & Sepsis

Crohn's Management

• Low fiber
• TPN- malnutrition
• Steroid- inflammation
• Azulfidine -antibiotic & anti-inflammatory effects
• Antibiotics like Flagyl (Metronidazole) and Cipro (Ciprofloxacin).
• Surgery: Ileostomy, Colectomy (Stoma found in the right lower w/ continuos water fecal drainage

Ulcerative Colitis

• Watery Diarrhea
• Mucous ulceration (intestine)
• Inflammation starts from the rectum, it ascends until the entire lower colon
• Stool is with pus, mucus, and blood plus Severe Bleeding
• Age groups -15-40yrs
• Rectal involvement + familiar and associated w/ stress

Ulcerative Colitis Management

• Low fiber diet
• TPN-sever malnutritioon
• Steroids(hydrocortisone)- inflammation
• Azufidine- infection/inflammation
• Surgery- Ileostomy, Proctocolectomy

Hemmorrhoids

• Dilated blood vessels of the anal canal
• Caused by: Constipation Pregnancy, obesity, prolonged sitting or standing, wearing constricting clothing, liver cirrhosis, right sided congestive heart failure(anything affecting blood flow to that lower extremities

Hemmorrhoids: Clinical Manifestations

• Constipation
• Anal Pain
• Rectal Bleeding
• Anal Itchiness

Hemmorrhoids: Management

• High fiber diet
• Increase oral fluid intake
• Stool softeners/bulk laxatives
• Apply cold packs to the anal area followed by warm sitz bath
• Apply witch hazel soaks and topical anesthetics

Surgical Management

• Hemorrhoidectomy

:Pre-Op Post Op

• Low residue/Stool softeners

Post Op Post-care

Assist client to a side-lying position

• Monitor the client for urinary retention
• Encourage them Warm sitz bath 12 to 24 hours post- op
• Stool softeners/ Increase fluid
• Continued Rectal bleeding, drainage, & Pain with defacation
• Assist client in a side- lying position
• Apply ice packs over the dressing as prescribed for the first 12 hours

Intussusception

• Telescoping of one portion of bowel (proximal) into another portion (distal)
• Results in an obstruction to the passage of intestinal contents

Clinical Manifestations

• Currant jelly stools stools (Stools containing blood and mucous)
• Colicky abdominal pain knees to the abdomen
• vomitting of gastric content/bile stained Fecal emesis
• Hypoactive or hyperreactive bowel sounds
• Palpable sausage shaped mass mass in the upperquadrant

Management

###- Monitor the signs of perforation and shock.Administer antibiotics ###- Monitor Antibiotics iv fluids/ decom-Ngt/ normal stool

Monitor bowel sounds.Administer clear

###- Hydrostatic surgery req barium enema

Colorectal Cancer 70%

:Predisposing Factors

• -Above 40, dietary factors, low fibe/ high protein/ refinined and other factors

clinical management of colorectal cancer

• Duke’s classification; staged A-D/ 5 year survival rate is less than 5%
• Guidelines for early detection: early rectal exams above 40, blood stool tests at 50s and proctosigmoids tests with negative results

Management options:

Chemo and radio therapy

Nursing Management of Colostomy

• Colostomy
• -Ascending: watery drainage
• -Transverse -the right side proximal drains semi- formed feces. the left stoma distal drains mucus-
• -Decending and sigmoid the right side of the abdomen.
• Fecal Drainage is well formed and to be done at home

colostomy Post operative care

• Managing perineal wound in APR , Irrigations and absorbent dresssing for a whie
• • Drainage will continue
• The T-binder will continue
• Provide Side and -sit baths
• Monitor the Stoma which will be red and edematous for the first week and drain fluid withing a week.
• Monitor fluid and empty bag regularly to prevent issues with air quality
• Irrigation with an enema to remove build up and increase the stoma, the stoma can be dilated. With gloves apply to the open sore. Remember to clean the surface afterword. You can always add a protective skin barrier.