GIT Disorders

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Organ of digestive systems

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 Anatomic and Physiologic Overview
• The GIT is a 23 to 26 foot long that extends from
the mouth to the anus.
What are he two divisions of the digestive system?

• The esophagus is a muscular tube, w/c is

approximately 25 cm in length that takes food
from the pharynx to the stomach.

3
 Anatomic and Physiologic Overview
• The stomach is situated in the left upper portion
of the abdomen under the left lobe of the liver.
• The stomach:
• stores food during eating,
• secretes digestive fluids, and
• propels the partially digested food into the
small intestine.
• The stomach has four anatomic regions: The
cardia (entrance), fundus, body, and pylorus
(outlet).
• The pylorus has pyloric sphincter.
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 Anatomic and Physiologic Overview
• The small intestine is the longest segment of the
GIT.
It provides ~ 7000 cm of surface area for secretion
and absorption.
The sections are the duodenum, jejunum, and ileum.

They terminate at the ileocecal valve which prevents

reflux of bacteria into the small intestine.
• Vermiform appendix is attached to the cecum that
has little or no physiologic function.
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 Anatomic and Physiologic Overview
• The large intestine consists of an ascending, a
transverse segment, and a descending segment.

• The terminal portion are the sigmoid colon,

rectum, and the anus.
• The striated muscle forms both the internal and the
external anal sphincters to regulates anal out let.

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 Anatomic and Physiologic Overview

• The GIT receives blood from thoracic and

abdominal aorta and veins that return blood from
the digestive organs and the spleen.

• Blood flow to the GIT is about 20% of the total

cardiac output and increases significantly after
eating.
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 Anatomic and Physiologic Overview

• Sympathetic nerves exert an inhibitory effect on

the GIT, decreasing gastric secretion and motility
and causing the sphincters and blood vessels to
constrict.

• Parasympathetic nerve stimulation causes

peristalsis and increases secretory activities.
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 Functions of the Digestive System

Primary functions of the GI tract are the following:

– The breakdown of food particles into the molecular
form for digestion.

– The absorption into the bloodstream of small nutrient

molecules produced by digestion.

– The elimination of undigested unabsorbed foodstuffs

and other waste products.

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 Disorders of the Teeth
Dental Plaque and Caries
• Tooth decay is an erosive process that begins with
the action of bacteria on fermentable
carbohydrates in the mouth which produces acids
that dissolve tooth enamel.
• A recent study found that soft drinks caused
dental erosion by directly attacking the enamel.
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 Disorders of the Teeth…
The extent of damage to the teeth depends on the ff:

– The presence of dental plaque that adheres to

the teeth & damages the tooth.
– The strength of the acids,
– The ability of the saliva to neutralize them,
– The length of time the acids are in contact with
the teeth and,
– The susceptibility of the teeth to decay.

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 Disorders of the Teeth…

• Dental decay begins with

a small hole, usually in:
– A fissure (gap or cleft)
or
– An area that is hard to
clean.
• Left unchecked, the decay
extends into the dentin.
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 Disorders of the Teeth…
• Because dentin is not as hard
as enamel, decay progresses
more rapidly and eventually
reaches the pulp of the tooth.

• When the blood, lymph

vessels, & nerves are exposed,
they become infected and an
abscess may form, either
within the tooth or at the tip of
the root.

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 Disorders of the Teeth…
• Soreness and pain usually occur with an abscess.
• As the infection continues, the patient's face may swell,
and there may be pulsating pain.
• X-ray:- determine the extent of damage and the type of
treatment needed.
• Treatment for dental caries includes:
– Fillings,
– Dental implants, and
– Extraction,
– Antibiotic if necessary.
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Dental filling-a tooth filling is a procedure wherein the damaged and decayed
part of a tooth is removed and the area is filled with a replacement material
to protect against like gold; porcelain; silver amalgam (which consists of
mercury mixed with silver, tin, zinc, and copper); or tooth-colored, ...

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Dental implants are medical devices surgically implanted into the jaw to restore a
person's ability to chew or their appearance.
Dental implant surgery is a procedure that replaces tooth roots with metal, screwlike
posts and replaces damaged or missing teeth

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• A tooth extraction is a dental procedure during which
your tooth is completely removed from its socket.

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 Disorders of the Teeth…
Preventive Measures of dental caries
• Practicing effective mouth care
• Reducing the intake of starches and Sugars

• Applying fluoride to the teeth or drinking fluoridated

water, using fluoridated toothpaste ; or using sodium
fluoride tablets, drops, or lozenges

• Refraining from smoking

• Controlling diabetes, and

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 Disorders of the Esophagus
• The esophagus is a mucus-lined, muscular tube that
carries food from the mouth to the stomach.
• Transport food and fluid is facilitated by two sphincters.
The upper esophageal sphincter, also called the hypo
pharyngeal sphincter.

• The lower esophageal sphincter, also called the gastro

esophageal sphincter or cardiac sphincter, is located at the
junction of the esophagus and the stomach.
• An incompetent lower esophageal sphincter allows reflux
(backward flow) of gastric contents.

