Problems in Malabsorption and Elimination MEDIUM

• Malabsorption disorders involve the digestive system's inability to absorb major vitamins, minerals, and nutrients.
• Interruptions can occur anywhere in the digestive system, leading to decreased absorption.

Causes of Malabsorption

• Mucosal disorders include celiac disease, Crohn’s disease, and radiation enteritis, which cause generalized malabsorption.
• Luminal disorders include bile acid deficiency, Zollinger-Ellison syndrome, pancreatic insufficiency, small bowel bacterial overgrowth, or chronic pancreatitis.
• Lymphatic obstruction interferes with the transport of fat byproducts into the systemic circulation, which can be caused by neoplasms or surgical trauma.

Managing Lactose Intolerance

• Deficiency of lactase results in the inability to digest lactose, leading to milk intolerance.
• Milk intolerance symptoms can be prevented by eliminating milk and milk substances.
• Processed foods with added dried milk should be avoided to prevent milk intolerance symptoms.
• Lactase preparations can be used before eating or with the first bite of food, and in turn, can help reduce milk intolerance symptoms.
• Most people can tolerate milk or milk products in small amounts throughout the day.
• Yogurt with active cultures aids in lactose digestion in the intestine.
• Milk and milk products eliminated from the diet may cause deficiencies in calcium and vitamin D.

Celiac Disease

• Celiac disease is a malabsorption disorder caused by an autoimmune response to gluten.
• Gluten is found in wheat, barley, rye, other grains, malt, dextrin, and brewer’s yeast.
• Celiac disease prevalence is about 1% in the United States and is more common in women and Caucasians.
• Individuals with type 1 diabetes, Down syndrome, and Turner syndrome are at higher risk.

Pathophysiology of Celiac Disease

• Nearly 30% of the US population may be genetically predisposed to celiac disease and share HLA-DQ2 or HLA-DQ8.
• The autoimmune response to gluten inflames the epithelial cells of the small intestine, resulting in micronutrient and macronutrient absorption loss.
• Mucosal villi of the small intestine become denuded and cannot function, leading to systemic nutritional deficits.

Clinical Features of Gastrointestinal disorders

• Gastric resection with gastrojejunostomy can cause weight loss, moderate steatorrhea, and anemia due to decreased pancreatic stimulation and poor mixing of food, bile, and pancreatic enzymes.
• Pancreatic insufficiency results in reduced intraluminal pancreatic enzyme activity leading to maldigestion of lipids and proteins, abdominal pain, weight loss, marked steatorrhea, azotorrhea, and glucose intolerance.
• Ileal dysfunction can cause diarrhea, weight loss with steatorrhea, and decreased vitamin B12 absorption due to loss of ileal absorbing surface.
• Stasis syndromes can cause weight loss, steatorrhea, and low vitamin B12 absorption caused by overgrowth of intraluminal intestinal bacteria.
• Zollinger-Ellison syndrome causes ulcer diathesis and steatorrhea due to hyperacidity in the duodenum inactivating pancreatic enzymes.
• Lactose intolerance results in diarrhea and cramps after ingesting lactose-containing foods due to deficiency of intestinal lactase and high concentration of intraluminal lactose.
• Celiac disease causes weight loss, diarrhea, bloating, anemia, osteomalacia, steatorrhea, azotorrhea, and malabsorption of folate and iron due to a toxic response to gliadin.
• Tropical sprue causes weight loss, diarrhea, anemia, steatorrhea, and low absorption of D-xylose and vitamin B12 due to an unknown toxic factor resulting in mucosal inflammation.
• Whipple disease causes arthritis, hyperpigmentation, lymphadenopathy, serous effusions, fever, weight loss, steatorrhea, and azotorrhea due to bacterial invasion of intestinal mucosa.
• Certain parasitic diseases can cause diarrhea, and weight loss due to damage or invasion of surface mucosa; steatorrhea
• Immunoglobulinopathy results in frequent association with Giardia, hypogammaglobulinemia, or isolated immunoglobulin A deficiency as well due to decreased local intestinal defenses.

