Gastrointestinal Disorders Part 2: Inflammatory Disorders PDF

Gastrointestinal Disorders Part 2: Inflammatory disorders Kayla Berrios, MSN-Ed, RN Inflammatory Bowel Disease Ulcerative Colitis Crohn's disease  Crohn's disease: Overview Autoimmune disorder that can affect any portion of the GI tract, results in diseased pat...

Gastrointestinal Disorders Part 2: Inflammatory disorders Kayla Berrios, MSN-Ed, RN Inflammatory Bowel Disease Ulcerative Colitis Crohn's disease  Crohn's disease: Overview Autoimmune disorder that can affect any portion of the GI tract, results in diseased patches interspersed among healthy tissue. ​ Over time, the inflammation affects all the layers of the GI tissue and can cause strictures, obstructions, and fistulas.​ Average age of onset is late 20's: can also onset 50's-60's. ​ Increased risk with family history, smoking, living in urban or industrial areas​ Symptoms are often intermittent: periods of exacerbation and remission​ There is no cure, but disease can  Fever, crampy abdominal pain Crohn's Diarrhea (usually non-bloody) 5 + times per day Steatorrhea (mucus/fatty stools) disease: Fatigue, unintentional weight loss due to anorexia Assessment Post-prandial bloating, borborygmi (loud, frequent bowel sounds) findings Oral ulcerations Fistula formation (bowel-bowel, bowel-stomach, bowel- bladder, bowel-skin, bowel-vagina)  Crohn's disease: Labs & Diagnostics LABS: ESR (erythrocyte sedimentation rate): elevated CRP (C-reactive protein): elevated Anemia (vit B12 deficiency and folic acid deficiency) Low albumin Electrolyte abnormalities DIAGNOSTICS: Barium studies (can help identify strictures and fistula formation) CT scan (can show abscess formation and inflammation) Endoscopy/colonoscopy/sigmoidoscopy for biopsy and direct visualization of GI tract Crohn's Disease: Medical management Dietary restriction: reduce greasy/fatty foods, dairy products, gas-producing foods, and high-fiber foods. Nutritional supplementation (Ensure, Boost, etc.) Medications: give B12 and folic acid as indicated glucocorticoids for inflammation antidiarrheal medications as needed  Crohn's disease: Nursing Care Monitor intake/output, vitals, (any signs of hypovolemia or infection) Monitor electrolytes, replace as needed Replace fluids lost Administer medications as ordered Post-operative monitoring, wound care Teach patient about  Ulcerative Colitis: Overview Inflammatory disease of the large intestine that affects the mucosal layer beginning in the rectum and colon and spreading into adjacent tissue. This creates ulcerations in the intestinal wall, causing bloody diarrhea with mucous appearance. Peak incidence in teens to 20's, then again in 50's-60's. Cause unknown: increased incidence in those of European, North American, or Ashkenazi Jewish descent Often increase/worsening in symptoms with each flare Ulcerative Colitis: Assessment findings Weight loss (due to malabsorption of nutrients) Abdominal pain Chronic bloody diarrhea with mucous Labs & Diagnostics Anemia (lower Hgb & Hct) due to chronic blood loss Elevated ESR (indicates inflammation) Electrolyte imbalances (due to diarrhea and malabsorption) Barium enema to show areas of ulcerations & inflammation Colonoscopy or sigmoidoscopy for direct visualization  Ulcerative Colitis: Nursing Care Teach patient to keep food diary to identify irritating foods Recommend low-fiber, high-protein, high- calorie diet Administer ordered medications: give antidiarrheals, corticosteroids to decrease inflammation, anticholinergics to decrease cramping/discomfort Ensure good skin care, especially perianal Monitor for complications: dehydration, malnutrition, toxic megacolon/infection Wound care for post-operative patients  Gastritis Inflammation of the stomach lining Causes: physiological stress from illness, medications (NSAIDs), alcohol use, pernicious anemia, H. Pylori infection, prior abdominal surgeries Can be acute or chronic Gastritis may cause changes within the cells of stomach lining that lead to gastric cancer, lymphoma, and malnutrition Hematemesis, melena may also be present Nursing care depends on cause: lab monitoring, medications, lifestyle modifications,  Gastroenteritis : Pathophysiology Acute inflammation of the gastric and intestinal mucosa, most commonly due to bacterial, viral, protozoal, parasitic infection. Can also be due to irritation from chemical or toxin exposure or allergic response. Causes diarrhea and vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal track. Often called "stomach bug" or Gastroenteritis: Assessment findings N/V, diarrhea (may or may not be bloody), abd pain/distention Flu-like symptoms: malaise, headache, may have fever Signs of dehydration: dry skin/mucous membranes, decreased urine output, tachycardia, poor skin turgor, increased heart rate, decreased blood pressure LABS & DIAGNOSTICS CBC (elevated WBCs due to infection) CMP: electrolytes (imbalance), BUN/Creatinine (elevated d/t dehydration) Stool sample (checks for ova and parasites)  Gastroenteritis : Nursing Care Give antiemetics, antidiarrheals as indicated (one or the other but not both. Need to allow the organism to exit the body) Antibiotics (only if bacterial infection confirmed) Stop oral intake when acute: then resume gradually (clear liquids, then progress diet as tolerated) IV fluids and/or Oral rehydration therapy (Gatorade, Pedialyte, etc), replace electrolytes Teaching point: HANDWASHING is primary way to prevent!  