GI part III

Clostridioides difficile (C. diff) infection

Spore producing bacteria that can cause host of GI symptoms and even lead to life-threatening complications. Common infection in and out of health care facilities. Associated with development of Psdeudomembranous colitis (PMC colitis).

Most common etiology of C Diff

Antibiotic use

Potential complications of C Diff

Electrolyte imbalances, Dehydration and volume depletion, Acute Pre-renal kidney failure, Perforated colon, Toxic megacolon

Antibiotics and other medications most often associated with c diff

Clindamycin (MOST common) (a cephalosporin) Other cephalosporins (ceftriaxone, cefazolin, cephalexin) Fluoroquinolones (ciprofloxacin, levofloxacin)Penicillins (piperacillin/tazobactum, meropenem)

risk factors for C diff

PPI use, Staying in a health care facility, Having a serious illness, weakened immunity, Abdominal surgery or GI procedure, Older age, Hx of c. diff infection

Assessment findings C Diff

Diarrhea that can be watery or even bloody (Pus or mucous possible) Abdominal cramps, pain or tenderness, Fever, Nausea, loss of appetite, Dehydration signs, Elevated WBC count, possible signs of renal dysfunction

C diff no diarrhea?

Toxic megacolon / obstruction

C diff Patient Care

Notify the primary care provider and initiate contact precautions, Wash hands with soap and water, DO NOT USE ALCOHOL BASED HAND SANITIZER!, Collect stool samples when ordered. Educate regarding fecal microbial transplant (FMT) if indicated, Possible nasogastric tube (NGT), Perineal care, Observe for signs of systemic infection

Stool sample make sure

Wash hands/glove, Avoid urine and toilet paper contamination, Tongue blade, Deliver promptly

C diff Medications

Metronidazole (Flagyl), Vancomycin

Vancomycin

for C diff, liquid not IV, watch of ototoxicity and nephrotoxic

C diff labs

Acid Base Balance, Serum Sodium, Serum potassium, BUN & Creatinine

Herniation

a protrusion of abdominal contents through an area of weakened muscle in the abdominal cavity. May be congenital or acquired and typically occurs because of weakened abdominal muscles along with increased abdominal pressure. Presents as a swelling or mass that may be palpated, particularly with increased intra-abdominal pressure. May be reducible or irreducible (this is a problem!).

Types of abdominal hernias

inguinal, femoral, ventral or incisional and umbilical

Hernias Patient Care Measures

Weight loss if appropriate, Fiber/fluids in the diet, Avoidance of heavy lifting/straining, Education on reduction, Truss use, Surgical correction (open or laparoscopic repair), Teach signs of strangulation! Signs of bowel obstruction!

When a hernia won’t reduce

NEVER forcibly reduce a hernia!, Teach patient to seek immediate care 20-30 mins

Signs of strangulation and obstruction

abdominal distention, nausea, vomiting, pain, fever, and tachycardia. Soft OK, Hard NOT good

Hernias Post-operative care/patient education

Wound care, report signs of infection, Fiber/fluid in the diet, stool softener if needed, Ambulate, no heavy lifting/avoid straining, Pain management

Hernias Post-operative care Cough and deep breathe?

with cation, splint when couching

For inguinal hernia repair, post op care as above, plus

May need scrotal support, ice bags to scrotum, May have difficulty urinating immediately post op, Techniques to help pt void, May require straight cath

Post Op Hernia Urinary Retention

4 hrs post op or significant discomfort Bladder scan

Inflammatory Bowel Diseases

Ulcerative Colitis and Crohn’s Disease

Ulcerative Colitis and Crohn’s Disease Common Assessment Features

Persistent diarrhea (blood possible) Abdominal pain or cramps, Fever potential, Weight loss and fluid imbalances, Malnutrition, anemia and delayed growth, Mouth ulcers

Extra-intestinal Manifestations Inflammatory Bowel Diseases

Uveitis, Sclerosing cholangitis , Nepthrolithiasis, Cholelithiasis, Joint disorders, Skin disorders, Oral ulcerations

Uveitis

inflammation of the uvea, the eye's middle layer

Sclerosing cholangitis

chronic liver disease where bile ducts become inflamed

Nepthrolithiasis

kidney stones

Cholelithiasis

gallstones

Ulcerative Colitis Disease Specific Manifestations

Pain often worse in left lower quadrant (LLQ), Severe diarrhea, may have more then 20 stools per day, Blood, mucous (crypt abscess possible) and pus common in the stool, Tenesmus possible, Dehydration

Crohn’s Disease Disease Specific Manifestations

Right lower quadrant (RLQ) pain, Malnutrition and electrolyte disturbance, Diarrhea less severe than with UC, Stool does not usually contain blood

Crypt Abscess

an accumulation of inflammatory cells, such as neutrophils, within the glandular crypts of the gastrointestinal tract