Clinical Manifestations of Celiac Disease

• Common GI symptoms include diarrhea, steatorrhea, abdominal pain, distention, flatulence, and weight loss.
• Non-GI symptoms can include fatigue, malaise, depression, hypothyroidism, migraine headaches, osteopenia, anemia, seizures, paresthesias, and a red, shiny tongue.
• Ridges in tooth enamel, tooth discoloration, or yellowing can also occur.
• Dermatitis herpetiformis, a rash with itchy papules and vesicles, is frequently associated with celiac disease in adults.

Assessment and Diagnostic Findings of Celiac Disease

• Assessment includes comprehensive evaluation of signs and symptoms, family history, and risk factor assessment.
• Definitive diagnosis involves serologic tests and endoscopic biopsy while the patient is consuming gluten.
• IgA anti-tissue transglutaminase (tTG) test shows high sensitivity and specificity.
• Findings are confirmed with upper endoscopy and biopsies of the proximal small intestine.

Medical Management of Celiac Disease

• Celiac disease is a chronic, noncurable, lifelong disease treated by avoiding gluten.
• A dietitian consultation is advisable for a gluten-feee diet plan.
• Full restoration of intestinal villi integrity may take a year.
• Symptoms can still occur despite adhering to a gluten-free diet, impacting quality of life.
• Other manifestations may require specific treatments, like supplements for anemia or osteoporosis treatment.

Nursing Management of Celiac Disease

• Education is provided on adhering to a gluten-free diet and avoiding gluten products.
• Oat products may be cross-contaminated with wheat.
• Gluten-free foods can become contaminated in restaurants through shared preparatory space/equipment.
• Patients should be vigilant in asking restaurant staff about gluten-free food preparation.

How to Avoid Gluten

• Naturally gluten-free food choices, such as fresh fruits and vegetables, meat and poultry, fish and seafood, dairy, beans, legumes and nuts, corn, rice, soy, quinoa, and potatoe are safe.
• Foods containing wheat, barley, bran, durum, spelt, faro, rye, bulgur, graham, semolina, farina, emmer, and triticale, should be avoided.
• Foods, such as cakes, pastries, cookies, breads, pastas, rolls, pizza, crackers, brewer’s yeast, malt, malt extract, and malt flavoring commonly contain gluten.
• Caution should be exercised when eating foods, such as candies, caramel-colored foods, cornflakes and puffed rice cereals, oat products not specifically labeled as produced in gluten-free facilities, processed lunch meats and “shaped” foods, salad dressings, condiments, soy sauce, seasonings, or soft drinks.

Intestinal Obstruction

• Blockage prevents the normal flow of intestinal contents through the intestinal tract.
• Mechanical obstruction comes from extrinsic or intrinsic lesions.
• Functional or paralytic obstruction occurs when the intestinal musculature cannot propel contents along the bowel.
• Obstruction can occur in the large or small intestine and is partial or complete.
• Severity depends on the region of the bowel affected, the degree of occlusion, and the vascular supply to the bowel wall.
• Adhesions, hernia, and tumor account for 90% of obstructions in the small intestines.
• Most obstructions in the large intestines occur in the sigmoid colon and are caused by cancer (60%), diverticular disease (20%), and volvulus (5%).

Mechanical Causes of Obstruction

• Adhesions cause a kinking of an intestinal loop when loops of the intestine become adherent to areas that heal slowly or scar after abdominal surgery.
• Intussusception results in a narrowed intestinal lumen and strangulation of the blood supply when one part of the intestine slips into another part located below it.
• Volvulus causes the intestinal lumen to become obstructed and gas and fluid to accumulate when the bowel twists and turns on itself, occluding the blood supply.
• Hernia can cause complete obstruction and obstruct blood flow to the area if there is protrusion of the intestine through a weakened area in the abdominal muscle wall.
• Tumor within the wall of the intestine extending into the intestinal lumen result in partial or complete obstructions.

