Ch. 47

Lower Gastrointestinal Problems

Irritable Bowel Syndrome (IBS) Definition

Chronic abdominal pain and altered bowel patterns (diarrhea, constipation, or mixed) without known organic cause

IBS Diagnostic Rome Criteria

Abdominal pain/discomfort at least 1 day/week for 3 months associated with 2+ defecation/stool changes

Common IBS Dietary Intolerances

Gluten and FODMAPs (fermentable oligo-, di-, monosaccharides, and polyols)

IBS Interprofessional Care

Low FODMAP diet, symptom diary, exercise, CBT, antispasmodics, and antidepressants

Appendicitis Definition

Inflammation of the appendix; most common emergent abdominal surgery

Appendicitis Etiology & Pathophysiology

Luminal obstruction leads to distention, venous engorgement, bacterial accumulation, gangrene, and perforation

Peak Age for Appendicitis

10 to 30 years

Appendicitis Initial Pain Location

Dull periumbilical pain accompanied by anorexia, nausea, and vomiting

Appendicitis Classic Localized Pain Site

Persistent right lower quadrant (RLQ) pain at McBurney's point

Physical Signs of Appendicitis

Fever, rigidity, rebound tenderness, muscle guarding, and positive psoas/obturator/Rovsing signs

Preferred Imaging for Appendicitis

Abdominal CT scan

Preoperative Nursing Rule for Appendicitis

Keep NPO, give IV fluids/analgesia; NO heat on abdomen and NO enemas/laxatives to prevent rupture

Postoperative Appendicitis Care

Early ambulation, advance diet as tolerated, IV antibiotics if appendix ruptured

Primary Peritonitis Cause

Blood-borne organisms entering the peritoneal cavity

Secondary Peritonitis Cause

Perforation of abdominal organs spilling contents into peritoneal cavity (e.g. ruptured appendix, perforated ulcer)

Universal Sign of Peritonitis

Tenderness over the involved area

Signs of Peritoneal Irritation

Rebound tenderness, abdominal rigidity (board-like abdomen), and muscle spasm

Major Complications of Peritonitis

Hypovolemic shock, sepsis, intraabdominal abscess, paralytic ileus, and ARDS

Patient Positioning for Peritonitis

Lie with knees flexed to decrease abdominal wall tension and pain

Inflammatory Bowel Disease (IBD) Definition

Chronic autoimmune GI inflammation characterized by periods of remission and exacerbation

IBD Age Bimodal Peak

Begins in teens or early adulthood, with a second peak in the 60s

Dietary Risk Factors for IBD

High intake of refined sugar, total fat, polyunsaturated fatty acids (PUFA), and omega-6 fatty acids

Protective Dietary Factors for IBD

High intake of raw fruits, vegetables, omega-3 rich foods, and dietary fiber

Medication Risk Factors for IBD

NSAIDs, antibiotics, and oral contraceptives

Crohn's Disease Anatomical Location

Occurs anywhere from mouth to anus; most common in distal ileum and proximal colon

Crohn's Disease Inflammatory Pattern

Skip lesions (normal tissue between areas of inflammation) affecting all bowel wall layers (transmural)

Crohn's Disease Mucosal Appearance

Cobblestone appearance from deep ulcerations

Distinct Complications of Crohn's Disease

Strictures (causing obstruction), deep fistulas, and intraabdominal abscesses

Primary Symptoms of Crohn's Disease

Diarrhea, cramping abdominal pain, and weight loss from malabsorption

Ulcerative Colitis (UC) Anatomical Location

Involves colon and rectum; starts in rectum and spreads continuously toward cecum

Ulcerative Colitis Wall Layer Affected

Mucosal layer (innermost layer only)

Classic Mucosal Finding in UC

Pseudopolyps (tongue-like mucosal projections into bowel)

Severe UC Clinical Stool Picture

10 to 20 bloody diarrhea stools per day with mucus, fever, rapid weight loss, and anemia

Distinct Complication of Severe UC

Toxic megacolon (extreme colonic dilation at high risk for perforation)

