Noninflammatory Bowel Disorders

• Noninflammatory bowel disorders include hemorrhoids, cancer, hernia, irritable bowel syndrome (IBS), and intestinal obstruction.

Hemorrhoids

• Hemorrhoids are distended or edematous intestinal veins caused by increased intra-abdominal pressure.
• Straining, obesity, prolonged sitting or standing, constipation, and weight lifting can increase intra-abdominal pressure.
• Pregnancy increases the risk of developing hemorrhoids.

Cancer of the Small or Large Intestine

• Can be caused by age-related changes, genetic influence, or chronic bowel diseases like Crohn's or ulcerative colitis.
• Those 50 years or older have an increased risk.

Hernia

• Bowel herniation is the displacement of the bowel through a weakness in the abdominal muscle.
• The bowel protrudes into other areas of the abdominal cavity.
• Incisional hernias may occur post-surgery due to inadequate healing from malnutrition, infection, or obesity.
• A hernia that cannot be moved back into place with gentle palpation is considered irreducible and requires immediate surgical evaluation.
• In a strangulated hernia, blood supply is cut off to a portion of the bowel, increasing the risk of obstruction, necrosis, and perforation.
• Findings of a strangulated hernia include abdominal distention, tachycardia, vomiting, abdominal pain, and fever, requiring surgical intervention.

Hernia Risk Factors

• Male sex (indirect inguinal hernia)
• Advanced age (direct hernia)
• Increased intra-abdominal pressure due to pregnancy or obesity (femoral, adult-acquired umbilical hernia)
• Genetics (congenital umbilical hernia)

Hernia Expected Findings

• Protrusion or lump at the involved site.
• Sites include the groin area, umbilicus, or a healed incision.

Hernia Patient-Centered Care

• If surgery is not required, instruct the client to wear a truss pad with a hernia belt during waking hours.
• Inspect the skin under the pad daily.
• Postoperative client education includes to avoid increased intra-abdominal pressure for 1 to 3 weeks by avoiding coughing, straining, and lifting objects greater than 10 lb.
• Postoperative client education includes to apply ice as prescribed, inspect, and report redness or swelling at the incisional site.
• Prevent constipation with increased dietary fiber and fluids.
• Rest for several days and return to work when recommended by the surgeon, typically 1 to 2 weeks postoperatively.

Irritable Bowel Syndrome (IBS)

• IBS is a gastrointestinal system disorder causing changes in bowel function, including chronic diarrhea, constipation, bloating, and/or abdominal pain.
• Environmental, immunological, genetic, hormonal, and stress factors are thought to influence development and course.
• Food intolerances can worsen the manifestations.

IBS Environmental Factors

• Dairy products
• Caffeinated beverages
• Infectious agents

IBS Immunological Factors

• Cytokine genes (pro-inflammatory interleukins)
• Tumor necrosis factor (TNF) alpha

IBS Stress-Related Factors

• Anxiety
• Depression

IBS Diagnostics

• Diagnosed primarily based on the presence of manifestations.
• Criteria include recurrent abdominal pain for 3 days during a month in the past 3 months, accompanied by two or more of the following:
  • Improvement when the client moves their bowels.
  • Onset when there is a change in frequency of stools.
  • Onset when there is a change in appearance of stools.

IBS Health Promotion and Disease Prevention

• Avoid foods that trigger exacerbation, such as dairy, wheat, corn, fried foods, alcohol, spicy foods, and aspartame.
• Avoid alcoholic and caffeinated beverages, and other fluids containing fructose and sorbitol.
• Consume 2 to 3 L of fluid per day from food and fluid sources.
• Increase fiber intake to approximately 30 to 40 g/day.

IBS Risk Factors

• Female sex
• Stress
• Eating large meals containing a large amount of fat
• Caffeine intake
• Alcohol Intake

IBS Expected Findings

• Cramping pain in abdomen.
• Abdominal pain
• Nausea
• Anorexia
• Abdominal bloating
• Belching
• Diarrhea (diarrhea-predominant IBS)
• Constipation (constipation-predominant IBS)
• Hyperactive or hypoactive bowel sounds
• Sensation of incomplete defecation
• Mucous in stools

IBS Lab Tests

• Complete blood count (CBC), blood albumin, erythrocyte sedimentation rate (ESR), and occult stools are typically within the expected reference range.

