Problems in Malabsorption and Elimination EASY

• Disorders of malabsorption occur when the digestive system can't absorb major vitamins, minerals, and nutrients
• Interruptions anywhere in the digestive process can lead to decreased absorption

Categories of Conditions Causing Malabsorption:

• Mucosal (transport) disorders: cause generalized malabsorption (celiac disease, Crohn’s disease, radiation enteritis)
• Luminal disorders: cause malabsorption (bile acid deficiency, Zollinger-Ellison syndrome, pancreatic insufficiency, small bowel bacterial overgrowth, or chronic pancreatitis)
• Lymphatic obstruction: interferes with fat transport into systemic circulation (neoplasms, surgical trauma)

Managing Lactose Intolerance:

• Lactase deficiency results in intolerance to milk because it is essential for digesting and absorbing lactose
• Prevent symptoms by eliminating milk and milk substances
• Processed foods may contain dried milk as a filler
• Lactase preparations (Lactaid drops) can pretreat foods or be taken with the first bite
• Most people can tolerate 1 to 2 cups of milk daily, best if ingested in small amounts throughout the day.
• Yogurt with "active cultures" aids lactose digestion better than lactase preparations.
• Milk and milk products are rich in calcium and vitamin D, so supplements may be needed to prevent deficiencies and osteoporosis

Celiac Disease:

• Celiac disease is a malabsorption disorder triggered by an autoimmune response to gluten
• Gluten is commonly found in wheat, barley, rye, malt, dextrin, and brewer’s yeast.
• The prevalence is estimated at ≈1% in the United States
• Women are afflicted twice as often as men
• More common among Caucasians, but rates are rising among non-Caucasians
• Higher risk if there is a family history, type 1 diabetes, Down syndrome, and Turner syndrome
• Manifestation may occur at any age in genetically predisposed individuals

Pathophysiology of Celiac Disease:

• Nearly 30% of the US population is genetically predisposed
• Predisposed individuals share HLA-DQ2 or HLA-DQ8
• Autoimmune response to gluten involves both humoral and cell-mediated responses
• Response leads to inflammation of epithelial cells lining the small intestines, especially in the proximal portion
• Mucosal villi become denuded, impairing absorption of micronutrients and macronutrients, resulting in systemic nutritional deficits

Diseases/Disorders and Pathophysiology:

• Gastric resection with gastrojejunostomy: Decreased pancreatic stimulation and poor mixing lead to weight loss, steatorrhea, and anemia
• Pancreatic insufficiency: Reduced enzyme activity leads to lipid and protein maldigestion, abdominal pain, weight loss, steatorrhea, and glucose intolerance
• Ileal dysfunction: Reduced bile salt pool and vitamin B12 absorption lead to diarrhea, weight loss, and steatorrhea
• Stasis syndromes: Bacterial overgrowth deconjugates bile salts and utilizes vitamin B12, leading to weight loss and steatorrhea
• Zollinger-Ellison syndrome: Hyperacidity inactivates pancreatic enzymes, causing ulcers and steatorrhea
• Lactose intolerance: Lactase deficiency leads to high lactose concentration and osmotic diarrhea, causing diarrhea and cramps after lactose ingestion
• Celiac disease: Toxic response to gliadin destroys absorbing surface of intestine, causing weight loss, diarrhea, bloating, anemia, osteomalacia, and steatorrhea
• Tropical sprue: Unknown toxic factor causes mucosal inflammation and villous atrophy, leading to weight loss, diarrhea, anemia, and steatorrhea
• Whipple disease: Bacterial invasion of intestinal mucosa, leading to arthritis, hyperpigmentation, lymphadenopathy, fever, weight loss, and steatorrhea
• Parasitic diseases: Damage or invasion of surface mucosa, causing diarrhea, weight loss, and steatorrhea
• Immunoglobulinopathy: Decreased intestinal defenses and lymphoid hyperplasia, often associated with Giardia, causing hypogammaglobulinemia or IgA deficiency

Clinical Manifestations of Celiac Disease:

