Week 11 Fall 2024. Lower GI Conditions PDF

Applied Pathophysiology & Pharmacology I FA L L 2 0 2 4 WE E K 1 1 : LOW E R G ASTROINTESTINAL CON DI T I ONS P ROF. A N N OU J. DAV I  Outline and Objectives Review lower GI System & List common Describe common lower accessory organs phar...

Applied Pathophysiology & Pharmacology I FA L L 2 0 2 4 WE E K 1 1 : LOW E R G ASTROINTESTINAL CON DI T I ONS P ROF. A N N OU J. DAV I  Outline and Objectives Review lower GI System & List common Describe common lower accessory organs pharmaceutical options GI conditions List common manifestations of lower for GI conditions GI dysfunction Indications and administration Clinical manifestations Describe the role of the Microbiome considerations Diagnostics and the Gut-Brain connection Treatment Nursing considerations Lower GI System Review Small Intestine Duodenum Approx 12” long Fixed shape & position Jejunum Approx 2.5m long Digestion Ileum Approx 3.5m long Absorption Ileocecal valve Opens into large intestine Small Intestine Mucosa Intestinal villi Finger-like projections contained in the lining Increase surface area for digestion and absorption of nutrients Microvilli Microscopic projections covered with a fuzzy coat called brush border Contains many digestive enzymes Crypts of Lieberkühn Intestinal glands that secrete about 2 L of fluid/day into lumen of intestine Fluid reabsorbed by villi Large Intestine Cecum Pocket at entry Appendix Colon Ascending (R side) Transverse Descending (L side) Sigmoid (S-bend) Rectum Rectal vault Anal canal Anal sphincters Internal - involuntary External - voluntary The Microbiome The Microbiome All body surfaces in contact with the environment are colonized by microorganisms Collectively termed “microbiome” Biome: environment characterized by climate and dominant flora & fauna Outnumbers our own nucleated body cells by a factor of 10 Human cells = approx 1012 vs Microbial cells = approx 1013 Variety of microorganisms are part of the human microbiome including bacteria, fungi, viruses, and others Dependent on the habitat, the composition of the microbiome differs significantly The gut is mainly populated by various bacterial species (> 99%) NOTE: bile acids (BA), antimicrobial peptides (AMPs), and concentration of short- chain fatty acids (SCFAs) https://media.springernature.com/original/springer-static/image/art%3A10.1007%2Fs00428-017-2277-x/MediaObjects/428_2017_2277_Fig1_HTML.gif Gut-brain connection Diversity is Key to Healthy Microbiome Complex ecosystem unique to each individual >400 species per person Viewed as integral part of the body, essential for proper organ function Protection from invasive pathogens Contribute to metabolic process Accessory Organs of Digestion Appendix Liver Gallbladder Pancreas The Appendix Historically believed to be useless vestigial tissue/organ Evidence suggests it is likely a storage reservoir for microbiome Current working theory Serves as GI “seed bank” for microorganisms needed to repopulate digestive microbiome prn Multicolored Paper Art of the Human Microbiome by artist Rogan Brown Appendicitis Typically caused by blockage S/S include Periumbilical pain + N/V RLQ rebound tenderness Fever Abd cramping Dysuria WBCs Dx method: CT scan or US Tx options Antibiotics Appendectomy Perforation can be life threatening!!! Liver Largest gland of the body Very vascular organ Portal vein & hepatic artery Functions Glucose metabolism Ammonia conversion Protein metabolism Fat metabolism Vitamin and iron storage D, K, B12 Bile formation Bilirubin excretion Drug metabolism Gallbladder Storage container for bile produced by hepatocytes Communicates with duodenum via common bile duct & sphincter of Oddi Bile Emulsifies fat → Promotes intestinal absorption of fatty acids, cholesterol, lipids Cholangitis: inflammation of the bile duct system Often d/t gallstone obstruction Can lead to infection S/S include: fever, RUQ pain, jaundice, AMS, SIRS Tx includes: hydration, Abx ERCP: gold standard for biliary decompression if needed  ERCP https://www.nejm.org/doi/full/10.1056/nejmct1208450 Pancreas Exocrine Function Digestive enzymes enter duodenum via biliary tract Amylase Trypsin Lipase Secretin Endocrine Function Hormones released into blood stream Insulin: promotes CHO metabolism https://www.olivelab.org/the-pancreas-overview.html Glucagon: stimulates hepatic glycogenesis Pancreatitis Types Common Causes Clinical Findings Acute: pancreatic duct ETOH use DO Pain becomes obstructed N/V enzymes back up causing Biliary tract obstruction autodigestion and inflammation of Neoplasms Abd distention the pancreas Decreased BS Chronic: progressive Trauma Abnormal VS inflammatory