B.

SC NURSING
Medical And Surgical Nursing I
UNIT- V Gastro-Intestinal System
Small Intestinal Malabsorption &
Obstruction
Mrs. V. Brahatha
Assistant Professor
 Objectives
On completion of this class, the student will be able to,
• Define malabsorption.
• Know the causes of malabsorption.
• Describe the types of malabsorption..
• Enlist the signs and symptoms of malabsorption..
• List the diagnostic methods to diagnose malabsorption.
• Explain the treatment modalities.
Definition:
-It is a state arising from abnormality in absorption
of food nutrients across the gastrointestinal
tract(GIT).

-Impairment can be of single or multiple nutrients

depending on the abnormality.

-This may lead to malnutrition and a variety of

anaemias. 3
 Malabsorption constitutes the pathological
interference with the normal physiological
sequence of body such as:

Digestion(intraluminal process),

Absorption (mucosal process) and

Transport (postmucosal events) of nutrients.

4
 Causes of Malabsorption

Intestinal malabsorption can be due to:

digestive failure caused by enzyme deficiencies

structural defects
mucosal abnormality
infective agents
systemic diseases affecting GIT

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 1. Due to digestive failure:

• Pancreatic insufficiencies:
• cystic fibrosis
• chronic pancreatitis
• carcinoma of pancreas

• Bile salt insufficiency:

• obstructive jaundice
• bacterial overgrowth

5
 2. Due to structural defects:
•Inflammatory bowel diseases commonly: Crohn's
Disease
• Gastrectomy and gastro-jejunostomy
• Fistulae, diverticulae and strictures.
• Infiltrative conditions such as amyloidosis, lymphoma.
•Short bowel syndrome.
•Eosinophilic gastroenteropathy etc.

7
 3. Due to mucosal abnormality:
-Coeliac disease

4. Due to enzyme deficiencies:

-Lactase deficiency inducing lactose intolerance
- Disaccharidase deficiency
- Enteropeptidase deficiency

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 Others

5. Due to infective agents:

-Whipple's disease
-Intestinal tuberculosis
-Tropical sprue
-Parasites e.g. Giardia lamblia.
6. Due to other systemic diseases
affecting GI tract:
-Hypo and hyperthyroidism
-Diabetes mellitus
-Hyper and Hypoparathyroidism
9
-Carcinoid syndrome,-Malnutrition.
Symptoms of malabsorption
.
• Symptoms can
abe
1.Extraintestinal
2.Intraintestinal
•  Diarrhoea, often steatorrhoea is the most common feature. It isdue to
impaired water, carbohydrate and electrolyte absorption.
•  Othersymptoms include:
• - Weight loss
• -Growth retardation
• -Swelling or edema
• -Anaemias
• -Muscle cramps and bleeding tendencies

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11
 1.Celiac sprue

• common cause of malabsorption

-. • - Age: ranging from first
year of life through the eighth decade.
• Etiology: not known.
• But three factors can
contribute:
• environmental.
• immunologic.
• genetic factors
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 Factors causing Celiac Sprue
• Environmental factor:
• - There is association of the disease
with gliadin, a component of gluten
that is present in wheat.
• 2. gliadin. Immunologic factor:-
Serum antibodies are detected such as
anti-
• 3. Genetic factor:- Almost all patients
express the HLA-DQ2 allele
13
 Diagnosis:

- A small-intestinal biopsy should be

done for suspected patients.
- The hallmark of celiac sprue is the
presence of an abnormal small-
intestinal biopsy.

14
 2.Tropical Sprue

• Caused by infectious agents including

Giardia lamblia, Yersinia enterocolitica,
Clostridum difficile.
• -it tends to involve the distal small
bowel.
• -total villous atrophy is uncommon

15
 3.Crohn’s Disease

It is an inflammatory bowel disease

Marked by patchy areas of
inflammation anywhere in GIT from
mouth to anus .
 Body ’s immune system attacks GIT
leading to chronic inflammation.

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 4. Short Bowel Syndrome

-Following resection, diarrhea and/or

steatorrhea can appear due to decrease
in the area of the absorptive surface area.
-Other symptoms include cramping,
bloating and heartburn.

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 5.Bacterial Overgrowth Syndrome

- There is proliferation of colonic-type

bacteria within the small intestine.
- Due to stasis caused by impaired
peristalsis . This lead to diarrhea and
malabsorption.

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 Pathophysiology:

*•Bacterial over growth leads to:

1.Metabolize bile salt resulting in
deconjugation of bile salts;
Bile Salt and malabsorption of fat.