Diverticulitis : Overview Inflammation of small outpouchings along the intestinal tract called diverticula. Any part of the small or large intestines may be involved, most common in the sigmoid colon. DiverticuLOSIS: the condition of having diverticula (more than half of Americans over age 60 develop this) DiverticuLITIS: the inflammation/infection of the diverticula Patho: Certain types of undigested foods can become trapped in the diverticula/pouches, this creates bacteria to multiply and create Diverticulit is: Nursing Care Also, monitor for complications: Abscess Obstruction Fistula hemorrhage Perforation Sepsis/peritonitis Diverticuli tis Diet Cholecystitis: Overview Inflammation of the gallbladder, often accompanied by the formation of gallstones (cholelithiasis) in 90% of cases. Local edema occurs around inflammation, the gallbladder distends due to retained bile (causes more irritation and pain), and ischemic changes can occur due to reduced bloodflow. Can be acute or chronic. Risk Factors: increased age, female, overweight, having family history, rapid weight loss diets, and pregnancy Cholecystitis: Assessment findings Abdominal pain (usually upper, epigastric, or RUQ) that may radiate to right shoulder or upper-mid back Murphy's sign: increased pain in RUQ on palpation and inspiration Pain often after eating, intermittent or constant N/V, especially after eating fatty foods Increased gas (belching and flatulence) Can have pruritis (itching) of skin due to buildup of bile salts Clay-colored stools Can have jaundice and icterus (yellow skin, yellow sclera of eyes)  Cholecystitis: Labs & Diagnostics Labs: WBC (elevated with infection or inflammation) Bilirubin (elevated if gallstones are obstructing the bile duct) LFTs elevated (AST, ALT, AlkPhos) if bile duct obstructed Amylase and lipase may be mildly elevated: why? Diagnostics: CT scan, Ultrasound (shows stones and/or inflammation)  Cholecystitis: Treatments & Nursing Care Based on symptoms: acute or chronic, obstructed or non- obstructing Low-fat diet. Replace fat soluable vitamins (A, D, E, K) as needed. IV fluids, antiemetics, possibly NG tube if acute vomiting Pain control Antibiotics for acute symptoms/infection Surgery: can remove gallbladder (cholecystectomy: open or laparoscopic)  Pancreatitis: Overview Inflammation of the pancreas which causes destructive cellular changes Acute pancreatitis: pancreatic enzymes start autodigesting the pancreas which develops fibrous/damaged tissue. Can be life- threatening. Chronic pancreatitis: recurrent episodes of exacerbation, leading to fibrosis and decreased pancreatic function Pancreatitis may cause pleural  Pancreatitis: Assessment findings Epigastric pain (inflammation and stretching of pancreatic duct) Gnawing continuous severe abdominal pain Knee-chest position can reduce tension and reduce pain Nausea & vomiting Turner's sign: blue-gray color to skin in flank area Cullen's sign: bluish discoloration to skin in periumbilical area Blood glucose fluctuation Pancreatitis: Labs & Diagnostics Lipase elevated! Amylase (in blood/serum and urine) elevated Bilirubin elevated WBC elevated (due to infection and inflammation) ESR elevated (due to inflammation) Elevated glucose (decreased insulin production by pancreas) Diagnostics: CT (shows inflammation) CXR (may show pleural effusions)  NPO (bowel rest, to reduce release of pancreatic enzymes) IV fluids for hydration Pain management (often require Pancrea admission for IV pain meds) May need NG tube if vomiting severe titis: Watch for complication: abcess or Treatments pseudocyst (may require surgery) Monitor respiratory status (risk for & Nursing pleural effusions) Care If severe and ongoing, may need TPN Chronic: if pancreas damaged, may need pancreatic enzymes with each meal, and may need insulin for glucose control Appendicitis: Overview An acute inflammation of the vermiform appendix (a pouch that sits in the RLQ), that becomes obstructed with stool, foreign body, or tumor. The mucosal lining of the appendix continues to secrete fluid, which then fills up the pouch and increases pressure. This can lead to decreased blood supply and can cause necrosis or perforation. Peak incidence from childhood to 30. Rupture/perforation may occur within 36-48 hours, leading to peritonitis and sepsis.  