Intestinal and Rectal Disorders

Intestinal and Rectal Disorders

Normal Bowel Function and Defecation

• The small intestine (duodenum, jejunum, ileum) absorbs nutrients.
• The large intestine (colon) absorbs water and forms stool.
• The rectum and anus store and eliminate waste.
• Defecation is stimulated by peristalsis and rectal distension.
• Defecation is influenced by diet, hydration, physical activity, and neurological control.

Constipation

• Primary (functional) constipation results from lifestyle factors, such as low fiber intake or dehydration.
• Secondary constipation may be caused by medications (opioids, antacids), neurological disorders (Parkinson's, stroke), or endocrine disorders (hypothyroidism).
• Signs and symptoms of constipation include infrequent bowel movements (less than 3 per week), straining, hard stools, and feeling of incomplete evacuation.
• Management includes dietary changes (increase fiber to 25-30g/day), hydration (2-3 liters of water daily), regular physical activity, and medications.
• Medications for constipation include bulk-forming laxatives (Psyllium), stool softeners (Docusate sodium), osmotic agents (Lactulose, Polyethylene glycol), and stimulant laxatives (Senna, Bisacodyl).

Diarrhea

• Diarrhea can be caused by infections (bacterial, viral, parasitic), food intolerance (lactose intolerance, celiac disease), or medications (antibiotics, laxatives).
• Diarrhea can lead to dehydration (especially in children and the elderly), electrolyte imbalances (hypokalemia, hyponatremia), and malabsorption.
• Management involves oral rehydration therapy (ORT) for mild dehydration, IV fluids for severe dehydration, antidiarrheal medications (Loperamide, Bismuth subsalicylate) if not infectious, probiotics, or diet modifications (BRAT diet - bananas, rice, applesauce, toast).

Hemorrhoids

• Internal hemorrhoids are located inside the rectum and may prolapse.
• External hemorrhoids are found under the skin around the anus and are more painful.
• Risk factors include chronic constipation, pregnancy, obesity, and prolonged sitting or standing.
• Symptoms include rectal bleeding (bright red blood), pain, itching, swelling, or a lump near the anus.
• Treatment involves lifestyle changes (increase fiber, hydration, avoid straining), topical treatments (hydrocortisone creams, witch hazel), sitz baths, or surgical interventions (hemorrhoidectomy, rubber band ligation for severe cases).

Irritable Bowel Syndrome (IBS)

• IBS subtypes include IBS-C (constipation dominant), IBS-D (diarrhea dominant), and IBS-M (mixed type).
• Common IBS triggers: stress, high-fat foods, caffeine, dairy, and artificial sweeteners.
• Symptoms: abdominal pain or cramping, altered bowel habits (diarrhea, constipation, or both), bloating, and excessive gas.
• Management: low FODMAP diet (avoid fermentable carbs) and medications.
• Medications for IBS include antispasmodics (Dicyclomine), fiber supplements (for IBS-C), Loperamide (for IBS-D), and probiotics.

Inflammatory Bowel Disease (IBD)

• Ulcerative Colitis (UC) affects the colon and rectum with continuous inflammation.
• Crohn's Disease can affect any part of the GI tract with patchy inflammation.
• Symptoms include chronic diarrhea (may contain blood or mucus), abdominal pain, weight loss, and malnutrition.
• Treatment includes anti-inflammatory drugs (Mesalamine, Sulfasalazine), corticosteroids for flare-ups, immunomodulators (Azathioprine, Infliximab), or surgery (colectomy for UC, bowel resection for Crohn's).

Diverticulosis and Diverticulitis

• Diverticulosis is the formation of small pouches (diverticula) in the colon.
• Diverticulitis is the inflammation/infection of diverticula.
• Diverticulitis symptoms: LLQ pain, fever, and nausea/vomiting.
• Diverticulitis treatment: high-fiber diet for prevention and antibiotics for infection.
• Other treatments: bowel rest (NPO, IV fluids) and surgery if complications occur (abscess, perforation).

Bowel Obstruction

• Small Bowel Obstruction (SBO) can be caused by adhesions, hernias, or tumors.
• Large Bowel Obstruction can result from colorectal cancer, volvulus, or diverticular disease.
• Symptoms include cramping abdominal pain, distension, vomiting (possibly with fecal odor), and absence of bowel movements or gas.
• Management includes NPO status, nasogastric (NG) tube for decompression, IV fluids, and surgical intervention if the obstruction does not resolve.

Colorectal Cancer

• Risk factors: family history, high-fat/low-fiber diet, smoking/alcohol use, or history of IBD.
• Symptoms to note include change in bowel habits, blood in stool, unintentional weight loss, and abdominal pain.
• Screening and prevention measures: colonoscopy (recommended at age 50, or earlier if high risk), high-fiber/low-fat diet and regular physical activity.
• Treatment options: surgery (colectomy), chemotherapy, and radiation therapy.