disorder with Medications Fever, tachycardia destruction of the pancreas cells are replaced by fibrous tissue Abnormal Labs pressure within the pancreas Elevated amylase & lipase increases, obstructing the Elevated WBCs pancreatic and common bile ducts Interventions Treatments IV Fluids Strict NPO Pain management Abx Insulin Invasive procedure options Acute: ERCP Chronic: Whipple Nursing Considerations ABCs IV access Positioning for comfort May need NGT for decompression Whipple Monitor VS, labs, etc. Lower GI Assessment Lower GI Dysfunction: Clinical Manifestations Abdominal discomfort Pain Pressure Source: James Palinsad. https://www.flickr.com/photos/99329675@N02/11064976153 Cramping Distention Diarrhea Constipation Melena Hematochezia By Evil Erin - https://www.flickr.com/photos/evilerin/3158385504, CC BY-SA 4.0, https://en.wikipedia.org/w/index.php?curid=57380968 Constipation Dietary: low in fiber Abnormally infrequent (3x/day) Inflammatory Nutritional Loose or liquid stool bowel factors diseases May be Acute or Chronic Increased Treatment options: motility Nonsurgical Dietary Infestation GI Surgery Bacteria Behavioral Viruses Pharmacologic Protozoa Surgical Bowel resection Drug induced  Antidiarrheals Coat the walls of the GI tract Adsorbents Binds to the causative bacteria or toxin, which is then eliminated through the stool Ex: bismuth subsalicylate (Pepto-Bismol), activated charcoal Decrease intestinal muscle tone and peristalsis of GI tract Anticholinergics Slows movement of fecal matter through the GI tract Ex: belladonna alkaloids Decrease motility and reduce pain by relief of rectal spasms Opiates Allow more time for water and electrolytes to be absorbed Ex: paregoric, opium tincture, codeine, over-the-counter (OTC) loperamide, diphenoxylate Probiotics Supply missing bacteria to the GI tract and suppress growth of diarrhea-causing bacteria Ex: Lactobacillus acidophilus (Bacid)  Antidiarrheals: Nursing Considerations Monitor for Caution!! Contraindications Assessment therapeutic effect Older patients, bleeding History of narrow-angle Fluid status, I&O, Notify prescriber risk, recent bowel glaucoma, GI electrolytes, and immediately if surgery, or confusion obstruction, myasthenia mucous membranes symptoms persist May cause urinary gravis, or toxic before, during, and May indicate condition retention, HA, AMS, dry megacolon after starting treatment requiring invasive skin/mucous intervention membranes, and/or blurred vision Pepto inhibits platelets, adsorbents inhibit vit K absorption Review Question A patient is experiencing diarrhea while completing a course of antibiotic therapy. Which of the following agents does the nurse anticipate administering to the patient? A. L. acidophilus (Bacid) B. bismuth subsalicylate (Pepto-Bismol) C. diphenoxylate with atropine (Lomotil) D. loperamide (Imodium A-D) Review Question A patient who takes Coumadin has been prescribed an adsorbent for diarrhea. It is important for the nurse to monitor the patient for s/s bleeding and elevated INR (supratherapeutic) due to interference with _____ absorption. A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K Review Question Which antidiarrheal does the nurse associate with the development of adverse effects of urinary retention, headache, confusion, dry skin, and blurred vision? A. Anticholinergics B. Adsorbents C. Probiotics D. Opiates Healthy colonoscopy GI Conditions  Common Lower GI Conditions Motility Inflammatory Malabsorption Neoplasms Disorders Bowel Disorders Disorders Irritable Bowel Colitis Polyps Celiac Disease Syndrome Crohn’s Cancer Short-gut Bowel Disease Syndrome Obstruction Diverticular Disease Motility Disorders INTESTINAL OBSTRUCTION IRRITABLE BOWEL SYNDROME  Condition: Intestinal Obstruction Partial or complete blockage of intestinal tract Most common site: small intestine Mechanical (physical obstruction) Adhesions, hernia, tumors, impacted feces, volvulus, intussusception Functional (peristalsis inhibited) Medications, ischemia, nervous system impairment Contributing factors Previous abdominal surgery with adhesions (scar tissue) Congenital abnormalities of the bowel Metastatic carcinoma, particularly cancer of the intestinal tract or female reproductive organs Decreased muscle tone and/or activity associated with medications or neurological impairment Normal KUB Bowel obstruction Normal KUB Bowel obstruction Clinical manifestations Constipation (may be an early manifestation) Dehydration Electrolyte depletion Abdominal pain Nausea and vomiting Mechanical obstruction Case courtesy of Dr Lee-Anne Slater, Radiopaedia.org, rID: 14591 BS initially hyperactive Functional obstruction BS hypoactive or