Intestinal/Rectal

How many people in the US have GI disease?

60–70 million.

Contributing factors to lower GI disease

High stress, irregular eating, too little fiber and water, no daily exercise. The mind and emotions strongly affect GI disease.

Four abnormalities of fecal elimination

Constipation, diarrhea, fecal incontinence, IBS.

Definition of constipation

Fewer than 3 BMs per week, OR BMs that are hard, dry, small, or difficult to pass.

Is constipation a disease?

No, it’s a symptom. It can point to an underlying disease.

Who gets constipation most commonly?

Women, pregnant people, post-surgical patients, older adults (65+), non-Caucasians, and people of lower socioeconomic status.

What is perceived constipation?

When someone’s bowel pattern doesn’t match what they consider normal. Chronic abuse of enemas, laxatives, or suppositories defines it.

Causes of constipation

Meds; weakness, immobility, or fatigue; inability to increase intra-abdominal pressure; lack of time or ignoring the urge; low fiber and fluids; no exercise; stress.

Meds that cause constipation

Opioids, anticholinergics, antidepressants, anticonvulsants, antispasmodics, CCBs, diuretics, aluminum or calcium antacids, iron.

Why does immobility cause constipation?

Movement gets the gut moving. Lying around all day leads to constipation.

What happens when the urge to defecate is ignored?

The muscles become insensitive to the stool and need a stronger stimulus. This can cause colon spasm and colicky abdominal pain.

Four types of constipation

Functional (most common; treat with fiber and fluids), slow-transit (inherited, e.g., Hirschsprung’s), defecatory disorders (pelvic floor), and opioid-induced.

Clinical manifestations of constipation

Fewer than 3 BMs/week, distention, pain, bloating, feeling of incomplete evacuation, straining, and small, lumpy, hard, dry stools.

Complications of constipation

Arterial pressure fluctuations, fecal impaction, hemorrhoids, fissures, rectal prolapse, megacolon.

How does straining cause arterial pressure fluctuations?

The Valsalva maneuver blocks venous return and lowers cardiac output, causing a brief BP drop that can lead to dizziness or syncope.

What is megacolon?

A dilated, atonic colon from a fecal mass blocking the colon. It can lead to perforation.

Best time to try to defecate

After a meal or a warm drink.

Recommended daily fiber

25–30 g/day.

Medical management of constipation

Education, trying after meals or warm drinks, exercise to strengthen abdominal muscles, bowel habit training, more fiber and fluids, laxatives only if needed.

Why use laxatives only when needed?

With regular use, the body forgets how to go on its own.

Laxative types and examples

Bulk-forming (Metamucil), saline (milk of magnesia), osmotic (polyethylene glycol), lubricant (mineral oil), stimulant (bisacodyl), softener (docusate).

Constipation nursing interview topics

Onset and duration, current and past patterns, what they expect as normal, lifestyle, PMH and surgical history, meds, bowel habits.

Nursing goal for constipation

Restore and maintain a regular pattern: respond to the urge, enough fluid and fiber, learn prevention, relieve anxiety, avoid complications.

Definition of diarrhea

More than 3 BMs per day with more liquid consistency.

Symptoms often associated with diarrhea

Urgency, perianal discomfort, incontinence, nausea.

Acute vs. persistent vs. chronic diarrhea

Acute: self-limiting, 1–2 days. Persistent: 2–4 weeks. Chronic: more than 4 weeks, may come back sporadically.

Causes of diarrhea

Anything that increases intestinal secretions, decreases mucosal absorption, or alters motility: viral infections, meds, malabsorptive disorders, anal sphincter defect.

Most common bacteria in antibiotic-associated diarrhea

C. difficile. Consider it in anyone with unexplained diarrhea who is on or recently took antibiotics.

Non-inflammatory vs. inflammatory diarrhea

Non-inflammatory: toxins disrupt fluid transport, causing large volumes of watery stool. Inflammatory: the pathogen invades the mucosa, causing smaller volumes of bloody stool (e.g., dysentery).

Secretory vs. osmotic diarrhea

Secretory: high volume, from bacterial toxins or chemo. Osmotic: unabsorbed particles pull water in (lactase deficiency, pancreatic dysfunction).

