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Management of patients with

Anorecteal Disorders

page : 1292-1305

Prepared by:
Zaida Santos Jo
Contents:

Intestinal disorders Intestinal Obstruction

· Irritable bowel syndrome -Small bowel obstruction
· Conditions of Mal absorption - Large bowel obstruction

Acute inflammatory intestinal Inflammatory Bowel Diseases:

disorders - Crohn's disease
· Peritonitis - Ulcerative Colitis
· Appendicitis
· Diverticular disease
Intestinal obstruction
- exists when blockage prevents the normal flow of intestinal
contents through the intestinal tract.
Two types

a. Mechanical obstruction: see

table 47- 4 pp 1328
- obstruction due to pressure

b. Functional or paralytic obstruction:

-cannot propel the contents along the
bowel - causes :
- amyloidosis,
-muscular dystrophy,
-endocrine
-disorders such as diabetes, or
neurologic disorders such as
Parkinson disease.
Small Bowel Obstruction
Clinical Manifestations
- initial symptom is wavelike and colicky pain due to persistent peristalsis both above and
below the blockage.
- pass blood and mucus but no fecal matter and no flatus.
- Vomiting occurs- intestinal contents propelled toward the mouth instead of toward the
rectum
- signs of dehydration like intense thirst, drowsiness, generalized malaise, aching, and a
parched tongue and mucous membranes. = HYPOVOLEMIA
- abdomen becomes distended.

priority is to start IV
Assessment and Diagnostic Findings

a. Abdominal x-ray and CT scan findings include abnormal quantities of gas, fluid, or both in the
intestines and sometimes collapsed
distal bowel.
b. Laboratory studies (i.e., electrolyte studies and a CBC) reveal a picture of dehydration, loss of
plasma volume, and possible infection.
Medical Management

1. Decompression of the bowel

through an NG tube if partial

2. surgical intervention if complete

obstruction

Before surgery, IV fluids are necessary

to replace the depleted water,
sodium, chloride, and potassium
Surgical Management
a. Repair
repairing the hernia or dividing the
adhesion

b. Removing affected bowel may

be removed and an anastomosis
performed.

c. Laparoscopy - it can facilitate

diagnosis and is easily converted to
open laparotomy if warranted
Nursing Management
For Non surgery cases

- maintaining the function of the NG tube,

- assessing and measuring the NG output,
- assessing for fluid and electrolyte imbalance,
- monitoring nutritional status,
- assessing for manifestations consistent with resolution (e.g., return
of normal bowel sounds, decreased distention, subjective
abdominal improvement in abdominal pain and tenderness,
passage of flatus or stool
Large Bowel Obstruction
A large bowel obstruction results in an
accumulation of intestinal contents, fluid, and
gas proximal to the obstruction.

It can lead to severe distention and perforation

If the blood supply is cut off, - condition is life

threatening.

Adenocarcinoid tumors account for the majority

of large bowel obstructions
Medical Management
a. colonoscopy may be performed to
untwist and decompress the bowel.

b. Cecostomy – to clear bowels of feces

for patient at risk for surgery

c. ileoanal anastomosis may be

performed if removal of the entire large
bowel is necessary

d. Surgical resection to remove the

obstructing lesion.

e. temporary or permanent colostomy

creation
REVIEW COLOSTOMY
CARE IN THE LAB

diet: low residue diet for

first 6 to 8 months
avoid pop corn and
coconut they can
obstruct ostoma
Nursing Management:

a. monitor the patient for symptoms indicating that the intestinal

obstruction is worsening
b. provide emotional support and comfort.
c. The nurse administers IV fluids and electrolytes as prescribed.
d. prepares the patient for surgery if does not respond to
nonsurgical treatment, like education as the patient’s condition
indicates.
e. routine postoperative nursing care is provided, including
abdominal wound care after surgery
b. Restorative Proctocolectomy With Ileal Pouch Anal Anastomosis

- the
procedure involves connecting the ileum to the anal pouch
(made from a small intestine segment) (see Fig. 47-6).
Contents:
Diseases of the Anorectum
· Anorectal abscess,
· Anal Fistula,
· Anal Fissure,
· Haemorrhoids,
· Pilonidal Sinus/ Cyst
DISORDERS OF THE ANORECTUM
Anorectal Abscess

- An anorectal abscess ( painful

collection of pus) is caused by
obstruction of an anal gland with
dried debris, resulting in
retrograde infection

- Can be found in spaces in and

around the rectum
Common to People with
- Crohn’s disease
- immunosuppressive like AIDS
Manifestations :
-complain of dull perianal
discomfort and itching,
- increased pain with defecation.
- perianal edema;
-abnormal fecal discharge, such
as pus, mucous, or blood.
- fever

Medical management:
- incise and drain the abscess is
the treatment of choice
- The wound may be packed
with an absorptive dressing
Anal Fistula:
-a tiny, tubular, fibrous tract that extends into the anal
canal from an opening located beside the anus in the
perianal skin
Result from an abscess.
- trauma
- fissures,
- or Crohn’s disease.