• Common GI symptoms include diarrhea, steatorrhea, abdominal pain, distention, flatulence, and weight loss (more common in children)
• Adults may present with fatigue, malaise, depression, hypothyroidism, migraine headaches, osteopenia, anemia, seizures, paresthesias, and a red, shiny tongue
• Some may show ridges in tooth enamel and discoloration
• Dermatitis herpetiformis: a rash with itchy papules and vesicles on forearms, elbows, knees, face, or buttocks

Assessment and Diagnostic Findings of Celiac Disease:

• Assessment of signs, symptoms, family history, and risk factors
• Definitive diagnosis: serologic tests and endoscopic biopsy
• Patients must continue consuming gluten during testing to avoid false-negative serologic results
• First serologic test: IgA anti-tissue transglutaminase (tTG), which is 90% sensitive and 95% specific
• Findings are confirmed with upper endoscopy with biopsies of the proximal small intestine

Medical Management of Celiac Disease:

• Chronic, noncurable, lifelong disease
• Treatment: strict gluten-free diet
• Consultation with a dietician
• Full restoration of intestinal villi integrity may take a year
• Symptoms may still occur despite strict adherence to a gluten-free diet (can impact quality of life)
• Anemia: folate, cobalamin, or iron supplements
• Osteopenia: osteoporosis treatment

Nursing Management of Celiac Disease:

• Patient and family education regarding adherence to a gluten-free diet is a must
• Caution about cross-contamination (e.g., oats processed in facilities with wheat, gluten-free foods prepared in shared spaces)
• Patients must inquire about food preparation in restaurants and dining halls.

How to Avoid Gluten:

• Choose naturally gluten-free foods: fresh fruits, vegetables, meat, poultry, fish, seafood, dairy, beans, legumes, nuts, corn, rice, soy, quinoa, and potato
• Avoid foods containing wheat, barley, rye, brewer’s yeast, malt, and modified food starch from wheat (cakes, pastries, breads, pastas, pizza, beer)
• Read labels carefully on candies, caramel-colored foods, cornflakes, oat products, processed lunch meats, salad dressings, soy sauce, seasonings, and sauces

Intestinal Obstruction:

• Blockage that prevents normal flow of intestinal contents

Types of Intestinal Obstructions:

• Mechanical obstruction: Lesions from outside or within the intestines obstruct flow (adhesions, hernias, tumors, strictures, intussusception

• Functional or paralytic obstruction: Intestinal musculature can't propel contents (amyloidosis, muscular dystrophy, endocrine disorders (diabetes), neurologic disorders (Parkinson’s disease), ileus (temporary blockage post-surgery)

• Obstructions can be partial or complete, and occur in the large or small intestine

• Severity depends on the location, degree of occlusion, and disturbance of the vascular supply

• Most obstructions occur in the small intestine

• Main causes of small intestine obstructions: adhesions, hernia, and tumor

• Other causes of small bowel obstruction: Crohn’s disease, intussusception, volvulus, and paralytic ileus

• Most obstructions in the large intestines occur in the sigmoid colon

• Common causes of large bowel obstruction: cancer (60%), diverticular disease (20%), and volvulus (5%).

• Other causes of large bowel obstruction: benign tumors, strictures, and obstipation or fecal impaction

Causes of Mechanical Obstruction:

• Adhesions: Intestinal loops adhere after abdominal surgery, causing kinking of the intestinal loop
• Intussusception: One part of the intestine slips into another part (like a telescope), narrowing the intestinal lumen and strangulating blood supply
• Volvulus: Bowel twists on itself and occludes the blood supply, obstructing the intestinal lumen and causing gas and fluid accumulation
• Hernia: Protrusion of intestine through a weakened area in the abdominal muscle wall, obstructing intestinal flow and blood flow
• Tumor: A tumor extends into the intestinal lumen or causes pressure on the intestinal wall, partially obstructing the lumen and potentially leading to complete obstruction

Small Bowel Obstruction Pathophysiology:

• 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
• Third-spacing of fluids reduce circulating fluid volume and dehydration
• Continued distention and edema compromise perfusion, leading to ischemia, necrosis, rupture, or perforation, resulting in peritonitis