Potential complication of Ulcerative Colitis

Toxic megacolon, Perforated colon, Severe dehydration, Increased blood clot risk, Cancer risk

Potential complication of Crohn’s Disease

Bowel obstruction, Malnutrition, Ulcers, Fistulas, Anal fistulas. Increased blood clot risk, Cancer risk

Fistulas

an abnormal tunnel or connection between two body parts

Fistulas treatment

Surgery, Abx, Wound care, Hydration, Stool softener, Fiber and fluids, Pain mngmt

IBD Diagnostics

Labs and Endoscopy, imaging studies, FOBT

IBD Diagnostics labs

Elevated WBC, C reactive protein, ESR, Decreased Hgb & Hct possible, Electrolyte imbalances, Hypoalbuminemia

Patient Care Measures for Daily Management of IBD Diet considerations

Highly individualized, Avoid any foods that cause discomfort, May help to avoid certain foods/substances (GI stimulants)

foods/substances (GI stimulants) IBS

Milk, Gluten, Chocolate, Citrus juices, Cold or carbonated drinks, Nuts, seeds, popcorn, Alcohol, Caffeine, High fat, Spicy foods, Allergenic foods

Patient Care Measures for Daily Management of IBD

Possibly monthly B12 injections with Crohn’s, Rest and stress reduction, Psychosocial evaluation and support

IBD Medications Disease control 5-amynosalicylates

reduce inflammation,

IBD Medications Disease control Antimicrobials

metronizole flagyl

IBD Medications Disease control Corticosteroids

solumedrol, reduce inflammation, increase BG, increase riks of infection, increase fluid retention

IBD Medications Disease control Immunosuppressants and Immunomodulator

increase risk for infection

IBD Medications Disease control Antidiarrheals

slows gut, if taken too often can increase risk for toxic megacolon

Medications IBS Pain control

Narcotic dependence may be an issue, NSAID’s can make GI symptoms worse

Care of pt IBD With disease exacerbation (inflammation present)

NPO, possible TPN if severe symptoms, Low fiber, low residue, low to no dairy Fluid and e-lyte monitoring and management, Pain management, Daily weight, I & O, Skin care (barrier cream) Surgical considerations

Surgical considerations Ulcerative colitis With disease exacerbation

Removal of all or most of the colon with or without removal of the anus. Ileostomy. Ileoanal reservoir, Koch/Kock Pouch

Surgical considerations Chron’s

Bowel resections and Ostomy potential

Diverticulum

A small, pouch-like protrusion or “herniation” of the GI tract, particularly the colon.

diverticulosis

when a bunch of diverticulum get together in the intestine

Diverticular disease

Unless inflammation is present, there are often no symptoms— are often discovered on routine endoscopic screening exams.

Diverticulitis

When inflammation is present, Inflamed — can bleed or rupture/perforate, leading to abscess, hemorrhage, peritonitis and sepsis!

Why do diverticula develop

pressure, constipation, decrease fluids, low fiber

And why do diverticula become inflamed?

food gets trapped, local flora

Assessment Findings with diverticulitis (inflammation present)

Abdominal tenderness or pain (LLQ), possible bloating and distension, Fever, possible leukocytosis, Possibly nausea and vomiting, anorexia, Alterations in bowel habits (with possible mucous and/or blood), In the older adult, possible mental status change

diverticulitis If perforation manifestations

board like abdomen, rebound tenderness, hemorrhage, tender, sign of obstruction, adb compartment syndrome, no BM, no flatus, distention pain Nasua

diverticulitis Sepsis potential (early warning signs?)

Low LOC, BP and HR

For Patient with diverticulosis (every day, living with the condition, management)

Diet considerations, Fiber and fluids, Avoid foods with seeds, kernels, nuts (evidence non-conclusive), (probiotics less likely to develop) Avoid straining, bending, lifting. Weight reduction if appropriate, Teach about manifestations of infection

For patients with mild diverticulitis (a mild flair up)

Clear liquids, advance as tolerated, Broad spectrum antibiotics, mild analgesics, Instruct to report worsening symptoms (fever, increase in pain, bleeding)

For diverticulitis patients with more severe pain and inflammation (may require hospitalization)

IV hydration, electrolyte monitoring and replacement, Evaluate fluid volume status, Pain management, IV Antibiotics, Bedrest, NPO, possible NGT, No laxatives or Enemas

Diverticulitis Patients may ultimately require

surgical intervention (bowel resection), may be routine, or on an emergent basis if peritonitis, obstruction or abscess is present. Bowel resection w/ possible colostomy, No bowel prep b4 surgery if severe

Barium studies and endoscopy

SHOULD NOT normally be performed when inflammation is present Risk for perforation of diverticula!

