498 GI

Celiac Disease: Diagnosis

• Diagnosis can be confirmed through a small intestinal biopsy or skin biopsy, especially in patients with dermatitis herpetiformis; biopsy should be completed before starting a gluten-free diet
• Symptom presentation is important to consider
• Symptoms disappearance should be monitored when a gluten-free diet is introduced
• It is important to rule out irritable bowel syndrome due to similar symptoms

Celiac Disease: Management

• Strict adherence to a gluten-free diet for life is necessary
• Avoid wheat, barley, oats, and rye products; pure oats do not contain gluten, but oat products might
• Treatment of dehydrated patients includes fluid administration and monitoring of serum electrolytes and osmolality
• Intake and output, skin turgor, mucous membranes, and urine specific gravity should be monitored
• Assess growth and development of children

Celiac Disease: Management (Dietician and Support)

• It's important to consult a dietician familiar with Celiac disease management
• Education to the family is important
• Lifelong compliance to a strict gluten-free diet is essential
• Identify and treat nutritional deficiencies, which may include multi-vitamins, vitamin D, and calcium
• Local, provincial, and national support groups
• Continuous follow-up with healthcare providers is needed
• A combination of corticosteroids and a gluten-free diet

Celiac Disease: Patient Education

• Written and verbal instructions on gluten-free diet are crucial
• The importance of clients reading labels for gluten content in medications, food additives, preservatives, and stabilizers should be reinforced
• Advise a healthy balanced diet
• Should avoid Cross-contamination when preparing gluten-free food
• Seek medical attention for celiac crisis
• Diet and lifestyle compliance is important

Celiac Disease: Nutritional Information

• Gluten is found in barley, beer, ale, breading, brewer's yeast, couscous, dextrin, farro, graham flour, modified wheat starch, oatmeal, oats, pastas, rye bread, semolina, and wheat bran
• Broth, burgers, flavored coffee, imitation seafood, medications, sausages, sauces, seasonings, and soy sauce may contain gluten
• Safe foods include beef, pork, poultry, fish, eggs, milk, cheese, vegetables, fruit, rice, corn, and gluten-free products

Irritable Bowel Syndrome: Diagnosis

• Diagnosis is based on history and physical examination
• Other disorders such as colorectal cancer, peptic ulcer disease, inflammatory bowel disease, and malabsorption disorders should be ruled out
• Diagnostic criteria is based on Rome IV (2016), characterized by recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following:
  • Symptoms related to defecation
  • Symptoms associated with a change in stool frequency
  • Symptoms associated with a change in stool form/appearance

Irritable Bowel Syndrome: Management

• Treatment depends on whether the patient has pain, diarrhea, or constipation
• Antispasmodics reduce muscle spasms, abdominal pain, and cramping
• Low-dose antidepressants help relieve depression and anxiety
• Antidiarrheals (e.g., Loperamide) reduce stool frequency and gastric movement
• Laxatives improve constipation
• Prosecretory and analgesic agents increase fluid in the digestive tract and reduce pain sensitivity
• Prokinetic agents stimulate bowel movement and contractions

Irritable Bowel Syndrome: Dietary Management

• Dietary fiber of 30-40 grams/day helps regulate bowels and reduce diarrhea and constipation
• Over-the-counter therapies include osmotic laxatives, bulk-forming laxatives (e.g., psyllium), and stool softeners

Irritable Bowel Syndrome: Patient Education

• Food triggers should be identified via a food diary
• High-fat foods may worsen symptoms
• Alcohol, caffeine, and sorbitol sweeteners should be avoided
• Oral hydration is key (drink water)
• Probiotic supplements may reduce abdominal pain, bloating, and bowel movement irregularity
• Focus on Stress Reduction

Irritable Bowel Syndrome: Lifestyle Management

• Eat smaller meals
• Introduce fiber to reduce symptoms
• Use stress reduction techniques like acupuncture, deep breathing, visualization, meditation, and yoga
• A healthy lifestyle and encourage exercise
• Promote sleep and healthy sleep patterns
• Peppermint oil can be helpful

Ulcerative Colitis & Crohn's: Diagnosis

• Ulcerative Colitis: history and physical examination, colonoscopy, sigmoidoscopy, barium enema, CBC, ESR, electrolytes, BUN, creatinine, albumin, stool culture to rule out C. difficile, and stool sample to rule out occult blood are needed
• Crohn’s Disease: history and physical exam, CBC and ESR, serum chemistries, testing of stool for occult blood, barium enema, sigmoidoscopy and colonoscopy with biopsy are needed

Ulcerative Colitis & Crohn's: Management Goals

• Bowel rest
• Control inflammation
• Manage fluids and nutrition
• Manage patient stress
• Provide education
• Provide symptomatic relief

Ulcerative Colitis & Crohn's: Pharmacological Therapy

• Sulfasalazine, corticosteroids (oral prednisone or hydrocortisone enemas) and immunosuppressant therapy (cyclosporine or Infliximab) can be used
• For corticosteroids, ensure that Cushing’s syndrome, HTN, hirsutism, and mood swings should be monitored for

Ulcerative Colitis: Surgical Interventions

• Surgery is indicated if treatment fails, exacerbations are frequent and debilitating, massive bleeding or perforation occurs, or tissue changes suggest dysplasia or carcinoma
• Surgical procedures include total proctocolectomy with permanent ileostomy or ileoanal reservoir