Clinical manifestations of diarrhea

More frequent, more fluid stools; cramps; distention; borborygmus; anorexia; thirst.

What is borborygmus?

The rumbling noise of gas moving through the intestines.

Voluminous greasy stool suggests?

Intestinal malabsorption.

Blood, mucus, or pus in stool suggests?

Inflammatory enteritis or colitis.

Oil droplets in stool suggest?

Pancreatic insufficiency.

Nocturnal diarrhea may be a sign of?

Diabetic neuropathy.

Diagnostics for diarrhea

CBC, BMP, UA, stool samples. Endoscopy or barium enema can help find the cause.

Complications of diarrhea

Dehydration, electrolyte loss (especially K+), skin problems.

Why is low K+ from diarrhea dangerous?

It can cause dysrhythmias, and it increases digoxin’s effects.

Signs of low potassium

Muscle weakness, dysrhythmias, decreased motility.

Why are older adults at higher risk with diarrhea?

They dehydrate fast and develop low K+. They also get skin breakdown more easily (less turgor, less SQ fat).

Skin care for diarrhea

Always use barrier cream and treat excoriation.

Antidiarrheal drug name to know

Loperamide (Imodium).

Medical management of diarrhea

Infection control, loperamide, probiotics, and antibiotics or anti-inflammatories as needed. Treat the cause.

Diarrhea nursing interview

Health history, PMH and surgical history, diet, and recent illness or travel to another area.

Diarrhea nursing interventions

More fluids and low-bulk foods until symptoms subside; avoid caffeine, alcohol, dairy, and fatty foods; give loperamide as prescribed; IV fluids for rapid rehydration; monitor electrolytes closely.

Foods to avoid with diarrhea

Caffeine, alcohol, dairy, fatty foods.

Risk of taking too much loperamide

Constipation.

Definition of fecal incontinence

Recurrent involuntary passage of stool for at least 3 months.

Range of presentation

Minor soiling, occasional urgency and loss of control, or complete incontinence.

Causes of fecal incontinence

Anal sphincter weakness, pelvic floor disorders, neuropathies (diabetes), inflammation (radiation, IBD), CNS disorders (dementia, stroke, SCI, MS), and diarrhea or impaction with overflow.

Diagnostics for fecal incontinence

History to find the cause, rectal or endoscopic exam, pelvic MRI.

Medical management of fecal incontinence

Correct the cause. Options: psyllium, loperamide 30 min before meals, biofeedback with pelvic floor training, bowel training, sacral nerve stimulation.

Nursing management of fecal incontinence

Health history, bowel training program, perianal skin care (briefs short term only, cleansers, protectants), fecal incontinence device short term.

How long can a fecal incontinence device stay in?

Short term only, for liquid stools (no more than 4 weeks in a row). It isn’t sent home with the patient.

What is IBS?

Recurrent abdominal pain with disordered BMs: diarrhea, constipation, or both.

Who gets IBS most?

Women under 45.

IBS triggers

Chronic stress, sleep deprivation, surgery or infection, diverticulitis, genetics, foods.

Trigger foods for IBS

Milk, yeast products, eggs, wheat, red meat.

Pathophysiology of IBS

A functional disorder of intestinal motility.

How is IBS diagnosed?

After tests rule out structural or other disorders: stool diary, CBC, CRP, stool studies, colonoscopy.

IBS pain pattern

Pain, bloating, and distention, often brought on by eating and relieved by defecating.

Disorders that often occur with IBS

GERD, chronic fatigue syndrome, fibromyalgia, chronic pelvic pain, interstitial cystitis, migraines, anxiety, depression.

Goals of IBS management

Relieve pain and control the diarrhea or constipation.

IBS lifestyle changes

Stress reduction, enough sleep, exercise, soluble fiber or restricting trigger foods and reintroducing them slowly.

IBS medications

Antidiarrheals (loperamide for IBS with diarrhea), antispasmodics, antidepressants.

Alternative IBS therapies

Probiotics, peppermint oil, CBT.

IBS patient education

Stool diary, lifestyle and diet changes, self-care, stop alcohol and smoking.