absent Treatment Fluid/electrolyte replacement Remove mechanical blockage Decompression (NG tube) Surgical intervention Bowel perforation: intestinal wall ruptures → release of If left uncorrected may cause intestinal contents into the peritoneal toxic megacolon, perforation, or space = acute ischemia and necrosis leading to surgical emergency! peritonitis, bowel gangrene, sepsis, and shock!!! Megacolon in extreme cases Case courtesy of Dr Rahul Kulkarni, Radiopaedia.org, rID: 21444 Toxic Megacolon Massive dilation of colon Cause: prolonged constipation Complication of Inflammatory Bowel disease, intestinal obstruction, or bowel infection (e.g. c. difficile) Pseudomembranous colitis may result in acute megacolon: surgical emergency Huge dilated loops of large bowel visible on KUB may resolve within the first 24 hours with decompression, but many patients will require a colectomy fatal if untreated Condition: Irritable Bowel Syndrome (IBS) Alternating diarrhea and constipation accompanied by abdominal cramping pain with no identifiable pathologic process in the GI tract Also called spastic colitis or irritable colon syndrome Idiopathic Normal peristalsis wave is interrupted by irregular spasms Clinical presentation Diarrhea, constipation, or alternating pattern of both Abdominal cramping pain Mucus in stool Treatment (palliative) Rx Antidiarrheal agents Laxatives Antispasmodic medications Dietary High fiber diet Avoid irritating foods (food diary) Alternative therapies Bowel directed relaxation Deep steady breathing Music Cradle a hot water bottle Therapeutic massage Hypnotherapy Yoga and meditation Support groups  Review Question A silent abdomen 3 hours after bowel surgery most likely indicates A. peritonitis. B. mechanical bowel obstruction. C. perforated bowel. D. functional bowel obstruction. Inflammatory Bowel Disorders DIVERTICULAR DISEASE PSEUDOMEMBRANOUS COLITIS ULCERATIVE COLITIS VS CROHN’S DISEASE Condition: Diverticular Disease Presence of diverticula in the colon Micro-herniations in mucosa Genetic predisposition Diverticulosis vs Diverticulitis A: Diverticulosis (chronic condition) Asymptomatic B: Diverticulitis (acute inflammation) Diarrhea Constipation Distension Fever Acute lower abdominal pain Elevated WBCs (leukocytosis) Abscess formation or perforation Serious complication!! May https://www.aafp.org/afp/2013/0501/hi-res/afp20130501p612-f2.gif require emergency surgery Risk Reduction & Treatment Fiber Avoid nuts, small seeds * (*controversial) Probiotics Kefir By Dezzawong - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=8322266 Live culture yogurt Sauerkraut Kimchi Tempeh Kombucha Antibiotics Surgery https://www.flickr.com/photos/76588981@N02/ Condition: Pseudomembranous Colitis Colitis: Inflammation of the mucosal lining of the colon Numerous causes: infection, IBD, toxins Antibiotic-Associated Colitis Acute inflammation and necrosis of large intestine Caused by Clostridium difficile (exposure to antibiotics) Mediated by bacterial toxins Clinical manifestations Diarrhea (often green or bloody) Abdominal pain Fever Leukocytosis De la CDC/ James Archer - https://phil.cdc.gov/phil/details.asp?pid=16786, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=57207136 Sepsis Bowel perforation (rare) By Klinikum Dritter Orden, München. Abteilung Innere Medizin I Vielen Dank an Christoph Kaiser für die Überlassung des Bildes zur Veröffentlichung! - Klinikum Dritter Orden, München. Abteilung Innere Medizin I Vielen Dank an Christoph Kaiser für die Überlassung des Bildes zur Veröffentlichung!, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=12469399 Treatment Hydration!!! Stop antibiotic use (if possible) In-hospital: contact isolation Oral antimicrobial Rx: IV metronidazole (Flagyl) PO vancomycin Recurrence common Resistant colonization: Colectomy Fecal transplant: transfer of fecal material from another healthy person to the source patient via gastric tube or enema Fecal Transplant Story  Condition: Ulcerative Colitis Chronic inflammatory disease of the mucosa & submucosa of the rectum and colon The most common form of inflammatory bowel disease worldwide Idiopathic though noted hereditary pattern Large ulcers form in mucosal layer of colon and rectum Begins as inflammation at base of crypts of Lieberkühn → damage results → abscess formation in crypts → abscesses begin to coalesce → large ulcerations develop in epithelium Hallmark clinical manifestations are bloody diarrhea and lower abdominal pain Have exacerbations and remissions Associated with increased cancer risk after 7 to 10 years of disease https://www.nature.com/articles/s41572-020-0205-x Ulcerative Colitis & Toxic Megacolon  