GI 2

peritonitis

peritonitis

life-threatening, acute inflammation & infection

causes:

• contamination of peritoneal cavity

• perforation (appendicitis, diverticulitis, PUD)

• gangrene gallbladder/bowel, bowel obstruction

• tumors, leakage during sx, CAPD

s/s:

• abd pain localized/poorly localized/referred to shoulder

• rigid, boardlike, distended abd

• high fever, tachycardia, dec UO, dehydration, N/V/A, dec BS

peritonitis labs & mgmt

inc WBC/neutrophils

blood c/s: organism, septicemia

abd xray: free air/fluid

assess VS for septic shock (very low BP, dec pulse pressure, inc HR, inc RR, inc temp, skin changes, LOC changes)

prevention: strict asepsis

peritonitis sx & postop

MIS

postop

• may leave incision open, peritoneal irrigation via drain (sterile technique)

• monitor LOC, VS, resp, I&O Qh immediately after sx

• semi-fowlers contain abd. drainage in lower abd, lung expansion

report to HCP

• unusual, foul smelling drainage

• swelling, redness, hyperpigmentation, warmth/bleeding from incision site

• temp>101F

• abd. pain

• wound dehiscence/ileus

appendicitis s/s

pain then N/V, rebound tenderness

gangrene & sepsis within 24hrs

risk of perforation esp after 48hrs

perforation s/s

• WBC> 20,000

• abd pain that increases with pain/movement, relieved by bending at R hip/knees

appendicitis interventions

IV fluids, keep NPO for possible sx

semi-fowler contain abd drainage in lower abdomen

opioids, IV antibiotics

suspected/confirmed perforation → avoid laxatives/enemas/heat to abd

appendicitis sx

laprascopy—return to usual activities 1-2wk

lapratomy—if high risk/perforated

• abd binder

• manage sutures

• drain: JP or NGT

• return to usual activities 4-6wk

ulcerative colitis

inflammation: colon & rectum only

inc colon cancer risk, perforation

s/s

• profuse, bloody diarrhea

• abd pain relieved by defecation

• malaise, anorexia, anemia, dehydration, fever, wt loss

• fever + tachycardia: dehydration, peritonitis, bowel perforation

crohn’s

inflammation: any part of bowel

terminal ileus near ileo-cecal valve

cobblestone or skip lesions

fistulas, anal abscesses, granulomas

alert for s/s peritonitis, small bowel obstruction, nutritional/fluid imbalance

s/s

• diet: high animal fats & sugar, no fruit/veg

• stools: steatorrhea

• abd pain: crampy, RLQ, confused with appendicitis

• BS: dec/absent if severe inflammation/obstruction. inc high pitched/rushing in areas of narrowed bowel loops

• muscle guarding, masses, rigidity, tenderness

• severe wt loss due to malabsorption

labs

• inc WBC, dec H&H, dec folic acid, Vit B12, albumin, inc CRP, ESR

fistula/abscess

• inc temp, inc WBC, dec H&H, FE (dec K & Mg)

xray: narrowing, ulceration, stricture, fistula

MRE: bowel activity & motility

CD vs UC

CD

• not curative

• stools less bloody, less frequent than UC

• transmural: skip lesions, cobblestone

• location: terminal ileum

• 5-6 loose, soft, nonbloody stool

• 15-40yo

• cx: fistula, nutritional defeciency

UC

• more common, mucosa & submucosa only (no transmural)

• continuous lesions

• rx: total removal of colon & rectum

• location: rectum → cecum

• 10-20 liquid bloody stool

• 15-35yo & 55-70yo

• cx: hemorrhage, nutritional defeciency

UC mgmt

dec animal fats & sugars, inc fruits & veg, no smoking

keep diary of s/s, monitor skin

CD mgmt

if severe s/s → NPO

if malnourished → TPN

avoid coffee, alcohol, milk, gluten

peripheral parenteral nutrition V(PPN)

PIV, short term

fat based, need CHO

monitor irritation

do not reuse tubing

fat overload s/s:

• fever, inc trig, clotting problem, multisystem organ failure

total parenteral nutrition (TPN)

central line/PICC with IV pump, long term

hypertonic, high glucose

cx

• F/E imbalance (K, Na, high Ca)

• hyperosmolar—fluid shifts (CRI, CHF)

