CHAPTER 8 GASTROINTESTINAL SYSTEM DISORDERS. BY Dr. Uche Amaefuna-Obasi THERE ARE MORE TO LECTURES THAN JUST SLIDES. Digestive Disorders Introduction Doctors who specialize in gastroenterology see patients with digestive problems. The gastrointestinal (GI) tract is composed of the following; Esophagus Stomach Small intestine Large intestine Colon Rectum Biliary tract Gallbladder Liver Pancreas Disorder related to any of this organ are called Gastro-Intestinal Disorder. Anatomy and Pathophysiology Length = feet (9-10 meters) GI Tract Functions Secretion Digestion Absorption Motility Elimination DIGESTIVE SYSTEM FUNCTIONS: ingest food DIGESTION:break it down into small molecules ABSORPTION:absorb nutrient molecules ELIMINATION:eliminate nondigested wastes ASSESSORY ORGANS : pancreas, liver, gallbladder CN X: Vagus Nerve Involves: esophagus, stomach, small intestines, gallbladder, and large intestines Parasympathetic: stimulates motor and secretory activity, relaxes sphincters Disease under GI disorder: Gastro-esophageal Reflux Disease. Peptic Ulcer Disease Inflammatory Bowel Disease Nausea and Vomiting Diarrhea Constipation Irritable Bowel Syndrome Portal Hypertension Cirrhosis Drug-Induced Liver Disease Pancreatitis Viral Hepatitis Oral Cavity Teeth: chewing Mucin and amylase: breaks down food Tongue Pharynx Esophagus: 2 sphincters STOMATITIS Inflammation of the oral mucosa (mouth) Causes: trauma, organisms, irritants, nutritional deficiency, diseases, chemotherapy S/S: swelling, pain, ulcerations, excessive salivation, halitosis, sore mouth Treatment: pain relief, removal of causative factor, oral hygiene, medications, soft bland diet GINGIVITIS Inflammation of the gums Causes: poor oral hygiene, poorly fitting dentures, nutritional deficiency S/S: red, swollen, bleeding gums, painful Treatment: dental hygiene, prevention of complications Interventions: Stomatitis and Gingivitis Assess mouth condition Administer medications Mouth care Soft bland diet, no spicy foods Observe for complications Teach importance of mouth and gum care HERPES SIMPLEX TYPE 1 Infection affecting the lips and mucous membranes of the mouth Causes: Herpes simplex virus S/S: Vesicles on the mouth, nose or lips, malaise, edema of surrounding area Treatment: Antiviral medication (Zovirax), analgesics, symptomatic relief Interventions: Administer meds, keep lesions dry, provide symptomatic relief LEUKOPLAKIA Abnormal thickening and whitening of the epithelium of the mucous membranes of the cheeks and tongue Causes: Chronic irritation S/S: Thickened white or reddish lesions on the mucous membrane, lesions can not be rubbed off Treatment: May be surgically removed or treated with chemotherapy, meticulous oral hygiene Interventions: Assess mouth frequently, assist with oral hygiene, discuss removal of sources of irritation ORAL CANCER Malignant lesions may develop on the lips, oral cavity, tongue and pharynx. Generally squamous cell carcinomas Causes: high alcohol consumption, tobacco use, external irritants S/S: Leukoplakia, swelling, edema, numbness, pain Diagnosis: biopsy Treatment: Surgery Radiation or chemotherapy depends on the size and location of the lesion Interventions: consult MD for special mouth care, monitor respiratory status, keep HOB elevated, administer pain med, assess ability to swallow and talk, assess for infection at incision site, education Esophagus Tube from pharynx to stomach Upper esophageal sphincter (UES or cardiac sphincter) closed except when swallowing Lower esophageal sphincter (LES) closes entrance to stomach; prevents reflux of stomach contents back into esophagus ESOPHAGITIS Inflammation or irritation of the esophagus Causes: Reflux of stomach contents, irritants, fungal infections, trauma, malignancy, intubation S/S: heartburn, pain, dysphagia Treatment: treat underlying cause Interventions: soft bland