GI Disorders

GI Disorders Overview

• Focus on peritonitis, bowel obstructions, ostomy, pancreatitis, and biliary tract diseases.

Learning Objectives

• Describe the interprofessional and nursing management of peritonitis.

• Distinguish among small and large bowel obstructions, including causes, clinical manifestations, and interprofessional and nursing management

• Select nursing interventions to manage the care of the patient after bowel resection and ostomy surgery.

Key Terms

• Acute Pancreatitis, Bowel Obstruction, Cholecystitis, Cholelithiasis, Chronic Pancreatitis, ERCP, Fistula, Jaundice, Ostomy, Paralytic Ileus, Peritonitis.

Peritonitis

Etiology and Pathophysiology

• Inflammation of the peritoneum due to bacteria/infection or chemicals.

• Causes:

  • Primary: Blood-borne organisms (virus, bacteria).

    • Ex. Acites from cirrhosis

  • Secondary: Organ perforation (Leakage into the peritoneum from organs).

    • Ex. Ruptured appendix, stab wound, peritoneal dialysis (Catheter care), ulcer perforation.

• Initial chemical irritation can progress to bacterial peritonitis → fluid shifts and adhesions.

Clinical Manifestations Peritonitis

• Severe, continuous RUQ abdominal pain—most common symptom.

• Rebound tenderness, rigidity, guarding, and spasm - common.

• Other symptoms: Shallow breathing, fever, tachycardia, shallow breathing, nausea, vomiting, altered bowel habits.

• Potential complications: Hypovolemic shock, sepsis, intra-abdominal abscess (pus), paralytic ileus (temporary blockage of food and gas in the digestive tract), ARDS (fluid in air sacs).

Diagnostic Studies

• Involves history & physical examination (H & P), CBC, CMP, imaging tests (US, x-ray), and peritoneoscopy.

  • Peritoneal dialysis? Is it done appropriately and sterile? At home or clinic? (H&P)

Interprofessional Care

• Perforation requires immediate surgical intervention.

• Preoperative: NPO, NG suction (intermittent), IV fluids, antibiotics, analgesics, antiemetics.

  • Often used as early intervention methods.

• Postoperative: Similar to preoperative care with additional monitoring and parenteral nutrition.

Nursing Management

• Vital sign monitoring (I&Os, O₂)

• IV access (18 G or sometimes a 20 G for blood)

• Pain management

• NPO; NG tube to low & intermittent suction

• Monitor fluid and electrolyte balance.

• Assess for worsening symptoms (sepsis, peritonitis spread).

• Emotional support.

Intestinal Obstruction

Types and Causes

• Small Bowel Obstruction (SBO):

  • Mechanical (physical obstruction blocking movement): Surgical adhesions aka scar tissue (most common), hernias, Crohn’s disease (strictures), cancer, intussusception (blockage from intestine telescoping into another) .

  • Nonmechanical (reduced or absent peristalsis): Paralytic ileus (most common), vascular emboli.

• Large Bowel Obstruction (LBO):

  • Mechanical: Colorectal cancer/CRC and diverticular disease (most common), volvulus (intestine folds onto itself), adhesions, ischemia, Crohn’s disease.

  • Nonmechanical: Pseudo-obstruction (impaired peristalsis w/out obstruction), paralytic ileus, vascular emboli.

• Most mechanical obstructions occur in the small intestine.

• Pathophysiology for SBO and LBO: Fluid, gas, and intestinal contents back up proximally (right before site) of the obstruction.

  • Results in proximal bowel distension → reduces fluid absorption and stimulates intestinal secretion → Distal bowel empties and collapses (determines partial/full)→ Pressure in bowel lumen → increased capillary permeability (fluid moving out) → fluid leaks into the peritoneal cavity (peritonitis risk) → decreased circulating BV → hypotension and hypovolemic shock→ Bowel becomes edematous and ischemic (lactic acid increased from deoxygenating) → Gangrene and necrosis → Perforation of the bowel wall → peritonitis and severe systemic infection.

    

Nonmechanical Obstruction Subtypes

• Paralytic ileus (most common): Lack of intestinal peristalsis and bowel sounds.

