Disorders in Malabsorption and Elimination HARD

• Malabsorption disorders involve the digestive system's inability to absorb major vitamins, minerals, and nutrients, potentially occurring anywhere in the digestive system.
• Conditions causing malabsorption are categorized into mucosal disorders, luminal disorders, and lymphatic obstruction.

Patient Education: Managing Lactose Intolerance

• Lactose intolerance results from a deficiency of lactase, which is essential for digesting lactose from milk.
• Symptoms are prevented by eliminating milk and milk substances.
• Processed foods with dried milk fillers should be avoided.
• Lactase preparations or enzyme tablets can reduce symptoms when taken with food.
• Yogurt with active cultures aids lactose digestion and is better than lactase preparations.
• Milk and milk products are rich in calcium and vitamin D, so eliminating them may lead to deficiencies and osteoporosis.

Celiac Disease

• Celiac disease is a malabsorption disorder caused by an autoimmune response to gluten found in wheat, barley, rye, and other grains.
• The prevalence is around 1% in the United States, with women affected twice as often as men.
• It is more common among Caucasians but rates are rising among non-Caucasians with familial risk, also higher among those with type 1 diabetes, Down syndrome, and Turner syndrome.
• It can manifest at any age in genetically predisposed individuals.

Pathophysiology of Celiac Disease

• Nearly 30% of the US population is genetically predisposed, sharing HLA-DQ2 or HLA-DQ8 alleles.
• Autoimmune response to gluten inflames small intestine epithelial cells, specifically in the proximal portion.
• Mucosal villi become denuded, resulting in impaired micronutrient and macronutrient absorption, leading to systemic nutritional deficits.

Diseases/Disorders and Pathophysiology/Clinical Features

• Gastric resection with gastrojejunostomy leads to decreased pancreatic stimulation and poor mixing, causing weight loss, steatorrhea, and anemia.
• Pancreatic insufficiency reduces intraluminal enzyme activity, leading to lipid and protein maldigestion, weight loss, steatorrhea, and glucose intolerance.
• Ileal dysfunction reduces bile salt pool size and vitamin B12 absorption, causing diarrhea, weight loss, and steatorrhea.
• Stasis syndromes cause bacterial overgrowth, deconjugation of bile salts, and vitamin B12 utilization, resulting in weight loss and steatorrhea.
• Zollinger-Ellison syndrome causes hyperacidity, inactivating pancreatic enzymes and leading to ulcers and steatorrhea.
• Lactose intolerance results in high intraluminal lactose, causing osmotic diarrhea and cramps after lactose consumption.
• Celiac disease causes a toxic response to gliadin, leading to destruction of the absorbing surface, weight loss, diarrhea, and malabsorption.
• Tropical sprue, caused by an unknown toxic factor, results in mucosal inflammation and malabsorption, leading to weight loss, diarrhea, and anemia.
• Whipple disease, caused by bacterial invasion, leads to arthritis, hyperpigmentation, lymphadenopathy, fever, weight loss, and steatorrhea.
• Parasitic diseases cause damage or invasion of surface mucosa, resulting in diarrhea, weight loss, and steatorrhea.
• Immunoglobulinopathy decreases intestinal defenses and causes lymphoid hyperplasia, often associated with Giardia.

Clinical Manifestations of Celiac Disease

• Common GI symptoms include diarrhea, steatorrhea, abdominal pain, distention, flatulence, and weight loss, more common in children.
• Non-GI symptoms in adults include fatigue, malaise, depression, hypothyroidism, migraine headaches, osteopenia, anemia, seizures, paresthesias, and a red, shiny tongue.
• Other signs include ridges in tooth enamel and dermatitis herpetiformis.

Assessment and Diagnostic Findings of Celiac Disease

• Diagnosis involves assessing signs, symptoms, family history, and risk factors.
• Definitive tests include serologic tests and endoscopic biopsy while patient is still on a gluten diet.
• IgA anti-tissue transglutaminase (tTG) test is highly sensitive and specific.
• Confirmation is done via upper endoscopy with small intestine biopsies.

