NCLEX: Gastrointestinal Disorders

Gastrointestinal Disorders: Common GI Disorders

Focus topic: Gastrointestinal Disorders

Gastrointestinal Disorders: Hepatitis, nonviral

Focus topic: Gastrointestinal Disorders

Nonviral hepatitis is an inflammation of the liver that usually results from exposure to certain chemicals or drugs. Most patients recover from nonviral hepatitis, although a few develop fulminating hepatitis or cirrhosis.

What causes it
Causes of nonviral hepatitis include:
• hepatotoxic chemicals, such as carbon tetrachloride, trichlor oethylene, and vinyl chloride
• hepatotoxic drugs such as acetaminophen (Tylenol)
• poisonous mushrooms.

After exposure to a hepatotoxin, hepatic cellular necrosis, scarring, Kupffer’s cell hyperplasia, and infiltration by mononuclear phagocytes occur with varying severity. Alcohol, anoxia, and preexisting liver disease exacerbate the effects of some toxins. Unlike toxic hepatitis, which appears to affect all exposed people indiscriminately, drug-induced hepatitis may begin with a hypersensitivity reaction unique to the individual. Symptoms usually manifest after 2 to 5 weeks of therapy.

What to look for
Look for these signs and symptoms:
• anorexia, nausea, and vomiting
• jaundice
• dark urine
• hepatomegaly
• possibly, abdominal pain
• possibly, clay-colored stools and pruritus (in cholestatic form).

What tests tell you
• Liver biopsy may help identify the underlying disorder, especially if it shows infiltration with WBCs and eosinophils.
• Elevated serum transaminase levels (ALT and AST), total and direct serum bilirubin levels (with cholestasis), alkaline phosphatase levels, and WBC count can all occur in nonviral hepatitis.
• Increased eosinophil levels may occur in drug-induced nonviral hepatitis.

How it’s treated
Effective treatment aims to remove the causative agent by lavage, catharsis, or hyperventilation, depending on the route of exposure. Dimercaprol (BAL in Oil) may serve as an antidote for toxic hepatitis caused by gold or arsenic poisoning, but it doesn’t prevent drug-induced hepatitis caused by other substances. Corticosteroids may be ordered for patients with the drug-induced type of the disorder.

What to do
• Monitor closely for complications of liver failure (bleeding and hepatic coma).
• Ensure adequate hydration and nutrition.
• Relieve the patient’s nausea, pruritus, and abdominal pain.
• Evaluate the patient. He should be able to maintain normal nutrition and hydration, make lifestyle and dietary changes, and seek follow-up care as needed.

Gastrointestinal Disorders

Gastrointestinal Disorders: Hepatitis, viral

Focus topic: Gastrointestinal Disorders

The viral form of hepatitis is an acute inflammation of the liver marked by liver-cell destruction, necrosis, and autolysis. In most patients, hepatic cells eventually regenerate with little or no residual damage. However, old age and serious underlying disorders make complications more likely. The prognosis is poor if edema and hepatic encephalopathy develop.

Types of hepatitis
Five major forms of viral hepatitis are currently recognized, each caused by a different virus:

  • Type A is transmitted almost exclusively by the fecal-oral route, and outbreaks are common in areas of overcrowding and poor sanitation. Day-care centers and other institutional settings are common sources of outbreaks.
  • Type B accounts for 5% to 10% of post-transfusion hepatitis cases in the United States. Vaccinations are available and are now required for health care workers and school children in many states.
  • Type C accounts for about 20% of all viral hepatitis as well as most cases that follow transfusion.
  • Type D, in the United States, is confined to people frequently exposed to blood and blood products, such as I.V. drug users and hemophiliacs.
  • Type E was formerly grouped with type C under the name non-A, non-B hepatitis. In the United States, this type mainly occurs in people who have visited an endemic area, such as India, Africa, Asia, or Central America.

What causes it
All forms of viral hepatitis are caused by hepatitis viruses A, B, C, D, or E.

Despite the different causative viruses, changes to the liver are usually similar in each type of viral hepatitis. Varying degrees of liver cell injury and necrosis occur. These changes in the liver are completely reversible when the acute phase of the disease subsides. A fairly common complication is chronic persistent hepatitis, which prolongs recovery up to 8 months. Some patients also suffer relapses. A few may develop chronic active hepatitis, which destroys part of the liver and causes cirrhosis. In rare cases, severe and sudden (fulminant) hepatic failure and death may result from massive tissue loss.