Ostomy Care (Ileostomy and Colostomy)

• Stoma should be healthy and appear pink/red and moist.
• An unhealthy stoma will appear pale, dusky, or black (ischemia).
• Nursing interventions: Empty pouch when 1/3 to 1/2 full.
• Change appliance every 3-5 days, or if leaking.
• Clean skin with warm water, avoiding alcohol-based cleansers and prevent skin irritation with barrier creams.

Malabsorption Syndromes

• Common types include Celiac Disease, Lactose Intolerance, and Short Bowel Syndrome.
• Symptoms: chronic diarrhea, steatorrhea (fatty stools), weight loss, and nutrient deficiencies (Iron, B12, Vitamin D).
• Management for Celiac Disease: gluten-free diet. For Lactose Intolerance: lactose avoidance or lactase supplements. Additionally, administer nutritional supplements for deficiencies.

Appendicitis

• Symptoms: RLQ pain (McBurney's point), rebound tenderness, nausea, vomiting, low-grade fever, and increased WBC count.
• Management includes surgical removal (appendectomy) and NPO before surgery.
• Pain management and monitor for signs of rupture (sudden relief of pain followed by peritonitis).

Short Bowel Syndrome (SBS)

• SBS Definition: malabsorption disorder due to extensive small intestine resection, leading to poor nutrient absorption.
• Causes may include surgical removal of large portions of the small intestine, Crohn's disease complications, and congenital birth defects.
• Symptoms of SBS: chronic diarrhea, steatorrhea (fatty stools), malnutrition, weight loss, and vitamin/mineral deficiencies (B12, iron, calcium).
• SBS Management: high-protein/low-fat diet and small frequent meals.
• Nutritional support: Parenteral nutrition (TPN) if severe. Medications, such as antidiarrheal agents or bile acid sequestrants. Small bowel transplant if needed.

Celiac Disease

• Celiac Disease definition: autoimmune disorder triggered by gluten ingestion & causes damage to intestinal villi, leading to malabsorption.
• Symptoms: chronic diarrhea, fatigue, weight loss, bloating, abdominal pain, and anemia (iron deficiency).
• Celiac Diagnosis: blood tests for anti-tissue transglutaminase (tTG) antibodies and endoscopic biopsy of the small intestine.
• Celiac Disease Management: strict gluten-free diet (lifelong). Supplementation of iron, calcium, vitamin D, and B12. Monitor for complications (osteoporosis, anemia, lactose intolerance).

Lactose Intolerance

• A Lactose Intolerance Definition: deficiency of lactase enzyme, leading to inability to digest lactose.
• It results in bloating and gas.

Fecal Incontinence

• Fecal Incontinence definition: loss of bowel control, leading to unintentional stool passage.
• Fecal Incontinence causes: nerve damage (stroke, multiple sclerosis, diabetes), weak pelvic muscles (childbirth, aging).
• Can be a result of chronic constipation leading to overflow incontinence.
• Fecal Incontinence can be managed by: bowel training techniques, Dietary modifications (high-fiber diet), Pelvic floor exercises (Kegels). In severe cases surgical Options can be explored.

Gastroenteritis

• Gastroenteritis Definition: Inflammation of the stomach and intestines, usually caused by infection.
• Causes: Viral (rotavirus, norovirus). Bacterial (Salmonella, Escherichia coli), Parasitic (Giardia).
• Gastroenteritis presents as: Nausea, vomiting, diarrhea.
• Can also lead to: Dehydration (dry mouth, dizziness, reduced urine output).
• Management: Oral rehydration therapy (ORT) for mild cases, IV fluids for severe dehydration.
• Avoid anti-diarrheal medications if bacterial infection is suspected, proper hand hygiene to prevent spread.

Peritonitis

• Peritonitis Definition: Inflammation of the peritoneum, often due to infection.
• Peritonitis Causes: Perforated ulcer, appendicitis rupture, bowel perforation, Peritoneal dialysis infection.
• Presentation: Severe abdominal pain, guarding, Board-like rigidity of the abdomen, High fever, tachycardia.
• Emergency Management: Immediate IV antibiotics, Surgical intervention if necessary (laparotomy, drainage), IV fluids and electrolyte replacement.