Medical Management of Celiac Disease

• Celiac disease is a chronic, lifelong disease.
• Treatment involves strict adherence to a gluten-free diet, with resolution taking up to a year.
• Symptoms may persist despite adherence, and may require specific treatments like folate, cobalamin, or iron supplements for anemia, and treatment for osteoporosis.

Nursing Management of Celiac Disease

• Education includes adherence to a gluten-free diet and avoiding cross-contamination.
• Oat products and gluten-free foods prepared in shared facilities can be contaminated.
• Vigilance is needed when asking restaurant staff about food preparation.

Patient Education: How to Avoid Gluten

• Naturally gluten-free foods: fresh fruits, vegetables, meat, poultry, fish, seafood, dairy, beans, legumes, nuts, corn, rice, soy, quinoa, and potato.
• Foods to avoid: wheat, barley, bran, durum, spelt, faro, rye, bulgur, graham, semolina, farina, emmer, and triticale which are generally used in cakes, pastries, cookies, breads, pastas, rolls, pizza, crackers, brewer’s yeast, malt, malt extract, and malt flavoring, modified food starch made from wheat.
• Exercise caution with candies, caramel-colored foods, cornflakes, puffed rice cereals, oat products, lunch meats, shaped foods, salad dressings, condiments, soy sauce, seasonings, sauces and soft drinks, carefully reading labels.

Intestinal Obstruction

• Blockage prevents normal flow of intestinal contents through the intestinal tract.
• Mechanical obstruction includes extrinsic lesions (adhesions, hernias, abscesses) and intrinsic lesions (tumors, strictures, intussusception).
• Functional or paralytic obstruction is caused by impaired intestinal musculature due to interruption of innervation or vascular supply.

Types and Causes of Obstruction

• Obstruction can occur in the large or small intestine, and can be partial or complete.
• Severity depends on affected bowel region, degree of occlusion, and vascular supply disturbance.
• Most obstructions occur in the small intestine, caused by adhesions, hernias, and tumors.
• Other causes of small bowel obstruction include Crohn’s disease, intussusception, volvulus, and paralytic ileus.
• Large bowel obstruction is commonly caused by cancer (60%), diverticular disease (20%), and volvulus (5%).

Mechanical Causes of Obstruction

• Adhesions: Intestinal loops adhere to areas that heal slowly after surgery, causing kinking.
• Intussusception: One part of the intestine slips into another, narrowing the lumen and strangulating blood supply.
• Volvulus: Bowel twists, occluding blood supply and causing gas and fluid accumulation.
• Hernia: Intestine protrudes through a weakened abdominal area, obstructing flow and blood supply.
• Tumor: A tumor within or outside the intestine causes partial or complete obstruction of the lumen.

Pathophysiology of Small Bowel Obstruction

• Intestinal contents, fluid, and gas accumulate proximal to the obstruction.
• Abdominal distention and fluid retention reduce absorption and stimulate gastric secretion.
• Increased pressure within the intestinal lumen decreases capillary pressure, causes third-spacing of fluids which results in decreased circulating fluid and dehydration.
• Continued distention and edema lead to ischemia, necrosis, rupture, and peritonitis.

Clinical Manifestations of Small Bowel Obstruction

• Initial symptom is crampy, wavelike pain due to peristalsis.
• Patient may pass blood and mucus but no fecal matter or flatus.
• Vomiting occurs, potentially with intestinal contents propelled toward the mouth.
• Dehydration signs: thirst, drowsiness, oliguria, malaise, parched tongue.
• Abdomen becomes distended. Vomiting leads to loss of hydrogen ions and potassium, causing metabolic alkalosis; dehydration and acidosis develop from water and sodium loss.
• Hypovolemic or septic shock may occur.

Assessment and Diagnostic Findings of Small Bowel Obstruction

• Diagnosis is based on symptoms, physical findings, and imaging studies.
• Early bowel sounds are high-pitched and hyperactive, later becoming hypoactive.
• Changes in bowel sound pattern or intensity may indicate strangulation or ischemic bowel.
• X-rays and CT scans show abnormal gas and fluid quantities in the intestines.
• Lab studies indicate dehydration, plasma volume loss, and possible infection.

Medical Management of Small Bowel Obstruction

• Decompression via NG tube is necessary, especially for partial obstructions.
• Hypertonic water-soluble GI contrast media (Gastrografin) can stimulate peristalsis, abdominal x-ray is taken within 6 to 24 hours to determine probability of needing surgical intervention.