Appendicitis

Usually occurs as a result of a fecalith or other foreign body blocking the opening, leading to inflammation and infection. Edema leads to decreased blood flow—gangrene or perforation can occur within 24-36 hours! Can lead to perforation and peritonitis (with sepsis potential)!

Appendicitis Assessment findings/diagnostics

Nausea/vomiting, Elevated temp, Elevated WBCs Pain! (most common cause of RLQ pain). Cramping, periumbilical, Ultimate shift to RLQ, McBurney’s point, Rovsing’s sign

McBurney’s point

pain in lower right abdomen

Rovsing’s sign

presses on the left lower quadrant, causes pain in the right lower

Appendicitis Patient Care

NPO, Hydration with IV fluids, Pain management with caution, Comfort measures(semi flower position, knees flexed, ice pack) , Prepare for surgery (open vs. laparoscopic), NO enemas pre-op, NO heat to the abdomen!

Appendicitis Increased pain with coughing or movement and relief followed by diffuse pain could indicate

perforation and peritonitis! Abrupt change in pain status Elevated HR, Decreased BP

Gallbladder how it works

the liver produces bile which emulsifies fat, gallbladder stores bile, duodenum releases CCK, CCK stimulates the gallbladder to contract

Acalculous Cholecystitis

gallbladder inflammation

Calculous Cholecystitis (Cholelithiasis)

gallbladder stones

Functional Gallbladder Disorder (HIDA scan, ejection fraction <40 %)

low faction gallbladder not squeezing

What’s the big deal with gallbladder disease?

An inflamed gallbladder can become gangrenous or perforate leading to peritonitis (with sepsis potential).

when gallbladder stones are present

the bile duct may become obstructed potentially causing hepatic and pancreatic inflammation. All of this can cause a lot of PAIN!

With bile duct obstruction (choledocholithiasis)

Hepatic inflammation and Pancreatic inflammation

Hepatic inflammation bile duct obstruction

Jaundice, pale stool, dark urine, pruritis. Elevated liver enzymes, bilirubin and PT with INR

Pancreatic inflammation bile duct obstruction

Pain RUQ, epigastric pain, LUQ, N/V. Oily, smelly stools. Elevated pancreatic enzymes (amylase, lipase)

Etiology/risk factors for gallbladder disease

The five “Fs”(fair, fat, female, fertile, over 40) Obesity or rapid weight loss, weight loss surgery, Diet high in saturated fat, Pregnancy (high progesterone) , American Indian, Caucasian

Medications that increase risk for gallbladder disease

estrogen, ocreotide, cholesterol lowering meds e.g.

Acalculous specific risk factors

abdominal surgery, Severe trauma, Long-term IV nutrition (> 1 month) Prolonged fasting, Sickle cell disease, Diabetes mellitus, Endotoxin, AIDS, Salmonella infection, Cytomegalovirus

gallbladder disease Assessment finding

Nausea/vomiting, Indigestion, belching, flatulence. Abdominal fullness,. Possible fever, Signs of duct obstruction (Jaundice, clay-colored stools, dark urine, steatorrhea)

Signs of duct obstruction

Jaundice, clay-colored stools, dark urine, steatorrhea (fat in stool)

gallbladder disease Assessment finding Pain!

(potentially vague/atypical in elderly and diabetics), Right upper quadrant (RUQ), May radiate to back and right shoulder, Worse after high fat or high volume meal, biliary colic, Murphy’s sign

biliary colic

severe pain when cystic duct is obstructed. May be accompanied by tachycardia, pallor, diaphoresis

Murphy’s sign

where a doctor presses on the upper right abdomen; if the patient feels sudden pain and stops breathing in as the inflamed gallbladder touches their hand, the sign is positive

Gallbladder disease Diagnostics Imaging

Ultrasound, HIDA scan, ERCP

HIDA scan

4-6 NPO, narcotics, give CCK

ERCP

esophagus to duct can remove duct but can increase inflamtion

Gallbladder disease Diagnostics labs

Liver enzymes, Pancreatic enzymes, WBC, Bilirubin elevated

Gallbladder disease Patient Care Measures

pain management, nausea, hydration, diet alteration, Possible antibiotics Surgical intervention

Gallbladder disease Patient Care Measures Pain management!

Hydromorphone (Dilaudid) Ketorolac (Toradol)

Gallbladder disease Patient Care Measures Nausea management!

Phenergan, Zofran

Gallbladder disease Diet alterations

For disease control low to no fat, With acute pain episode rest NPO

Laparoscopic cholecystectomy

Post anesthesia care (vital signs, LOC), Treat post op nausea/vomiting, Hydration (Not released home until tolerating liquids PO), Pain management (incision pain, pain from retained CO2), Encourage early ambulation, “Slow diet”, Incision site care (lap sites)

Tube feeding review

NG feeding- short term, Placement, Dobhoff, Assessment (Tolerating AND Aspiration risk) Feeding HOB elevated, check Residuals