Intestinal Anorectal Disorders

Fecal Incontinence

• This is the involuntary passage of stool from the rectum.
• Factors influencing it include:
  • The rectum's sensitivity
  • Stool consistency/amount
  • Anal sphincter integrity
  • Rectal motility

Causes of Fecal Incontinence

• Trauma, especially after rectal surgeries
• Neurologic disorders like stroke, multiple sclerosis, diabetic neuropathy, and dementia
• Inflammation and infection
• Diarrhea
• Chemotherapy and radiation treatment
• Fecal impaction and Pelvic floor relaxation
• Laxative abuse, medications, and advancing age which causes loss of anal or rectal muscle tone

Risk Factors

• Age
• Being female, nerve damage, dementia, and physical disability

Clinical Manifestations

• Minor soiling and occasional urgency
• Loss of bowel control (partial or complete)
• Poor control of flatus
• Diarrhea or constipation

Assessment & Diagnostic Tests

• Rectal examination and flexible sigmoidoscopy are used
• Barium enema, CT scan, and anorectal manometry

Medical Management

• If the cause is fecal impaction, the impaction is manually removed then the rectum is cleaned.
• Biofeedback therapy with pelvic floor muscle training can assist with decreased sensory awareness or sphincter control
• Bowel training programs can also be implemented.

Surgical Management

• Surgical reconstruction, artificial sphincter implantation, sphincter repair, and fecal diversion.

Nursing Management

• Gather a thorough health history, noting surgical history, dietary habits, bowel habits, any problems, and current medications.
• Initiate a bowel-training program, set a schedule for bowel regularity.
• Offer foods that thicken stool such as applesauce and psyllium fiber products.
• Maintain perineal skin integrity, minimize brief/diaper use, teach meticulous hygiene, and use skin protection products.
• Consider fecal incontinence devices.

Complications

• Emotional distress, from the loss of control of bodily functions
• Skin irritation because the constant contact with stool can cause sores or ulcers.

Prevention

• Reduce constipation by drinking plenty of fluids, eating more high-fiber foods, and increasing exercise.
• Aim to control diarrhea: treating or eliminating the cause of diarrhea can help prevent incontinence.
• Avoid straining during bowel movements as it could weaken sphincter muscles.

Irritable Bowel Syndrome (IBS)

• Complex syndrome marked by intermittent abdominal pain and stool pattern irregularities
• Peristaltic waves are affected in the intestine in both intensity and how well they propel fecal matter.
• Bowel pattern changes include constipation, diarrhea, or both.

Signs & Symptoms

• Abdominal distension, excessive flatulence and a continual urge to defecate
• Urgency and a sensation of incomplete evacuation

Rome IV Criteria for Diagnosis

• Recurrent abdominal pain (at least one day per week) during the last three months, associated with at least two of the following:
  • Related to defecation
  • Associated with changes in stool frequency or appearance

Cause and Incidence

• The cause of IBS is unknown, it is a functional disorder of intestinal motility linked to neuroendocrine dysregulation or vascular metabolic disturbance.
• IBS is more common in women.

Predisposing Factors

• Stress and psychological factors
• Prior gastroenteritis and specific food intolerance

Nursing Management for IBS

• For IBS with constipation:
  • Consume 20 g per day of dietary fiber and a bulking agent (Metamucil).
  • Tegaserod (Zelnorm) aids motility.
• For IBS with diarrhea:
  • Antispasmodic agents such as Dicyclomine [Bentyl] or Propantheline [Pro-Banthine] taken before meals
  • Loperamide (Imodium) is a synthetic opioid that minimizes intestinal water absorption and transit
  • Alosetron (Lotronex) can have side effects like severe constipation/ischemic colitis
• To generally treat IBS, avoid gas-forming foods (broccoli, cabbage)
• Avoid alcohol use and cigarette smoking
• Cognitive-behavioral therapy, acupuncture, hypnosis, Chinese herbs, and relaxation/stress management techniques.

Acute Inflammatory Disorders: Appendicitis

• Appendicitis is an inflammation of the appendix — a narrow, blind tube extending from the inferior cecum.
• Obstruction of the lumen by a fecalith (accumulated feces) is the most common cause.

