Chapter 52 (1)


Inflammatory Disorders

Intestinal Disorders

  • Peritonitis: Acute inflammation and infection of the visceral and parietal peritoneum.

  • Appendicitis: Inflammation of the vermiform appendix.

  • Bowel Disorders: Includes conditions like gastroenteritis and chronic diseases such as Crohn’s Disease and Ulcerative Colitis.

Peritonitis

Definition

  • Peritonitis is characterized as an acute inflammation or infection of the peritoneum, the membrane lining the abdominal wall and covering the abdominal organs. It is a life-threatening condition that, if not treated promptly, can lead to septic shock and organ failure.

Causes

  • Bacterial: Often caused by bacteria that enter the peritoneum through perforation (e.g., from a ruptured appendix) or penetration (e.g., stab wounds).

  • Chemical: Non-bacterial irritants such as bile, pancreatic enzymes, or gastric acid that leak into the peritoneal cavity.

Clinical Manifestations (Signs & Symptoms)

  • Early symptoms

    • rigid, board-like abdomen( classic)

    • abdominal pain (localized, shoulder or chest)

    • distented abdomen

    • N/V anorexia

    • diminishing bowel sounds

    • inabily to poo or pass gas

    • rebound tenderness in abdomen

    • high fever

    • tachycardia

    • hiccups

    • decreased urinary output

Management Strategies

  • Interprofessional Collaborative Care for Peritonitis:

    • Clinical manifestations checklist to distinguish between localized (localized pain, tenderness) vs. generalized (widespread symptoms) signs.

    • Diagnostic tests including:

      • WBC count > 20,000,

      • Blood cultures to identify pathogens,

      • BUN, creatinine, hemoglobin/hematocrit (H&H), and O2 saturation.

      • Abdominal imaging (e.g., X-ray) to assess for free air or fluid.

  • Nonsurgical Management:

    • IV antibiotics to control infection,

    • Administration of hypertonic fluids to restore electrolyte balance, (take daily weight)

    • Keeping the patient NPO (nothing by mouth) and using NGT (nasogastric tube) for gastric decompression.

  • Surgical Management:

    • Exploratory laparotomy may be required for severe cases to clean the peritoneal cavity and address the underlying cause.

    • Special care is required for managing open incisions post-surgery to prevent complications.

Appendicitis

Definition

  • Appendicitis is the acute inflammation of the vermiform appendix, often due to obstruction leading to infection. This condition typically presents with severe abdominal pain and can lead to complications if the appendix perforates.

Common Symptoms

  • Right lower quadrant (RLQ) pain, often starting around the umbilicus (McBurney point)

  • abdominal pain followed by N/V, anorexia

Diagnostic Overview

  • Obstructive Factors:

    • Common causes of obstruction include fecaliths, tumors, helminths, and infectious processes.

    • gangrene and sepsis can occur within 24 to 36 hrs, life threatening)

    • perfortaion may develop within 24 hrs

  • WBC Count:

    • An elevated WBC count (10,000-18,000; >20,000 indicates potential perforation).

  • Imaging:

    • Ultrasound and CT scans are gold-standard imaging modalities for diagnosis.

Management Strategies

  • Nonsurgical: Initial management includes keeping the patient NPO and monitoring closely.

  • Surgical Options:

    • Appendectomy is the removal of the inflamed appendix

    • NOTES: for females since it requires entry through the vagina

    • Laparoscopy: small incisions near the umbilicus

    • laparotomy, an open surgical approach with a large abdominal incision

    • Peritonitis and abscess found during surgery wound drains are inserted and NGT placed to decompress stomach

Gastroenteritis

Definition

  • Gastroenteritis is characterized by viral or bacterial infections resulting in inflammation of the gastric and intestinal mucosa.

    • epidemic viral:

    • norovirus: The leading foodborne disease occurs between November and april and is transmitted through the fecal-oral route

      • assess food and travel (outside the country)

      • interventions

        • rehydration; sport drinks and pedialyte

        • antibiotics: ciprofloxacin or azithromycin

        • gently clean area with warm water and use skin wipes, sitz baths

Symptoms

  • Symptoms commonly include nausea, vomiting, diarrhea, and abdominal cramping. The most frequent virus involved is the Norovirus, which peaks from November to April.

Management Strategies

  • Treatment typically involves rehydration strategies, possible use of antibiotics depending on the etiology, and maintaining hygiene and cleanliness.

Ulcerative Colitis (UC)

Overview

  • Ulcerative Colitis is a chronic inflammatory bowel disease characterized by widespread inflammation of the rectum and rectosigmoid colon.

    • mostly diagnosed between 15 and 35

Characteristics

  • Blood in Stools: Typically characterized by 10-20 episodes of liquid stools per day with bright red or dark maroon blood mixed in.

  • Mucus in Stools: commonly reported during flare-ups, indicating irritation of the bowel lining.

  • Tenesmus: A sensation of incomplete evacuation after a bowel movement, causing discomfort and urgency.

  • Left Lower Quadrant Pain (LLQ): Often described as discomfort or cramping in the LLQ, which may alleviate after defecation, reflecting inflammation in the colon and rectum.

  • Extraintestinal manifestations include migratory polyarthritis and ankylosing spondylitis.

Assessment and Diagnosis

  • A thorough history should focus on family history, previous surgeries, nutrition, and elimination patterns.

  • Physical examination includes checking for fever, abdominal distention, and signs of extraintestinal diseases.

