IRRITABLE BOWEL SYNDROME

• Functional disorder of
motility in small and large
intestines- no organic dse
• AKA: Spastic colon, irritable
colon, nervous indigestion,
pylorospasm and spastic
colitis, fxnal dyspepsia,
laxative or cathartic colitis-
no ulceration present
• Cause: stress,
– emotional factors
• Manifestation:
– result in increase motility which leads
to spasm and Chronic abdominal pain
(diffused pain) LLQ (dissipates after
passage of gas),
– alternating diarrhea and constipation,
– pasty pencil like stools,
• Hypersecretion of mucus
• Dyspeptic symptoms ( flatulence,
nausea, anprexia, belching)
• Spastic contractions (small, dry, hart,
pellet-like stools)
• Foul breath, sour stomach, cramps
• Behavioral disturbance ( anxiety,
depression, sleep disturbance,
weakness
• Diagnostic:
– No confirmatory dx , r/o organic
pathology
• Hx of nervousness and emotional
disturbances
–Barium enema,
–stool exam,
–Sigmoidoscopy/ colonoscopy-
reveal spasm
• Interventions (A-IBS)
– Antidiarrheals, antispasmodics
(Probanthine,
• avoid fatty, irritating and gas forming
foods,
– Increase fluid intake
• Increase fiber in the diet diet
– Bulk former ( metamucil)
– Stress management,
• Rest, exercise, limit responsibilities
 INTESTINAL OBSTRUCTION
• Partial or complete impairment of the
forward flow of the intestinal content
 Most in the small bowel- ileum (narrowest)
 Common surgical emergency
 Leads to nausea, vomiting, dehydration
and severe pain
 High mortality rate if not dx or tx within 24
hours
• Risk factors
–Mechanical factors
• Adhesion ( most common)
–Formed after abd . Sx
• Hernia ( incarcerated, strangulated)
• Volvolus (twisting bowel)
–Causes infarction
• Intussusception (telescoping bowel)
• Tumors (chief cause)
• Neurogenic factors
– Paralytic ileus
• Lack of peristaltic activity after abd. Sx
• Tx- aspiration of the secretion by gastric suction
until the bowel begins to fxn
• Vascular fctors
– Complete occlusion (mesenteric infarction)
• embolus
– Partial occlusion (abdominal angina)
• atherosclerosis
• PATHOPHYSIOLOGY
– Bowel N secrete 7-8 electrolyte rich fluid
– Obstruction partially retained fluid
– Distention
– Increase peristalsis- ends- flaccid
– Increase P and reduce absorptive ability
– Increase capillary permeability/
backward peristalsis
– Extravasate to peritoneal cavity
• Manifestations:
– abdominal distention, cramping pain,
diminished or absent bowel sounds, vomiting
fecal material, constipation
• Diagnostics: Abdominal US and X-ray
• Interventions:
– GI decompression using NGT, (Miller Abbott
tube or Cantor tube )
– Bowel resection with or without
anastomosis / colostomy
– NPO, F&E replacement
INFLAMMORY BOWEL DISEASE
(IBD)

Ulcerative colitis
Crohn’s disease
 Definition
• Crohn’s dse (regional • Ulcerative colitis
enteritis) – Entire length of the colon
– Chronic relapsing dse and involves only the
that may develop mucosa & submucosa
discontiuously in any – inflammation and
segment ulcertation that starts in
the rectosigmoid area and
– Most- terminal ileum spreads upward;
– Segmnetal & – mucosa is edematous,
Transmural thickened with eventual
-submucosa scarring; consequently
colon loses elasticity and
– Less common than UC absorption,
Ulcerative colitis