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 Disorders of the Esophagus
1. DYSPHAGIA
• Dysphagia (difficulty swallowing).This symptom may
vary from an uncomfortable feeling to acute pain on
swallowing (odynophagia).

• Obstruction of food (solid and soft) and even liquids

may occur anywhere along the esophagus.

• Often the problem is located in the upper, middle, or

lower third of the esophagus.
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 Disorders of the Esophagus…
2. Achalasia is absent or ineffective peristalsis of the distal
esophagus, accompanied by failure of the esophageal
sphincter to relax in response to swallowing.

• Narrowing of the esophagus just above the stomach

results in a gradually increasing dilation of the esophagus
in the upper chest.

• Achalasia may progress slowly and occurs most often in

people 40 years of age or older.

• The alteration in the peristalsis result from impairment of

the ANS innervating the esophagus. 26
 Clinical Manifestations
• Difficulty in swallowing both liquids and solids.

• Sensation of food sticking in the lower portion.

• Regurgitation-to relieve the discomfort produced by

prolonged distention of the esophagus.
• Chest pain and heartburn (pyrosis).

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 Assessment and Diagnostic Findings

• X-ray : esophageal dilation above the narrowing at the

gastro esophageal junction
• Barium swallow (esophagogram)

• CT scan of the esophagus

• Endoscopy may be used for diagnosis

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Endoscopy

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 Management…

• Instruct patient to eat slowly and drink fluids with meals.

• Calcium channel blockers and nitrates :used to decrease

esophageal pressure and improve swallowing.

• If these methods are unsuccessful, pneumatic (forceful) dilation

or surgical separation of the muscle fibers may be
recommended.

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 Management…
 Achalasia may be treated conservatively by pneumatic
dilation to stretch the narrowed area of the esophagus.
 Pneumatic dilation has a high success rate.

Achalasia may be treated surgically by:

• Esophagomyotomy (the muscle fibers that enclose the
narrowed area of esophagus)

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 Hiatal hernia
• Hiatal hernia is an anatomical abnormality in which part
of the stomach protrudes through the diaphragm and up
into the chest.
• Normally, the esophagus crosses the diaphragm, and
enters the abdomen through a hole in the diaphragm
called the esophageal hiatus.

• Just below the diaphragm, the esophagus joins the

stomach.
• In individuals with hiatal hernias, the portion of the upper
stomach slips up (herniated) through the hiatus and into
the chest.
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 Hiatal hernia…
Pathophysiology
• Normally, the opening in the diaphragm encircles the
esophagus tightly, and the stomach lies completely
within the abdomen.
• In a condition known as hiatal hernia, the opening in
the diaphragm becomes enlarged, and part of the upper
stomach tends to move up into the lower portion of the
thorax.

• Hiatal hernia occurs more often in women than men.

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 Types of Hiatal hernia…
1. Sliding (Type I ) hiatal hernia: when the upper stomach
and the gastro esophageal junction (GEJ) are displaced
upward and slide in and out of the thorax.
• It slides in to thoracic cavity when the patient is supine
and
• It usually goes back in to the abdominal cavity when the
patient is standing upright.
• About 90% of patients with esophageal hiatal hernia have
a sliding hernia.
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 Types of Hiatal hernia…
2. A paraesophageal hernia/Type II: occurs when all or part
of the stomach pushes through the diaphragm beside the
esophagus.

Furtherly classified as types II, III, or IV, depending on

the extent of herniation.

 In type IV the fundus, the greater curvature of the

stomach roll up via the diaphragm , forming a pocket
along side the esophagus.

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paraesophageal hernia
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Types of Hiatal hernia…

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 Hiatal hernia…
Causes
• Unknown, but
• Weakening of the muscle in the diaphragm around
esophagogastric opening.
• An abnormally loose attachment of the esophagus to the
diaphragm
• Factors the increase intrabdominal pressure including:
– Obesity,
– Pregnancy
– Ascites, tumor, small bowel obstruction…
– Heavy lifting, Intense physical excretion
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 Clinical Manifestations
Sliding hernia:
• Heartburn,
• Regurgitation, and
• Dysphagia, but 50% of patients are asymptomatic.
– Sliding hiatal hernia is often implicated in reflux.
Paraesophageal hernia:
– Sense of fullness after eating or may be asymptomatic.
– Reflux usually does not occur, because the gastro
esophageal sphincter is intact.
– The complications of hemorrhage, obstruction, and
strangulation can occur with any type of hernia
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 Assessment and Diagnostic Findings
Diagnosis is confirmed by x-ray studies, barium swallow,
and fluoroscopy.
Management
• Frequent, small feedings that can pass easily through the
esophagus
• Advise not to recline for 1 hour after eating, to prevent
reflux
• Elevate the head of the bed on 10 to 20 cm.

• Surgery is indicated in about 15% of patients

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 Diverticulum
• A Diverticulum is an out pouching of mucosa and sub
mucosa that protrudes through a weak portion of the
musculature .
• Diverticulum may occur in one of the three areas of the
esophagus.

1.The upper esophagus or pharyngoesophageal: the most

common.