Surgical Management of Small Bowel Obstruction

• Approximately 25% of patients require surgical intervention.
• Surgery is warranted when the bowel is completely obstructed or strangulated.
• Pre-surgery, IV fluids are necessary to replace depleted water, sodium, chloride, and potassium.
• Surgical treatment involves repairing hernias or dividing adhesions, and may involve removing the affected bowel portion.
• Open or laparoscopic techniques can be used.

Nursing Management of Small Bowel Obstruction

• For patients not requiring immediate surgery, nursing management includes maintaining NG tube function, output, assessing fluid and electrolyte balance and monitoring nutritional status.
• Assess for signs of resolution, like return of bowel sounds, decreased abdominal distention and improvement of abdominal pain.

Inflammatory Bowel Disease (IBD)

• IBD is a group of chronic disorders, including Crohn’s disease and ulcerative colitis, that result in inflammation or ulceration of the bowel.
• Approximately 10% to 15% of patients have indeterminate colitis.
• Prevalence is increasing in Europe, the United States, and Canada, and is also rising in South America, Africa, and Asia.
• Risk factors include family history, being Caucasian, of Ashkenazi Jewish descent, living in a northern climate or urban area.
• Diagnosis typically occurs between 15 to 40 years of age, with a second peak between 55 to 65.
• Current smokers are at risk for Crohn’s disease, while ex-smokers and nonsmokers are at risk for ulcerative colitis.
• Underlying factors are genetic predisposition, altered immune response, and altered response to gut microorganisms.
• Environmental triggers can incite the cell-mediated immune response resulting in inflammatory changes.
• Systemic symptoms include fever, arthralgias, malaise, and diaphoresis.

Crohn’s Disease

• Crohn’s disease is a chronic inflammation of the GI tract wall that extends through all layers (transmural lesion).
• Commonly occurs in the distal ileum and ascending colon.
• Ileitis involves only the ileum (35%), ileocolitis involves the ileum and colon (45%), and granulomatous colitis involves only the colon (20%).

Pathophysiology of Crohn’s Disease

• Inflammation begins with crypt inflammation which progresses into ulcers.
• Lesions deepen into longitudinal and transverse ulcers, creating a cobblestone appearance.
• Fistulas, fissures, and abscesses form. Granulomas can occur in lymph nodes, bowel layers.
• Diseased segments are demarcated by adjoining normal tissue (skip lesions).
• Bowel wall thickens, the intestinal lumen narrows and diseased bowel loops adhere to other loops.

Comparison of Crohn’s Disease and Ulcerative Colitis

• Crohn's Disease: Prolonged, variable course, characterized by exacerbations and remissions. Transmural thickening and deep, penetrating granulomas. Ileum and ascending colon are usually affected with bleeding, usually not that severe.
• Ulcerative Colitis: Exacerbations and remissions. Ulceration of the mucosa with minute mucosal ulcerations. Rectum and descending colon are affected with common and severe bleeding.
• Crohn's Disease: Common perianal involvement and fistulas; less severe diarrhea; common abdominal mass.
• Ulcerative Colitis: With the exception of bleeding being common and severe, has none of the other issues.
• Barium studies for Crohn's Disease show regional, discontinuous skip lesions, narrowing the colon, thickening of bowel wall, mucosal edema, and stenosis/fistulas. Sigmoidoscopy may be unremarkable unless accompanied by perianal fistulas. Colonoscopy shows distinct ulcerations separated by normal mucosa.
• Barium studies for Ulcerative Colitis show diffuse involvement, no narrowing of colon, no mucosal edema. Sigmoidoscopy shows abnormal inflamed mucosa. Colonoscopy reveals friable mucosa with pseudopolyps or ulcers.
• Crohn's Disease treatment: Corticosteroids, aminosalicylates, immunomodulators (azathioprine) or monoclonal antibodies (infliximab, adalimumab), antibiotics, parenteral nutrition, partial or complete colectomy, with ileostomy or anastomosis.
• Ulcerative Colitis treatment: Corticosteroids, aminosalicylates, immunomodulators (azathioprine) or monoclonal antibodies (infliximab, adalimumab), bulk hydrophilic agents, antibiotics, proctocolectomy, with ileostomy.
• Crohn's Disease Systematic Complications: Small bowel obstruction, right-sided hydronephrosis, nephrolithiasis, colon cancer, cholelithiasis, arthritis, uveitis, erythema nodosum. Ulcerative Colitis Systematic Complications: Toxic megacolon, perforation, hemorrhage, colon cancer, pyelonephritis, nephrolithiasis, cholangiocarcinoma, arthritis, uveitis, erythema nodosum.