Pathophysiology of Small Bowel Obstruction

• Intestinal contents, fluid, and gas accumulate proximal to the obstruction.
• Abdominal distention and fluid retention reduce fluid absorption and stimulate more gastric secretion.
• Increased pressure within the intestinal lumen decreases venous and arteriolar capillary pressure.
• Third-spacing of fluids, electrolytes, and proteins into the intestinal lumen decreases circulating fluid volume and causes dehydration.
• Continued distention and edema can compromise perfusion, leading to ischemia, necrosis, rupture, or perforation and peritonitis.

Clinical Manifestations of Small Bowel Obstruction

• The initial symptom is crampy, colicky pain due to persistent peristalsis.
• Patients pass blood and mucus but no fecal matter or flatus.
• Vomiting occurs, potentially with intestinal contents propelled toward the mouth.
• Dehydration signs include intense thirst, drowsiness, oliguria, malaise, aching, and a parched tongue and mucous membranes.
• Abdomen becomes distended, more marked in lower obstructions, potentially causing reflux vomiting.
• Vomiting results in loss of hydrogen ions and potassium, leading to metabolic alkalosis.
• Hypovolemic or septic shock may occur due to dehydration and acidosis.

Assessment and Diagnostic Findings of Intestinal Obstruction

• Diagnosis is based on symptoms, physical assessment, and imaging studies.
• Bowel sounds are initially high-pitched and hyperactive, then hypoactive.
• Changes in pattern or increased intensity may indicate strangulation or ischemic bowel.
• Abdominal x-ray and CT scan show abnormal quantities of gas and fluid, and sometimes collapsed distal bowel.
• Laboratory studies show dehydration, loss of plasma volume, and possible infection.

Medical Management of Small Bowel Obstruction

• Decompression of the bowel through insertion of an NG tube is necessary.
• Administration of hypertonic water-soluble GI contrast media may stimulate peristalsis for patients with adhesions.

Surgical Management of Small Bowel Obstruction

• Surgical intervention is needed when the bowel is completely obstructed or strangulation and tissue necrosis is suspected.
• IV fluids replace depleted water, sodium, chloride, and potassium before surgery.
• Surgical procedures involve repairing the hernia or dividing the adhesion.

Nursing Management for Small Bowel Obstruction

• Nursing management includes maintaining NG tube function, measuring output, assessing fluid and electrolyte balance, monitoring nutritional status, and assessing for resolution.

Inflammatory Bowel Disease (IBD)

• IBD is a group of chronic disorders, including Crohn’s disease and ulcerative colitis, that cause inflammation or ulceration of the bowel.
• Approximately 10% to 15% of patients have characteristics of both disorders and are classified as having indeterminate colitis.
• The prevalence of IBD is highest in Europe, the United States, and Canada, with increasing incidence in South America, Africa, and Asia.
• Risk factors include family history, being Caucasian, of Ashkenazi Jewish descent, living in a northern climate and an urban area.
• Diagnoses typically occur between 15 to 40 years of age, with a second peak between 55 to 65 years of age
• Current smokers are at risk for Crohn’s disease, whereas ex-smokers or nonsmokers are at risk for ulcerative colitis.
• The underlying factors are genetic predisposition, altered immune response, and an altered response to gut microorganisms.
• Environmental triggers can trigger cell-mediated immune response.
• Inflammatory cytokines have been identified in systemic symptoms, such as fever, arthralgias, malaise, and episodes of diaphoresis.

Crohn’s Disease

• Characterized by subacute and chronic inflammation of the GI tract wall that extends through all layers.
• It most commonly occurs in the distal ileum and the ascending colon and the inflammatory process begins with crypt inflammation and abscesses, which develop into small, focal ulcers.
• Granulomas can occur in lymph nodes, the peritoneum, and through the layers of the bowel.
• Diseased bowel segments are sharply demarcated by adjoining areas of normal bowel tissue- skip lesions.
• As the disease advances, the bowel wall thickens and becomes fibrotic, and the intestinal lumen narrows.
• Diseased bowel loops sometimes adhere to other loops surrounding them.