What to look for
In the preicteric phase, look for:
• fatigue, malaise, arthralgia, myalgia, photophobia, and headache
• loss of appetite, nausea, and vomiting
• altered sense of taste and smell
• fever, possibly with liver and lymph node enlargement.

The icteric phase lasts 1 to 2 weeks. Signs and symptoms include:
• mild weight loss
• dark urine and clay-colored stools
• yellow sclera and skin
• continued hepatomegaly with tenderness.

The convalescent phase lasts 2 to 12 weeks or longer. Signs and symptoms include:
• continued fatigue
• flatulence, abdominal pain or tenderness, and indigestion.

Gastrointestinal Disorders

What tests tell you
• The presence of hepatitis B surface antigens and hepatitis B antibodies confirms a diagnosis of type B hepatitis.
• Detection of an antibody to type A hepatitis confirms past or present infection with type A hepatitis.
• Detection of an antibody to type C confirms a diagnosis of type C hepatitis. Viral load is measured by quantitative polymerase chain reaction assay and is useful in determining need for treatment and monitoring therapy.
• PT is prolonged (more than 3 seconds longer than normal indicates severe liver damage).
• Serum transaminase levels (ALT and AST) are elevated.
• Serum alkaline phosphatase levels are slightly elevated.
• Serum and urine bilirubin levels are elevated (with jaundice).
• Serum albumin levels are low, and serum globulin levels are high.
• Liver biopsy and scan show patchy necrosis.

How it’s treated
The patient should rest in the early stages of the illness and combat anorexia by eating small meals high in calories and protein. (Protein intake should be reduced if signs of precoma — lethargy, confusion, mental changes — develop.) Large meals are usually better tolerated in the morning. Other measures include the following:
• Chronic hepatitis B with liver inflammation is treated with interferon alfa-2b for 16 weeks. Monitoring of blood counts is essential during treatment.
• Lamivudine (Epivir) is another hepatitis B therapy that decreases the viral load of hepatitis B.
• Current therapy for hepatitis C includes interferon or a combined interferon and ribavirin therapy. The decision on how to treat the individual is made after laboratory tests and liver biopsy confirm hepatic inflammation or early cirrhosis. Treatment lasts from 6 to 18 months, based on the outcome and genotype of the virus. The patient needs instruction on self-injection and adverse effects.
• Laboratory tests — including CBC with differential, thyroid studies, liver function tests, and hepatitis quantitative studies — help determine the effectiveness of therapy and prevent complications during treatment. Drug dosages may be reduced if WBC count, hemoglobin level, or hematocrit drop below normal.
• Adverse effects of medication include depression, flu-like syndrome, fatigue, malaise, and GI disturbance.

Patients, take charge!

Focus topic: Gastrointestinal Disorders

• Patients need to be proactive in their treatment to properly monitor and succeed in taking their medication. Current eradication rates of combined therapy in patients with hepatitis C range from 30% to 40%.
• Antiemetics, such as trimethobenzamide or benzq uina mide, given 30 minutes before meals can help relieve nausea and prevent vomiting; the patient shouldn’t take phenothiazines, which have a cholestatic effect. If vomiting persists, the patient needs I.V. infusions
• In severe hepatitis, corticosteroids may give the patient a sense of well-being and may stimulate the appetite while decreasing itching and inflammation; however, their use in hepatitis is controversial.

What to do
• Observe enteric and blood and body fluid precautions for all types of hepatitis. Inform visitors about isolation precautions.
• Give the patient plenty of fluids (at least 4,000 ml/day). Encourage the anorexic patient to drink fruit juices. Also, offer chipped ice and effervescent soft drinks to promote adequate hydration without inducing vomiting.
• Record weight daily, and keep accurate intake and output records.
• Observe the patient’s stool for color, consistency, frequency, and amount.
• Watch for signs of hepatic coma, dehydration, pneumonia, vascular problems, and pressure ulcers.
• Report all cases of hepatitis to health officials. Ask the patient to name anyone he came in contact with recently.
• Evaluate the patient. He should be able to maintain adequate hydration and nutrition, follow appropriate isolation precautions, modify his diet and lifestyle as needed, and obtain appropriate follow-up care. His close contacts also should seek evaluation and possible vaccination.

Gastrointestinal Disorders

Gastrointestinal Disorders: Intestinal obstruction

Focus topic: Gastrointestinal Disorders

In an intestinal obstruction, the lumen of the small or large bowel becomes partly or fully blocked. Small-bowel obstruction is far more common (affecting 90% of patients) and usually more serious. If left untreated, complete obstruction in any part of the bowel can cause death within hours from shock and vascular collapse. Intestinal obstruction is most likely to occur after abdominal surgery or in persons with congenital bowel deformities.