2. The mid-esophageal area.

3. The lower area of the esophagus.

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 Diverticulum…
• Esophageal diverticula can be categorized as:
1.True diverticula contains all the layers of the
esophageal wall,
2. False diverticula that contains only the mucosa, or
submucosa
3.Intramural diverticula: mucosal out pouching within
the wall.

• The diverticula may result from the weakness in the wall

associated with:
 Increased intra luminal pressure or
Traction from fibrosis in the mediastinum. 45
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Diverticula of the distal esophagus
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 Clinical Manifestations
• Difficulty of swallowing
• Fullness in the neck

• Belching
• Regurgitation of undigested food-recumbent position

• The pouch, becomes filled with food or liquid

• Halitosis and a sour taste -because of the decomposition

of food retained.

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 Assessment and Diagnostic Findings
• A barium swallow -to determine the exact nature and
location of a diverticulum.
• CT scan

• Esophagoscopy - is contraindicated because of the

danger of perforation.

• Blind insertion of a nasogastric tube should be avoided

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 Differential Diagnoses
• Achalasia

• Esophageal Cancer

• Esophageal Motility Disorders

• Esophageal Spasm

• Esophageal Stricture

• Gastroesophageal Reflux Disease

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 Management
Management: Surgical options include
Diverticulectomy

Complications:
• Malnutrition,

• Aspiration and

• Perforation

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 Gastritis
• Gastritis: an inflammation of the gastric or stomach
mucosa.
• It is a common GI problem.

Gastritis may be:

• Acute-lasting several hours to a few days, or

• Chronic- repeated exposure to irritating agents or

recurring episodes of acute gastritis

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 Acute Gastritis
Acute gastritis is often caused by:
– Dietary indiscretion: contaminated food or irritating or
highly seasoned food.
Other causes of acute gastritis include
• Overuse of ASA and other NSAIDs

• Excessive alcohol intake

• Bile reflux, and radiation therapy

• Strong acid or alkali ingestion: cause mucosal

gangrene or perforation.
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 Chronic gastritis
Chronic gastritis : prolonged inflammation of the stomach
may result from:
• Repeated episodes of acute gastritis

• Benign or malignant ulcers of the stomach

• Helicobacter pylori

– Dietary factors such as caffeine

– The use NSAIDs

– Alcohol; smoking,
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 Clinical manifestations
Acute gastritis
Abdominal discomfort

Headache, lethargy,

nausea, anorexia, vomiting, and hiccupping

Hemorrhage
Chronic gastritis
Anorexia, heartburn after eating, belching,
A sour taste in the mouth, or nausea and vomiting

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 Assessment and Diagnostic Findings
Diagnosis can be determined
• Endoscopy,

• Upper GI radiographic studies

• Histological examination of a tissue

• H. Pylori test

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 Medical Management
Acute gastritis
• Refrain from alcohol and food until symptoms subside.

• Non-irritating diet is recommended

• IV fluids If the symptoms persist

• Blood transfusion and fluid replacement If bleeding

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 Medical Management…
• If gastritis is caused by ingestion of strong acids or
alkalis, treatment consists of diluting and neutralizing the
offending agents.

– To neutralize acids, common antacids (e.g. Aluminum

hydroxide).
– To neutralize an alkali, diluted lemon juice or diluted
vinegar .

• If corrosion is extensive or severe, emetics and lavage are

avoided because of the danger of perforation and damage
to the esophagus.
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 Medical Management…
Chronic gastritis
• Focuses on evaluating and eliminating the specific causes
• Modifying patient’s diet
• Promoting rest
• Reducing stress
• Initiating pharmacotherapy

• H. pylori may be treated with antibiotics (e.g, TTC or

Amoxicillin, combined with Clarithromycin,
metronidazole) and a proton pump inhibitor (Omeprazole)
and possibly bismuth salts.
• Regular injection of vitamin B 12 are needed.
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 Gastric and Duodenal Ulcers
A peptic ulcer is an excavation (hollowed-out area) that
forms in the mucosal wall of :
1. The esophagus
2. The stomach
3. The pylorus (between stomach and duodenum)
4. The duodenum (first part of small intestine).
 Erosion of a circumscribed area of mucous membrane is
the cause
• This erosion may extend as deeply as the muscle layers or
through the muscle to the peritoneum.
• Peptic ulcers are more likely to be in the duodenum than
in the stomach. 60
 Causes
 Infection with H. pylori

 excessive secretion of HCL

 Factors may increase HCl secretion:

Stress

Caffeinated beverages

Smoking, and

Alcohol

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 Causes …
 Familial tendency may be a significant predisposing
factor

 A further genetic link is noted in the finding that people

with blood type O are more susceptible to peptic ulcers
than are those with blood type A, B, or A.

 Other predisposing factors associated with peptic ulcer

include chronic use of NSAIDs.
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 Causes …
Three major causes of peptic ulcer disease are now
recognized:

1. NSAIDs; Inhibit biosynthesis of prostaglandin.

2. Chronic H pylori infection:

• Adhesin: help to adhere gastric cells.
• Urease: hydrolyzes urea into ammonia &co2.
• Catalase: protect from immune system attack.

