Acute Abdominal Pain Lower GI Problems

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Acute Abdominal PainLower GI Problems

• Module 2

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Acute Abdominal PainEtiology

• Inflammation
• Crohns
• Appendicitis
• Cholecysitis
• Colitis, etc.
• Vascular
• Aneurysm
• Gynecological
• PID
• Ectopic Pregnancy

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Acute Abdominal PainEtiology

• Infectious disease
• Giardia
• Salmonella
• Others
• Perforation
• GI Bleed
• Trauma

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Acute Abdominal PainClinical Manifestations

• PrimaryPain
• Rebound tenderness
• Abdominal distention/rigidity
• N/V
• Diarrhea
• Hematemesis
• Melena
• Hypovolemic Shock

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Acute Abdominal PainDiagnostic Studies

• HP
• Pelvic/Rectal exam
• Chemistries, CBC, Stool
• Abdominal x-ray
• Pregnancy test r/o ectopic
• Exploratory lap

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Acute Abdominal PainNursing Care

• Frequent VS, monitor for bleeding, hypovolemic
  shock
• Assess abdomen carefully
• Distention
• Pulsations, scars
• Pigmentation changes
• Bowel sounds
• Diminished or high pitched-ileus
• Absent-obstruction, perforation
• Gentle palpation
• Monitoring N/V, Bowel movements

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Acute Abdominal PainNursing Care-Pre op

• CBC, Type and cross match, Chemistries
• ABCs
• IV
• Consent/NPOPrep
• Insert NG ?

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Acute Abdominal PainNursing Care-Post op

• VS
• NGT-if upper GI, may be dark brown/red drainage
  fro 12 hrs then light yellow/green/brown
• Pt should not be nauseated/vomiting with properly
  placed NGT
• IO
• Monitor wound
• Parenteral fluids
• Antiemetics
• Pain management
• Assess bowel sounds/flatuence/distention
• Monitor for bowel sounds-within 72 hrs after
  surgery
• Bowel movement within 4 days-stool softener may
  be prescribed
• Advance diet per MD

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Abdominal Trauma

• Etiology
• Blunt
• Falls
• MVA
• Assault
• Explosions
• Crushing injuries
• Penetrating
• Knife/Gunshot,etc

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Abdominal TraumaAssessment Findings

• Hypovolemic shock
• Open wounds
• Impailed objects
• N/V
• Abdominal distention/rigidity/pain upon palpation
• Hematuria
• Rebound pain/Radiating pain

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Abdominal TraumaNursing Care

• ABCs, Frequent VS, Monitor for s/s shock
• O2
• Control bleeding-direct pressure
• Multiple IVs with large gauge needles (LR)
• CBC, Type and cross match, Chemistries, Urine
• Foley

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Abdominal TraumaNursing Care

• Stabilize impaled object with dressing DO NOT
  REMOVE OBJECT
• Cover organs with sterile saline dressing
• NGT if ordered
• Possible peritoneal lavage
• Prepare for OR

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Irritable Bowel Syndrome (IBS)

• Can be acute/chronic
• Intermittent and recurrent abdominal pain with an
  alteration in bowel patterns

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Irritable Bowel Syndrome (IBS)Signs/Symptoms

• Diarrhea and/or constipation
• Flatuence
• Abdominal distention/bloating
• Urgency
• Stress
• Food Intolerances

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Irritable Bowel Syndrome (IBS)-Diagnosis

• HP
• R/O other GI disorders
• Rome criteria-symptom based criteria for IBS

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Irritable Bowel Syndrome (IBS)-Treatment

• High fiber diet/Metamucil
• Avoid gas producing foods, i.e. cabbage, broccoli
• Anticholinergic agents
• Bentyl
• Lotronex
• For IBS that causes diarrhea
• Zelnorm
• Increases movement of stool through colon for
  those who experience constipation
• Stress management

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Inflammatory Diseases

• Appendicitis
• Peritonitis
• Gastroenteritis

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Appendicitis

• Inflammation of the appendix
• Etiology
• Obstruction of the lumen by fecalith
  (accumulation of feces)-most common
• Foreign body
• Tumor/growth of tissue

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Appendicitis-Clinical Manifestations

• Periumbilical pain
• Anorexia, N/V
• Pain is persistent eventually shifts to right
  lower quadrant and localizes at McBurneys point
• McBurneys Point-Halfway between umbilicus and
  right iliac crest
• Localized and rebound tenderness

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Appendicitis-Clinical Manifestations

• Guarding
• Client lies still with right leg flexed
• Low grade fever may/may not be present
• Rovsings sign (Palpate left lower quadrant, pain
  occurs in right lower quadrant)

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Appendicitis-Complications

• Perforation
• Peritonitis
• Abscesses

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Appendicitis-Diagnostic Studies

• HP
• Palpation of the abdomen after auscultation
• CBC with diff
• U/A
• R/O other GI disorders
• Pregnancy test
• Prepare for OR

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Peritonitis-Etiology

• Primary causes
• Blood bone microorganisms
• Genital tract microorganisms
• Cirrhosis with ascities
• Secondary
• Ruptured appendix/diverticula/ischemic
  bowel/peptic ulcer
• Obstruction Of GI tract
• Penetrating trauma
• Peritoneal dialysis

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Peritonitis-Pathophysiology

• Can be acute or chronic
• Body attempts to wall off offending agent
• Adhesions formed

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Peritonitis-Clinical Manifestations

• Abdominal pain
• Tenderness over involved area
• Rebound tenderness/muscle rigidity
• Abdominal distention
• Fever, tachycardia, tachypnea
• N/V

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PeritonitisComplications

• Hypovolemic Shock
• Septicemia
• Intraabdominal abscess
• Paralytic ileus
• Organ failure
• Death