Clinical Manifestations of Crohn’s

• Symptoms usually begin insidiously, with diarrhea and right lower quadrant abdominal pain unrelieved by defecation.
• Scar tissue and granulomas interfere with intestinal transport.
• Eating stimulates crampy pains after meals.
• Patients tend to limit food intake, resulting in weight loss, malnutrition, and anemia.
• Chronic diarrhea and nutritional deficits cause weight loss and dehydration.
• Inflamed intestine may perforate, leading to intra-abdominal and anal abscesses, fever, and leukocytosis.
• Chronic symptoms include diarrhea, abdominal pain, steatorrhea, anorexia, weight loss, and nutritional deficiencies.
• Manifestations may extend beyond the GI tract, including joint disorders and arthritis.

Assessment and Diagnostic Findings of Crohn’s

• CT scans finds bowel wall thickening and mesenteric edema, as well as obstructions, abscesses, and fistulas.
• MRI identifies pelvic and perianal abscesses and fistulas.
• CBC assesses hematocrit and hemoglobin levels (may be decreased) as well as WBC count (may be elevated).
• ESR is usually elevated and Albumin and protein levels may be decreased, indicating malnutrition.

Complications of Crohn’s

• Intestinal obstruction, stricture formation, perianal disease, fluid and electrolyte imbalances, malnutrition from malabsorption, fistula and abscess formation.
• Enterocutaneous fistula is a common type of small bowel fistula.
• Abscesses result from internal fistula causing fluid accumulation and infection.
• Patients with colonic Crohn’s disease are at increased risk of colon cancer.

Ulcerative Colitis

• Ulcerative colitis is a chronic ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum with exacerbation.
• Inflammatory changes start in the rectum and progress through the colon.

Pathophysiology of Ulcerative Colitis

• Affects the superficial mucosa of the colon with multiple ulcerations.
• Inflammation damages the colonic epithelium, causing bleeding and the mucosa becomes edematous and inflamed.
• Lesions are contiguous; occurs one after the other., bowel narrows cause of muscular hypertrophy and fat deposits.
• Abscesses, fistulas, obstruction, and fissures are uncommon because the inflammatory process is not transmural

Clinical Manifestations of Ulcerative Colitis

• Predominant symptoms include diarrhea (mucus, pus, or blood), left lower quadrant abdominal pain, and intermittent tenesmus. Bleeding leads to pallor, anemia, and fatigue.
• Other symptoms include anorexia, weight loss, fever, vomiting, dehydration, and cramping. Stool amounts to six or more liquid stools daily. *Disease is classified as mild, severe, or fulminant.
• Extraintestinal features include skin lesions, eye lesions, joint abnormalities, and liver disease.

Assessment and Diagnostic Findings of Ulcerative Colitis

• Abdominal x-ray studies determine the cause of symptoms.
• Colonoscopy distinguishes ulcerative colitis from other diseases.
• Colonoscopy may reveal friable, inflamed mucosa with exudate and ulcerations.
• CT scanning, MRI, and ultrasound studies can find involvement
• Stool is positive for blood -Laboratory tests include low hematocrit and hemoglobin levels as well as an elevated WBC count, low albumin levels, and an electrolyte imbalance, Stool examinations performed to rule out dysentery.

Complications of Ulcerative Colitis

• Complications: toxic megacolon, perforation, and bleeding.
• Toxic megacolon: inflammatory process extends into the muscularis, inhibits its ability to contract, which causes distention, fever, abdominal pain, vomiting, and fatigue.
• Without bowel perforation, a subtotal colectomy may be performed.
• Ulcerative colitis can result in diminished bone density due to increased risk of resulting in osteoporotic fractures.
• Patients that have ulcerative colitis have a increased risk for colon cancer.