Classifications

• Simple: appendix is inflamed but still intact
• Gangrenous: Tissue necrosis with microscopic perforation areas
• Perforation: Large perforation with contents flowing into the peritoneal cavity

Manifestations

• Begins with periumbilical pain; followed by anorexia, nausea, and vomiting
• Low-grade fever
• Pain becomes persistent and shifts to the RLQ at McBurney's point

Signs of Appendicitis

• Blumberg's sign (rebound tenderness) the abdomen is sensitive after the tips of the fingers are pressed gently into the abdominal wall and then withdrawn suddenly
• Rovsing's sign is felt at the RLQ when LLQ is palpated while the Psoas' sign show when the person lies still with right leg drawn up
• An Iliopsoas muscle test will result in pelvic pain if flexing the right thigh against resistance
• An Obturator muscle test will cause pain when the right thigh is flexed 90° and the leg rotated internally/externally.

Diagnostic Studies

• X-ray acts as a confirmatory test
• Complete bloodcount reveals an elevated WBC (10,000/mm3 – 20,000/mm3)
• Urinalysis is used to rule out urinary tract infection.

Complications & Management

• Perforation & peritonitis
• Surgical management: appendectomy (open abdominal or laparoscopic)

Nursing Management

• Implement with NPO.
• Avoid laxatives and enemas to prevent increased peristalsis, which could lead to perforation.
• Apply an ice bag to the RLQ.
• Place the patient in high-Fowler's position before and after surgery.
• Administer Morphine Sulfate for postoperative pain relief.
• Monitor the patient for signs of peritonitis.

Peritonitis

• Peritonitis is the inflammation of the peritoneum.
• Primary causes include bacterial infection such as E.coli, Klebsiella, Proteus, and Pseudomonas.
• Secondary causes include ruptured appendicitis, ruptured diverticulitis, perforated PUD, and postoperative complications.

Manifestations

• Abdominal pain (most common symptom)
• Tenderness, muscular rigidity and spasm, absent bowel sounds (paralytic ileus)
• High fever, tachycardia, diaphoresis
• Drawing the knees up to the chest

Complications

• Hypovolemic shock
• Septic shock
• Acute respiratory distress syndrome

Diagnostic Studies

• Elevated WBC count and hemoconcentration via CBC
• Peritoneal aspiration (paracentesis) tests for blood, bile, pus, amylase, fungus, or bacteria
• X-ray, CT scan, UTz, or perioneoscopy

Surgical & Nursing Management

• Surgical intervention involves laparoscopic repair to treat the underlying cause
• NPO, NGT insertion, IVF, semi-fowler's position with knees flexed, oxygen, analgesics, and antibiotics
• Monitor vitals frequently, and provide a quiet, restful environment post-op

Diverticular Disease

• Diverticulum: a saccular dilation/outpouching of the mucosa through the circular smooth muscle of the intestinal wall
• Diverticulosis: a condition where an individual has noninflamed diverticula
• Diverticulitis: an inflammation and obstruction of a colonic diverticulum

Causes

• Lack of dietary fiber intake
• Loss of muscle mass and collagen with aging
• Associated with obesity

Manifestations

• Diverticulum is primarily asymptomatic
• Diverticulitis:
  • LLQ abdominal pain (most common symptom)
  • Nausea, vomiting, changes in bowel habits, and bloating
  • Palpable abdominal mass

Diagnostics

• UTz & CT scan with contrast
  • Barium enema and colonoscopy are contraindicated
• CBC showing leukocytosis and elevated sedimentation rate

Nursing Management

• Emphasize a high-fiber diet rich in fruits and vegetables
• Minimizing fat and red meat intake
• High levels of physical activity
• Weight reduction for the obese
• Avoid increasing intra-abdominal pressure
• Observe for possible peritonitis

Pharmacological Management

• Bulk-forming laxatives such as Psyllium (Metamucil) and stool softeners like Docusate (Colace)
• Bisacodyl (Dulcolax), antispasmodics such as Propantheline (Pro-Banthine), and the pain reliever Meperidine (Demerol)
  • Note: Morphine is contraindicated

Acute Gastroenteritis (AGE)

• An inflammation of the mucosa of the stomach and small intestine
• Manifestations: nausea, vomiting, diarrhea, abdominal cramping and distension, fever, and increased WBC with blood or mucous in the stool.
• Cause: Salmonella and trichinosis in street foods or from contaminated water
• Monitoring Intake and Output.
  • If a patient shows vomiting or dehydration, IVF and NPO.

Nursing Management for AGE

• Institute medical asepsis and infection control
• Educate about proper handwashing and instruct on how to prep/handle foods.

