Chapter 41

Management of Patients with Intestinal and Rectal Disorders

Learning Objectives

  • Pathophysiology, Clinical Manifestations, Management of:

    • Constipation

    • Diarrhea

    • Fecal Incontinence

    • Irritable Bowel Syndrome

  • Identify Celiac Disease as a disorder of malabsorption; describe pathophysiology, clinical manifestations, and management.

  • Discuss nursing management of patients with:

    • Appendicitis

    • Diverticular Disease

    • Intestinal Obstruction

  • Compare Crohn’s Disease and Ulcerative Colitis in terms of:

    • Pathophysiology

    • Clinical Manifestations

    • Diagnostic Evaluation

    • Medical, Surgical, and Nursing Management

  • Identify purposes, indications, types, and administration techniques of Parenteral Nutrition access devices and formulas.

  • Use the nursing process as a framework for care of patients with:

    • Inflammatory Bowel Disease

    • Receiving Parenteral Nutrition

    • Colorectal Cancer

  • Explain nursing management of patients with Anorectal Disorders.

Constipation

  • Definition: Poorly understood condition; involves interference with the colon’s functions.

  • Pathophysiology:

    • Functional Constipation

    • Slow-Transit Constipation

    • Defecatory Disorders

    • Opioid-induced Constipation

  • Classes of Assessment Tools:

    • Patient’s history and physical exam

    • Barium Enema

    • Sigmoidoscopy

    • Stool Testing for occult blood

  • Complications:

    • Decrease in arterial pressure leading to orthostasis, dizziness, syncope

    • Fecal impaction leading to fecal incontinence

    • Hemorrhoids

    • Anal fissures

    • Rectal prolapse

    • Megacolon

  • Clinical Manifestations:

    • Fewer than 3 bowel movements per week

    • Abdominal distension

    • Abdominal pain and bloating

    • Sensation of incomplete evacuation

    • Straining at stool

    • Small-volume, lumpy, hard stools

  • Treatment Strategies:

    • Treat underlying causes

    • Exercise

    • Bowel habit training

    • Increased fiber and fluid intake

    • Medication management

  • Medical Management Considerations:

    • Onset and duration of constipation

    • Elimination patterns

    • Lifestyle factors: exercise, occupation, food/fluid intake, stress, past medical and surgical history, medication use, symptom assessment

  • Nursing Management: To be outlined further.

Diarrhea

  • Definition: Increased frequency of bowel movements characterized by a change in stool consistency.

  • Pathophysiology:

    • Non-Inflammatory Diarrhea: Caused by enteric pathogens secreting toxins that disrupt colonic fluid transport, resulting in large volume, loose, watery stools.

    • Inflammatory Diarrhea: Pathogens invading intestinal mucosa causing inflammation and smaller volume of bloody stools.

  • Acute, Persistent and Chronic Diarrhea characterized by more than 3 stools per day with altered consistency due to:

    • Infections

    • Medications

    • Tube feeding formulas

    • Metabolic and endocrine disorders

    • Various disease processes

  • Diagnostic Assessment:

    • CBC

    • Serum chemistries

    • Urinalysis

    • Routine stool examinations

  • Clinical Manifestations:

    • Increased stool frequency and fluid content

    • Abdominal cramping

    • Distention

    • Borborygmi (rumbling or gurgling noise)

    • Anorexia

    • Thirst

  • Medical Management:

    • Symptom control

    • Antidiarrheal Agents: Loperamide is the medication of choice

    • Other medication options: antibiotics, anti-inflammatory agents, probiotics

  • Nursing Management:

    • Monitor for dehydration, electrolyte imbalance, cardiac arrhythmias, urinary output, muscle weakness, paresthesia, hypotension, anorexia, and drowsiness.

Fecal Incontinence

  • Common Causes:

    • Anal sphincter weakness

    • Neuropathies

    • Pelvic floor disorders

    • Inflammation

    • CNS disorders

    • Diarrhea, fecal impaction, or behavioral issues

  • Clinical Manifestations:

    • Vary from soiling to complete incontinence

    • Poor control over gas, diarrhea, or constipation

    • Passive incontinence (no warning)

    • Urge incontinence (unable to reach the toilet in time)

  • Assessment & Diagnosis:

    • Patient history

    • Rectal exam

    • Flexible sigmoidoscopy

    • Anorectal manometry, defecography

    • Anal endosonography

    • Pelvic MRI

  • Management involves treating the underlying cause, using fiber supplements, biofeedback, pelvic floor training, bowel training, sacral nerve stimulation, and possible surgeries.

Irritable Bowel Syndrome (IBS)

  • Prevalence:

    • United States: 12%

    • Global: 11%

    • Most common in adults under 45 years and more prevalent in women.

  • Characteristics:

    • No structural or inflammatory damage observed.

    • Dysfunctional intestinal motility possibly due to neuroendocrine dysregulation.