IBS Hydrogen Breath Test

• A hydrogen breath test might be performed to identify malabsorption, impaired digestion, or an overgrowth of bacteria.
• The client exhales into a hydrogen analyzer before and after ingesting test sugar.
• Positive test results indicate excess hydrogen in the bloodstream from bacterial overgrowth or malabsorption.
• The client should remain NPO for at least 12 hours prior to test, except for sips of water.

IBS Patient-Centered Care

• Review strategies to reduce stress.
• Instruct the client to limit the intake of irritating agents like gas-forming foods, caffeine, and alcohol.
• Encourage a diet high in fiber and fluids.
• Instruct the client to keep a food diary to record intake and bowel patterns.
• The food diary is used to adjust diet to prevent exacerbations.

IBS Medications for Diarrhea-Predominant IBS (IBS-D)

• Loperamide decreases peristalsis and increases bulk.
  • Can cause drowsiness.
  • Discontinue if there is no response after 48 hours.
• Psyllium is a bulk-forming laxative.
  • Discontinue for abdominal cramping, rectal bleeding, and vomiting.
  • Monitor for electrolyte imbalance.
• Alosetron selectively blocks 5-HT3 receptors that innervate the viscera.
  • Use with caution in females and only as a last resort.
  • The expected result is increased firmness in stools and decreased urgency and frequency of defecation.
  • Indicated for IBS-D in females that has lasted more than 6 months and is resistant to conventional management.
  • Contraindicated for clients with a history of bowel obstruction, Crohn’s disease, ulcerative colitis, impaired intestinal circulation, or thrombophlebitis.
  • Manifestations should resolve within 1 to 4 weeks. Discontinue after 4 weeks if manifestations persist.
  • Avoid concurrent use of psychoactive drugs and antihistamines.
  • Report constipation, fever, increasing abdominal pain, fatigue, dark urine, bloody diarrhea, or rectal bleeding immediately because alosetron can cause ischemic colitis. Discontinue medication if these manifestations occur.

IBS Medications for Constipation-Predominant IBS (IBS-C)

• Lubiprostone increases fluid secretion in the intestine to promote intestinal motility.
  • Indicated for IBS-C in females.
  • Contraindicated for clients with known or possible bowel obstruction.
  • Take with food and water.
• Linaclotide increases fluid and motility in the intestine.
  • Can relieve pain and cramps.
  • Take daily about 30 minutes before breakfast.

Intestinal Obstruction

• Intestinal obstruction can result from mechanical or nonmechanical causes.
• Manifestations vary according to type.
• Mechanical obstruction occurs when the bowel is blocked by something outside or inside the intestines.
• Adhesions and fecal impactions cause mechanical obstructions.
• Complete mechanical obstructions should be addressed surgically.
• Nonmechanical obstructions are caused by diminished peristalsis within the bowel (paralytic ileus).
• Nonmechanical obstructions can occur postoperatively due to the handling of the intestines during surgery.
• Treatment focuses on fluid and electrolyte balance, decompressing the bowel, and relief/removal of the obstruction.

Intestinal Obstruction Risk Factor: Mechanical

• Encirclement or compression of intestine by adhesions, tumors, fibrosis (endometriosis), or strictures (Crohn’s disease, radiation). Postsurgical adhesions are often the cause of small bowel obstructions.
• Carcinomas are often the cause of large intestine obstructions.
• Older adult clients: Diverticulitis, fecal impaction, and tumors are common causes of obstruction.
• Bowel regimens can be effective in preventing impactions.
• Hernia (bowel becomes trapped in weakened area of abdominal wall)
• Volvulus (twisting) or intussusception (telescoping) of bowel segments

Intestinal Obstruction Risk Factor: Nonmechanical

• Decreased peristalsis secondary to the following
• Neurogenic disorders (manipulation of the bowel during major surgery and spinal fracture)
• Vascular disorders (vascular insufficiency and mesenteric emboli)
• Electrolyte imbalances (hypokalemia)
• Inflammatory responses (peritonitis or sepsis)
• Manifestations of nonmechanical obstructions include diffuse, constant pain, significant abdominal distention, and frequent vomiting.