  • Causes: Abdominal surgery (bowel and bladder last two things to wake up after surgery); peritonitis; inflammatory disorders; electrolyte imbalances (potassium/hypokalemia); thoracic or lumbar spinal fractures (those nerves go into GI system).

• Pseudo-obstruction (rare): Impaired peristalsis with no actual obstruction and mainly affects large intestine only.

  • Causes: Neurologic conditions, drugs, endocrine and metabolic
    problems, lung disease, trauma, burns.

• Vascular obstruction: emboli or thrombi alter blood supply to a part of the
  intestines.

Clinical Manifestations

• Hallmark Symptoms:

  • 1. Abdominal pain

  • 2. N/V (may be projectile)

  • 3. Distention

  • 4. Constipation (nothing there)

• ** Bowel sounds may be high pitched (above obstruction), absent (paralytic ileus), or hypoactive (LBO).

Interprofessional and Nursing Management (least invasive → most invasive, unless emergency)

• Conservative Management (Preferred):

  • NG Tube for Decompression (hallmark treatment)

    • Monitor I&Os (30mL/hr normal) / electrolytes / acid-base

    • Reduces bowel distention and risk of edema, necrosis, and perforation.

    • Measurement: Nares → earlobe → xiphoid process

  • IV Fluids & Electrolyte Replenishment.

  • NPO Status.

• Paralytic ileus and adhesion-related obstructions often resolve without surgical intervention.

• Acid-Base Imbalance:
  ◦ Metabolic alkalosis – high obstruction (from vomiting a lot)
  ◦ Metabolic acidosis – low obstruction

• Surgical Management:

  • Strangulation/Perforation → Emergency Surgery.

  • Colonoscopy for tumor removal or stricture dilation.

  • Partial or total colostomy or ileostomy for obstruction, necrosis, or perforation.

  • Resection of obstructed segment with anastomosis.

Bowel Resection and Ostomy Surgery

Indications

• Remove cancer, obstruction/fistula/perforation/traumatic injury repair, and treat an abscess, hemorrhage, or inflammatory diseases.

  • Common Etiologies: Colorectal cancer (CRC), IBD, necrotic bowel, perforated ulcer, diverticulitis, trauma.

Ostomy Types

• Traditional Ostomy

  • End Stoma: Distal bowel removed and permanent stoma.

  • Loop Stoma: (Usually temporary) anterior wall opened for fecal
    diversion and distal opening to drain mucus; plastic rod in place 7 to 10 days

  • Double-barrel Stoma (usually temporary, trying to put back together): Bowel divided and two stomas created; proximal for fecal diversion and distal for mucus drainage.

• Continent Ileostomy

  • Kock Pouch

  • Barnett Continent Ileal Reservoir

• Temporary or permanent.

• Stoma should appear red, moist, and painless.

• The more distal the ostomy, the more likely contents will
  resemble normal feces (because the stool has more time to pass through).

  

Preoperative Care

• Stoma site selection and considerations

  • Within rectus muscle (decreased risk of hernia)

  • Flat surface (no creases, seal less likely to leak)

  • Patient is able to see it but it’s under clothing

Nursing Interventions Post-Surgery

• Monitor for Postoperative Complications:

  • Delayed wound healing, infection, hemorrhage, fistulas.

    • Record bleeding

    • Unusual/foul odor

    • Edema, redness, high WBCs, drainage

  • Electrolyte imbalances and dehydration.

  • Abnormal output → notify HCP

• Ostomy Assessment:

  • Normal: Pink-red, moist, mild swelling.

  • Abnormal: Pale, dark, excessive bleeding, “dusky” (blueish).

  • Assess every 4 hours.

• Ostomy Care:

  • Empty pouch when 1/3 full.

  • Prevent gas buildup with diet modifications.

• Ostomy Education:

  • Demonstrate and observe patient/caregiver practice the following:

    • Remove old skin barrier, clean skin, correctly apply new skin barrier

    • Apply, empty, clean, remove pouch.

    • Empty pouch when 1/3 full.