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 etiology
• Crohn’s dse • Ulcerative colitis
– Bacterial
– Unclear
– Altered immunity
– Genetic basis
– Destructive enzyme
– Considered
and a lack of
autoimmune in protective substance
nature
– Emotional disturbance-
precipitate an
exacerbation
– young adults (15 to 20
years old)
 pathophysiology
• Crohn’s dse • Ulcerative colitis
1. Thickening and 1. Diffuse inflammation of
inflammation intestinal mucosa 
happens swelling of epithelial
cells  necrosis 
2. Healing lesions crypt formation  site
scar tissue formation of abscess  ulceration
 obstruction of GI > bleeding
tract 2. Chronic  narrowing of
3. Diarrhea, 3-5 / day lumen
without blood.
 manifestation
• Crohn’s dse • Ulcerative colitis
–Abdominal pain – RLQ – Bloody diarrhea
relieve after passing a  15-20 times daily
 with or without pus
flatus/stool
– Abdominal
–Diarrhea less severe than
cramping/tenderness
UC
– Colicky pain in LLQ
–Stool- Soft or semi-fluid ,
– N/V
foul smelling & fatty
– Fever
(Steatorrhea),
– Anorexia, Weight loss
–Weight loss, anorexia,
anemia, fatigue
 Diagnostic assessment
• Hct and hgb
• Barium enema with air contrast
• Colonoscopy
• biopsy
 Medical management
• Primarily aims to control the symptoms
– Anti inflammatory therapy (sulfasalazine),
steroids
• longer for crohn’s dse
– Antidiarrheal (Imodium, lomotil)
– Antispasmodic- dec postprandial pain and
diarrhea
– Fluids, electrolytes replacement
– Rest during acute attack
• Monitor bowel movement
consistency, frequency and volume.
• Correction of nutritional deficiencies
• Institute dietary management:
– Low-residue, lactose-free
– Elemental diet- residue free, low in fat and
digested mainly in the upper jejunum
– TPN if necessary- bowel rest, more useful
in crohn’s
• Observe for fluid and nutritional status
 Surgical management
• Commonly used to tx ulcerative colitis
• Indicative for both if complication arises
(obstruction, perforation, abscess, fisula)

– Total proctocolectomy with permanent

ileostomy
– Restorative procedure- ileorectal
anastomosis, ileoanal reservior, a Kock pouch
 procedure
• Total proctocolectomy with permanent
ileostomy
– Colon & rectum removed and anus closed
– Terminal ileum is brought out through
abdominal wall
– Permanent ileostomy formed
Colostomy/Ileostomy
 Comparison
Categories Colostomy Ileostomy
Definition A portion of colon is brought A portion of ileum is
thru the abdominal wall brouht thru
abdominal wall
Indications Inflammation or obstruction of Ulcerative, Chron’s
large bowel; congenital or
obstructive process of lower
intestinal tract, sigmoid/rectal
Ca
Purpose Provide outlet for intestinal Serve as an exit for
waste products waste products when
colon has been
removed
Discharge Liquid to formed stools Yellow green or brown
liquid
 ostoma Care
• Apply appliance
• Monitor for signs of leakage
• Monitor stoma for size, color, and bleeding
• Stoma care and irrigation
• Place petroleum gauze, or moist dressing over the
stoma
• Skin Care
• Avoid gas forming food
• Emptying pouch
• Diet, fluid and electrolyte balance
HEMORRHOIDS
Perianal varicose veins

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• Two Types of Hemorrhoids
– Internal - sup hemorrhoidal plexus
– External- inf hemorrhoidal plexus
• Causes
– Many anastomoses between plexuses
– lack of valve in portal vein
– Contributory factors: ( inc intra-abdominal
presure
• Chronic constipation, Pregnancy, Obesity
• Prolonged sitting or standing
• Wearing constricting clothings
• Disease conditions like liver cirrhosis, CHF
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27
• Pathophysiology
– Increase intra-abdominal pressure
(straining)
– Distenstion of hemorrhoidal vein
– Ampula is filled with formed stool
– venous obstruction (repetition)
– Permanent dilatation
– push outside
– bleeding
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 manifestation
• Enlarged mass at the anus (EH)
• Constipation( in an effort to prevent pain
or bleeding associated with defecation.)
• Anal pain
• Rectal bleeding
• Mucous secretion from the anus
• Anal itching
• Sensation of incomplete evacuation of
the rectum
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 diagnostic
• Ext. Hemorrhage:
– Visual examination
• Internal hemorrhage:
– History
– Digital palpation
– Proctoscopy

• Asking client to strain during assessment

cause the vein to dilate
 MEDICAL MANAGEMENT
• Used only for small, uncomplicated with mild
symptoms
– Reducing presure
– Relieving pain
• Hot Sitz bath, warm compress

• Pharmacologic
– Bulk laxatives
– Stool softener
– Local anesthetic application – Nupercaine
– Steriod- reduce pain and itching
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• Dietary management
– Increasing fluid and fiber
• Surgical
– Sclerotherapy
– Rubber band ligation – Int. hem
– Cryosurgery- freezing
– Laser removal
– Hemorrhoidectomy- vein is excised ( open
& closed)
 POSTOP CARE
• Patient Teaching
– Clean rectal area thoroughly after each
defecation
– Sitz bath at home especially after defecation
– Avoid constipation:
• High – fiber diet
• High fluid intake
• Regular exercise
• Regular time for defecation
– Use stool softener until healing is complete
– Notify physician for the following:
• Rectal bleeding
• Continued pain on defecation
• Continued constipation
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