3. Acid hypersecretory states such as Zollinger-Ellison

syndrome 63
 Causes …
The main cause of PUD is an imbalance between gastric
acidity and the strength of mucosal barrier against auto
digestion.
This imbalance result from;
1. Exposure of the mucosal lining to excessive gastric
secretion
• Gastroesophgeal reflux: expose the lowest part of the
esophagus
• Gastric hypersecretion: expose mucus to excessive HCL
secretion and pepsin.
• Rapid emptying of gastric contents in to duodenum:
expose to big shots of gastric HCL- duodenal ulceration.
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 Causes …
2. Disruption of mucosal barrier against auto digestion
• Diminished secretion of mucous as in anxiety and
nervous tension.

• Failure of secretin hormone to stimulate enough

alkaline to neutralize gastric juice as it enters the
duodenum

3. The role of NSAIDS:

• Inhibition of gastric mucosal prostaglandin synthesis/
which increase blood flow and stimulate alkaline, mucus
secretion
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Video animation

PUD_44.FLV

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 Gastric ulcer Vs Duodenal ulcer
Duodenal Ulcer
Incidence
– Age 30–60
– Male: female 2–3:1
– 80% of peptic ulcers are Duodenal
Signs, Symptoms, and Clinical Findings
– Hyper secretion of stomach acid (HCl)
– May have weight gain
– Pain occurs 2–3 hours after a meal; often awakened
between1–2 AM
– Ingestion of food relieves pain
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 Duodenal ulcer
• Vomiting uncommon

• Hemorrhage less likely than gastric ulcer, but if present

melena more common than hematemesis
• More likely to perforate than gastric ulcers

Malignancy Possibility
• Rare
Risk Factors
• H. pylori, alcohol, smoking
• stress
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 Gastric ulcer
Gastric Ulcer
Incidence
• Usually 50 and over, Male: female 1:1
• 15% of peptic ulcers are gastric
Signs, Symptoms, and Clinical Findings
• Normal to hypo secretion of HCl
• Weight loss may occur & Vomiting common
• Pain occurs after a meal; rarely occurs at night; may be
relieved by vomiting; ingestion of food does not help,
sometimes increases pain.
• Hemorrhage more likely to occur than with duodenal
ulcer; hematemesis more common than melena
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 Assessment and Diagnostic Findings
• P/E: epigastric tenderness, distension.
• A barium study of the upper GIT may show an ulcer;
• Endoscopy allows direct visualization of inflammatory
changes, ulcers, and lesions .
– Endoscopy may reveal lesions that are not evident on
x-ray studies because of their size or location
• Biopsy of the gastric mucosa
– H. pylori infection may be determined by biopsy and
histology with culture
• Breath test that detects H. pylori
• Serologic test for antibodies to the H. pylori antigen
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 Non pharmacologic therapy
A. Stress reduction and rest
• Physical and psychological modification

• Identifying situations that are stressful or exhaustion

B. Smoking cessation

C. Dietary modification

D. Avoiding use of meat extract, alcohol, coffee

E. Eating food that can be tolerated

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 Medical Management
• The goals are to eradicate H. pylori and to manage gastric
acidity

Methods used include:

– Medications

– lifestyle changes

– Surgical intervention

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 Pharmacologic Therapy
Currently, the most commonly used therapy in the Rx of
ulcers is:

A combination of antibiotics
proton pump inhibitors (Omeprazole)
 bismuth salts that suppresses or eradicates H. pylori

• Histamine 2 (H2) receptor antagonists and proton pump

inhibitors are used to treat NSAID-induced and other
ulcers not associated with H. pylori ulcers.

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 Pharmacologic Therapy
1. Drugs which neutralize the excess released gastric acid
(antacid)

2. Drugs which can inhabit gastric acid secretion (H2

blocker, anticholnergic, proton pump inhibitors,
prostaglandins, sedatives and dietary fats)

3. Cytoprotective agents which can enhance secretion of

the protective mucin.

4. Antibiotics to destroy the causative organism

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 Surgery
Surgery is usually recommended:
 for patients with intractable ulcers (those that fail to heal
after 12 to 16 weeks of medical treatment)
 Life-threatening hemorrhage

 Perforation

 Obstruction

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 Potential complications :

• Hemorrhage

• Perforation

• Penetration

• Pyloric obstruction (Goo, gastric outlet obstruction)

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 Intestinal and
Rectal Disorders

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 Appendicitis…
• The appendix is a small, finger-
like appendage about 10 cm (4
inch) long that is attached to the
cecum just below the ileocecal
valve.
• The appendix fills with food and
empties regularly into the cecum.
• Because it empties inefficiently
and its lumen is small, the
appendix is prone to
obstruction.
Although it can occur at any age, it occurs most frequently
between the ages of 10 and 30 years. 79
 Pathophysiology of Appendicitis
• Acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen.

• Once this obstruction occurs, the appendix subsequently

becomes filled with mucus and swells.