  • Pathophysiology Features:

    • Stress

    • Poor sleep

    • Neurohormonal changes

    • Bacterial overgrowth

    • Infections

    • Inflammation

    • Food intolerances

    • Surgery

  • Common Triggers: To be identified further.

  • Clinical Manifestations:

    • Abdominal pain, bloating, distention relieved by defecation.

  • Diagnosis:

    • Rome IV Criteria:

    • Recurrent abdominal pain with 2 or more of: pain related to defecation, change in stool frequency, change in stool appearance, keeping a stool diary using the Bristol Stool Form Scale.

    • Labs including CBC, CRP, fecal calprotectin, celiac serologies, stool tests, colonoscopy to exclude other causes.

  • Management:

    • Lifestyle changes including stress management, regular sleep and exercise

    • Dietary changes such as adding soluble fiber, avoiding triggers, considering a low-FODMAP diet

    • Pharmacological approaches as outlined later.

Celiac Disease

  • Definition: Autoimmune disorder causing malabsorption due to an immune response triggered by gluten ingestion.

  • Pathophysiology: Gluten causes inflammation and damage to small intestinal villi.

  • Demographics:

    • More common in women than men

    • Affects approximately 1% of the U.S. population

    • Familial component with higher risk in first-degree relatives (30% genetically predisposed)

    • Associated with conditions like Type 1 Diabete, Down syndrome, Turner Syndrome.

  • Clinical Manifestations:

    • GI: Diarrhea, steatorrhea, abdominal pain, bloating, distention, weight loss

    • Non-GI: Fatigue, malaise, depression, anemia, hypothyroidism, migraines, seizures, paresthesia, osteopenia/osteoporosis, glossitis, dermatitis herpetiformis.

  • Diagnosis:

    • Serologic testing ideally conducted while the patient is consuming gluten.

    • IgA anti-tissue transglutaminase

    • Definitive diagnosis via upper endoscopy and biopsy confirmation.

  • Management:

    • Requires lifelong gluten-free diet

    • Consult with a dietitian

    • Supplements for deficiencies.

Peritonitis

  • Common Causes:

    • Bacterial: E. coli, Klebsiella, Proteus, Pseudomonas, Streptococcus

    • Sources: GI tract disorders, Fallopian tubes, trauma, surgery, peritoneal dialysis.

  • Pathophysiology: Leakage of GI contents into the peritoneal cavity leads to bacterial proliferation, resulting in tissue edema, fluid exudate, and peritoneal inflammation.

  • Assessment & Diagnosis:

    • Increased WBC count

    • Decreased hemoglobin and hematocrit

    • Electrolyte imbalances

    • ABGs may show acidosis and dehydration.

    • Imaging:

    • X-ray: Free air, distended bowel loops

    • Ultrasound/CT: Detect abscesses or fluid collections

    • Peritoneal aspiration and culture to identify organisms

    • MRI for intra-abdominal abscesses.

  • Clinical Manifestations:

    • Diffuse abdominal pain

    • Rebound tenderness, abdominal rigidity, distention

    • Diminished peristalsis, nausea, vomiting, anorexia

    • Fever, tachycardia, hypotension, oliguria/anuria

    • Can progress to sepsis and septic shock without treatment.

  • Management Strategies:

    • Fluid and electrolyte replacement

    • Broad-spectrum antibiotics started early

    • Control the source of infection

    • Nutritional support and respiratory support

    • Analgesics for pain and antiemetics if necessary

  • Nursing Management:

    • Monitor for signs of recovery

    • Gradually increase oral intake as symptoms improve

    • Watch for complications and prepare for emergency surgery if needed.

Appendicitis

  • Pathophysiology: Caused initially by obstruction from fecalith, lymphoid hyperplasia, or tumors. When obstructed, ischemia leads to bacterial overgrowth, inflammation, and possible gangrene or perforation.

  • Diagnostic Indicators:

    • WBC > 10,500/mm

    • Increased CRP within the first 12 hours

    • Imaging: CT scan or ultrasound.

  • Clinical Manifestations:

    • Early: Vague, periumbilical pain, anorexia

    • Progresses to sharp right lower quadrant pain (especially at McBurney’s point), nausea, low-grade fever

    • Special Signs: Rebound tenderness, Rovsing’s sign (RLQ pain on palpation of LLQ).

  • Geriatric Considerations:

    • Atypical presentations may include mild to no pain, no fever, or leukocytosis, leading to late diagnosis and increased complications or mortality.

  • Complications of Appendicitis:

    • Perforation leading to peritonitis, abscess formation, portal pylephlebitis.

  • Medical Management:

    • Immediate appendectomy along with IV fluids and antibiotics pre-operation

    • Laparoscopic method preferred for quicker recovery

    • If an abscess is noted, percutaneous drainage may occur prior to surgery.

  • Nursing Management:

    • Administer IV fluids, antibiotics, analgesics

    • Pre-operative care: High Fowler position, pain management, bowel sounds monitoring

    • Promote early ambulation post-operation for recovery, educate patients on wound care and activity limits before discharge.