diet, administer meds, elevate HOB, observe for complications ESOPHAGEAL VARICIES Tortuous, distended vessels of the esophagus may rupture and bleed causes: Portal hypertension caused by cirrhosis of the liver S/S Hematemesis, hemorrhage from UGI, black tarry stools, pain, shock Treatment: Sengstaken-Blakemore tube to control bleeding Iced saline lavage Medications (Vasopressin, antibiotics, analgesics) Surgeries: ligation, injection sclerotherapy Blood transfusions Interventions: administer meds provide pre/post op care administer blood transfusions monitor tube placement assess vital signs, bleeding CANCER OF THE ESOPHAGUS Prognosis is very poor, diagnosed at late stages Causes- no known cause, predisposing factors; irritation, poor oral hygiene S/S- progressive dysphagia, painful swallowing, weight loss, vomiting, hoarseness, coughing, iron deficiency, anemia, occult bleeding or hemmorage Treatment of CA of Esophagus Palliative treatment is common Radiation, chemotherapy surgery: Esophagectomy Esophagogastrostomy Esophagoenterostomy Gastrostomy Interventions Maintain NG tube after surgery Assess for signs of hemorrahage Monitor respiratory status monitor adequacy of nutritional intake ( high protein, high calorie diet) assess ability to swallow allow patient to ventilate feelings DISORDERS OF DIGESTION AND ABSORPTION N/V Hiatal Hernia Gastritis Peptic Ulcer Stomach Cancer Obesity Symptoms The following are some of the symptoms one could have that indicate a digestive problem: Indigestion or heartburn Pain in the abdomen Nausea and vomiting Diarrhea or constipation Bloating after eating Loss of appetite Vomiting blood or blood in the stool (feces) Common Symptoms of Gastrointestinal Disease Gastroesophageal Reflux Disease (GERD) Defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus Symptoms: Burning sensation after meals; heartburn, regurgitation or both, especially after meals Symptoms often aggravated by recumbency or bending over and are relieved by antacids GERD: Etiology ETIOLOGY: Any factor that relaxes the LES, such as smoking, caffeine, alcohol, or drugs. Any factor that increases the abdominal pressure, such as obesity, tight clothing at the waist, ascites, or pregnancy. Older age and/or a debilitating condition that weakens the LES tone. CONTIBUTING FACTORS: Excessive ingestion of foods that relax LES, e.g., fatty / fried foods, chocolate, tomatoes, alcohol Distended abdomen from overeating or delayed emptying Increased abdominal pressure resulting from obesity, pregnancy, bending at the waist, ascites or tight clothing at the waist Drugs that relax the LES, such as theophylline, nitrates, calcium channel blockers, anticholinergics, and diazepam (Valium) Drugs, such as NSAIDs, or events (stress) that increase gastric acid Debilitation or age-related conditions resulting in weakened LES tone Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance) Lying flat Signs & Symptoms of GERD Classic symptoms: Dyspepsia, especially after eating an offending food / fluid, and regurgitation. Other symptoms: Symptoms from throat irritation (chronic cough, laryngitis), hypersalivation, eructation, flatulence, or atypical chest pain from esophageal spasm. Chronic GERD can lead to dysphagia (difficulty swallowing). Complications of GERD Irritation to esophagus and mucosal injury Aspiration Barretts esophagus Esophageal erosions, ulcerations, or tears Chronic bronchitis Asthma (adult onset) Barretts Esophagus Diagnostic Testing History and Physical Dietary monitoring 24 hour ambulatory pH monitoring Esophageal manometry Endoscopy Diagnostic Interventions : GERD Barium Upper GI: Prepare the client for the procedure. Post procedure: Assess for bowel sounds and potential constipation. Endoscopy : Conscious sedation to observe for tissue damage Post procedure: Verify gag response prior to providing oral fluids or