Ulcerative Colitis: Post-Operative Care

• Routine observations for patients who have abdominal surgery
• Monitor stoma viability plus its mucocutaneous border, and that the peristomal skin integrity must be monitored
• Stoma output maybe as high as 1500 to 2000 mL per 24 hours
• IV fluid support is important to replace any ileostomy losses (> 1200 ml/24 hours)
• Monitor for signs of hemorrhage, abdominal abscesses, small bowel obstruction, dehydration, etc.
• NG tube may be removed when bowel function returns
• Systemic antibiotics are discontinued within 24 hours of the operation and corticosteroids are tapered post procedure

Ulcerative Colitis: Post-Operative Patient Teaching (Ileoanal Reservoir)

• Patients should be informed that mucus incontinence may occur transiently
• Kegel exercises should be recommended to strengthen the pelvic floor and sphincter muscles
• Perianal skin care from the first bowel movement should be performed

Perioperative Colostomy Care

• Stoma should be assessed, the skin should be protected, the pouch should be selected, patient education on ostomy self-care should be provided, and the patient to adapt psychologically to a changed body should be assisted
• Note that characteristics of the stoma include colour, edema, and bleeding
• Record volume, colour, and consistency of the drainage
• The type of liquid from the ostomy site should be assessed for either an Ileostomy or colostomy drainage
• Do not wipe the stoma for irrigation due to the response
• Teach the patient how to change the stoma, control odour, and identify signs and symptoms of complications

Ulcerative Colitis & Crohn's: Nutritional Therapy

• Identify trigger foods and eliminate them
• Identify safe foods that cause the least irritation
• Diet should consist of smaller, more frequent meals throughout the day
• Increase lactase-free products, as many Crohn’s and colitis sufferers appear to be lactose intolerant
• Reduce sugar and artificial sweeteners should they aggravate the gut
• Avoid drinking a lot of fluid during a meal, and instead after
• Reduce fat intake as it can be hard to digest
• Patients may require enteral supplements and parenteral nutrition
• Monitor for fluids and electrolyte losses or malabsorption and supplement as necessary
• Supplemental iron may be necessary

Ulcerative Colitis & Crohn's: Patient Teaching

• Encourage exercise, sports, and activities when in a remission
• Manage commitments and encourage patients not to over-commit
• Find support group or a community of individuals
• In cases of Diarrhea:
  • Patients should be encouraged to be clean, dry, and free of odour
  • Facilitate bowel movements, including close proximity to a bathroom or a bedside commode
  • Ensure a Deodorizer in the room
  • Meticulous perianal hygiene should be reinforced
• Reduce or discourage stress, encourage relaxation through methods such as meditation, yoga, mindfulness

Chronic Pancreatitis: Diagnosis

• Diagnosis is based on patient’s signs and symptoms.
• Laboratory test considerations: may test serum and lipase, bilirubin, alk phos, leukocytosis, and sedimentation rate
• Requires Stool samples should to assess for fecal fat content
• There may be deficiencies of fat-soluble vitamins and cobalamin, glucose intolerance, and possible diabetes
• ERCP is used to assess the ductal system

Chronic Pancreatitis: Management

• Maintenence on pancreatic is a major goal
• Maintain Pain control
• Control of pancreatic exocrine and endocrine insufficiencies
• Reduce alcohol intake
• Smoking should be eliminated as it accelerates the progression of the illness
• In some instances surgery may be required to remove any duct obstruction

Hepatitis C: Management

• Start treatment as soon as possible in most subgroups such as high grade liver damage
• Direct-acting antiviral agents (DAAs) offer less adverse effects and have a higher adherence rate

Hepatitis C: Patient Teaching

• There is no Hep C vaccine so stress infection control
• The primary intervention for Hep C is preventing transmission, testing/Screening
• Provide information regarding infection and safe practice: standard precautions.
• Always ensure condom use is used during sex
• Don't share personal hygiene items

Advanced Cirrhosis of the Liver: Esophageal Varices

• Portal hypertension is a large complication that causes esophageal varies
• Diagnose with upper endoscopy
• Avoid ETOH, ASA, NSAIDS- can give nonselective beta-blockers (propranolol) to reduce risk of bleeding by lowering portal venous and cardiac output
• Treatment for actively bleeding esophageal varices are esophageal balloon tamponade

Advanced Cirrhosis of the Liver: Management

• Pharmacological therapies for cirrhosis include Propranolol (Inderal or Nadalol), Proton Pump Inhibitor, Rifaximin (Zaxine), Neoyomycin sulphate, Vasopressin, Octreotide (Sandostatin), Vitamin K and Lactulose

Advanced Cirrhosis of the Liver: Patient Teaching

• Health promotion and prevention for the many causes of cirrhosis such as Alcohol, Viral hepatitis, Biliary obstruction, Obesity, and Right-sided heart failure
• Nursing interventions are related to complications such as monitoring Patients who have ascites and cannot breathe, plan for a paracentesis and to administer albumin
• If patients present with dyspnea, place the patient in semi-fowler’s or high fowler’s for max respiratory efficiency
• If the patient is taking diuretics, monitor serum sodium potassium, chloride, bicarb, and creatinine
• Ensure Good skin hygiene
• Ensure patients are aware of food labels and low sodium is encourged