• hyperglycemia

TPN maintenance

administer insulin

monitor hourly rate

if TPN soln unavailable, D10W/D20W until TPN soln

UC & CD drug therapy

iron, vitamins

anticholinergic (librax) to slow gut

antidiarrheals (imodium)

glucocorticoids for exacerbations (taper off)

immunosuppressive (imuran, mercaptopurine, methotrexate)

infliximab

• parenteral administration

• report injection site reactions

• SE: HA, abd pain, N/V

• avoid crowds & people with infection

• report any infection including cold/sore throat

natalizumab

• IV administration Q4wk

• for Crohn’s if other drugs are ineffective

• can cause PML (deadly infection that affects brain)

• be sure pt is free of any and all infections b4 admin

• report cognitive, motor, sensory changes immediately

vedolizumab

• moderate ~ severe Crohn’s

• IV admin at wk 0,2,6,8 then maintenance Q8wk

• does not cause PML, but be cautious

antibiotics for infection

aminosalicylate (5-ASA)

• for UC

• 2-4wk for effectiveness

• sulfasalazine

  • turns body secretions orange

  • report N/V/A, rash, HA

  • check allergies to sulfonamide or other sulfa drugs

  • need folic acid supp.

• mesalamine

  • better tolerated, less SE

  • ER PO, enema, supp

IBD postop care

MIS—no NGT, open sx—NPO, NGT x1-2days

ileostomy

• stool drains within 24hrs of sx at >1L/day

• fluids 500ml+/day

• after about a week, stool drainage slows (thicker)

second stage of sx—burning during bowel elimination (gastric acid not well absorbed by ileum)

pouchitis → metronidazole

stoma

location: RLQ abd. below belt line

abnormal: prolapse, retract into abd. wall

normal: pinkish~cherry red

report STAT to sx: grey, bluish, pale, dark stoma

output: initially dark green → eventually paste-like yellow green/yellow brown

normally little odor or sweet odor, foul/unpleasant odor when blockage/infection

postop care

avoid nuts and corn (cannot be digested well)

avoid cabbage, asparagus, brussels sprouts, beans (causes odor/gas)

regular postop pain control, antidiarrheal drugs

inc pain: peritonitis

prevent/monitor lower GI bleed

medical emergency!

GI bleeding scan

• localize site of bleeding

• does not determine cause of bleeding

• takes several hours to administer

• critical care pts are not candidates

monitor stool for blood loss—frank blood or melena

check VS, H&H, electrolytes

s/s of dehydration/anemia: fever, tachycardia, FVD, LOC change

notify RRT or HCP if bleeding

blood transfusion through 2 large bore cath (if Hgb<7)

1 bag PRBC per 1 Hgb

fistula management

common in crohn’s

diet

• high risk for malnutrition, dehydration, hypokalemia

• 3000cal/day

• high calorie, high protein, high vitamin, low fiber

• TPN if necessary

• 24H calorie count

• monitor UO, daily wts

skin

• ensure wound drainage is not in direct contact with skin

• clean skin promptly

high risk of sepsis & abscess

diverticula vs diverticulosis vs diverticulitis

diverticula

• pouchlike herniations of mucosa through muscular wall

• anywhere in GI tract, most common in sigmoid colon

• age 60+, low fiber diet, constipation, obesity

diverticulosis: many diverticula

diverticulitis

• inflammation of 1+ diverticula

• bowel irregularity, LLQ pain (sigmoid colon), N/A

• occult bleeding

• fever, inc WBC

acute diverticulitis s/s

low grade fever, severe abd pain, bloody, mahogany, tarry stools

diverticulitis dx & cx & mgmt

diagnosis

• xray/CT scan

• no barium enema in acute phase (risk for perforation)

• colonoscopy, sigmoidoscopy

• CBC

complications

• abscess, fistula, perforation, peritonitis, obstruction, adhesions

• hospitalize if: T>101F, persistent severe abd pain >3 days, lower GIB

management

• NPO, NGT LIS, IV fluids, broad spectrum abx

  • metronidazole, trimethoprim/sulfamethoxazole, ciprofloxacin

• avoid laxatives & enema for older adult (inc intestinal motility)

• diet

  • acute: CLD

  • uncomp: low fiber

  • avoid indigestible roughage

  • avoid all fiber while s/s diverticulitis, eventually reach high fiber diet as inflammation resolves

• avoid increasing intra-abdominal pressure during acute phase (avoid perforation)

• emergency surgery if peritonitis/pelvic abscess

  • colon resection with/without colostomy

  • NPO with NGT until peristalsis returns (flatulence, BS)

  • advance diet with peristalsis return

peritonitis vs appendicitis vs diverticulitis

peritonitis

• severe abd pain and distention

• diminished BS

• abd. pain lessens with movement

• N/V/A

• fever

• rigid abd

appendicitis

• N/V/A

• severe abd. pain and distention

diverticulitis

• severe abd pain and distention

• fever

intestinal obstruction causes what 2 things

hypovolemia & acute kidney injury

sm. bowel vs lg. bowel obstruction

small bowel

• rapid pain onset

• colicky & crampy pain

• frequent, copious vomiting

• upper abd. distention

• high pitched bowel sounds (borborgymi)