food. Medical Management for GERD Non-surgical Goals: relief of symptoms and prevent complications Life style changes: -Diet: smaller meals more frequent, limit or avoid carbonated beverages, coffee, chocolate, fats, mints, spicy or acidic food Medical Management Continued Life Style Changes: -Elevate HOB, sleep on LEFT side -AVOID smoking and ETOH -Avoid tight or restrictive clothing -Lose weight Medical Management Antacids, Antacids, E.g., aluminum hydroxide (Mylanta), neutralize excess acid. -- should be administered when the acid secretion is highest (1 to 3 hr after eating and at bedtime). --Antacids should be separated from other medications by at least 1 hr. Histamine 2 (H2) receptor antagonists Histamine 2 (H2) receptor antagonists E.g., ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), and cimetidine (Tagamet), reduce the secretion of acid. The onset is longer than antacids, but the effect has a longer duration. Proton Pump inhibitors (PPI) Proton Pump inhibitors (PPI) E.g., pantoprazole (Protonix),omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid) reduce gastric acid by inhibiting the cellular pump necessary to secrete it. Studies show that PPI are more effective than H2 antagonists. Other Medications E.g., metoclopramide hydrochloride (Reglan), increase the motility of the esophagus and stomach. Normal Esophagus GERD Complications of GERD Esophagitis, stricture or ulcer Barretts Esophagus (premalignant state) Barretts Esophagitis Acid Reflux Symptom- burning sensation RX- avoid chocolate and peppermint, coffee, citrus, fried or fatty foods, tomato products stop smoking- take antacids dont lay down 2-3 hours after eating. When small quantities of stomach acid are regurgitated into the esophagus Hiatus Hernia Structural disorder A portion of the stomach pushes up into the chest cavity through the spot normally occupied by the esophagus. Usually have this from birth, but can get it from obesity or from strenuous physical activity. Need surgery usually to correct it. Hiatal Hernia An outpouching of a portion of the stomach into the chest through the esophageal hiatus of the diaphragm Heartburn after heavy meals or with reclining after meals May worsen GERD symptoms Anatomy of Esophagus and Hiatal Hernia Types of Hiatal Hernias Sliding: (Most Common) esophagogastric junction and portion of the fundus slide upward through the esophageal hiatas Rolling: the fundus and portions of the stomach rolls through the esophageal hiatas Causes of Hernias Muscle weakness Anatomic defects Congenital weakness Prolonged increased abdominal pressure Surgery Trauma Obesity Sliding Rolling Adult onset asthma Symptoms worse after meals Symptoms worse in recumbent position Feeling full after eating Breathlessness or feeling of not be able to breath Chest pain like angina feeling of suffocation Symptoms worse in recumbent position Symptoms of Hernias Diagnostic Testing Barium Swallow Study Medical Management Diet Medications (GERD) Weight Loss Avoid late night food Avoid straining/vigorous exercise No restrictive or binding clothes Surgical repair: Laparoscopic Nissen Fundoplication Illustration of Fundoplication Stomach Function of Stomach Ingestion of food Food reservoir Digestive process: -movement -gastrin secretion: hydrochloric acid and pepsin -chyme Stomach Chief cells secrete pepsinogen (antecedent of pepsin- the chief enzyme of gastric juice which converts proteins into peptones). Parietal cells secrete hydrochloric acid, water and intrinsic factor (increases absorption of vitamin B complex). Sore or lesion that forms in the mucosal lining of the stomach Gastric ulcers in the stomach and duodenal ulcer in the duodenum Cause H. pylori (bacteria) is primary cause Lifestyle factors that contribute: cigarette smoking, alcohol, stress, certain drugs. Symp burning pain in abdomen, between meals and early morning, may