Clostridium difficile (C. diff) Infection

• C. Diff. Definition: Bacterial infection leading to severe diarrhea and colitis.
• C. Diff. Risk factors: recent antibiotic use (clindamycin, cephalosporins, fluoroquinolones, hospitalization, immunosuppression.
• Symptoms of clostridium difficle: Watery diarrhea (foul-smelling), Fever, abdominal pain, Severe cases: Pseudomembranous colitis.
• C. Diff. Management: Discontinue causative antibiotic. Administer metronidazole or vancomycin. Strict infection control (contact precautions, handwashing with soap and water). Probiotics help recurrence prevention.

Intestinal Perforation

• Intestinal Perforation Definition: A hole or tear in the intestinal wall.
• It is caused by: Trauma, gunshot/stab wounds, Untreated ulcers, appendicitis rupture, Complications of Crohn's disease or diverticulitis.
• Symptoms may include: Severe abdominal pain, Board-like rigidity, Absent bowel sounds, Signs of shock (tachycardia, hypotension).
• Emergency mangement focuses on: NPO status, IV fluids, broad-spectrum antibiotics, Immediate surgery (exploratory laparotomy, repair of perforation), Monitor for sepsis and peritonitis.

Nursing Considerations for GI Disorders

• Important aspects of Bowel Elimination Assessment:Frequency, color, consistency, shape, Presence of blood, mucus, or undigested food.
• Important aspects of Dietary Considerations for GI Health:High-fiber diet for constipation & Low-residue diet for inflammatory conditions.

Hepatic Disorders (Liver Diseases)

Liver Anatomy and Function

• The liver metabolizes carbohydrates, fats, and proteins.
• The liver detoxifies harmful substances.
• The liver produces bile for digestion.
• The liver stores vitamins (A, D, B12) and minerals (iron, copper).
• The liver regulates blood clotting via synthesis of clotting factors.
• The liver breaks down red blood cells and converts hemoglobin to bilirubin.

Hepatitis (Liver Inflammation)

• Viral infections (Hepatitis A, B, C, D, E).
• Alcohol consumption.
• Autoimmune conditions.
• Drug-induced (acetaminophen overdose).
• Fatty liver disease.
• Hepatitis leads to fatigue, malaise & jaundice (yellow skin/eyes).
• Hepatitis leads to Abdominal pain (RUQ), Dark urine, pale stools & Nausea, vomiting.
• Hepatitis Types: Hepatitis A (HAV): Fecal-oral transmission, self-limiting. Hepatitis B (HBV): Bloodborne, sexually transmitted, lead to chronic infection. Hepatitis C (HCV): Bloodborne, leads to chronic disease/cancer. Hepatitis D (HDV): Only in those with HBV. Hepatitis E (HEV): Fecal-oral, dangerous in pregnancy.
• Hepatitis Supportive care (hydration, rest).
• Hepatitis can be treated with: Antiviral medications (HBV, HCV), Vaccination for HAV and HBV & its important to Avoid alcohol and hepatotoxic drugs.

Cirrhosis (Chronic Liver Scarring)

• Chronic hepatitis (HBV, HCV).
• Alcoholic liver disease.
• Non-alcoholic fatty liver disease (NAFLD).
• Autoimmune hepatitis.
• Biliary obstruction.
• Cirrhosis leads to Jaundice as well as Ascites.
• Hepatic Encephalopathy (Toxin buildup affects brain function. Liver Cancer (Hepatocellular Carcinoma.
• Cirrhosis Management involves a Low-sodium diet and diuretics for ascites, Lactulose for hepatic encephalopathy as well as Beta-blockers (propranolol) for varices. Liver transplant end-stage cases.

Fatty Liver Disease (Steatosis)

• Fatty Liver Disease (Steatosis) is normally caused by Alcoholic fatty liver disease (AFLD). or Non-alcoholic fatty liver disease (NAFLD) due to obesity/diabetes.
• Its important to Avoid high-protein diets, but if left unchecked it can leads to Cirrhosis (Chronic Liver Scarring).

Portal Hypertension

• Portal Hypertension (High Blood Pressure in the Liver's Portal System), mostly caused by Cirrhosis
• Symtoms can include Splenomegaly/enlarged spleen as well as Ascites.
• Esophageal Varices can also present with Caput medusae/dilated abdominal veins.
• Portal hypertensions is managed with Beta-blockers or Endoscopic ligation.

Liver Cancer (Hepatocellular Carcinoma)

• Hepatocellular Carcinoma normally stems from chronic HBV/HCV.
• Other contributing factos can be Cirrhosis or Aflatoxin exposure.

Wilson's Disease.

• Wilson's Disease: Autosomal recessive disorder leading to copper buildup.
• Leads to: Neurological symptoms (tremors, dystonia), Kayser-Fleischer rings (copper deposits in eyes) and Dysfunction of liver.
• Wilson's disease is a diagnosis of exclusion via Serum ceruloplasmin levels & managed with or without Copper chelation therapy.