• bowel movements present for a short time

• sever F&E imbalance

• met alkalosis

large bowel

• gradual pain onset

• mild → moderate, crampy pain

• vomiting rare

• lower abd. distention

• absent bowel sounds

• obstipation (severe or complete constipation, no bowel movement)

• no F&E imbalance

• met acidosis

CT/MRI shows gas above obstruction

visible peristalsis, cramping, tenderness

ask: passing stool or gas? partial obstruction → diarrhea

mechanical vs nonmechanical bowel obstruction

mechanical bowel obstruction

• mild, intermittent, colicky pain

• lower abd distention & obstipation

• ribbonlike stool if obstruction is partial

nonmechanical bowel obstruction

• constant, diffuse discomfort, no colicky pain

• abd distention

• dec bowel sounds early, absent bowel sounds later

• vomiting—rarely profuse and rarely foul odor

bowel obstruction nonsurg mgmt

NGT

• assess Q4h (placement, patency, output)

• low cont. suction

• semi fowler’s

• frequent oral/nares care

monitor BP & pulse

assess abd BID

• bowel sounds (dc suction when listening)

• distention

• flatus

opiates temporarily withheld

IV fluids 2-4L isotonic with potassium

• monitor for FVE in older adults

• monitor hypokalemia if vomiting a lot

lower bowel obstruction—disimpaction or enema

postop ileus: alvimopan PO (inc GI motility)

older adult

• inc fruits & veg for fiber

• high use of laxatives lead to atonic colon (dec abd. muscle)

• exercise daily

bowel obstruction surg

exp lap first, open lap if needed

postop care:

• NGT until peristalsis return

• CLD → ADAT

• IS, TCDB

• suture/staple mgmt—abd binder

CRC screening

@ 40yo

• discuss screening need with HCP

• if family hx: begin early & more frequently

>45yo

• fecal occult blood test Q1yr (2-3 separate stool samples x3days)

• sigmoidoscopy or CT colonography Q5yr

• colonoscopy Q10yr

avoid:

• smoking, alcohol, physical inactivity

• fatty, refined carb, low fiber diet

CRC s/s

rectal bleeding, anemia, change in stool consistency or shape

occult/mahogany/bright red stool

hematochezia (BRB in stool)

gas pains, cramping, incomplete evacuation

avoid 48hr prior to giving a stool specimen

• ASA, Vit C, iron, corticosteroids, red meat

inc CEA (carcinoembryonic antigen)

CRC cx

metastasis, obstruction, perforation, abscess, fistula, peritonitis

CRC nonsurg mgmt

chemo: stage 2-3 post sx

radiation: control pain, hemorrhage, bowel obstruction

• standard of care for rectal cancer

monoclonal antibody: cetuximab (inc T killer cell)

• used if metastasis

CRC postop

NGT to gastric decompress

pain mgmt: IV PCA

DVT prophylaxis

place pouch ASAP

stoma assessment—report if:

• stoma ischemia/necrosis

• continuous heavy bleeding

• mucocutaneous separation

colostomy starts functioning in 2-3days

empty pouch when 1/3~1/2 full

CRC pouch system

flat firm abdomen: flexible or nonflexible

firm abdomen with lateral crease/fold: flexible

deep creases, flabby abd., retracted stoma, stoma flush or concave to abd surfce → convex appliance with stoma belt

CRC perineal wound care

drains—serosanguinous for 1-2mo postop

comfort measures

• sitz bath 10-20min 3-4x/day

• allowed: side lying, foam pad/soft pillow to sit on

• avoid: sitting for long time, air ring/rubber donut

cx: F-E balance, infection

CRC postop care

stool softeners

• colon resection—s/s of obstruction or perforation

  • cramping, abd pain, N/V

• avoid gas-producing food and carb. bev

• 4-6wk to establish bowel patterns

ostomy skin care

• skin sealant, dry before pouch application

• stoma powder/paste if raw/skin stripping

• filler cream to fill crevice & crease

• fungal rash → antifungal cream/powder

hypokalemia s/s

flat T waves, ST depression, prominent U wave

dec DTR, muscle cramping, flaccid paralysis

de motility, hypoactive to absent bowel sounds

constipation

abd distention

hypomagnesemia s/s

ST depression, T wave inversion (vfib if severe)

tachycardia

inc DTR

nystagmus (abnormal eye movement)

diarreha