be relieved by eating or taking antacids. Diagnosis x-ray, presence of bacteria Rx H 2 blockers ( drugs) that block release of histamine Peptic Ulcer Disease (PUD) A mucosal lesion of the stomach or duodenum PUD Causes Results when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin Types of PUD Gastric Ulcers: -a break in mucosal barrier, hydrochloric acid injures epithelium -back diffusion of acid or dysfunction of the pyloric sphincter -Mucosal Inflammation Duodenal Ulcers: -increase acid content dumped into duodenum Types of PUD Stress Ulcers: -Unknown etiology, presence of increased levels of hydrochloric acid, ischemia, and erosive gastritis seen -Trauma, head injuries, respiratory failure, shock sepsis Signs and Symptoms Intermittent sharp, burning, or gnawing pain Gastric pain occurs to the left and may be relieved by food A change in appetite with or weight loss (gastric) Nausea or vomiting Bloody stools Signs and Symptoms Frequent burping or bloating Duodenal pain is usually to the right of the epigastruim and pain occurs 90 min-3 hours after eating. Pain often awakes patients up at night A change in appetite with weight gain (duodenal) Diagnostic Tests History and Physical (family history) Endoscopy (EGD) Stool for occult blood H-pylori test (carbon ureas breath test) Gastric secretion studies Biopsy Medical Management Drug Therapy Diet Therapy Lifestyle Changes Surgical Intervention Complications Gastrointestinal bleeding Gastric Perforation Pyloric obstruction Treatment of Complications GI bleed Perforation Pyloric obstruction Surgical Interventions Vagotomy & Pyloroplasty Gastroenterostomy pyloroplasty Post Operative Management Assess patient Assess vital signs Monitor gastric decompression and output Monitor labs Monitor continued ileus Monitor for gastric delay emptying and recurrent ulcerations Characteristics and Comparisons Between Gastric and Duodenal Ulcers Gastric ulcer formation involves inflammatory involvement of acid-producing cells but usually occurs with low acid secretion; duodenal ulcers are associated with high acid and low bicarbonate secretion. Increased mortality and hemorrhage are associated with gastric ulcers. Gastric and Duodenal Ulcers Gastric Surgery Indicated when ulcer complicated by: Hemorrhage Perforation Obstruction Intractability (difficult to manage, cure) Pt unable to follow medical regimen Ulcers may recur after medical or surgical tx Gastric Surgery Resective surgical procedures anastamosis connection of two tubular structures Gastrectomy surgical removal of part or all of stomach Hemigastrectomy = half Partial gastrectomy Subtotal gastrectomy = 30-90% resected Gastric surgical procedures. Fig p. 661. Gastric Surgery Billroth I = gastroduodenostomy Partial gastrectomy anastomosis to duodenum To remove ulcers, other lesions (cancer) Billroth II = gastrojejunostomy Partial gastrectomy - anastomosis to jejunum Allows resection of damaged mucosa Reduces number of acid producing cells Reduces ulcer recurrence Gastric Surgery Total gastrectomy Removal of entire stomach Rarely done = negative impact on digestion, nutritional status In extensive gastric cancer & Zollinger-Ellison syndrome not responding to medical management Anastomosis from esophagus to duodenum or jejunum Zollinger-Ellison Syndrome PUD caused by gastrinoma Gastrin producing tumor in pancreas Gastrin = hormone stimulates HCl prod Causes mucosal ulceration 50 70% are malignant Any part of esoph., stomach, duod., jejun. Removal of tumor, gastrectomy Gastric Disorders 23/12/ Gastric volvulus Turning, twisting, or telescoping of the stomach onto or into itself Symptoms Acute pain Shock and hypotension Abdominal distention Inability to vomit Dyspnea Gastric surgical procedures. (cont.) Fig p. 661. Pyloroplasty Surgical enlargement of pylorus or gastric outlet To improve gastric emptying with obstructions