2.Damage of the intestinal villi by:

 Bacterial invasion
 Toxin/.
 Metabolic products
• Damaged villi cause total villous atrophy.
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 6. Whipple's Disease
• Cause: by the bacteria Tropheryma whipplei.
•Effect:Chronic multisystem disease associated
with diarrhea, steatorrhea, weight loss,
arthralgia, and central nervous system (CNS) and
cardiac problems .
• Diagnosis:
•- identification of T. whipplei by polymerase
chain reaction (PCR).
• - PAS-positive macrophages in the small
intestine and other organs with evidence of
disease.
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 * Management of malabsorption

 Replacement of nutrients, electrolytes and fluid may

be necessary.
 I n severe deficiency, hospital admission may be
required for parenteral administration.
 Pancreatic enzymes are supplemented orally n i
pancreatic insufficiency.
 Dietary modification is important in some conditions:
 Gluten-free diet in coeliac disease.
 Lactose avoidance in lactose intolerance.
 Antibiotic therapy will treat Small Bowel Bacterial
overgrowth.
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INTESTINAL OBSTRUCTION
 Objectives
On completion of this class, the student will be able to,
• Define intestinal Obstruction.
• Know the causes of intestinal obstruction
• Describe the types of intestinal obstruction.
• Enlist the signs and symptoms of intestinal obstruction.
• Analyze the exact pathophysiology.
• List the diagnostic methods to diagnose intestinal
obstruction.
• Explain the treatment modalities.
• Enumerate the Nursing measures intestinal obstruction
• List the complications of intestinal obstruction.
 Definition

• Bowel obstruction occurs when the normal

propulsion and passage of intestinal contents
does not occur.
Intestinal obstruction

Mechanical obstruction Paralytic ileus

 Intestinal Obstruction
• This obstruction can involve only the small intestine
(small bowel obstruction), the large intestine (large
bowel obstruction), or via systemic alterations,
involving both the small and large intestine
(generalized ileus).

• The "obstruction" can involve a mechanical

obstruction or, in contrast, may be related to
ineffective motility without any physical obstruction,
so-called functional obstruction, "pseudo-
obstruction," or paralytic ileus
 Classification

 Dynamic/ adynamic
 Small bowel obstruction [ high or low ]
 Large bowel obstruction
 Acute
 Chronic
 Acute on chronic
 Subacute
 Simple
 Strangulated
 Closed loop obstruction
 Intestinal obstruction is classified as
two types

 DYNAMIC /Mechanical : where peristalsis is

working against a mechanical obstruction.
 Adynamic:
• 2 forms
• Peristalsis may be absent e.g. paralytic ileus.
• Peristalsis may be present in a non- propulsive
forms. E.G: mesenteric vascular occlusion
 Mechanical/dynamic obstruction
There is physical blockage of intestinal lumen which
due to:
1. Intramural : (within the wall) congenital-tumor-
hematoma-inflammatory
2. Extramural : (outside the wall)adhesion-volvulus-
hernia –abscess-hematoma
3. Intraluminal obstruction: (inside the lumen)
stone-meconium-foreign body- impaction
(stool-worm-barium)
• This mechanical obstruction can be partial

( lumen narrowed but allow transit some content) or

complete ( lumen totally obstruction) this classify
to
A. Simple mechanical obstruction
(No vascular impairment)
B. Closed loop obstruction

( Both ends are obstructed e.g. volvulus)

C. Strangulation obstruction
Closed loop obstruction – adhesions
and twisted
 On the basis of nature it is classified
into

 Acute

 Chronic

 Acute on chronic

 Subacute
 Acute Obstruction
 It usually occur in small bowel obstruction with
sudden onset of severe colicky central
abdominal pain, distention and early vomiting
and constipation.
 Chronic Obstruction
 Usually seen in large bowel obstruction with
lower abdominal colic and absolute constipation,
followed by distention.
 Acute on Chronic Obstruction

 Acute exacerbations of a chronic condition

 Functional Classification

 Simple mechanical
 Strangulated
 Closed loop
 Based on Etiology

• Causes From Outside the wall (Extraluminal)

• Causes From the wall (Intramural)

• Causes In the lumen (intraluminal)

 Clinically Classified as

• Small bowel obstruction (high or low)

• Large bowel obstruction

 Cause of Intestinal Obstruction

• Adhesions- 40%

• Tumors -15%

• Inflammatory- 15%

• Obstructed hernia-12%

• Intraluminal-10%

• Miscellaneous -8%
 Etiology
Dynamic(mechanical)from the wall
1 Tb
2 Crohn’s
3 Tumors
4 Stricture
5 Congenital ………
.
 Etiology