Management of Inflammatory Bowel Disease

• Medical treatment aims at inducing disease remission, using induction therapy, and preventing flare-ups, using maintenance therapy.

Medical Management: Pharmacologic Therapy

• Aminosalicylates are the first pharmacologic agents selected to induce and maintain remission of mild to moderate IBD.
• Sulfa-free aminosalicylates are used for patients with sulfa allergies.
• Common adverse effects include headaches, nausea, and diarrhea.

Medical Management: Corticosteroids

• Corticosteroids decrease inflammation.
• Corticosteroids are given orally (prednisone) in outpatient treatment or parenterally (hydrocortisone) in patients in the hospital.
• corticosteroids are for short term use due to inhibiting the healing capacity of the intestines.

Medical Management: Immunomodulators

• Immunomodulator alters the pathologic immune response present in IBD.
• Reduces inflammation.
• Not used for reducing remission.
• Used as maintenance therapy.
• CBC MUST Be monitored because the medications depress bone marrow function.

Medical Management: Anti-tumor necrosis factor (TNF) medications

• Inhibit the inflammatory effects of the cytokine TNF in the gut.
• Infliximab has proved to be effective at inducing and maintaining the remission of IBD.
• Anti- TNF Medications must be tested for viral infections.
• Risk for cancers.

Medical Management: Nutritional Therapy

• Oral fluids and a low-residue, high-protein, calorie diet with supplemental vitamin therapy and iron replacement will supply all needs.
• Fluids with Electrolytes replaces lost amounts which causes diarrhea and dehydration.
• Foods that stimulate causes increased discomfort and bloating are avoided.
• Cold foods/ smoking can be avoided.
• Follow FODMAP diets which has been helpful.
• Probiotic Supplements might be needed in ulcerative colitis.
• Patients are at risk for malnourishment.
• Oral nutrition and enteral nutrition are preferred.
• Patient may require parental nutrition.

Surgical Management of IBD

• One third of patients with severe ulcerative colitis can be treated with surgery.
• Sixty to 70% of patients with Crohn’s disease can be treated with surgery.
• Patients with UC or Crohn disease will need to be relieved with strictures.
• Severe cases benefit from the intestinal transplant.

Proctocolectomy and Total Colectomy with Ileostomy

• recommended that the patient with IBD with a severely diseased colon and rectum that is refractory to medical therapy. However surgical cure is not possible with Crohn’s disease
• ileostomy- allow for drainage with matter from he ileum to the outside of the body,
• An ileostomy is indicated after proctocolectomy total colectomy this is considered a permanent Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis
• the surgical procedure of choice that removes the need of a permanent ileostomy.
• The procedure removes diseased parts and maintains anal control. Night time elimination is reduced
• Dietary intolerances may stay with the patient

Continent Ileostomy

• The Kock pouch- elimantes the need for an excluse fecal collection bag. However has issue with malfunction with the valve.

Nursing Process: Management of the Patient with Inflammatory Bowel Disease

• The nurse will obtains a health history to find if there is IBD and if there is any pain; if its nausea, anorexia, a or family history.
• Discuss dietary patterns. *find out if there is any lactose intolerance

Nursing Diagnosis of IBD

• Diarrhea
• Acute pain
• Hypovolemia
• Impaired nutritional status
• Activity intolerance
• Anxiety
• Difficulty coping
• Risk for impaired skin integrity
• Lack of knowledge concerning the process and management of the disease

Planning and Goals of IBD

• Attainment of normal bowel Relive pain
• Prevent fluid volume deficit
• Optimize nutrition and weight
• Avoid fatigue
• Reduce anxiety
• Promotion of effective coping
• Absence of skin breakdown
• Increase knowledge about the disease process and self-help management
• Avoiding complications

Nursing Interventions of IBD

• Maintain normal elimination patterns
• Relieve pain
• Maintain fluid intake
• Optimize nutrition
• Promote rest

Overview of malabsorption disorders, including categories like mucosal and luminal disorders. Focus on lactose intolerance, its causes, and management through dietary changes and enzyme supplements. Celiac disease is introduced as another malabsorption disorder related to gluten sensitivity.