or when vagotomy interferes with gastric emptying May contribute to Dumping Syndrome Ulcer recurrence is common Roux-en-Y Gastric partitioning distal ileum, proximal jejunum Often for bariatric purposes (wt. loss) Wt loss for 12 18 wks with 50 60% excess wt. Loss Roux-en-Y Nutritional Goals: Prevent deficiencies Promote eating, lifestyle changes to maintain losses Mechanical soft diet ~ 3 mo., then solid foods Small amounts 1 oz. To 1 cup Overeating = N & V, reflux Vagotomy Severing all or part of the vagus nerves to the stomach With partial gastrectomy or pyroplasty Significant decrease in acid secretion truncal vagotomy no vagal stimulation to liver, pancreas, other organs, stomach selective vagotomy or parietal cell vagotomy eliminates stimulation to stomach Carcinoma of the Stomach Obstruction and mechanical interference Surgical resection or gastrectomy Prevention of GI cancers: fruits, vegetables, and selenium Increase risk of GI cancers: alcohol, overweight, high salted or pickled foods, inadequate micronutrients Diseases of Stomach Indigestion Acute gastritis from: H. pylori tobacco, chronic use of drugs such as: Alcohol Aspirin Nonsteroidal antiinflammatory agents Indigestion (Dyspepsia) Symptoms Abdominal pain Bloating Nausea Regurgitation Belching Dyspepsia Treatment Avoid offending foods Eat slowly Chew thoroughly Do not overindulge Gastritis Normally gastric & duodenal mucosa protected by: Mucus Bicarbonate (acid neutralized) Rapid removal of excess acid Rapid repair of tissue Gastritis Erosion of mucosal layer Exposure of cells to gastric secretions, bacteria Inflammation & tissue damage Gastritis Helicobacter Pylori (H. pylori) Bacteria, resistant to acid Damages mucosa Treat with bismuth, antibiotics, antisecretory agents Causes ~92% duodenal ulcers; 70% gastric ulcers Atrophic Gastritis Loss of parietal cells in stomach Hypochloria = in HCl production Achlorhydria = loss of HCl production Decrease or loss of intrinsic factor production Malabsorption of vitamin B 12 Pernicious anemia vitamin B 12 injections or nasal spray NAUSEA AND VOMITING Nausea: unpleasant sensation usually preceding vomiting, may have abdominal pain, pallor, sweating, clammy skin Causes: irritating food, infection, radiation, drugs, hormonal changes, surgery, inner ear disorders, distention of the GI tract Vomiting: forceful expulsions of stomach contents through the mouth. Occurs when vomiting reflex in the brain is stimulated. Projectile vomiting- is forceful ejection of stomach contents. Regurgitation- gentle ejection of stomach contents without nausea or retching MNT in NAUSEA/VOMITING Nausea & Vomiting Prolonged vomiting = hyperemesis Loss of nutrients, fluids, electrolytes Dehydration, electrolyte imbalance, wt. loss Medications: Antinauseants Antiemetics Complications and Treatment May lead to dehydration, metabolic alkalosis, aspiration Treatment: Antiemetics( Phenergan, Dramamine, Scopolamine patch Reglan), IV fluids, NG tube, TPN Care: through assessment, keep patient comfortable, offer liquids, position on side, suction setup in the room Goals of MNT in Nausea/Vomiting Decrease the frequency and severity of nausea and/or vomiting Maintain optimal fluid balance and nutritional status Prevent development of anticipatory nausea, vomiting, and learned food aversions MNT for Nausea/Vomiting When vomiting stops, introduce ice chips if older than 3 years of age. If tolerated, start with rehydration beverage or clear liquids, 1 tsp every 10 minutes. Increase to 1 Tbsp every 20 minutes. Double amount of fluid every hour. If diarrhea is present, use only rehydration beverage. Apple juice Sports drink Warm or cold tea Lemonade MNT for Nausea/Vomiting When there has been no vomiting for at least 8 hours, initiate oral intake slowly with adding one solid food at a time in very small increments. Choose the following types of