Inflammatory Bowel Disease (IBD)

• Regional Enteritis (Crohn's Disease), the most frequent site of inflammation and ulceration is the terminal ileum. With Inflammation involving all layers of the bowel wall (transmural lesions) With very deep ulcerations.

Ulcerative Colitis

• Usually starts in the rectum and spreads in a continuous pattern up the colon
• Inflammation involves mucosa and submucosa

Clinical Manifestations of Crohn's Disease

• Skip lesions where healthy tissue is interspersed with areas of classic cobblestone.
• Palpable mass felt in right iliac fossa, RLQ pain, crampy abdominal pain after meals, abdominal tenderness and spasm (pain relieved by defecation)
• There is weight loss, anemia (due to malabsorption), and steatorrhea (excessive fat in the stool)
• Diarrhea and Fever

Clinical Manifestations of Ulcerative Colitis

• Continous areas of ulcerations (rectum and colon) and inflammation of the mucosa and submucosa
• LLQ pain, intermittent tenesmus, and rectal bleeding
• Bloody diarrhea (10-20x a day)
• Minimal nutritional deficiencies and fever

Complications of IBD

• Regional Enteritis (Crohn's Disease): Fistula and Malnutrition as well as an increased chance of of recurrence after surgery
• Ulcerative Colitis: Can include Toxic megacolon, Perforation, Colon cancer, Hemorrhage, Skin lesions (erythema nodosum), Eye lesions (Uveitis), and Arthritis

Diagnostics for Crohn's Disease & Ulcerative Colitis

• Crohn's Disease would require:

  • Barium study (Upper GI) with the classic "string sign"
  • CT scan showing bowel wall thickening and fistula formation
  • CBC revealing decreased Hemoglobin and Hematocrit
  • ESR and C-reactive proteins revel reveal an elevation
  • Serum Albumin reveals diminished level
  • WBC reveals an infectious process
  • Capsule endoscopy and prevalence in Ashkenzai Jews Whites

• Ulcerative Colitis would require:

  • Barium enema shows mucosal irregularities, shortening of the colon, and dilation of bowel loops.
  • Colonoscopy to show Friable and Infected mucosa -> Whites often get and are Diagnosed from adolescence through 30 year old

Causes of Inflammatory Bowel Disease

• Unknown but can by caused from:
  • Autoimmune= CARD 1
  • Hereditary
  • Environment factors= food additives, pesticides, tobacco, radiation

Pharmacological Management of IBD

• Aminosalicylates: decreases GI inflammation.
  • Sulfasalazine may cause orange discoloration of skin and urine, avoid sunlight.
  • Mesalamine and Olsalazine
• Antimicrobials: prevent or treat secondary infections
  • Metronidazole (Flagyl), Ciprofloxacin (Cipro), Clarithromycin (Biaxcin)
• Cortiocosteriods: Decrease inflimmation
  • Prednisone, Hydrocortisone, Methylprednisolone
• Immunosuppressants suppress immune response
  • Azathioprine (Imuran), Cyclosporine, 6-Mercaptopurine, Biologic therapy inhibits the cytokine tumor necrosis factor (TNF), Infliximab (Remicade).

Ileostomy

• Surgical procedure that involves Total Proctocolectomy with Permanent Ileostomy: involves the removal of colon and rectum with closure of the anus. Then and the end of ileum is brought out through the abdominal wall to create a ostomy. and The stoma is usually placed in the RLQ below the belt line.
• Surgical procedure that involves Total Proctocolectomy with Permanent Ileostomy uses what is called “Kock Pouch”, a surgical procedure where the the distal segment of the Ileum to create a one way Nipple Valve.

Ileostomy Nursing Management

• Enhance nutritional status/ nutritional therapy
  • Diet high in CHON, calories, low residue, low in fat and suppplement with Vitamin therapy,iron, electrolytes, and blood replacement. Avoid all forms of Smoking / Alcohol, and and Diarrheal foods with rest periods.
• Provide with emotional support with psychotherapy and group sessions.