Mechanical obstruction in the lumen

1 Gall stones BEZOARS

WORMs

2 Foreign bodies

3 Bezoars

4 Worms FECES
GALL STONES
5 Feces ………..
 Etiology
Mechanical extraluminal 1- bands
NDS

2 Adhesions
COM
3 Abscess

4 Hernias

5 Compression

ABSCESS
Intussusceptions
Duodenal Artesia
Intestinal Tumor
Adhesive Bands and Constriction
 Etiology

Adynamic intestinal obstruction.

1. Peritonitis

2 Electrolytes’ imbalance

3 Post-operative

4 Ischemia

5 Drugs
 Pathophysiology

Simple obstruction :
1 Above the obstruction
OBSTRUCTION : peristalsis increases
intestine dilates reduction in peristaltic
strength flaccidity and paralysis

2 Below the obstruction:

Normal peristalsis & absorption until it
becomes empty it contracts &
becomes immobile
 Pathophysiology

Distention of the intestine is caused

by accumulation of:

1 Gas
2 Fluids

gas Distention
fluids

fluids
 Pathophysiology

Gas in the intestine is due to:

1. Swallowed air

2. Bacterial overgrowth

3. Diffusion from blood

 Pathophysiology

Fluids come from :

1. Ingested fluids

2. Saliva

3. Gastric and intestinal juice

4. Bile & pancreatic secretions

 Pathophysiology

Dehydration caused by :

1. Reduced intake

2. Reduced absorption

3. Increased loss (vomiting & fluid shift)

 Pathophysiology

Systemic effects of obstruction :

1. Water and electrolyte losses (lead to hypovolemia)
2. Toxic materials and toxemia (lead to sepsis)
3. Cardiopulmonary dysfunction (atelectasis)
4. Renal failure
5. Shock and death
 Pathophysiology

Strangulation leads to impaired venous return

Increased congestion

-free peritoneal fluid

-Edema of intestinal wall

-Blood in the lumen

-Impaired arterial blood supply

-Ischemia and gangrene

 Pathophysiology :

(1) Proximal segment

•Hyper peristaltic phase
•Anti peristaltic phase
•Stage of dilatation
•Fluid accumulation
•Gas accumulation
•Increased tension,
Ischemia
(2) Distal segment collapsed
 Adynamic obstruction causes
Either localized or generalized
Small intestine
- Postoperative
- Intra-abdominal abscess or
peritonitis
- Mesenteric embolism or thrombosis
Large intestine
- Retroperitoneal hematoma
- Drugs
- Hypokalemia
- Idiopathic
Strangulated Obstruction
 Strangulated Obstruction :

 Strangulating obstruction is obstruction with

compromised blood flow; it occurs in nearly 25%
of patients with small-bowel obstruction.

 It is usually associated with hernia, volvulus, and

intussusceptions.

 Strangulating obstruction can progress to

infarction and gangrene in as little as 6 h.
Venous obstruction
• Occurs first, followed by arterial
occlusion, resulting in rapid
ischemia of the bowel wall.
• The ischemic bowel becomes
edematous and infarcts, leading to
gangrene and perforation.
• In large- bowel obstruction,
strangulation is rare (except with
volvulus)
Closed Loop Obstruction
 Closed Loop Obstruction
 Closed loop obstruction is a specific
type of obstruction in which two
points along the course of a bowel
are obstructed at a single location
thus forming a closed loop.

 Usually this is due to adhesions, a

twist of the mesentery or internal
herniation.
• In the large bowel it is known as a
volvulus.

• In the small bowel it is simply known as small

bowel closed loop obstruction.

• Obstruction to the blood supply occur either from

the same mechanism which caused obstruction
or by the twist of the bowel on mesentery.
 Main findings

Vomiting

Intestinal
Pain obstruction Distention

constipation
 Pain
 Pain is the first symptom
encountered, it occurs
suddenly and is usually
severe..
 It is colicky in nature and
usually centered on the
umbilicus(small bowel) or
lower abdomen (large
bowel).
 The pain coincides with the
increasing peristaltic activity
 Vomiting
 The more distal the obstruction
,The longer the interval between the
onset of symptoms and the
appearance of nausea and vomiting

 More proximal the obstruction, more

the frequency.