Clinical Manifestations of Small Bowel Obstruction:

• Initial symptom: crampy pain due to persistent peristalsis
• Patient passes blood and mucus but no fecal matter or flatus
• Vomiting occurs, with intestinal contents propelled toward the mouth
• Dehydration signs: intense thirst, drowsiness, oliguria, malaise, aching, and a parched tongue and mucous membranes
• Early in the process: patient may continue to have flatus and stool due to distal peristalsis
• Abdomen becomes distended
• Vomiting results in loss of hydrogen ions and potassium, leading to metabolic alkalosis
• Dehydration and acidosis develop from loss of water and sodium
• Hypovolemic shock and septic shock may occur

Assessment and Diagnostic Findings of Small Bowel Obstruction:

• Diagnosis based on symptoms, physical assessment, and imaging studies
• Early on: bowel sounds are high-pitched and hyperactive; later, bowel sounds will be hypoactive
• Changes in bowel sounds indicate strangulation or ischemic bowel
• Abdominal x-ray and CT scan reveal abnormal quantities of gas and fluid in the intestines and collapsed distal bowel
• Lab studies reveal dehydration, loss of plasma volume, and possible infection

Medical Management of Small Bowel Obstruction:

• Decompression: NG tube insertion
• Hypertonic water-soluble GI contrast media (Gastrografin) may stimulate peristalsis (administered via NG tube, which is clamped for 2 to 4 hours, then an abdominal x-ray is taken)
• Evidence of dye in the large intestine predicts resolution of obstruction without surgery

Surgical Management of Small Bowel Obstruction:

• Surgery is needed if the bowel is completely obstructed (strangulation and tissue necrosis warrant surgery)
• Before surgery: IV fluids are administered to replace water, sodium, chloride, and potassium
• Surgical treatment depends on the cause
• Hernia and adhesions: surgical procedure involves repairing the hernia or dividing the adhesion
• The surgical procedure: affected bowel may be removed and an anastomosis performed (open or laparoscopic technique)

Nursing Management of Small Bowel Obstruction:

• Maintaining NG tube function.
• Assessing and measuring NG output.
• Assessing for fluid and electrolyte imbalance.
• Monitoring nutritional status.
• Assessing for resolution (return of normal bowel, decreased abdominal distention, subjective improvement in abdominal pain and tenderness, passage of flatus or stool)

Inflammatory Bowel Disease (IBD):

• Group of chronic disorders: Crohn’s disease and ulcerative colitis which result in inflammation or ulceration of the bowel
• 10% to 15% of patients have characteristics of both disorders and are classified as having indeterminate colitis
• Prevalence in the United States is estimated at 1.3% of adults

Risk Factors for IBD:

• Family history
• Being Caucasian.
• Of Ashkenazi Jewish descent.
• Living in a northern climate
• Living in an urban area
• Commonly diagnosed in people 15 to 40 years of age
• Second peak incidence in adults 55 to 65 years of age
• Current smokers are at risk for Crohn’s disease, but those who are ex-smokers or nonsmokers are at risk for ulcerative colitis

Underlying Factors of IBD:

• Genetic predisposition
• Altered immune response
• Altered response to gut microorganisms
• Environmental triggers (air pollutants), food, tobacco, and viral illnesses may trigger the cell-mediated immune response
• Inflammatory cytokines have been identified in the pathologic and clinical characteristics
• Systemic symptoms: fever, arthralgias, malaise, and episodes of diaphoresis

Crohn’s Disease (Regional Enteritis):

• Subacute and chronic inflammation of the GI tract wall that extends through all layers
• Commonly occurs in the distal ileum and the ascending colon (ileitis, ileocolitis, and granulomatous colitis)

Crohn’s Disease Pathophysiology:

• Inflammatory process begins with crypt inflammation and abscesses, which develop into small, focal ulcers
• Lesions deepen into longitudinal and transverse ulcers, separated by edematous patches, creating a cobblestone appearance
• Inflammation extends into the peritoneum, forming fistulas, fissures, and abscesses
• 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)
• Bowel wall thickens and becomes fibrotic, and the intestinal lumen narrows
• Diseased bowel loops sometimes adhere to other loops surrounding them