Why a stool diary in IBS?

It helps determine the patient’s IBS category.

What is celiac disease?

A malabsorption disorder caused by an autoimmune response to gluten.

Grains with gluten

Wheat, barley, rye, and other grains.

Pathophysiology of celiac disease

Gluten triggers an autoimmune response. Small intestine cells become inflamed and the villi are stripped away (denuded), so nutrients can’t be absorbed.

Who gets celiac disease more?

Women (2x as often as men), Caucasians, and 1st-degree relatives. It can start at any age.

GI signs of celiac disease

Diarrhea or steatorrhea, abdominal pain, distention, flatulence, weight loss, dermatitis. More common in children.

What is steatorrhea?

Oily, fatty stool.

Non-GI symptoms in adults

Fatigue, malaise, depression, hypothyroidism, migraines, osteopenia, anemia, seizures, tingling in hands and feet, red shiny tongue, dermatitis herpetiformis.

Diagnostic tests for celiac

IgA anti-tissue transglutaminase (tTG) blood test, plus upper endoscopy with biopsy of the proximal small intestine.

Is celiac curable?

No. It’s chronic and lifelong. Treatment is avoiding gluten.

How long do the villi take to heal on a gluten-free diet?

About a full year.

Medical management of celiac

Dietitian consult to identify foods to avoid, plus treatment of specific problems (e.g., anemia).

Celiac nursing education

Gluten-free diet, avoid cross-contaminated foods, ask restaurants how food is prepared, read labels, avoid OTC products with gluten (e.g., toothpaste).

What is an acute abdomen?

A “surgical abdomen”: sudden abdominal pain without trauma, usually needing quick surgery to prevent peritonitis, sepsis, and septic shock.

Lower GI causes of acute abdomen

Appendicitis, severe diverticulitis, intestinal obstruction. All can lead to peritonitis.

What is peritonitis?

Acute inflammation of the peritoneum. It’s a life-threatening emergency.

What is the peritoneum?

The serous membrane lining the abdominal cavity and covering the organs.

Internal vs. external causes of peritonitis

Internal: bacterial infection from GI disease (organ rupture). External: abdominal surgery or trauma (gunshot, stab), or CAPD (peritoneal dialysis).

Most common type of peritonitis

Secondary: an organ perforates and spills (appendix, peptic ulcer, diverticulitis).

Primary vs. tertiary peritonitis

Primary: spontaneous bacterial infection of ascites fluid, usually in liver failure or cirrhosis. Tertiary: a superinfection in an immunocompromised patient (e.g., TB with AIDS).

Pathophysiology of secondary peritonitis

Organ contents leak, bacteria multiply, tissues swell, and the peritoneal fluid turns turbid. GI hypermotility comes first, then paralytic ileus.

Peritonitis pain pattern

Diffuse at first, then constant, sharp, and localized over the affected site.

⭐ What does a rigid, board-like abdomen indicate?

Intra-abdominal bleeding or fluid leaking into the abdomen. It’s an emergency, so see this patient first.

How do peritonitis patients position themselves?

They guard movement, keep knees flexed, lie still, and breathe shallowly.

Why is the abdomen distended and tender in peritonitis?

Infected fluid and gas build up.

What is rebound tenderness?

Severe pain when deep pressure is applied and then released.

Vital sign changes in peritonitis

Fever and rising pulse, with BP dropping over time (shock or sepsis).

GI symptoms of peritonitis

Anorexia, nausea, vomiting.

Peritonitis lab findings

High WBCs and neutrophils (bands), Hgb/Hct low if blood is lost, abnormal K+, Na+, Cl-. Blood cultures may grow E. coli.

Peritonitis imaging

Abdominal x-ray (air and fluid levels, distended loops; free air means perforation), ultrasound (abscesses, fluid), CT or MRI (abscess).

Invasive exams for peritonitis

Peritoneal aspiration with C&S (identifies the organism) and peritoneal lavage.

Peritonitis medical/nursing management

IV fluids, colloids, and electrolytes; analgesics, antiemetics, and early antibiotics; O2; NPO with NG tube; surgery (excision, resection, repair, drainage).