Diverticular Disease

  • Definition: Diverticula are sac-like herniations of the bowel lining, most commonly in the sigmoid colon.

  • Risk Factors:

    • Lower fiber diet

    • Obesity

    • Smoking

    • Use of NSAIDs

    • Family history

    • High intake of red meat, fats, refined sugar.

  • Asymptomatic Cases:

    • May exhibit mild constipation, diarrhea, or bloating.

  • Distinction Between Diverticulosis and Diverticulitis:

    • Diverticulosis: Multiple diverticula without inflammation; mild symptoms may include LLQ pain and constipation/obstruction.

    • Diverticulitis: Infection and inflammation of diverticula, can lead to complications.

  • Diagnosis:

    • For Diverticulosis: CBC, CT scan with contrast

    • For acute conditions: may include abscess, bleeding, peritonitis evaluations.

    • Chronic assessments may include looking for fistulas and bowel obstructions.

  • Medical Management of Acute Diverticulitis:

    • Uncomplicated treatment involves rest, clear liquids, advanced high-fiber/low-fat diet, with potential antibiotics

    • In complicated cases, NPO, IV fluids, NG suction if distended, heavy antibiotic therapy.

  • Surgical Management:

    • Can involve one-stage resection of the diseased colon or a two-stage procedure (Hartman Procedure: colostomy followed by reanastomosis if necessary).

    • CT-guided abscess drainage if needed.

  • Nursing Management:

    • Encourage at least 2 liters of fluid intake and soft, high-fiber foods

    • Recommend daily exercise and schedule for bowel movements

    • Monitor food triggers and consider bulk laxatives (psyllium).

  • Geriatric Considerations:

    • Older adults may express less pronounced symptoms and often delay reporting due to fear; muscle degeneration can increase incidence.

Intestinal Obstruction

  • Types:

    • Mechanical obstruction versus functional obstruction, affecting either the small or large intestine.

  • Clinical Manifestations:

    • Crampy, wave-like (colicky) abdominal pain

    • Vomiting, lack of flatus or stool passage

    • Signs of abdominal distention and dehydration

    • Early bowel sounds: hyperactive, high-pitched; later stages: hypoactive or absent.

  • Assessment and Diagnostics:

    • Imaging via X-ray or CT

    • Labs for fluid and electrolyte imbalances.

  • Medical Alert: Maintaining fluid and electrolyte balance is crucial due to potential NG tube losses or NPO status.

  • Management Strategies:

    • Fluid and electrolyte monitoring, NG tube decompression, Gastrografin via NG, observing for changes in symptoms, and possible surgical intervention for complete obstruction or if strangulation risk exists.

Inflammatory Bowel Disease (IBD)

  • Table 41-5 Overview of IBD:

    • Crohn's Disease:

    • Prolonged, variable disease course with transmural thickening, typically affecting the ileum and ascending colon, characterized by deep, penetrating granulomas.

    • Ulcerative Colitis:

    • Exacerbations and remissions, found mainly in the rectum and descending colon, marked by mucosal ulcerations.

  • Medical Management of IBD:

    • Include corticosteroids, aminosalicylates, immunomodulators, monoclonal antibodies, antibiotics, and parenteral nutrition as required.

  • Nursing Interventions:

    • Focus on maintaining normal elimination patterns, providing access to bathrooms, promoting bed rest, monitoring weight and fluid intake, administering medications, managing pain with appropriate treatments, and encouraging dietary compliance.

Parenteral Nutrition

  • Indications:

    • Nutritional intake insufficient to maintain an anabolic state; impaired ability to ingest food orally; preoperative and postoperative needs; decreased oral intake for more than one week; weight loss of 10% or more; muscle wasting.

  • Nursing Management:

    • Monitor daily weight, caloric intake, I/O, blood glucose levels, and electrolytes;

    • Preventing infections related to catheter use; educate the patient about potential complications (e.g., pneumothorax, air embolism).

Colorectal Cancer

  • Overview:

    • Third most common site of new cancer cases in the U.S.; necessitates regular screening.

  • Clinical Manifestations:

    • Changes in bowel habits, blood in stool, tenesmus, obstruction symptoms, abdominal or rectal pain, feelings of incomplete evacuation.

  • Assessment Tools:

    • Involves health history review, nutritional status, characteristics of stool, and signs of complications like GI bleeding or infections.

Nursing Intervention for the Patient with Cancer of the Colon or Rectum

  • Key Components:

    • Prepare the patient for surgery and provide emotional support; maintain optimal nutrition; monitor for complications; manage wound care and colostomy if needed.

Anorectal Conditions

  • Common conditions include proctitis, anorectal abscess, anal fistula, anal fissure, hemorrhoids, and pilonidal sinus or cyst.

Care of the Patient with an Anorectal Condition

  • Assessment Focus:

    • Health history, including pruritus, pain, elimination patterns, diet, exercise, and inspections of the area; recommend at least 2L water/day and high-fiber foods; monitoring for complications; self-care education aimed at hygiene and diet management.