Comparison of Crohn’s Disease and Ulcerative Colitis

• Crohn's Disease has a prolonged and variable course with exacerbations but has transmural thickening and deep penetrating granulomas.
• Ulcerative colitis has exacerbations and remissions but has mucosal ulceration and minute, mucosal ulcerations.
• The location for Crohn's is usually in the ileum and the ascending colon with common perianal involvement and fistulas whereas ulcerative colitis is in the rectum and descending colon.
• Bleeding is usually not present in patients with Crohn's but it is common and can be severe in patients with ulcerative colitis, diarrhea is less severe in patients with Crohn's and abdominal mass is more prevalent.
• Ulcerative colitis patients can be "cured" by colectomy while it is common for recurrence in Chron's

Clinical Manifestations of Crohn’s Disease

• Right lower quadrant abdominal pain is unrelieved by defecation.
• Scar tissue and granulomas interfere with the intestine's ability to transport products of upper intestinal digestion through the constricted lumen.
• Crampy pains occur after meals, leading to limited food intake, weight loss, malnutrition, and secondary anemia.
• Ulcers and inflammatory changes result in a weeping, edematous intestine.
• Disrupted absorption causes chronic diarrhea and nutritional deficits, which can lead to significant weight loss and dehydration.
• The inflamed intestine may perforate, leading to intra-abdominal and anal abscesses resulting in fever and leukocytosis.
• Chronic symptoms include diarrhea, abdominal pain, steatorrhea, anorexia, weight loss, and nutritional deficiencies.

Assessment and Diagnostic Findings of Crohn’s Disease

• CT scan can show bowel wall thickening and mesenteric edema, as well as obstructions, abscesses, and fistulas.
• MRI is sensitive and specific in identifying pelvic and perianal abscesses and fistulas.
• CBC may reveal decreased hematocrit and hemoglobin levels.
• ESR is usually elevated, and albumin and protein levels may be decreased.

Complications of Crohn’s Disease

• Include intestinal obstruction or stricture formation, perianal disease, fluid and electrolyte imbalances, malnutrition from malabsorption, and fistula and abscess formation.
• Enterocutaneous fistula, an abnormal opening between the small bowel and the skin, can occur.
• Abscesses can result from an internal fistula, and colonic Crohn’s disease increases the 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.
• Characterized by unpredictable periods of remission and exacerbation with bouts of abdominal cramps and bloody or purulent diarrhea, in which, inflammatory changes begin in the rectum and progress proximally through the colon.

Pathophysiology of Ulcerative Colitis

• Ulcerative colitis affects the superficial mucosa of the colon, characterized by multiple ulcerations, diffuse inflammations, and desquamation of the colonic epithelium.
• Bleeding occurs as a result of the ulcerations, and the mucosa becomes edematous and inflamed.
• Lesions are contiguous, occurring one after the other.
• The bowel narrows, shortens, and thickens due to muscular hypertrophy and fat deposits.
• Abscesses, fistulas, obstruction, and fissures are uncommon.

Clinical Manifestations of Ulcerative Colitis

• The clinical course is usually one of remissions and exacerbations.
• The predominant symptoms include diarrhea with mucus, pus, or blood; left lower quadrant abdominal pain; and intermittent tenesmus.
• The bleeding may be mild or severe, resulting in pallor, anemia, and fatigue.
• Patients may experience anorexia, weight loss, fever, vomiting, dehydration, cramping, and frequent liquid stools.
• Hypoalbuminemia, electrolyte imbalances, and anemia frequently develop.

Assessment and Diagnostic Findings of Ulcerative Colitis

• Abdominal x-ray studies determine the cause of symptoms and exclude free air, bowel dilation, or obstruction.
• Colonoscopy can distinguish ulcerative colitis from other diseases of the colon.
• Biopsies are taken to determine histologic characteristics and extent of disease.
• CT scanning, MRI, and ultrasound studies can identify abscesses and perirectal involvement.
• Stool is positive for blood, and low hematocrit and hemoglobin levels.
• WBC counts may be elevated.