foods: Without odor Low in fat Low in fiber Take prescribed antiemetics and other medications on a regular schedule to assist in prevention of nausea and vomiting. Take all other medications after eating. Nausea/Vomiting: Food and Feeding Issues Keep patient away from strong food odors Provide assistance in food preparation so as to avoid cooking odors Eat foods at room temperature Keep patient's mouth clean and perform oral hygiene tasks after each episode of vomiting Offer fluids between meals Patient should sip liquids throughout the day Cold beverages may be more easily tolerated Keep low-fat crackers or dry cereal by the bed to eat before getting out of bed Nausea/Vomiting: Lifestyle Issues Relax after meals instead of moving around Sit up for 1 hour after eating Wear loose-fitting clothes Provide fresh air with a fan or open window Limit sounds, sights, and smells that may trigger nausea and vomiting Other complementary and alternative medicine interventions that have anecdotal evidence (though clinical trials have not been conducted): Relaxation techniques Acupuncture Hypnosis OBESITY Increase in body weight, 20% over ideal, caused by excessive fat. Morbid obesity twice ideal Causes: heredity, body build, metabolism, psychosocial factors. Calorie intake exceeds demands. Treatment and care Weight reduction diet drug therapy, mainly Amphetamines Surgical procedures: Liposuction Lipectomy Jaw wiring Intragastric balloon Gastric bypass gastroplasty jejunoileal bypass care; assessment, diet monitoring, education DISORDERS AFFECTING ABSORPTION AND ELIMINATION MALABSORPTION CONDITION WHEN ONE OR MORE NUTRIENTS ARE NOT DIGESTED OR ABSORBED multiple causes lactase deficiency sprue: celiac/tropical treatment/care: depends on type lactase- hold milk products celiac sprue- hold gluten products tropical sprue- antibiotics, folic acid DIARRHEA The passage of loose liquid stools with increased frequency, associated with cramping, abd, pain Causes; (many), foods, allergies, infections, stress, fecal impaction, tube feedings, medications Complications- usually temporary/ can be dehydration, malnutrition Treatment/Care Treatment; GI rest, antidiarrheal drugs(Lomotil, Imodium, Kaolin, Aluminum hydroxide) Care: help determine cause, assess VS, weight, skin turgor, abdominal distention, perianal irritation, skin integrity CONSTIPATION HARD DRY INFREQUENT STOOLS PASSED WITH DIFFICULTY Causes: (many),inactivity, ignored urge, drugs, age related changes Complications: straining (Valsalva maneuver) and fecal impaction Treatment/Care Laxatives, suppositorys, enemas for prompt results stool softeners, increase fluids,dietary fiber Care: assessment, monitor fluids and diet, education, check for impaction INTESTINAL OBSTRUCTION Exists when there is obstruction in the normal flow of intestinal contents through the intestinal tract Mechanical- Pressure on the intestinal wall Paralytic- Intestinal musculature unable to propel contents along the bowel May be partial or complete Intestinal obstruction causes SMALL BOWEL: adhesions most common intussusception volvulus paralytic ilieus abdominal hernia LARGE BOWEL: carcinoma diverticulitis inflammatory bowel disorders volvulus Small Bowel vs Large Bowel Small: abdominal pain vomiting pass blood and mucous, no stool, no gas over time signs of dehydration Large: symptoms develop slowly constipation distended abdomen crampy lower abdominal pain fecal vomiting Management of bowel obstruction Small decompression If strangulated then surgery Large surgical resection with formation of colostomy Care: same as gastric surgery, management of NG tube A blind sac attached to the cecum and has no known function. When appendix becomes inflamed If it ruptures, bacteria from appendix can spread to peritoneal cavity. Symptoms- RLQ pain, rebound tenderness, fever, nausea, and vomiting RX - appendectomy