Clinical Manifestations of Crohn’s Disease:

• Onset is usually insidious, with diarrhea and right lower quadrant abdominal pain, unrelieved by defecation
• Scar tissue and granulomas interfere with the ability of the intestine to transport products through the constricted lumen
• Crampy abdominal pain occurs after meals
• Weight loss, malnutrition, and secondary anemia occur because patients limit food intake
• Ulcers and inflammation result in a weeping, edematous intestine that empties an irritating discharge into the colon
• Disrupted absorption causes chronic diarrhea and nutritional deficits, leading to weight loss and dehydration
• Inflamed intestine may perforate
• Fever and leukocytosis occur
• Chronic symptoms: diarrhea, abdominal pain, steatorrhea, anorexia, weight loss, and nutritional deficiencies
• Manifestations may extend beyond the GI tract, including joint disorders arthritis, skin lesions, erythema nodosum, ocular disorders uveitis, and oral ulcers
• Clinical course and symptoms can vary (periods of remission and exacerbation or a fulminating course)

Assessment and Diagnostic Findings of Crohn’s Disease:

• CT scan is indicated to find bowel wall thickening and mesenteric edema, obstructions, abscesses, and fistulas
• MRI is both highly sensitive and specific in terms of identifying pelvic and perianal abscesses and fistulas
• CBC assesses hematocrit and hemoglobin levels (may be decreased) and WBC count (may be elevated)
• ESR is usually elevated
• Albumin and protein levels may be decreased, indicating malnutrition

Complications of Crohn’s Disease:

• Intestinal obstruction or stricture formation.
• Perianal disease.
• Fluid and electrolyte imbalances.
• Malnutrition from malabsorption.
• Fistula and abscess formation
• Most common type of small bowel fistula: enterocutaneous fistula
• Colonic Crohn’s disease also increases the risk of colon cancer

Ulcerative Colitis:

• 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 abdominal cramps and bloody or purulent diarrhea
• Inflammatory changes typically begin in the rectum and progress proximally through the colon

Pathophysiology of 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
• Mucosa becomes edematous and inflamed
• Lesions are contiguous
• Bowel narrows, shortens, and thickens due to muscular hypertrophy and fat deposits
• Inflammatory process is not transmural, so abscesses, fistulas, obstruction, and fissures are uncommon

Clinical Manifestations of Ulcerative Colitis:

• Remissions and exacerbations
• Predominant symptoms: diarrhea, with mucus, pus, or blood; left lower quadrant abdominal pain; and intermittent tenesmus
• Bleeding may be mild or severe, resulting in pallor, anemia, and fatigue
• Anorexia, weight loss, fever, vomiting, and dehydration
• Classified as mild, severe, or fulminant, depending on the severity of the symptoms
• Hypoalbuminemia, electrolyte imbalances, and anemia frequently develop
• Extraintestinal manifestations: skin lesions, eye lesions, joint abnormalities, and liver disease

Assessment and Diagnostic Findings of Ulcerative Colitis:

• Abdominal x-ray studies are useful for determining the cause of symptoms
• Colonoscopy is the definitive screening test
• It may reveal friable, inflamed mucosa with exudate and ulcerations
• Biopsies determine histologic characteristics of the colonic tissue and extent of disease
• CT scanning, MRI, and ultrasound studies can identify abscesses and perirectal involvement
• Stool is positive for blood
• Lab test results: low hematocrit and hemoglobin levels, elevated WBC count, low albumin levels, electrolyte imbalance, and elevated C-reactive protein levels
• Elevated antineutrophil cytoplasmic antibody levels are common
• Stool examination for parasites and microbes

Complications of Ulcerative Colitis:

• Toxic megacolon- Inflammatory process extends into the muscularis, inhibiting its ability to contract and resulting in colonic distention.
  • Symptoms include fever, abdominal pain and distention, vomiting, and fatigue.
• Perforation.
• Bleeding.
• Ulceration- In toxic megacolon, the inflammatory process extends 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 toxic megacolon do not respond within 72 hours to medical management
• Subtotal colectomy may be performed if bowel perforation has not occurred
• Colectomy is indicated and is needed in up to one third of patients with severe ulcerative colitis
• Patients have significantly increased risk of osteoporotic fractures due to decreased bone mineral density
• Risk for colon cancer is increased (7% to 10% of patients with extensive ulcerative colitis)

Management of Inflammatory Bowel Disease:

• Most patients have periods of well-being interspersed with short intervals of illness
• Goal: disease remission, management process using induction therapy, and preventing flare-ups of the disease process while maximizing quality of life and maintenance therapy

Aminosalicylates

• Used to induce and maintain remission of mild to moderate IBD
• Sulfa-free aminosalicylates indicated for patients with sulfa allergies
• These drugs tend to be better tolerated by most patients, including those without sulfa allergies, and are effective in preventing and treating recurrence of inflammation
• More effective agents in treating ulcerative colitis than Crohn’s disease, although they are indicated as first-line agents for both types of IBDs
• Common adverse effects: headaches, nausea, and diarrhea

Corticosteroids

• Used in combination with other drugs such as aminosalicylates, or who are experiencing an exacerbation of the disease process.
• Potent anti-inflammatory effects
• Topical corticosteroids are widely used in the treatment of proctitis and colon disease associated with IBD
• Because corticosteroids can adversely affect intestinal wound healing, they are only indicated for short-term use

Immunomodulators

• They alter the pathologic immune response present in IBD
• Agents have demonstrated effectiveness in reducing inflammation and decreasing the need for corticosteroids, hospitalization, and surgery
• Takes at least 2 months before they are effective (but are useful as maintenance therapy)
• CBC must be periodically monitored for neutropenia and pancytopenia that may warrant reducing the dosage or changing to a different agent
• These agents can be immunosuppressive, placing patients at increased risk for pneumonia and cancers
• Adults should be advised to receive pneumococcal vaccination
• Women should be screened for cervical cancer annually
• Patients taking azathioprine or mercaptopurine should be screened annually for squamous cell carcinoma,

Anti-tumor Necrosis Factor (TNF) Medications

• Incorporate monoclonal antibodies that inhibit the inflammatory effects of the cytokine TNF in the gut
• Use in patients with moderate to severe IBD that is refractory to treatment with immunomodulators
• Effective at inducing and maintaining remission of IBD, especially Crohn’s disease
• Must be administered by IV infusion
• Can potentially reactivate latent viral infections, patients must be tested for tuberculosis and hepatitis B before treatment commences
• All age-appropriate immunizations should be up to date
• Higher risk for cancers (lymphomas and melanomas)

Nutritional Therapy:

• During Induction Therapy: oral fluids and low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement
• Patients prescribed corticosteroids may require supplemental calcium and vitamin D to prevent osteopenia.
• Fluid and electrolyte imbalances caused by diarrhea corrected by IV therapy or oral fluids
• Any foods that exacerbate symptoms are avoided.
• Cold foods and smoking avoided because they increase intestinal motility
• A FODMAP diet will improve patients symptoms (milk and lactose intolerance)
• Once Remisssion is Induced: patients with IBD are educated to avoid food triggers and maintain a diet that best meets their nutritional needs. Probiotic supplements maintain remission in patients with ulcerative colitis. A consultation with a dietician may be indicated
• Patients with IBD are at risk for becoming malnourished. Fewer patients with IBD are malnourished and require intensive nutritional therapy
• Oral nutrition or enteral nutrition is preferred to parenteral nutrition
• Parenteral nutrition may be indicated for patients intolerant of oral and enteral nutrition, or those with bowel obstruction or short bowel syndrome, also patients with Crohn’s disease and proximal fistula formation.