Condition: Crohn's Disease Chronic inflammation of all layers of intestinal wall resulting from blockage and inflammation of lymphatic vessels Affects proximal portion of the colon or terminal ileum Suggestive findings are ulcerations, strictures, fibrosis, and fistulas Clinical manifestations Intermittent bouts of fever and diarrhea may include hematochezia but, not as severe as ulcerative colitis Constant, chronic RLQ pain May have RLQ mass, tenderness Dr Saca Colonoscopy of Crohn’s Dz IBD Treatment Corticosteroids (acute flare-up) Dietary modifications Bowel Rest By D4duong - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=22793934 Severe cases usually require immunosuppressive Rx or biotherapies Imuran Cyclosporine Remicade Humira May require surgical intervention if extensive damage or strictures present (Nearly half of all with Crohn’s Dz need surgical By BruceBlaus - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=59619991 intervention) Temporary ileostomy Partial or total colectomy Review Question Ulcerative colitis is commonly associated with A. bloody diarrhea. B. malabsorption of nutrients. C. fistula formation between loops of bowel. D. inflammation and scarring of the submucosal layer of the bowel. Review Question Crohn’s disease is associated with all of the following complications, except A. fistulae B. green stool C. adhesions D. abdominal pain Neoplasms INTESTINAL POLYPS COLON CANCER Condition: Intestinal Polyps Any tissue protrusion into the GI lumen Sessile polyp: raised protuberance with a broad base Pedunculated polyp: attached to bowel wall by a stalk that is narrower than the body of the polyp Benign or malignant Major precursor lesion in development of colon cancer Clinical manifestations Usually none May cause occult or gross bleeding Abdominal pain Treatment Varies according to size, type, and location Usually removed through scope Standard polyp removal  Condition: Colon Cancer Second only to lung cancer as a cause of cancer deaths Risk factors Increased after age 40 High-fat, low-fiber diet Polyps Chronic irritation or inflammation Hereditary patterns Guidelines for colon cancer screening via colonoscopy Every 10 years starting at age 50y for average risk individual May need to be more frequent in higher risk individuals Important hereditary condition: Familial adenomatous polyposis (FAP) At least three close relatives with colorectal cancer, colorectal cancer involving at least two generations, and one or more cases of colorectal cancer occurring before age 50 years Intestinal polyp removal and CA diagnosis Malabsorption CELIAC DISEASE SHORT-GUT SYNDROME Condition: Celiac Disease Inherited autoimmune disorder associated consumption of gluten Protein found in wheat, rye, and barley Ingestion of gluten triggers inflammation and atrophy of the villi in the small intestine Reduced mucosal surface area Decreased brush border enzymes Leads to Impaired nutrient absorption Increased risk for intestinal malignancy Clinical manifestations Diarrhea Abdominal pain Constipation Bloating Conditions associated with deficiencies (anemias, delayed clotting, Rickets) Diagnosis & Treatment Confirmed via Intestinal bx Anti-tissue transglutaminase antibody (anti-ttG) Immunoglobulin A (IgA) endomysial antibody Treatment includes Strict gluten-free diet Supplemental iron, folate, B12, fat-soluble vitamins (A, D, E, K) By Manu5 - http://www.scientificanimations.com/wiki-images/, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=70777064 Oral corticosteroids or other immunomodulating agents for refractory flare-ups  Condition: Short-gut Syndrome Complication related to surgical removal of large portions of small intestine Rapid transit time and reduced surface area for absorption (if ileocecal valve removed) Reduced ability to absorb nutrients Clinical manifestations Diarrhea and malabsorption Treatment Gradual increase in oral intake May help remaining villi to enlarge Temporary or indefinite intravenous nutritional support http://cceffect.org/feature/what-is-ulcerative-colitis-uc/ GI Conditions: Nursing Considerations Alteration in GI function may cause Taboo subject Affects patient and family great emotional distress and inability Social events often center on food to participate fully in social activities consumption Frequently compounded by anxiety, Benefit from a sensitive approach to meeting depression, body image disturbances, needs and sexual dysfunction Challenges with being away from Limitations at work, school, travel, sports, home outdoor activates 75 Next week… In-class Quiz #5 on 11/5 Lecture: Genetics and Mutations Preview: Banasik: 5, 6, 7 & 11 & Karch: 15 (p. 265) & 17