• This increases pressure within the lumen and the walls of

the appendix,
• Resulting in thrombosis and occlusion of small vessels,
and stasis of lymphatic flow.
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 Pathophysiology of Appendicitis…
• As the former progresses, the appendix becomes
ischemic and then necrotic.
• As bacteria begin to leak out through the dying walls,
pus forms within and around the appendix.

• The end result of this cascade is appendiceal rupture

causing peritonitis, which may lead to septicemia and
eventually death.
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 Clinical Manifestations
• Vague epigastric or per umbilical pain progresses to RLQ
pain along with
• low-grade fever, nausea and vomiting.

• Loss of appetite is common

• Local tenderness at McBurney’s point

• Rebound tenderness.

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 Clinical Manifestation
• If the appendix curls behind the cecum, pain may be felt
in the lumbar region.

• If its tip is in the pelvis, pain may be elicited only on

rectal examination

• If appendix is resting against the rectum, Pain on

defecation suggests

• If the tip is near the bladder /the ureter, Pain on urination

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 Clinical Manifestations

• Diffused pain if the appendix has ruptured

• Abdominal distention as a result of paralytic ileus

• Constipation

– Laxatives may produce perforation

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 Clinical Manifestations…
Rovsing’s sign
• Pain may be elicited by palpating the LLQ; this causes
pain to be felt in the RLQ.
– Continuous deep palpation starting from the left iliac
fossa counterclockwise along the colon may push
bowel contents towards the ileocecal valve and
– Thus increasing pressure around the appendix.

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 Clinical Manifestations…
Obturator sign
• If an inflamed appendix is in
contact with the Obturator
internus, spasm of the muscle
• Flexing and internal rotation of
the hip will cause pain in the
hypogastrium.

87
 Clinical Manifestations…
Psoas sign
• Pain is on the RLQ with passive extension of the
patient's right hip .
– This reveals inflammation of the peritoneum
overlying the iliopsoas muscles and inflammation of
the Psoas muscles themselves.

• Straightening out the leg causes pain because it stretches

these muscles, while flexing the hip activates the
iliopsoas and therefore also causes pain.

88
 Clinical Manifestations…
Sitkovskiy(Rosenstein)'s sign
• Increased pain in the right iliac region as patient lies on
left side.

Dunphy's sign
• Increased pain in the RUQ with coughing.
Kocher's (Kosher's) sign
• The history pain starts in the epigastric region at the
beginning of disease with a subsequent shift to the right
iliac region.
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 Assessment and Diagnostic Findings

• Complete P/E

• X-ray findings

• CT scan (94% sensitive & 95 specific) ,

• Ultrasonography

• Elevated WBCs count,

• U/A to rule out pregnancy &UTI.

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Ultrasonography

91
 Management
Surgery is indicated if appendicitis is diagnosed
• IV fluids: To correct or prevent fluid and electrolyte
imbalance and dehydration until surgery is performed.
• Antibiotics

• Analgesics: after the diagnosis is made

• Appendectomy: as soon as possible to decrease the risk

of perforation
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93
 Complications
 Perforation  peritonitis or an abscess.

• The incidence of perforation is 10% to 32%

It occurs 24 hours after the onset of pain

• Symptoms of perforation

fever

toxic appearance, and

Continued abdominal pain or tenderness. 94

 Nursing Management
Goals:
 Relieving pain,

 preventing fluid volume deficit,

 reducing anxiety,

 eliminating infection from the potential or actual

disruption of the GI tract,
 maintaining skin integrity, and

 attaining optimal nutrition.

• An enema is contraindicated perforation 95
 Nursing Management…
• Semi-Fowler position reduces the pain

• opioid analgesic usually morphine sulfate

• oral fluids are administered when tolerated,

• Food is provided as tolerated on the day of surgery.

96
 Peritonitis
• Peritonitis is inflammation of the peritoneum lining the
abdominal cavity and covering the viscera.
• Peritonitis can be resulted from the following:
(1).bacterial infection w/c originate from:
– Diseases of the GIT(Appendicitis, perforated ulcer,
diverticulitis, Bowel perforation &
– Internal reproductive organs (in women) .
(2). external sources:
– Injury or trauma (E.g. gunshot wound, stab wound)
– An inflammation of organ outside the peritoneal area,
such as the kidney.

(3). Abdominal surgical procedures 97

98
 Pathophysiology
• Peritonitis is caused by leakage of contents as a result of
inflammation, infection, ischemia, trauma, or tumor
perforation.

• Edema of the tissues results in exudation of fluid

• Fluid in peritoneum becomes turbid with increasing

amounts of protein, WBCs, cellular debris, and blood.
• The immediate response of the intestinal tract is hyper
motility,
• soon followed by paralytic ileus with an accumulation of
air and fluid in the bowel.
99
 Clinical Manifestations….
• Symptoms depend on the location and extent of the
inflammation.

• At first, a diffuse type of pain is felt.

• Movement usually aggravates it

• The pain is constant, localized, and more intense near the

site of the inflammation.