APPENDICITIS Inflammation of the appendix appendix has no known function in the body opening becomes obstructed obstruction interferes with the drainage of secretions from the appendix Signs and symptoms Generalized epigastric pain at first that shifts to the RLQ pain at McBurney s point elevated temp, N/V, elevated WBC s( over 10,000) Treatment/Care NPO surgical removal IV s and antibiotics ice pack to the abd. LAXATIVES AND HEAT ARE CONTRAINDICATED Care: pain relief, fluid balance absence of infection, effective breathing PERITONITIS Inflammation of the peritoneum Causes; chemical bacterial contamination S/S pain, rebound tenderness, rigidity, distention, fever, tachcardia, tachypnea, N/V Treatment/Care NG tube, IV fluids, antibiotics, analgesics, surgery if indicated Care; Assessment- VS, pain, abd distention, BS, I/O, monitor cardiac output Celiac Disease Malabsorptive disorder. An allergic reaction to gluten, a protein present in most grains. The villi and microvilli of the small intestine are destroyed therefore preventing the absorption of nutrients. Only treatment is a gluten free diet. Normal villi Celiac Disease villi Crohns Disease Inflammatory disorder A chronic inflammation of the intestines. Ulcers in the intestines. Rectal bleeding, weight loss and fever. It has no known cause. Nuclear imaging or colonoscopy are used to diagnose it. Treatment may include medication, surgery or nutritional supplements. ABDOMINAL HERNIA A protrusion of the intestine through a weakness in the abdominal wall reducible irreducible Inguinal, umbilical, femoral, incisional S/S: smooth lump in the abdomen, usually not painful. If incarcerated, severe pain present Treatment/Care Treatment: Herniorrhaphy (an operation for hernia that involves opening the hernial sac, returning the contents to their normal place, obliterating the hernial sac, and closing the opening with strong sutures). Hernioplasty (the surgical operation to repair a hernia, in which the sac is excised, the abnormal opening is sewn up, and the weakness strengthened, most commonly using a polypropylene mesh). Care; absence of strangulation, monitor activity general surgery interventions with surgery 23/12/ Diverticular disease Saclike mucosal projections protrude through muscular layer of GI tract Projections may trap feces resulting in inflammation, infection, and rupture Seen most in sigmoid and descending colon Diverticular disease Risk factors Physical inactivity Constipation Obesity Smoking NSAID therapy Management Increase fiber intake 23/12/ Diverticulitis Normal bowel flora and fecal material becomes trapped in pouches resulting in inflammation, infection, and obstruction Signs and symptoms Fever Leukocytosis Pain or abdominal tenderness 23/12/ Assessment of diverticular disease Physical examination Questions regarding bowel history Diagnosis Abdominal CT scan Ultrasound 23/12/ Goals of treatment Eliminate bacterial infection Liquid diet advancing to low fiber to allow colon to rest 23/12/ Inflammatory Bowel Disease Ulcerative colitis Chronic inflammatory process Impacts superficial layers of colon walls Wide spread ulceration of colon walls Signs and symptoms Bloody diarrhea Lower left quadrant abdominal pain Weight loss 23/12/ Inflammatory Bowel Disease Ulcerative colitis Diagnosis Sigmoidoscopy Colonoscopy Rectal mucosa biopsy Stool specimens Treatment Oral corticosteroids 5-ASA drugs (5-aminosalicylic acid) Surgery 23/12/ Inflammatory Bowel Disease Crohns disease Chronic inflammatory disorder of the terminal ileum or colon Characterized by inflammation, linear ulcerations, and granulomas Signs and symptoms Diarrhea Fever Abdominal pain Weight loss 23/12/ Inflammatory Bowel Disease Crohns disease Diagnosis Abdominal CT scan Complete blood cell count Barium enema colonoscopy Treatment Oral corticosteroids Surgery 23/12/ Benign and Malignant Tumors