What causes it
Mechanical obstruction can result from:
• adhesions and strangulated hernias (usually small-bowel obstruction)
• carcinomas (usually large-bowel obstruction)
• foreign bodies (fruit pits, gallstones, worms)
• compression
• stenosis
• intussusception
• volvulus of the sigmoid colon or cecum
• tumors
• atresia.

Not mechanically obstructed

Focus topic: Gastrointestinal Disorders

Nonmechanical obstruction can result from:
• electrolyte imbalances
• toxicity
• neurogenic abnormalities
• thrombosis or embolism of mesenteric vessels
• paralytic ileus.

Intestinal obstruction develops in three forms:

  • In a simple obstruction, blockage prevents intestinal contents from passing, with no other complications.
  • In a strangulated obstruction, the blood supply to part or all of the obstructed section is cut off, in addition to blockage of the lumen.
  • When a close-looped obstruction occurs, both ends of a bowel section are occluded, isolating it from the rest of the intestine.

Cause and effect

Focus topic: Gastrointestinal Disorders

All three forms of obstruction cause similar physiologic effects. When intestinal obstruction occurs, fluid, air, and gas collect near the site. Peristalsis increases temporarily as the bowel tries to force its contents through the obstruction, injuring intestinal mucosa and causing distention at and above the site of the obstruction. Distention blocks the flow of venous blood and halts normal absorptive processes. As a result, the bowel begins to secrete water, sodium, and potassium into the fluid pooled in the lumen.

Gastrointestinal Disorders

What to look for
To help detect small-bowel obstruction, take the following steps:
• Assess the patient for colicky pain, nausea, vomiting, and constipation.
• Auscultate for high-pitched, loud, musical, or tinkling bowel sounds; borborygmi; and rushes (occasionally loud enough to be heard without a stethoscope).
• Palpate for abdominal tenderness with moderate distention. Rebound tenderness may occur when obstruction has caused strangulation with ischemia.
• Assess for vomiting of fecal contents in complete obstruction.

Significant signs: Blockage this way

Focus topic: Gastrointestinal Disorders

In large-bowel obstruction, take these steps:
• Assess for constipation in the first few days.
• Look for other signs and symptoms, including colicky abdominal pain, nausea (usually without vomiting at first), and abdominal distention. Eventually, pain becomes continuous and the patient may vomit fecal contents.

What tests tell you
• Abdominal X-rays confirm the diagnosis. They show the presence and location of intestinal gas or fluid. In small-bowel obstruction, a typical “stepladder” pattern emerges, with alternating fluid and gas levels apparent in 3 to 4 hours.
• CT scans rule out obstruction or identify perforation or volvulus.
• In large-bowel obstruction, barium enema reveals a distended, air-filled colon or a closed loop of sigmoid colon with extreme distention (in sigmoid volvulus).
• Early in diagnosis, laboratory results might be normal.

Lab levels: The highs and the lows

Focus topic: Gastrointestinal Disorders

The following laboratory results support a diagnosis of intestinal obstruction:
• Sodium, chloride, and potassium levels are decreased (from vomiting).
• WBC count is slightly elevated (with necrosis, peritonitis, or strangulation).
• Serum amylase level is increased (possibly from irritation of the pancreas).
• ABG analysis indicates metabolic alkalosis, a result of prolonged vomiting.

How it’s treated
Preoperative treatment aims to correct fluid and electrolyte imbalances, decompress the bowel to relieve vomiting and distention, and alleviate shock and peritonitis. Specific treatments might include these measures:
• Strangulated obstruction usually requires blood replacement as well as I.V. fluid administration. Passage of a Levin tube, followed by use of the longer, weighted Miller-Abbott tube, usually accomplishes decompression, especially in small-bowel obstruction.
• Esophagogastroduodenoscopy may be performed to remove obstructive lesions.
• Close monitoring of the patient’s condition determines the duration of treatment. If the patient fails to improve or his condition deteriorates, he’ll require surgery.
• In large-bowel obstruction, surgical resection with anastomosis, colostomy, or ileostomy commonly follows decompression with a Levin tube.
• TPN may be appropriate if the patient suffers a protein deficit from chronic obstruction, postoperative or paralytic ileus, or infection.
• Drug therapy includes analgesics or sedatives, such as meperidine (Demerol) — not opiates, which inhibit GI motility — and antibiotics for peritonitis caused by bowel strangulation or infarction.