  • Laboratory tests to assess include H&H, WBC counts, CRP, ESR, and decrease electrolytes (Na, K, CL), hypoalbuminemia (decreased serum albumin)

  • Imaging may include MR enterography (MRE), CT scans, colonoscopy, and barium enema.

Drug Therapy

  • Medications used in UC management may include:

    • Aminosalicylates (sulfasalazine), also called 5-ASA, are thought to have an anti-inflammatory effect on the lining of the intestine by inhibiting prostaglandin.

      • teach pt to increase folic acid supplement

      • report N/V, anorexia, rash, headache

    • glucocorticoids (prednisone): prescribed during exacerbations of the disease. adverse effects include hyperglycemia, osteoporosis, peptic ulcer disease, increased potential for infection, and adrenal insufficiency)

    • immunomodulators: alter an individual’s immune response

      • alone (not really effective) with steroids, which may offer a synergistic effect and decrease the amount of steroids needed.

  • Nutritional interventions may require patients to be NPO (TPN) during acute exacerbations to prevent further intestinal irritation.

  • minimize pain and monitor for lower bleeding

    • blood may be bright red (frank bleeding) or black and tarry (melena)

    • monitor VS, electrolyte vals and H&H, ( fever, tachycardia)

Surgical Management of UC

  • Surgery is often indicated in cases of toxic megacolon and may include:

    • Proctocolectomy with ileal pouch-anal anastomosis (IPAA), the gold standard for UC

      • removal of colon and most rectum

      • pouch connected to anus

      • temporary ileostomy (1-2 months)

    • Total proctocolectomy with permanent ileostomy.

      • removal of the colon, rectum, and anus with surgical closure of anus

  • ileostomy care

    • stoma is usually placed in RLQ

    • frequent assessment of stoma

    • after a while, the stool volume decreases and becomes thicker (paste-like) and turns yellow-green or yellow-brown

    • effluent (fluid material) has little odor or sweet odor (watch for signs of infection or foul odor)

    • skin barriers (gelatin or pectin)

    • empty pouch 1/3 or ½ full, change pouch every 3-7 days

    • no high fiber and high-cellulose foods

    • ileotomy usually drains stool within 24 hrs after surgery 1L/day

    • replace fluids 500 ml

    • avoid foods that cause odor or gas (cabbage, asparagus, brussel sprouts, beans); also avoid nuts and corn

Crohn’s Disease (CD)

Definition

  • Crohn’s Disease is a chronic inflammatory condition that can affect any part of the gastrointestinal tract, including the small intestine and colon. and causes thickened bowel walls

    • It is characterized by transmural inflammation, which can lead to complications such as fistulas, malnourishment, and malabsorption.

Management Strategies

  • A comprehensive assessment should include monitoring for weight loss, stooling patterns (diarrhea), fever, and abdominal tenderness (RLQ).

    • increase high-pitched or rushing sounds present over narrowed bowel loops

  • Laboratory monitoring should focus on anemia and electrolytes.

  • Drug therapy involves a similar approach to UC

    • biologic response modifiers (BRM): decrease inflammatory response (infliximab and certolizumab) which are given in healthcare setting

    • glucocorticoids

    • 5-ASA (azathioprine and mercaptopurine)

  • Nutritional strategies may involve TPN or supplementations for patients with significant malabsorption.

  • fistula management

    • diet requires at least 3000 cal daily to promote wound healing (TPN or TEN), low-fiber meals

    • skincare: make sure wound drainage isn’t in direct contact with the skin. clean skin

    • pouching: low wall suction not for long term

    • wound vac: negative pressure wound therapy( vacuum-assisted closure or wound VAC therapy) promotes wound healing

  • surgical management

    • resection small bowel/ileocecal

    • stricturoplasty

Diverticular Disease

Overview

  • Diverticular disease can occur at any point along the gastrointestinal tract,

  • diverticula pouchlike herniations of the mucosa through the muscular wall of any part of the gut (common in colon) occur at the point of weakness in the intestinal wall

  • diverticulosis (presence of many diverticula)

  • diverticulitis (inflammation of diverticula).

Symptoms

  • Patients may often be asymptomatic but can experience episodes of abdominal pain, fever, nausea, vomiting, and tenderness during exacerbations.

intervention

  • nonsurgical management:

    • don’t give laxatives or enemas

    • active diverticulitis provides a low-fiber diet and when inflammation resolves provide a high-fiber diet

    • check stools for flank bleeding

  • surgical management:

    • colon resection

  • care management:

    • high cellulose and hemicellulose fiber (wheat bran, whole grain bread, cereals. diet including 25 to 35 g on fiber a day.

Celiac Disease

Definition

  • Celiac disease is a multi-system autoimmune disorder that causes chronic inflammation in the small intestine, leading to malabsorption of nutrients and chronic diarrhea when gluten is consumed.

  • symptoms

    • weight loss

    • diarrhea/constipation

    • steatorrhea (fatty stools)

    • vomiting, abdominal distention

Treatment

  • The mainstay of treatment involves adherence to a strict gluten-free diet to prevent inflammation and symptoms.

Parasitic Infections

Overview

  • Parasitic infections occur when parasites invade the gastrointestinal system, potentially causing a variety of gastrointestinal symptoms, including diarrhea, abdominal pain, and systemic illness.

Prevention

  • Handwashing is crucial in preventing the spread of parasitic infections, and treatment protocols vary based on the type of organism involved.

  • Monitoring and treatment should be aimed at eliminating the infection and restoring health.