Appendicit is: Assessment findings N/V, may have low grade fever Abdominal pain: often starts periumbilical, then travels to RLQ RLQ between the anterior iliac crest and umbilicus (McBurney’s point) Rebound tenderness Abdominal pain that increases with cough or movement and is relieved by bending the right hip suggests perforation Labs: WBCs Diagnostics: CT or US shows inflammed/enlarged appendix  Appendicitis : Nursing Care Keep NPO Manage pain Prepare for emergency surgery (appendectomy, may be open or laparoscopic) Do not use heat- increases circulation and puts at risk for perforation. Monitor for signs of rupture or perforation  Why's the liver so important anyway? Hepatic o Glucose Metabolism o Ammonia Conversion system o Protein Metabolism (Liver) o Fat Metabolism overview o Vitamin and Iron storage o Bile Formation Brunner & Suddarth textbook, pg 1366 o Bilirubin Excretion o Metabolism of Drugs/Medications Liver problems: what might the RN assess? Jaundice (skin Malaise, Labs: and sclera), weakness, Abdominal pain o LFTs (aka liver enzymes): pruritis fatigue  AST, ALT, Alk Phos (elevated) o Ammonia Anorexia, Weight gain, or  may be elevated, often accompanied Pale-colored nausea/vomitin unexplained stools by AMS g weight loss o Bilirubin  may be elevated Edema, Hematemesis, o Serum albumin increasing Esophageal melena, abdominal varices  usually low hematochezia girth (ascites) o Total serum protein Easy bruising, Tremors,  Usually low petechiae, Changes in asterixis o PT/INR spider mental status (flapping angiomas tremor)  may be prolonged or increased Cirrhosis/liver failure: Overview Cirrhosis: injury to the cellular structure of the liver causing scarring/fibrosis/nodules due to inflammation and necrotic changes. Bile ducts and blood vessels can become blocked, liver becomes enlarged (hepatomegaly). There is increased pressure in the portal vein (portal hypertension). Can develop esophageal varices (rupture can cause life-threatening upper GI bleed) Causes: often due to chronic alcohol use, hepatitis, drugs/toxins, fatty liver, etc.  Cirrhosis : Paracentesis procedure Cirrhosis can cause fluid to shift into peritoneal cavity, causing abdominal ascites. Paracentesis may be performed to remove this fluid, especially if ascites become so severe that the swollen abdomen starts pressing up on the lungs, causing respiratory difficulty. If more than 4-5L removed, may give IV albumin to help body maintain homeostasis. Hepatiti s A, B, C, D, E Hepatitis (Definition): Refers to an inflammatory condition of the liver, most commonly caused by a viral infection (A,B,C,D,E) Possible non-viral causes include: 1. Excessive alcohol use 2. Hepatoxic medications 3. Autoimmune diseases Risk Factors for Hepatitis ContaminatedA, E or water food (fecal-oral) Risk Factors for Hepatitis B, C, IVDDrug Use Tattoos Body piercings Sharing razors Unprotected sex Symptoms: Acute vs. Chronic  Hepatitis A Transmission: fecal-oral route Often via contaminated food or water, or contact with infected stool (incontinent individuals, anal sexual activity). Can occur during travel to developing countries. Symptoms: ACUTE only Treatment: Supportive therapy (symptom management) REST! Brunner & Suddarth pg 1385 Hepatitis B Transmission: Body fluids / Blood Symptoms: ACUTE or Chronic Treatment: o Acute: symptom management, rest o Chronic: Anti-viral medications, Interferon medications Brunner & Suddarth pg  Hepatitis C Transmission: Blood Symptoms: Acute or Chronic, often asymptomatic Treatment: o Acute: symptom management, rest o Chronic: anti-viral medications o**Important: even if treated, reinfection can occur! Brunner & Suddarth pg 1390  Hepatitis D Transmission: Blood & Body fluids CAN ONLY EXIST ALONGSIDE HEP B!! Symptoms: ACUTE or Chronic Treatment: o Acute: symptom management, rest o Chronic: Interferon medications Brunner & Suddarth pg  Hepatitis E Transmission: fecal-oral route Often via contaminated food or water in areas of poor sanitation Symptoms: ACUTE only Treatment: Supportive therapy (symptom management) REST! Brunner & Suddarth pg 1391  Hepatitis: what labs might be elevated? Liver enzymes: AST, ALT, Alk Phos Bilirubin (in blood and in urine) Urine may show protein Hepatitis panel will be drawn to test for which antibodies or antigens are present/elevated, specific to the types: Hep A virus antibodies Hep B surface antigen Hep C virus antibodies Hep D virus antibodies Hep E virus antibodies  Acute liver failure Complicati Cirrhosis of liver ons of Hepatitis Liver cancer Hepatic Encephalopathy Patient Teaching