Surgical Management:

• When nonsurgical measures fail to relieve severe symptoms of IBD, surgery may be necessary
• Surgical procedures performed for strictures of the small bowel: laparoscope-guided strictureplasty (intestines are left intact) and small bowel resection (diseased segments of the small intestines are resected, and the remaining portions of the intestines are anastomosed)
• Surgical removal of up to 80% of the small bowel can be tolerated
• Intestinal transplant improves quality of life for some patients

Proctocolectomy and Total Colectomy with Ileostomy:

• Proctocolectomy with ileostomy is recommended in the patient with IBD with a severely diseased colon and rectum that is refractory to medical therapy
• This surgery cures the disease in patients with ulcerative colitis; however surgical cure is not possible with Crohn’s disease
• An ileostomy is a type of fecal diversion that allows for drainage of fecal matter, called effluent, from the ileum to the outside of the body. Nursing management of the patient with an ileostomy is discussed later in this chapter.
• The drainage is liquid to unformed and occurs at frequent intervals
• Either temporary or permanent
• Can prevent severe ulcerative colitis if you do restorative proctocolectomy with ileal pouch anal anastomosis (IPAA)
• A permanent ileostomy: for patient with Crohn’s disease who need a total colectomy.

Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis:

• Surgical procedure of choice in cases: The rectum can be preserved because it eliminates the need for a permanent ileostomy. Voluntary defecation is maintained, and anal continence is preserved
• ileum connects to anal pouch (small intestine segment), and the surgeon connects the pouch to the anus in conjunction with removing the colon and the rectal mucosa
• Temporary loop ileostomy diverts effluent.
• Diseased colon and rectum are removed, voluntary defecation is maintained, and anal continence is preserved
• Decreases number of bowel movements significantly
• Nighttime elimination is gradually reduced to one bowel movement
• Complications include irritation of the perianal skin from leakage of fecal contents, stricture formation, pelvic abscess, fistula, small bowel obstruction, and pouchitis
• Associated with the risk of infertility in women
• Dietary intolerances may persist, and increased stool output, flatulence, and perineal irritation are associated with consumption of nuts, corn, chocolate, spicy foods, onions, and citrus fruits.

Continent Ileostomy:

• Kock pouch: proctocolectomy w/ terminal ileum is used to create a J- or S-shaped continent ileal reservoir by diverting a portion of the ileum to the abdominal wall and creating a stoma
• Eliminates the need for an external fecal collection bag
• Accumulates in the pouch for several hours and removed by a catheter
• Used less: restorative proctocolectomy with IPAA (greater complication)
• Advantages: is potential improved body image and lack of external drainage appliance

Nursing Process for Management of the Patient with Inflammatory Bowel Disease:

• Assess: Onset of abdominal pain; the presence of diarrhea, fecal urgency, or tenesmus, nausea, anorexia, or weight loss, any family history of IBD
• Diet patterns and smoking habits. Also pattern of bowel elimination.
• Note any allergies and food intolerance: milk intolerance

Nursing Diagnosis

• Common diagnosis: Diarrhea associated with the inflammatory process, Acute pain associated with increased peristalsis and GI inflammation, and Hypovolaemia associated with anorexia, nausea, and diarrhea.

Planning

• Make sure your patient reaches the goals of normal bowel movements, relief of abdominal pain and cramping, prevention of fluid volume deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, and increased knowledge about the disease process and self-health management

Nursing Interventions:

• Maintain normal elimination patterns: relationship between diarrhea and/or foods
• Provide ready access: bathroom, commode, or bedpan
• Clean the environment
• Administer antidiarrheal medications
• Relieving pain: Character of the pain (dull, burning, or crampy)
• Administer analgesic agents
• Position changes and diversional activities (also heat)
• Maintaining Fluid Intake: Monitor patients symptoms and record
• Monitor daily: weight gain and loss
• Signs: of fluid loss, dry skin or fatigue, temperature
• Maintain optimal nutrition: Monitor diet change and also monitor weight and what you eat, and what is not eaten
• Promoting rest: recommend intermittent rest periods, and schedules or restricts activities

Malabsorption disorders occur when the digestive system cannot absorb essential vitamins, minerals, and nutrients. These disorders arise from interruptions in the digestive process. Conditions are categorized based on the underlying cause, such as mucosal, luminal, or lymphatic issues.