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PeritonitisDiagnostic Studies

• HP
• Auscultation then palpation
• CBC, Chemistries
• R/O other GI disease
• Pregnancy test
• Peritoneal aspiration
• X-ray of abdomen
• US/CT scan
• Peritonoscopy

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PeritonitisTreatment

• Identify and eliminate cause
• For nonoperative candidate
• NGT
• Analgesic
• Antibiotics
• TPN/fluids
• Surgery

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Gastroenteritis

• Inflammation of mucosa of stomach and small
  intestine
• Signs/Symptoms
• N/V/D
• Abdominal cramping/distention
• Fever, elevated WBC
• Blood/mucous in stool
• Multiple causative agents

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Gastroenteritis

• Usually self limiting
• NPO
• IV fluid replacement
• Antibiotics if indicated
• Antimicrobials/Anti-infectives

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Inflammatory Bowel Disease (IBD)

• Chronic, recurrent inflammation
• Periods of remission and exacerbation
• Etiology
• Unknown
• Possibilities
• Infectious agent
• Autoimmune
• Food allergies
• Heredity
• Two major types
• Ulcerative colitis
• Crohns disease

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Ulcerative ColitisPathophysiology

• Inflammation/ulceration of colon and
  rectum-begins in rectum and ascends
• First onset 15-30 yr
• Second onset 60-80 years
• Involves mucosa and submucosa
• Mucosa is hyperemic and edematous in affected
  area
• Abscesses develop in crypts of Liberkuhn
• Continuous distribution
• Pseudopolyps common

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Ulcerative ColitisClinical Manifestations

• Severe tenesmus
• Rectal Bleeding
• Cramping
• Fever-acute attacks
• Weight loss

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Ulcerative ColitisIntestinal Complications

• Intestinal
• Hemorrhage
• Stricture-rare
• Perforation
• Toxic megacolon
• Increased risk of colorectal cancer
• Anal abscesses-rare

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Ulcerative ColitisExtraintestinal Complications

• Peripheral arthritis
• Ankylosing spondylitis
• Erythema of skin
• Aphthous ulcers
• Conjunctivitis
• Uvetitis

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Ulcerative ColitisDiagnostic Studies

• HP
• CBC, Chemistries (possible decrease in
  electrolytes)
• Sigmoidoscopy/Colonscopy
• Barium enema
• Stool for OB, CS of stool

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Ulcerative ColitisTreatment

• Low roughage (residue) diet, no milk
• Antimicrobials
• Sulfasalazine (5-ASA) as retention enema
• Rowasa suppositories, oral
• Prednisone
• Immunosuppressive agents-Remicade
• Anticholinergics, Banthine
• Antidiarrheal i.e. Lomotil

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Ulcerative ColitisTreatment

• IV colloids/crystalloids
• NPO
• TPN
• NGT
• Surgery-can be curative
• Proctocollectomy with permanent illeostomy
• Proctocollectomy with continent illeostomyKochs
  pouch
• Total collectomy

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Chrohns DiseasePathophysiology

• Occurs anywhere along GI tract-most frequent
  terminal illeum
• Segmental distribution
• Involves entire wall of intestine (transmural)
• Small bowel involvement
• Areas of involvement are usually
  discontinous-skip lesions
• Granulomas may be present

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Chrohns DiseaseClinical Manifestations

• Nonbloody diarrhea
• Abdominal cramping pain
• Fever common
• Severe weight loss
• Malabsorption and nutritional deficiency common

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Chrohns DiseaseComplications

• Fistulas common-cardinal feature
• Strictures common
• Anal abscess common
• Perforation
• Increased risk for colorectal cancer
• Impaired nutritional absorption
• Extraintestinal complications similar to
  Ulcerative colitis

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Chrohns DiseaseDiagnostic Studies

• HP
• Endoscopy with biopsy (granulomas)
• Barium studies
• CBC, Chemistries
• Stool for OB

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Chrohns DiseaseTreatment

• Sulfasalazine only if large intestine involved
• High calorie, high vitamin, high protein, low
  residue diet
• Steroids
• Immunosuppressive therapy
• TPN
• Stress management
• Surgery-
• Intestinal resection
• Not usually curative

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Intestinal Obstruction

• Intestinal contents cannot pass through GI tract
• Can be
• Partial
• Complete
• Types
• Mechanical-physical obstruction i.e. tumor,
  adhesions
• Pseudoobstruction-appears to be mechanical but
  not demonstrated on radiological exam
• Nonmechanical-neuromuscular, vascular problem
• Paralytic illeus is most common i.e. after surgery

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Intestinal ObstructionPathophysiology

• Fluid, gas, intestinal contents accumulate
• Distention occurs, distal bowel collapses
• Pressure occurs
• Increase in capillary permeability
• Edema, congestion, and necrosis can occur
• Electrolytes lost to peritoneal cavity
• Vomiting

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Intestinal ObstructionClinical Manifestations
Small Intestine

• Rapid onset
• Frequent vomiting
• Colicky pain
• Feces
• Minimal abdominal distention

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Intestinal ObstructionClinical Manifestations
Large Intestine

• Gradual onset
• Cramping abdominal pain
• Absolute constipation
• Increased abdominal distention

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Intestinal ObstructionDiagnostic Studies

• Abdominal x-rays-most useful
• HP
• Barium enemas-only if no perforation
• Endoscopy
• CBC, Chemistries, BUN, elevated WBC may indicate
  strangulation
• Stool for OB

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Intestinal ObstructionTreatment

• NGT to decompress bowel
• Sigmoidoscopy/Colonoscopy
• IV, TPN
• Surgery
• Resect bowel
• Partial/total colectomy
• Colostomy
• Ileostomy