  • Males: 3-12 months erectile dysfunction

  • Females: Vaginal dryness and decreased sensations

  • “Burp bag” due to grassiness.

  • May experience rectal bowel movement up to 3 days after surgery if emergency surgery was performed

• Dietary Management:

  • Small, frequent meals, adequate fluid intake.

    

• Psychosocial Support:

  • Address body image concerns, depression, coping strategies.

  • Normal ADLs within 6-8 weeks and avoid heavy lifting.

• Colostomy Function:

  • Output after peristalsis returns or up to 2 days after resuming diet

  • Excess gas common for 2 weeks

• Ileostomy Function:

  • First 24-48 hours minimal drainage (liquid-semiliquid)

  • Peristalsis returns → 1500-1800 mL/day

  • Water absorption increases and feces thickens while volume decreases

  • Chew thoroughly any nuts, raisins, popcorn, coconut, mushroom, olive, stringy veggies, foods with skins, dried fruits, and meats with casings (otherwise lead to an obstruction).

• Anal Canal:

  • Kegel exercise recommended after 4 weeks

  • Incontinence of mucus

  • Phantom rectal pain

Acute Pancreatitis

Pathophysiology and Etiology

• **Autodigestion of pancreas due to premature pancreatic enzyme activation and injury to pancreatic cells (severe pain) by digesting normal organ tissue.

  • Anatomy: Pancreas sits behind stomach. *******Meal ingested → cephalic (produce liver enzymes and → Gastric (food niters stomach) → ******** 1:32:18

    • Mild:

      • Edematous or interstitial

    • Severe:

      • Necrosis, organ failure, sepsis

      • 50% have long-lasting endocrine and exocrine dysfunction

      • Overall fatality rate 9%

• Causes:

  • Gallstones / gallbladder disease (most common in women), chronic alcohol use (most common in men) 10-11 drinks per day for 10 years.

  • Hypertriglyceridemia (>1000 mg/dL): high triglycerides → kilo microns (?) → affects permeability

  • Less common: Drug reactions or pancreatic cancer.

Clinical Manifestations

• Sudden onset

• Severe, LUQ or mid-epigastric pain, radiating to the back.

• Nausea/Vomiting (remains unrelieved) & Abdominal Guarding.

• Jaundice, Abdominal Distension.

• **Cullen’s Sign (periumbilical ecchymosis/bruising around the navel) & Grey Turner’s Sign (flank ecchymosis/bruising on the flanks) = sign of bleeding/hemorrhage.

• Vital Signs:

  • **Respiratory System: Cyanosis and crackles because

Complications

• Pancreatic pseudocyst: Fluid, pancreatic enzymes, debris, and exudates surrounded by wall.

• abscess, lung complications, electrolyte imbalances, diabetes, cellular malnutrition.

• Potential Systemic Complications:

  • Pleural effusion, atelectasis, pneumonia, ARDS, hypotension or shock,

Diagnostic Studies/Labs

• Elevated serum amylase and lipase, contrast CT imaging (look at vasculature, see if hemorrhage), and ultrasounds.

• MRCP: Moves stones

• Amylase and lipase → first line.

  • Amylase:

    • Produced by skeletal muscles, ovaries, etc

    • Pseudo cyst or abscess = elevated

  • Lipase:

    • Primary diagnostic marker

Interprofessional Care

• Aggressive hydration (LR to convert lactate into bicarb or NS), usually start 250 mL/hr.

• Metabolic: Give oxygen if less than 95% (curve is moving to the right) and monitor blood glucose levels.

• Pain management (morphine unless pancreatitis caused by gallstone)

• Minimizing pancreatic stimulation,

• Check lipase labs to see if the care is working.

Acute Pancreatitis Recovery

• Nutrition therapy *** 1:57:50

Biliary Tract Disease 2:00:34

Overview

• Cholecystitis and cholelithiasis are primary disorders with varying severity and treatment options including laparoscopic and open surgery.

Clinical Manifestations

• Biliary colic pain, nausea, vomiting, jaundice, changes in bowel habits.

Interprofessional Care

• Emphasis on infection management, fluid balance, and post-surgical recovery.