Complications of Ulcerative Colitis

• Include toxic megacolon, perforation, and bleeding as a result of ulceration.
• Toxic megacolon involves inflammation extending into the muscularis, inhibiting its ability to contract and resulting in colonic distention.
• Symptoms include fever, abdominal pain and distention, vomiting, and fatigue.
• Patients with ulcerative colitis have an increased risk of osteoporotic fractures and colon cancer.

Management of Inflammatory Bowel Disease

• Medical treatment aims to induce disease remission and prevent flare-ups while maximizing quality of life.
• Pharmacologic therapy is indicated to meet the goals of inducing and maintaining remission of IBD.

Pharmacologic Therapy for Inflammatory Bowel Disease (IBD)

• Aminosalicylates are the first agents selected for the treatment of mild to moderate IBD, and sulfa free aminosalicylates are indicated for patients with sulfa allergies.
• Common adverse effects of aminosalicylates include headaches, nausea, and diarrhea.
• Corticosteroids such as prednisone and hydrocortisone, are used for patients who have not responded to treatment, because of their potent anti-inflammatory effects.
• Immunomodulators such as azathioprine, alter the patholic immune response and are useful as maintenance therapy, but it takes at least 2 months before they are effective.
• These agents depress bone marrow function; therefore, the CBC must be periodically.
• Anti-tumor necrosis factor (TNF) medication such as infliximab inhibits the inflammatory effects of the cytokine TNF in the gut and are indicated for patients with moderate to severe IBD.

Nutritional Therapy for Inflammatory Bowel Disease (IBD)

• Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement meet nutritional needs, reduce inflammation, and control pain and diarrhea.
• Dietary intolerances may persist after the IPAA is formed.
• Fluid and electrolyte imbalances are corrected by IV therapy as necessary.
• Patients who have lost more than 10% of their lean body mass may require intensive nutritional therapy, which might include enteral nutrition or parenteral nutrition.

Surgical Management of Inflammatory Bowel Disease (IBD)

• Surgery may be necessary if non-surgical measures fail to relieve severe symptoms, for ulcerative colitis patients that have colon cancer, and for Crohn's disease patients with a small bowel obstruction
• Patients with either ulcerative colitis or Crohn’s disease may require surgery to relieve strictures such as laparoscopically-guided strictureplasty in which blocked or narrowed sections of the intestines are widened
• Rare, patients with severe Crohn's disease may benefit from an intestinal transplant.

Proctocolectomy and Total Colectomy with Ileostomy

• Proctocolectomy with ileostomy is recommended in the patient with IBD with a refractory severely diseased colon and rectum, and total colectomy is indicated usually for patients with severe ulcerative colitis.
• Nursing management of the patient with an ileostomy is discussed later in this chapter

Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis

• Restorative proctocolectomy with IPAA is the surgical procedure of choice in cases where the rectum can be preserved.
• With IPAA or restortive proctocolectomy, voluntary defecation is maintained, and anal continence is preserved.
• Complications of ileoanal anastomosis include irritation of the perianal skin from leakage of fecal contents, stricture formation at the anastomosis site, pelvic abscess, fistula, small bowel obstruction, and pouchitis (i.e., inflammation of the ileoanal pouch)

Continent Ileostomy

Nursing Process for Management of IBD patients

• Obtain a health history to identify symptoms, family history, dietary patterns and smoking habits.
• Nursing diagnoses may include diarrhea, acute pain, hypovolemia, impaired nutritional status, activity intolerance, anxiety, difficulty coping, risk for impaired skin integrity, and a lack of knowledge
• Encourage intermittent rest periods during the day and restrict activities to conserve energy and reduce the frequency of bowel movements.
• Provide ready access to a bathroom or bedpan while ensuring that the environment is clean.
• Monitor daily weights for fluid gains or losses and assess the patient for signs of fluid volume deficit

Malabsorption disorders occur when the digestive system fails to absorb essential nutrients, vitamins, and minerals. These interruptions can happen anywhere in the digestive system, leading to reduced absorption. Conditions like celiac disease and enzyme deficiencies can cause malabsorption, requiring dietary management and medical intervention.