100
 Clinical Manifestations
• Extreme tender, distension, and muscular rigidity over
the affected area of the abdomen

• Rebound tenderness and paralytic ileus

• Nausea and vomiting

• peristalsis is diminished

• Toc and PR increase, and

101
 Diagnostic Findings
• The WBCs count is elevated
• The Hgb and HCT :low if blood loss
• Serum electrolyte studies : altered levels of K, NaCl.

• An abdominal x-ray : air and fluid levels & distended

bowel loops

• CT scan of the abdomen : abscess formation

• Peritoneal aspiration for culture and sensitivity studies

102
 Complications
• Generalized sepsis:

– Sepsis is the major cause of death from peritonitis.

– Shock resulted from septicemia or Hypovolemia.

• The inflammatory process  intestinal obstruction, due

to bowel adhesions

• The two most common postoperative complications:

wound evisceration and
abscess formation
103
Wound evisceration

104
 Medical Management…
• Fluid, colloid, and electrolyte replacement
• Large doses of IV antibiotic until the specific organism
causing the infection is identified

• Analgesics
• Antiemetic for nausea and vomiting
• Intestinal intubation and suction assist in:
– Relieving abdominal distention
– Promoting intestinal function
105
 Medical Management…

• Surgical objectives include:

removing the infected material and

correcting the cause

• Surgical treatment:

Excision if appendix, or anastomosis of intestine

Repair if perforation, and

Drainage if abscess

Fecal diversion if extensive sepsis. 106

 Nursing Management

• BP if shock is present

• Urine output

• Accurate recording of all intake and output

• Ongoing assessment of pain, GI function, and fluid and

electrolyte balance
• Analgesics and

• positioning for comfort &decreasing pain

107
 Nursing Management…
• Signs of subsiding from peritonitis include:

– Decrease of Toc and PR

– Softening of the abdomen,

– Return of peristaltic sounds,

– Passing of flatus and bowel movements.

• Increases fluid and food intake gradually and

• Reduces Parenteral fluids

108
 Intestinal Obstruction
Intestinal obstruction is a partial or complete blockage
of the bowel that prevents the contents of the intestine
from passing through.

Two types of processes can hinder this flow

A. Mechanical obstruction: An intraluminal obstruction

or a mural obstruction from pressure on the intestinal
walls occurs.
B. Functional obstruction: The intestinal musculature
cannot propel the contents along the bowel.
109
 Intestinal Obstruction …
Causes of mechanical obstruction of the small intestine
 Intussusceptions: Telescoping of one segment of bowel
into another.
 Adhesions: scar tissue that forms after surgery

Tumors blocking the intestines

Volvulus (twisted intestine)

Stenosis & strictures
Hernias, and
Abscesses 110
Volvulus

111
 Intestinal Obstruction …
Causes of mechanical obstruction of the colon
Colon cancer

Diverticulitis: pouches become inflamed or infected

Twisting of the colon (Volvulus)
Impacted feces
Narrowing of the colon caused by inflammation and
scarring (stricture)
Causes of functional obstruction
Muscular dystrophy, or
Neurologic disorders such as Parkinson's disease.
112
 Intestinal Obstruction
• Its severity obstruction depends on:
– The region of bowel affected,
– The degree to which the lumen is occluded, and
– The degree to which the vascular supply to the bowel
wall is disturbed
• Most bowel obstructions occur in the small intestine:

Adhesions are the leading cause of small bowel

obstruction,
followed by hernias & neoplasms.
113
 Intestinal Obstruction…

• Most obstructions in the large bowel occur in the sigmoid

colon.
• The most common causes are:

• Carcinoma,

• Benign tumors,

• Diverticulitis, and

• Inflammatory bowel disorders.

114
 Small Bowel Obstruction
Pathophysiology
• Intestinal contents, fluid, and gas accumulate above the
intestinal obstruction  abdominal distention.
• As pressure within the lumen increases,  decrease in
venous and arteriolar capillary pressure.

• This causes edema, congestion, necrosis, and eventual

perforation of the wallperitonitis.

115
 Small Bowel Obstruction

Pathophysiology…
• Reflux vomiting b/c abdominal distention results in

loss of H + & K +

loss of Cl- & K + in the blood

metabolic alkalosis.
• DHN b/c loss of water & sodium

 hypovolemic shock.

116
 Clinical Manifestations
• Initially, crampy pain that is wave like and colicky.
• Passing blood and mucus, but no fecal matter & no flatus.
• Vomiting

• If the obstruction is complete eventually assume a

reverse direction,

with the intestinal contents propelled toward the

mouth instead of toward the rectum.

117
 Clinical Manifestations
If the obstruction is in the ileum, fecal vomiting takes place:
• First, the patient vomits the stomach contents

• Then the bile-stained contents

• Finally the darker, fecal-like contents of the ileum

• The unmistakable signs of dehydration become evident:

intense thirst, drowsiness, generalized malaise, aching,
and a dry tongue and mucous membranes.
118
 Clinical Manifestations…

• The abdomen becomes distended

• The lower GIT obstruction is more marked by the

abdominal distention.
• If the obstruction continues uncorrected,

Hypovolemic shock occurs from dehydration and

Loss of plasma volume

119
 Assessment and Diagnostic Findings
• Previously described symptoms

• Abdominal x-ray & CT scan: quantities of gas, fluid both

in the bowel
• Electrolyte studies and a CBC reveal a picture of

Dehydration,

Loss of plasma volume, and

 Possible infection.