Curative Surgery for Ulcerative Colitis

Total proctocolectomy (with permanent ileostomy or IPAA ileal pouch)

Systemic Complications of IBD

Ankylosing spondylitis, multiple sclerosis, liver disease, malabsorption, and osteoporosis

Osteoporosis Screening Requirement in IBD

Baseline bone density scan (DEXA) and repeat every 2 years

JAK Inhibitor Testing Requirement (Rinvoq / Skyrizi)

Must test for Tuberculosis (TB) prior to starting treatment

Folic Acid Requirement in IBD

Daily folic acid supplements required when taking sulfasalazine or methotrexate

Calcium & Potassium Needs in IBD

Required during corticosteroid therapy to prevent osteoporosis and electrolyte deficits

Enteral Nutrition During Acute IBD Exacerbations

Liquid enteral feedings (lactose-free, easily absorbed) help achieve remission and rest bowel

Strictureplasty Purpose in Crohn's

Opens narrowed areas while keeping intestine intact, reducing risk for Short Bowel Syndrome

Mechanical Bowel Obstruction Definition

Physical occlusion of the intestinal lumen

Most Common Cause of Small Bowel Obstruction (SBO)

Surgical adhesions

Most Common Causes of Large Bowel Obstruction (LBO)

Colorectal cancer (CRC) and diverticular disease

Nonmechanical Bowel Obstruction Definition

Reduced or absent peristalsis from neuromuscular impairment

Most Common Nonmechanical Obstruction

Paralytic ileus (caused by abdominal surgery, peritonitis, or hypokalemia)

Strangulated Bowel Obstruction

Obstruction with compromised blood supply; emergency surgery required to prevent gangrene

Stoma Definition

Outer visible part of a surgically created abdominal opening for fecal elimination

Ileostomy Output Characteristics

Liquid to thin paste output; involuntary continuous drainage needing a pouch

Sigmoid Colostomy Output Characteristics

Formed, normal-looking stool; patient may regulate emptying time

Initial Post-Op Ileostomy Output Volume

1500 to 1800 mL/day initially; decreases to ~500 mL/day as intestine adapts

Normal Healthy Stoma Appearance

Pink to bright red, mild swelling, and small amount of oozing/bleeding

Critical Stoma Alert (Ischemia/Necrosis)

Dark purple, blue, or black stoma indicates compromised blood supply (report immediately)

Optimal Stoma Placement Criteria

Within rectus muscle, flat skin surface, visible to patient, discreet under clothing

Rule for Pouch Emptying

Empty stoma pouch when it is 1/3 full to prevent weight pulling seal off skin

Ileostomy Daily Fluid Intake Requirement

At least 2 to 3 Liters of fluid per day to prevent dehydration and electrolyte imbalance

Food Precaution for Ileostomy Patients

Chew food extremely well to avoid lumen obstruction from fibrous foods

Loop Colostomy Feature

Bowel loop brought to abdominal surface held by plastic bridge for 7 to 10 days

Double-Barrel Stoma Ends

Proximal stoma for fecal diversion; distal stoma functions as a mucus fistula

Continent Ileostomy (Kock / Barnett Pouch)

Internal ileal reservoir with nipple valve manually drained using a catheter

Diverticulula Definition

Saccular outpouchings or dilations of the colon mucosa

Most Common Anatomical Site for Diverticula

Left colon (descending and sigmoid colon)

Diverticulosis Definition

Presence of multiple noninflamed diverticula; usually asymptomatic

Diverticulitis Definition

Inflammation of one or more diverticula

Classic Pain Location for Diverticulitis

Acute pain in the left lower quadrant (LLQ)

Older Adult Presentation in Diverticulitis

May be afebrile with normal WBC count and minimal abdominal tenderness

Preferred Diagnostic Test for Diverticulitis

CT scan of abdomen with oral contrast

Acute Diverticulitis Hospital Care

NPO status, IV fluids, IV antibiotics, bed rest, and bowel rest

Long-Term Dietary Teaching for Diverticulosis

High-fiber diet and fluid intake of at least 2 Liters per day