Manifestations
- Purulent drainage or stool may leak constantly from
the cutaneous opening.

Medical management:
-Surgery- fistulectomy (i.e., excision of the fistulous tract)
- wound is packed with gauze.
- Postoperative medications include analgesics and
antibiotics.
Anal Fissure

- An anal fissure is a longitudinal tear or

ulceration in the lining of the anal
canal usually just distal to the dentate line (see
Fig. 47-11B).

caused by :

- trauma of passing a large, firm stool from

persistent tightening of the anal canal
because of stress and anxiety (leading to
constipation).

- childbirth, trauma,

- anal intercourse
Manifestations:
Painful defecation,
burning, bleeding characterize fissures.
Bright red blood may be seen on the toilet tissue after a bowel movement.

Management :

a. dietary modification with addition of fiber supplements, stool softeners and bulk
agents, an increase in water intake,
b. sitz baths
c. Anal dilation under anesthesia may be required
d. perianal or intra-anal application of nitroglycerin ointment, calcium channel
blockers, minoxidil, or
e. botulinum toxin (Botox) injections have increased the rate of healing and lowered
pain levels in chronic anal fissures;
Hemorrhoids
-are dilated portions of veins in the anal canal.
Common in
- Shearing of the mucosa during defecation results in
the sliding of the structures in the wall of the anal
canal, including the hemorrhoidal and vascular
tissues.
- Increased pressure in the hemorrhoidal tissue due
to pregnancy may initiate hemorrhoids or
aggravate existing ones.

2 classifications or types:
a. Internal hemorrhoids - above the internal sphincter

b. external hemorrhoids appearing outside the

external sphincter
Manifestations:
itching and pain
bright red bleeding with defecation.

External hemorrhoids :
- severe pain from the inflammation and edema
- clotting of blood within the hemorrhoid
Internal hemorrhoids are not usually painful until they bleed or prolapse when they
become enlarged.

Can be relieved by:

- relieved by good personal hygiene
- avoiding excessive straining during defecation
- high residue/ fiber diet increased fluid intake
- hydrophilic bulk-forming agents such as psyllium may help
- analgesic ointments and suppositories, and astringents (e.g., witch hazel)
reduce engorgement
- Warm compresses
- sitz baths 3x a day esp, within 48 hours after hemoorhoidectomy
 Nonsurgical treatments for hemorrhoids bipolar diathermy
Infrared photocoagulation

- Rubber band
Sclerotherapy - ligation procedure.
Surgical treatments:

- rubber band ligation procedure

- Stapled hemorrhoidopexy uses
surgical staples to treat prolapsing
hemorrhoids
- hemorrhoidectomy

instructions post
hemorrhoidectomy
slide 48
Pilonidal Sinus or Cyst
- A pilonidal sinus or cyst is found in the
intergluteal cleft on the posterior
surface of the lower sacrum

- formed from an infolding of epithelial

tissue beneath the skin,
- small sinus openings.
- Hair frequently is seen
- it results from local trauma
- It may be formed congenital
Manifestations:
- Rarely cause symptoms
-when there infection produces an irritating drainage or an
abscess.
Medical Management:
- Incision and drainage under local anesthesia.
- further surgery might be indicated to excise the cyst and any
secondary sinus tracts.
- Absorptive dressings are placed in the wound to keep its edges
separated while healing occurs
Nursing Management:
- mostly health teachings
health education

- to keep the perianal area as clean as with warm water and

then drying with absorbent cotton wipes.
- avoid rubbing the area with toilet tissue.
- to do a sitz bath and
- teach ice and analgesic ointments to decrease the pain.
- Warm compresses may promote circulation and soothe irritated tissues.
- Sitz baths taken 3 to 4 times each day can relieve soreness and pain .
teach how to test the temperature of the water.
- Medications may include topical anesthetics (i.e., suppositories),
astringents,
antiseptics,tranquilizers, and antiemetic agents
- Wet dressings saturated with equal parts of cold water and witch hazel
help relieve edema.
- to take at least 2 L of water daily
- recommend Bulk laxatives such as psyllium and stool softener
- to increase fluids and fiber
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