120
 Medical Management
• Decompression of the bowel:

by a NG or small bowel tube is successful.

• Surgical intervention:

When the bowel is completely obstructed or

strangulation.
• IV therapy:
to replace the depleted water, Na, Cl, & K+ before
surgery.
• surgical treatment depends on the cause of the obstruction.
121
 Medical Management…
• If it is due to hernia, repairing the hernia
• If it is due to adhesions, dividing the adhesion

• If the portion of bowel affected, bowel may be removed

and an anastomosis performed.

• The complexity of the surgical procedure for intestinal

obstruction depends on:
– The duration of the obstruction and
– The condition of the intestine.
“Never let the sun rise or set on small-bowel
obstruction” 122
 Nursing Management
• Maintaining the function of the NG tube, assessing and
measuring the NG output,
• Assess fluid and electrolyte imbalance, monitoring
nutritional status, and

• Assess return of normal bowel sounds, decreased

abdominal distention, improvement in abdominal
tenderness, passage of flatus or stool.

• Report discrepancies in intake and output, worsening of

pain or abdominal distention, and increased NG output.
123
Intussusceptions invagination or shortening of the colon
caused by the movement of one segment of bowel into
another

124
Volvulus of the sigmoid colon; the twist is
counterclockwise in most cases
125
Hernia (inguinal). The sac of the hernia is a continuation of
the peritoneum of the abdomen.

The hernial contents are intestine, omentum, or other

abdominal contents that pass through the hernial opening
into the hernia sac.

126
 Large Bowel Obstruction
Pathophysiology
• As in small bowel obstruction, large bowel obstruction
results in an accumulation of intestinal contents, fluid,
and gas proximal to the Obstruction.

• Obstruction in the large bowel can lead to severe

distention and perforation unless some gas and fluid can
flow back through the ileal valve.
127
 Large Bowel Obstruction…

 If the blood supply is cut off, necrosis (tissue death)

occur; this condition is life threatening.

• In the LI, dehydration occurs more slowly than in the SI

b/c the colon can absorb its fluid contents.

• Adenocarcinoid tumors account for the majority of large

bowel obstructions

128
 Clinical Manifestations…
• In the large bowel obstruction, the symptoms are
developed slowly.
• If obstruction in the sigmoid colon or the rectum,
constipation may be the only symptom for days.

• Eventually, the abdomen markedly distended, and crampy

pain of lower abdominal

• Finally, fecal vomiting develops

• Symptoms of shock may occur
129
 Assessment and Diagnostic Findings

• Diagnosis is based on symptoms

• Abdominal X-ray studies: show a distended colon.

130
 Management

• Colonoscopy to untwist and decompress the Bowel

• Colostomy for patients who have poor surgical risks

and urgently need relief from the obstruction

– The procedure provides an outlet for releasing gas

and a small amount of drainage

131
 Management

• A rectal tube may be used to decompress an area that is

lower in the bowel

• surgical resection is usual treatment to remove the

obstructing lesion

• An ileoanal anastomosis may be performed if it is

necessary to remove the entire large colon. 132
Hernias

133
133
 Hernias
• Hernia: is a protrusion of an organ via the wall of the
cavity in which it is normally contained.
• Most commonly occur in the abdominal wall.

• It is due to a gap in, or weakness of abdominal muscle

• Hernia can be congenital or acquired

– Increased intra-abdominal pressure is the most
common cause of acquired hernia.
• Hernia become bigger when the patient cough, strains, or
works hard, because this increase intrabdominal pressure.
134
 Types of Hernias
A. Inguinal hernia: Makes up 75% of all abdominal wall
hernias and up to 25 times more often in men than
women.

1. Indirect inguinal hernia

– Follows pathway that testicles made during pre birth
development.
– normally closes before birth but remains a possible
place for a hernia.
– Sometimes the hernial sac may protrude into the
scrotum.
– This occur at any age but common as age increase.
135
 Types of Hernias
2. Direct inguinal hernia
– This occurs slightly to the inside of the sight for the
indirect hernia, in a place where the abdominal wall
is naturally slightly thinner.
– It rarely will protrude into the scrotum.

 The direct hernia almost always occurs in the middle-

aged and elderly because abdominal walls weaken as
age increase.
136
Types of Hernias…

137
 Types Hernia
B. Femoral hernia
– The femoral canal is the way that the femoral artery,
vein, and nerve leave the abdominal cavity to enter the
thigh.
– Although normally a tight space, sometimes it allows
abdominal contents (usually intestine) into the canal.

– This hernia causes a bulge in the middle of the thigh.

– Rare and usually occurring in women, it is at risk of

becoming irreducible and strangulated. 138
139
Types of Hernia…

140
 Types Hernia…
Causes of femoral hernia
• Most of the time, no clear cause of a hernia. Some
hernias may be congenital.
– Chronic constipation
– Chronic cough
– Heavy lifting
– Obesity
– Straining to urinate because of an enlarged prostate.