Benign tumors or polyps seen in 75% of persons over age 50 Predisposing factors Age Diet Family history Prior diagnosis polyps 23/12/ Benign and Malignant Tumors Malignant tumor 2nd most common malignancy in the United States Increase incidence with age Predisposing factors Family history Inflammatory bowel disease History of colorectal tumors 23/12/ Benign and Malignant Tumors Malignant tumor Signs and symptoms Change in bowel habits Abdominal pain Abdominal mass Anemia Rectal bleeding Weight loss 23/12/ Benign and Malignant Tumors Malignant tumor Diagnostic testing Colonoscopy Carcinoembryonic antigen levels Sigmoidoscopy Fecal occult blood testing Treatment Surgical resection 23/12/ Liver and Biliary Disorders Signs and symptoms Older adults often present with vague, ambiguous symptoms Fatigue Weight loss Anorexia Malaise 23/12/ Liver 4 functions: manufacture (production and excretion of bile), storage(glucose as glycogen, vitamins and minerals), transformation and excretion (phagocyte system-breakdown of RBCs, WBCs and bacteria) of a number of substances involved in metabolism. Liver and Biliary Disorders Risk of disease increases with aging Hepatitis A Hepatitis B Hepatitis B and C Hepatic cysts Common in older adults Typically benign 23/12/ Infectious hepatitis Cause virus Spread through contaminated food or H 2 O Serum Hepatitis Caused by virus found in blood Transmitted by blood transfusion or being stuck with contaminated needles (drug addicts) Health care workers at risk and should be vaccinated Use standard precautions for prevention Liver and Biliary Disorders Metastatic carcinoma Most common liver cancer Highest rates in those aged 5070 Associated with alcohol and tobacco use 23/12/ Liver and Biliary Disorders Metastatic carcinoma Signs and symptoms Jaundice Variceal bleeding (Varices are dilated blood vessels in the esophagus or stomach caused by portal hypertension. They cause no symptoms unless they rupture and bleed, which can be life- threatening.) Ascites (the accumulation of fluid in the peritoneal cavity, causing abdominal swelling.) Right upper quadrant pain Weight loss Enlarged liver 23/12/ Liver and Biliary Disorders Metastatic carcinoma Diagnostic tests Liver function tests Abdominal ultrasound CT scan Liver biopsy Treatment based upon tumor stage and patients health status 23/12/ Chronic progressive disease of the liver Normal tissue replaced by fibrous connective tissue 75% caused by excessive alcohol consumption Biliary tract Gallbladder and duct system. Functions to concentrate and store bile. Liver and Biliary Disorders Gallstones Increased incidence with age 1:3 people over age 70 have gallstones Symptoms Right upper quadrant pain Gas Distention Nausea and vomiting 23/12/ Gallstones Can block the bile duct causing pain in the shoulder blades and digestive disorders and jaundice Small ones may pass on their own, large ones surgically removed Surgical removal of gallbladder = Cholecystectomy Cholecystitis: Inflammation of gallbladder. Liver and Biliary Disorders Gallstones Diagnostic testing Abdominal CT scan Ultrasound Treatment Laparoscopic cholecystectomy Pharmacological dissolution Extracorporeal shock wave lithotripsy Dietary modifications 23/12/ Pancreas Both exocrine and endocrine functions. Exocrine: contributes to the process of digestion by secreting pancreatic enzymes (amylase and others). Endocrine: secretion of insulin, glucagons, somatostatin, polypeptide. Pancreatitis Acute pancreatitis Symptoms Epigastric pain Nausea and vomiting Elevated serum liver function studies Amylase Lipase Bilirubin Alkaline phosphatase 23/12/ Pancreatitis Acute pancreatitis Treatment Nasogastric suction Pain management Hyperalimentation Fluid replacement 23/12/ Pancreatitis Chronic pancreatitis Symptoms Weight loss Diarrhea Diabetes Persistent pain Treatment Behavior modification Surgery 23/12/