Acute Abdominal Pain Lower GI Problems

Acute Abdominal Pain Lower GI Problems Module 2 Acute Abdominal Pain—Etiology • Inflammation – Crohn’s – Appendicitis – Cholecysitis – Colitis, etc. – Vascular • Aneurysm • Gynecological – PID – Ectopic Pregnancy Acute Abdominal Pain—Etiology • Infectious disease – Giardia – Salmonella • Others – Perforation – GI Bleed – Trauma Acute Abdominal Pain—Clinical Manifestations • • • • • • • • Primary—Pain Rebound tenderness Abdominal distention/rigidity N/V Diarrhea Hematemesis Melena Hypovolemic Shock Acute Abdominal Pain—Diagnostic Studies • • • • • • H&P Pelvic/Rectal exam Chemistries, CBC, Stool Abdominal x-ray Pregnancy test r/o ectopic Exploratory lap Acute Abdominal Pain—Nursing 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 Acute Abdominal Pain—Nursing Care-Pre op • CBC, Type and cross match, Chemistries – ABC’s – IV – Consent/NPO Prep – Insert NG ? Acute Abdominal Pain—Nursing 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 • I&O • 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 Abdominal Trauma • Etiology – Blunt • • • • Falls MVA Assault Explosions – Crushing injuries – Penetrating • Knife/Gunshot,etc Abdominal Trauma—Assessment Findings • • • • • • • Hypovolemic shock Open wounds Impailed objects N/V Abdominal distention/rigidity/pain upon palpation Hematuria Rebound pain/Radiating pain Abdominal Trauma—Nursing Care ABC’s, Frequent VS, Monitor for s/s shock O2 Control bleeding-direct pressure Multiple IV’s with large gauge needles (LR) • CBC, Type and cross match, Chemistries, Urine • Foley • • • • Abdominal Trauma—Nursing 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 Irritable Bowel Syndrome (IBS) • Can be acute/chronic • Intermittent and recurrent abdominal pain with an alteration in bowel patterns Irritable Bowel Syndrome (IBS)— Signs/Symptoms • • • • • • Diarrhea and/or constipation Flatuence Abdominal distention/bloating Urgency Stress Food Intolerances Irritable Bowel Syndrome (IBS)Diagnosis • H&P • R/O other GI disorders • Rome criteria-symptom based criteria for IBS 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 Inflammatory Diseases • Appendicitis • Peritonitis • Gastroenteritis Appendicitis • Inflammation of the appendix • Etiology – Obstruction of the lumen by fecalith (accumulation of feces)-most common – Foreign body – Tumor/growth of tissue Appendicitis-Clinical Manifestations • Periumbilical pain • Anorexia, N/V • Pain is persistent eventually shifts to right lower quadrant and localizes at McBurney’s point • McBurney’s Point-Halfway between umbilicus and right iliac crest • Localized and rebound tenderness Appendicitis-Clinical Manifestations • • • • Guarding Client lies still with right leg flexed Low grade fever may/may not be present Rovsing’s sign (Palpate left lower quadrant, pain occurs in right lower quadrant) Appendicitis-Complications • Perforation • Peritonitis • Abscesses Appendicitis-Diagnostic Studies • H&P • Palpation of the abdomen after auscultation • CBC with diff • U/A • R/O other GI disorders • Pregnancy test • Prepare for OR 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 Peritonitis-Pathophysiology • Can be acute or chronic • Body attempts to ―wall off‖ offending agent • Adhesions formed Peritonitis-Clinical Manifestations • • • • • • Abdominal pain Tenderness over involved area Rebound tenderness/muscle rigidity Abdominal distention Fever, tachycardia, tachypnea N/V Peritonitis—Complications • • • • • • Hypovolemic Shock Septicemia Intraabdominal abscess Paralytic ileus Organ failure Death Peritonitis—Diagnostic Studies • • • • • • • • • H&P Auscultation then palpation CBC, Chemistries R/O other GI disease Pregnancy test Peritoneal aspiration X-ray of abdomen US/CT scan Peritonoscopy Peritonitis—Treatment • Identify and eliminate cause • For nonoperative candidate – NGT – Analgesic – Antibiotics – TPN/fluids – Surgery 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 Gastroenteritis • • • • • Usually self limiting NPO IV fluid replacement Antibiotics if indicated Antimicrobials/Anti-infectives 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 – Crohn’s disease Ulcerative Colitis—Pathophysiology • Inflammation/ulceration of colon and rectumbegins 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 Ulcerative Colitis Clinical Manifestations • • • • • Severe tenesmus Rectal Bleeding Cramping Fever-acute attacks Weight loss Ulcerative Colitis Intestinal Complications • Intestinal – Hemorrhage – Stricture-rare – Perforation – Toxic megacolon – Increased risk of colorectal cancer – Anal abscesses-rare Ulcerative Colitis Extraintestinal Complications • • • • • • Peripheral arthritis Ankylosing spondylitis Erythema of skin Aphthous ulcers Conjunctivitis Uvetitis Ulcerative Colitis Diagnostic Studies • H&P • CBC, Chemistries (possible decrease in electrolytes) • Sigmoidoscopy/Colonscopy • Barium enema • Stool for OB, C&S of stool Ulcerative Colitis—Treatment • • • • • • • • 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 Ulcerative Colitis—Treatment • • • • • IV colloids/crystalloids NPO TPN NGT Surgery-can be curative – Proctocollectomy with permanent illeostomy – Proctocollectomy with continent illeostomy— Koch’s pouch – Total collectomy Chrohn’s Disease Pathophysiology • 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 Chrohn’s Disease Clinical Manifestations • • • • • Nonbloody diarrhea Abdominal cramping pain Fever common Severe weight loss Malabsorption and nutritional deficiency common Chrohn’s Disease—Complications • • • • • • • Fistulas common-cardinal feature Strictures common Anal abscess common Perforation Increased risk for colorectal cancer Impaired nutritional absorption Extraintestinal complications similar to Ulcerative colitis Chrohn’s Disease Diagnostic Studies • • • • • H&P Endoscopy with biopsy (granulomas) Barium studies CBC, Chemistries Stool for OB Chrohn’s Disease—Treatment • 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 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 Intestinal Obstruction Pathophysiology • • • • • 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 Intestinal Obstruction Clinical Manifestations Small Intestine • • • • • Rapid onset Frequent vomiting Colicky pain Feces Minimal abdominal distention Intestinal Obstruction Clinical Manifestations Large Intestine • • • • Gradual onset Cramping abdominal pain Absolute constipation Increased abdominal distention Intestinal Obstruction Diagnostic Studies • • • • • Abdominal x-rays-most useful H&P Barium enemas-only if no perforation Endoscopy CBC, Chemistries, BUN, elevated WBC may indicate strangulation • Stool for OB Intestinal Obstruction—Treatment • • • • NGT to decompress bowel Sigmoidoscopy/Colonoscopy IV, TPN Surgery – Resect bowel – Partial/total colectomy – Colostomy – Ileostomy