• For intussusception, hydrostatic reduction may be attempted by infusing barium into the rectum. If this fails, manual reduction or bowel resection is performed.

What to do
• Monitor the patient’s vital signs frequently. Decreased blood pressure may indicate reduced circulating blood volume due to blood loss from a strangulated hernia. Remember, as much as 10 L of fluid can collect in the small bowel, drastically reducing plasma volume. Observe closely for signs of shock (such as pallor, decreased urine output, rapid pulse, and hypotension).
• Stay alert for signs and symptoms of metabolic alkalosis (including changes in sensorium, hypertonic muscles, tetany, and slow, shallow respirations) or acidosis (including shortness of breath on exertion, disorientation and, later, deep, rapid breathing, weakness, and malaise). Also watch for signs and symptoms of secondary infection, such as fever and chills.
• Monitor urine output carefully to assess renal function and possible urine retention from bladder compression by the distended intestine. If you suspect bladder compression, catheterize the patient for residual urine immediately after he has voided. Also, measure abdominal girth frequently to detect progressive distention.
• Provide thorough mouth and nose care if the patient has undergone decompression by intubation or if he has vomited. Look for signs of dehydration (such as a thick, swollen tongue; dry, cracked lips; and dry oral mucous membranes).
• Record the amount and color of drainage from the decompression tube. If necessary, irrigate the tube with normal saline solution to maintain patency.
• If a weighted tube has been inserted, check periodically to make sure it’s advancing. Help the patient turn from side to side (or walk around, if he can) to promote passage of the tube.
• Keep the patient in Fowler’s position as much as possible to promote pulmonary ventilation and ease respiratory distress from abdominal distention.
• Auscultate for bowel sounds, and watch for signs of returning peristalsis (passage of flatus and mucus through the rectum).
• Evaluate the patient. He should have normal fluid and electrolyte status, adequate oral intake, normal bowel sounds, and regular bowel elimination patterns. He should also be free from abdominal distention and complications.

Gastrointestinal Disorders

Gastrointestinal Disorders: Irritable bowel syndrome

Focus topic: Gastrointestinal Disorders

Also referred to as spastic colon or spastic colitis, irritable bowel syndrome (IBS) is marked by chronic symptoms of abdominal pain, alternating constipation and diarrhea, excess flatulence, a sense of incomplete evacuation, and abdominal distention. IBS is a common, stress-related disorder. About 20% of patients never seek medical attention for this benign condition that has no anatomic abnormality or inflammatory component. It’s twice as common in women as in men.

What causes it
IBS is usually associated with psychological stress but may also result from physical factors, such as:
• ingestion of irritants (coffee, raw fruits or vegetables)
• lactose intolerance
• abuse of laxatives
• hormonal changes (menstruation).

IBS appears to reflect motor disturbances of the entire colon in response to stimuli. Some muscles of the small bowel are particularly sensitive to motor abnormalities and distention; others are particularly sensitive to certain foods and drugs. The patient may be hypersensitive to the hormones gastrin and cholecystokinin. The pain of IBS seems to result from abnormally strong contractions of the intestinal smooth muscle as it reacts to distention, irritants, or stress.

Gastrointestinal Disorders


What to look for
These signs and symptoms alternate with constipation or normal bowel function:
• lower abdominal pain (usually relieved by defecation or passage of gas)
• diarrhea (typically occurring during the day)
• small stools that contain visible mucus
• possible dyspepsia
• abdominal distention.

What tests tell you
• Stool examination for blood, parasites, and bacteria can rule out other disorders.
• Other tests may include sigmoidoscopy, colonoscopy, barium enema, and rectal biopsy.

How it’s treated
• Counseling helps the patient understand the relationship between stress and her illness.
• Strict dietary restrictions don’t help, but food irritants should be investigated and the patient should be instructed to avoid them.
• Rest can also help, as can judicious use of sedatives and antispasmodics (such as diphenoxylate with atropine sulfate or dicyclomine). With chronic use, however, the patient may become dependent on these drugs.
• If IBS results from chronic laxative abuse, the patient may need bowel retraining to help correct the condition.

What to do
Evaluate the patient. She should modify her diet and lifestyle to control or avoid symptoms, demonstrate a regular bowel elimination pattern, understand the need for follow-up care, and know when to seek immediate attention. However, because the patient with IBS isn’t hospitalized, focus your care on patient teaching.

Gastrointestinal Disorders




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