 The interval ,frequency & nature of

vomitus depends on the site of
obstruction
In low bowel obstruction :

• The interval is longer may last for a day or two

• Feculent vomitus

• Vomiting is less frequent and does not cause

any relief.
 Visible Peristalsis
 Visible peristalsis may be present if the
abdomen is examined carefully.

 Mostly seen in proximal loops.

 Borborygmi is quite loud ,does not require

stethoscope to hear it .

 In auscultation sound of hyper peristalsis

coinciding with attack of colic characteristic
feature of intestinal obstruction.
Visible peristalsis
 Bloating

• The accumulation of chyme and gas gives rise

to a feeling of fullness and causes bloating.

• This may also give rise to high-pitched gurgling

sounds from the abdomen
 Fatigue

• Obstruction and the resulting digestive inability

hampers the absorption of vitamins and other
nutrients from food, leading to weakness,
headache and dizziness.

• Even regular activities may make the individual

feel exhausted and drowsy
 Infrequent Urination

• Dehydration due to diarrhea and vomiting,

results in the loss of body fluids and
electrolytes. As a response to this, the body
tries to retain water through lowered urine
output.
 Diagnosis

 History

 Clinical examination

 Investigations
 Physical Examination

• Inspection

• Palpation

• Percussion

• Auscultation

• Rectal examination
 Inspection

 Movement of the abdomen wall

 Umbilicus
 Shape of the abdomen
 Visible loop of bowel/visible peristalsis
 Scar
 Striae
 Prominent veins
 Pubic hair
 Hernia
 Palpation

 During colic there may be muscle guarding.

 Slight tenderness may be present between

attacks of pain.

 Tenderness and rigidity at the sight of

obstruction usually indicate strangulation.

 All the hernial orifices should be palpated to

exclude the presence of hernia.
 Percussion

 Percussion to hear any dullness or resonance

related to site of obstruction.

 Tenderness on light percussion suggest

strangulation.
 Auscultation

 Bowel sounds are initially loud and frequent

 Then as bowel distends the sounds become

more resonant and high pitched

 In strangulation bowel sound is completely

absent.
 Blood Examination

• CBC – high WBC

• Urea & electrolytes – changes because of

dehydration.

• Serum amylase level

• Metabolic acidosis – because of dehydration.

 Radiologic Evaluation

• X-rays

• Endoscopy or colonoscopy

• Barium studies

• CT scan
 Treatment

Three main measures-

 GI drainage

 Fluid &electrolyte replacement

 Relief of obstruction, usually surgical

 Treatment
Conservative:
 Nasogastric- aspiration by Ryles tube
 IV fluids- volume varies depending on
dehydration
 NPO
 Urinary catheter
 Check temp. And pulse 2 hourly
 Abdominal examination 8 hourly
 Broad spectrum antibiotics initiated early-
reduce bacterial overgrowth.
 Special Types of Obstruction

• Internal hernia : hernioplasty

• Strictures: resection and anastomosis.

• Bolus obstruction: laparotomy removal of stones

or by lithotripsy.

• Intussusception: laparotomy – reduction by

squeezing the most distal part.

• Volvulus: releasing band adhesions, resection

and anastomosis.
 Nursing Diagnosis

• Fluid volume deficit related to nausea, vomiting

• Acute pain related to distension , rigidity
• Diarrhoea related to obstruction in the intestine.
• Ineffective breathing pattern related to abdominal
distension
• Fear and anxiety related to crisis situation and
changes in the health status.
• Imbalanced nutrition less than body requirement
related to inability to ingest food
 Nursing Measures

• I/O chart

• Fluid maintenance

• Comfortable position

• Pain management.

• NPO

• Watch for signs of dehydration.

 Nursing Measures

• NG tube for decompression

• Provide liquid diet rich in protein and high caloric

diet.

• Watch for signs of metabolic alkalosis (changes

in sensorium, rapid, shallow respirations) or
acidosis (disorientation, weakness, malaise)

• Measure abdominal girth

• Listen for bowel sounds

 Complications

• Dehydration

• Electrolyte imbalance

• Infection

• Jaundice

• Perforation

• Peritonitis

• Sepsis
 Prognosis

• The prognosis for non-ischemic cases of SBO

is good with mortality rate of 3-5%, while that of
ischemia is 30%.

• Increased risk of future small bowel obstruction.

• 90% of patients form adhesions after surgery.

 Bibliography

• “Suddharth’s and Brunner” Textbook of Medical

– Surgical Nursing, South Asian Edition,
Wolters publication.

• http://www.webmed.com

• http://www.scribd.com

• lwwindia.co.in

• http://www.wikipedia.org