Intestinal Obstruction Small Bowel and Large Intestine Expected Findings

• Obstipation: the inability to pass a stool and/or flatus for more than 8 hr despite feeling the urge to defecate
• Abdominal distention
• High-pitched bowel sounds above the site of obstruction (borborygmi) with hypoactive bowel sounds below, or overall hypoactive
• Absent bowel sounds later in process
• Diarrhea or ribbon-like stools around an impaction with large intestine obstruction

Intestinal Obstruction Small Bowel Expected Findings

• Severe fluid and electrolyte imbalance
• Metabolic alkalosis
• Visible peristaltic waves (possible)
• Epigastric or upper abdominal distention
• Abdominal pain, discomfort
• Profuse, sudden projectile vomiting with a fecal odor

Intestinal Obstruction Lab Tests

• Increased hemoglobin, BUN, creatinine, and hematocrit can indicate dehydration.
• Increased blood amylase and WBC count can occur with strangulating obstructions.
• Arterial blood gases (ABGs) indicate metabolic imbalance, depending on obstruction type.
• Chemistry profiles reveal decreased blood sodium, chloride, and potassium.

Intestinal Obstruction Diagnostic Procedures

• X-ray: Flat plate and upright abdominal x-rays evaluate the presence of free air and gas patterns.
• Endoscopy determines the cause of obstruction.
• CT scan determines the cause and exact location of the obstruction.

Intestinal Obstruction: Nonmechanical Nursing Care

• Nothing by mouth with bowel rest.
• Check bowel sounds.
• Provide oral hygiene.
• Ensure IV fluids and electrolyte replacement (particularly potassium) are administered.
• Manage pain (once diagnosis identified).
• Encourage ambulation.
• Place in semi-Fowler’s position.

Intestinal Obstruction: Mechanical Nursing Care

• Prepare for surgery and assist with providing preoperative nursing care.
• Withhold intake until peristalsis resumes.

Intestinal Obstruction Medications

• Opioid antagonist (alvimopan) reverses the action of opioids on bowel motility in clients with a postoperative paralytic ileus.
  • Monitor for myocardial infarction.

Nasogastric (NG) Tube for Intestinal Obstruction

• A nasogastric (NG) tube with a vent is inserted to decompress the bowel.
• Maintain intermittent suction as prescribed.
• Check NG tube patency and placement. Irrigate every 4 hours, or as prescribed.
• Monitor and measure gastric output.
• Monitor nasal area for skin breakdown.
• Provide oral hygiene every 2 hours.
• Monitor vital signs, skin integrity, weight, and I&O.

Intestinal Obstruction: Surgical Interventions

• Procedures vary based on the cause of obstruction.
• Procedures include lysis of adhesions, colon resection, colostomy creation (temporary or permanent), embolectomy, thrombectomy, resection of gangrenous intestinal tissue, or complete colectomy.
• Exploratory laparotomy is performed to determine and correct the cause of obstruction if possible.
• Ensure the client understands the type of procedure (open or laparoscopic).
• Monitor vital signs.
• Assist with the administration of IV fluid replacement and maintenance as prescribed.
• Monitor bowel sounds.
• Maintain NG tube patency and measure output.
• Clamp NG tube as prescribed to check the client’s tolerance prior to removal.
• Advance diet as tolerated when prescribed, beginning with clear liquids. Clamp tube after eating for 1 to 2 hours.
• Instruct the client to report intolerance of intake following NG tube removal (nausea, vomiting, increasing distention).

Dehydration from Persistent Vomiting

• Monitor hydration through evaluation of hematocrit, BUN, orthostatic vital signs, skin turgor/mucous membranes, urine output, and specific gravity.
• Notify the provider of fluid or electrolyte imbalance.
• Monitor electrolytes, especially potassium levels.
• Assist with the administration of IV fluids as prescribed to replace electrolytes.