 Femoral hernias tend to occur more often in women

than in men.
141
 Types of Hernia…
C. Umbilical hernia
– These common hernias (10-30%) are often noted at
birth as a protrusion at the umbilicus.
– This is caused when an opening in the abdominal wall,
which normally closes before birth, doesn’t close
completely.
– Even if the area is closed at birth, these hernias can
appear later in life because it is a weaker place in the
abdominal wall.
– This often appear later in elderly people and middle-
aged women who have had children. 142
Types of Hernia…

143
 Types Hernia…
D. Incisional hernia
– Abdominal surgery causes a flaw/mistake/ in the
abdominal wall that must heal on its own.
– This flaw can create an area of weakness where a
hernia may develop.
– This occurs after 2-10% of all abdominal surgeries,
although some people are more at risk.
– After surgical repair, these hernias have a high rate of
returning (20-45%).
144
 Types Hernia…
E. Spigelian hernia
– This rare hernia occurs along the edge of the rectus
abdominous muscle, which is several inches to the
side of the middle of the abdomen.

145
 Types Hernia…
F. Obturator hernia
– This extremely rare abdominal hernia happens mostly
in women.
– This hernia protrudes from the pelvic cavity through
an opening in the pelvic bone (Obturator foramen).

– This will not show any bulge but can act like a bowel
obstruction and cause nausea and vomiting.
146
 Types Hernia…
G. Epigastric hernia
– Occurring between the navel and the lower part of
the rib cage in the midline of the abdomen, these
hernias are composed usually of fatty tissue and
rarely contain intestine.
– Formed in an area of relative weakness of the
abdominal wall, these hernias are often painless and
unable to be pushed back into the abdomen when
first discovered. 147
Types Hernia…

148
149
 Signs and Symptoms
• Painless lump to the painful, tender, swollen protrusion
of tissue that you are unable to push back into the
abdomen—possibly a strangulated hernia.

Asymptomatic reducible hernia

• New lump in the groin or other abdominal wall
area
• May ache but is not tender when touched.

• Pain precedes the discovery of the lump.

150
 Signs and Symptoms
– Lump increases in size when standing or when
abdominal pressure is increased (coughing)
– May be reduced (pushed back into the abdomen)
unless very large.
Irreducible hernia
– Usually painful enlargement of a previous hernia that
cannot be returned into the abdominal cavity on its
own or when you push it.
– Some may be long term without pain

151
 Signs and Symptoms…
– Can lead to strangulation.

– Signs and symptoms of bowel obstruction may occur,

such as nausea and vomiting.

Strangulated hernia…
– Irreducible hernia where the entrapped intestine has its
blood supply cut off.
– Pain always present followed quickly by tenderness
and sometimes symptoms of bowel obstruction (nausea
and vomiting).
– Pts may appear ill with or without fever.
152
 Signs and Symptoms…
• Surgical emergency

• All strangulated hernias are irreducible (but all irreducible

hernias are not strangulated)

153
 Diagnosis

• Physical examination

• Others :
– Ultrasound or

– CT scan may be helpful.

154
 Treatment
• It depends on whether it is reducible or irreducible or
possibly strangulated.
– Reducible: Can be treated with surgery

– Irreducible

• All acutely irreducible hernias need emergency

treatment because of the risk of strangulation.
• An attempt to push the hernia back can be made

– Strangulation: Operation 155

 HEMORRHOIDS
• Hemorrhoids are dilated portions of veins in the anal
canal.
• By the age of 50, about 50% of people have hemorrhoids
to some extent .

• 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.
156
 HEMORRHOIDS…
Hemorrhoids are classified as one of two types:

• Internal hemorrhoids: Those above the internal sphincter

and
• External hemorrhoids: Those appearing outside the
external sphincter.
• Hemorrhoids cause itching and pain .

• common cause of bright red bleeding with defecation.

157
 Hemorrhoids…
• External hemorrhoids are associated with severe pain
from the inflammation and edema caused by thrombosis
(i.e. clotting of blood within the hemorrhoid).

• May lead to ischemia of the area and eventual necrosis.

• Internal hemorrhoids are not usually painful until they
bleed or prolapsed when they become enlarged.

• Hemorrhoid symptoms and discomfort can be relieved by

good personal hygiene and by avoiding excessive
straining during defecation.
158
 HEMORRHOIDS…

• A high-residue diet that contains fruit and fibers along

with an increased fluid intake may be all the treatment
that is necessary to promote the passage of soft, bulky
stools to prevent straining.

• Warm compresses, sitz baths, analgesic ointments and

suppositories, and bed rest allow the engorgement to
subside.
159
 HEMORRHOIDS….
There are several types of non-surgical treatments for
hemorrhoids.

• Infrared photocoagulation, and laser therapy are newer

techniques that are used to affix (attach) the mucosa to
the underlying muscle.

• Injecting sclerosing solutions is also effective for small,

bleeding hemorrhoids. These help prevent prolapse.
• A conservative surgical treatment of internal hemorrhoids
is the rubber-band ligation procedure
160
161