Malabsorption

• Nutrients no longer effectively absorbed in the small intestines
• Causes:
  • Celiac Disease marked atrophy of the villi characterized in the proximal small intestine induced by ingestion of gluten-containing foods
  • Nontropical Sprue
  • Gluten = Made of high-Molecular weight protein in Barley, Rye, Oats and, Wheath
• Associated with autoimmune diseases, such as rheumatoid arthritis, type 1 diabetes mellitus, and thyroid disease

###Manifestations / Management of Malabsorption

• Foul-smelling diarrhea, Abdominal distension, Anorexia, Wasting,Failure to thrive.
• Confirmatory Histologic / diagnostic examination with biopsy shows flattened mucosa and noticeable losses of villi -Management involves: - Gluten-free diet for life , - Corticosteroids

###Example Of Foods Free of Gluten

• Eggs, Potatoes, Butter, Cheese or Cottage cheese, Meat/Fish/Poultry, Soy/Unflavored Milk Product, Bread product, Peanut Butter, Fresh Fruits,
• Flax/Corn /Rice/Tapioca ,Coffee ,Tea, Corn Tortillas ,Cocoa.

Lactase Deficiency

• a condition in which the lactase enzyme is deficient or absent
  • Lactose is the enzyme that breaks down lactose into glucose and galactose
  • Can be genetic
  • Related to Inflimmatory Bowel Disease, Gastroenteritis, AND Celiac Disease
• Causes :Bloating, flatulence, cramping abdominal pain, and diarrhea, which are often confirmed by a lactose tolerance test or a lactose hydrogen breath test.
• Treats by Avoid milk, milk products,and Calcium supplements and live culture yogurt as a alternative with commercially available Lactaid enzyme .

Intestinal Obstruction

• Partial or complete impairment of forward flow of intestinal contents occurs due with Blockage of movement that causes an in movement through parts of small and large intestine:

Causes of Intestinal Obstruction.

• Mechanical Obstruction an obstruction caused by pressure on the intestinal wall occurs:
  • Adhesions: which lead to intussusceptions or loops of intestine becoming one located below Intusseception
  • volvulus/ tummor

Nonmechanical Obstruction

• neurological or vascular related disorders called paralytic ileus and may be due to postoperative abdominal surgeries and can result In mesentery infarction with presence of bowel sounds with CBC

Clinical Manifestations:

Small Intestinal Obstructions has Onset, that is Vomiting frequently with Copious colicky intermittent pain due to feces.

• Large Intestinal Obstructions has onset, then gradual low grade cramping the abdomen, constipation Abdominal distention is related to fluid levels with Gas in Intenstiones, and
• Diangostics through Abdominal imaging such as rays using Bariun Enemas to locate, CBC and Ultrasonds

Treatments of Intertional Obstuction

• Surgical= Partitial/ Total colectomy, or Ileostomy after colonoscopy because extensive obstruction ( NPOA, Insertation, Decomression, Analgesiz
• Medical management of F&E
• Nursing actions include: -F&E, Asecultating, Palate bowel sunds, passing stones through F&E with IO with dehydration and Comfort patient.

Management of Clients With Anorectal Disorders: Hemorrhoids

• Dilated hemorrhoidal veins, which has two types: =Located Above internals- below internal above external-
• Degree of internal Hemorrhoid Prolabses is 1st-No Prolapse with Just vein appearance -2nd Prolapse of straining but comes back slowly -3nd need someone to push the protrusion back but does not stay -Prolapsed out and never comes back Result from stretching during heavy deication,
• During defecation, venules become dilated
• Symptoms-Pruritus, rectal pain, prolapse, Asym

Hemmorhoids- Treatments and Solutions

• DRE-visual for exterrnal examination .
• Rubber band Ligation with Anoscopy and Ligation
• Sclertheraphy 5% Injection of Phenol in the the base causing Thrombusus
• StapledHemmohectomy removes prolapses Hemorrhiodactomy surgical removal that is painful with 5-20 minutes Sitz Bath
• Nursing Solutions includes hydro cortisol cream that prevent side effects such as Derm/Mucosal.

###Anal Fissure

• Skin ulcer that line the area that cause irritation and inflammation.
• Causes of skin issues

Treatment of Anal Fissures:

• Local injection of botulinum toxin (botox)

-Topical NTG, calcium channel blockers= are used to decrease rectal anal pressure and with stool.

• Surgical Management including,excision if the fissurtes of the issues for better resond to treatments.
• Surgical Managements can can be followed a 3 ways
  • Fistulotmy/Fistulectomy
• Anal Fistula
• Complication of Crohhns that requires persistient cleaning or stull in vagina ,butt cheeks with surgicals action.
• Anorectal Abscess that cuases infection or aids in the site that need removal such as Local pain and swelling
• Foul-smelling drainage
• Tenderness

-Elevated temparute from this may need anal packing with surgical dranage and compresses.