ULCERATIVE COLITIS

Definition: Is a recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum. Age groups commonly affected are 15 to 40 years of age Cause: Unknown Common among JewishAmericans It has a familial pattern Associated with stress

Pathophysiology: Affects the superficial mucosa of the colon and is characterized by multiple ulceration, diffuse inflammations, and desquamation or shedding of the colonic epithelium. Bleeding occurs as a result of the ulceration. Mucosa becomes edematous and inflamed. Abscess form, and infiltrate is seen in the mucosa and submucosa with clumps of neutrophils in the crypt lumens Bowel narrows, shortens, and thickens because of muscular hypertrophy and fat deposits. Clinical Manifestation: Diarrhea (20 to 30 watery stools per day) Mucous ulceration of the intestine Inflammation starts from the rectum, it ascends until the entire lower colon is affected. Stool with pus, mucous, and blood Abdominal pain Weight loss Anorexia Fever Vomiting Dehydration Feeling of an urgent need to defecate

Diagnostic Test and Findings: Stool is positive for blood Low hematocrit and hemoglobin concentration Elevated white blood cell count Low albumin level Electrolyte imbalance Abdominal x-ray Sigmoidoscopy or colonoscopy Barium enema: show mucosal irregularities, focal strictures or fistulas, shortening of the colon, and dilation of the bowel loops. Endoscopy: reveal friable, inflamed mucosa with exudates and ulceration. CT scanning, Magnetic resonance imaging and ultrasound: can identify abscesses and perirectal involvement Leukocyte scanning: useful when severe colitis prohibits the use of endoscopy to determine the extent of inflammation. Complication: Toxic megacolon, Perforation and bleeding as a result of ulceration, vascular engorgement, and higly vascular granulation tissue Medical Management: Nutritional Therapy - Oral fluids and a low-residue, high-protein, high calorie diet with supplemental vitamin therapy and iron replacement - Any food that exacerbate diarrhea are avoided - Cold foods and smoking are avoided Pharmacologic Therapy - Sedatives, Antidiarrheal and antiperistaltic medication: used to minimize peristalsis to rest the inflamed bowel - Aminosalicylate formulation such as sulfasalazine (Azulfidine): effective for mild or moderate inflammation and are used to prevent or reduce recurrences in long term maintenance regimen. - Antibiotics: used for secondary infections - Corticosteroids: used to treat severe and fulminant disease. - Immunomodulators (eg. Azathioprene, 6-mercaptopurine, methotrexate): used to alter the immune response

 Surgical Management - Total Colectomy and Ileostomy - Intestinal transplant: patient with severe regional enteritis - Proctocolectomy with Ileostomy: recommended when the rectum is severely involved. - Strictureplasty - Fecal diversion

Nursing Management: Careful monitoring Parenteral nutrition Fluid replacement Emergent surgery

-GAMES-

DIVERTICULITIS
Definition: Is acute inflammation and infection caused by trapped fecal material and bacteria in an out pouching of the mucosal lining of the colon. Is most common in the sigmoid colon Cause: Unknown Low intake of dietary fiber is considered a predisposing factor Pathophysiology: Diverticulum forms when the mucosa and submucosal layers of colon herniate through the muscular wall because of high intraluminal pressure, low volume in the colon and decrease muscle strength in the colon. Bowel contents can accumulate in the diverticulum and decompose, causing inflammation and infection.

 Diverticulum can become obstructed and then inflamed if the obstruction continues. Inflammation tends to spread to the surroundings bowel wall, giving rise to irritability and spasticity of the colon. Abscesses develop and may eventually perforate, leading to peritonitis and erosion of the blood vessels with bleeding. Clinical Manifestation: Crampy abdominal pain in the left lower quadrant that worsen with movement, coughing or straining Chronic constipation with episodes of diarrhea Weakness Fatigue Low grade fever Anorexia Nausea and vomiting Abdominal distention and tenderness Occult bleeding Diagnostic Test and Findings: CT Scan: reveal abscesses Abdominal X-ray: demonstrate free air under the diaphragm if a perforation has occurred from the diverticulitis. Colonoscopy: determine the extent of the disease and rule out other conditions Complete blood count: revealing an elevated leukocyte count and elevated sedimentation rate. Complication: Peritonitis, Abscess formation and bleeding. Medical Management: Dietary and Medication Management - Rest, Analgesics - Diet is clear liquid, then high fiber, low fat diet: helps to increase stool volume, decrease colonic transit time, and reduce intraluminal pressure. - Fluid intake of 2,500-3000 mls./day - Antibiotics

Antispasmodics such as propantheline bromide (Pro-banthine) and Oxyphencyclimine (Daricon) - Bulk of laxative - Opioid: for pain relief Surgical Management - One-stage resection in which the inflamed area is removed and primary end-to-end anastomosis is comleted. - Multiple-stage procedure for complication such as obstruction and perforation.

APPENDICITIS
Definition: Is inflammation of the vermiform appendix Most common reason for emergency abdominal surgery Males are affected more than females and teenagers more than adults. Pathophysiology: The appendix becomes inflamed and edematous as a result of either becoming kinked or occluded by a fecalith, tumor, or foreign body. Inflammatory process increase intraluminal pressure, initiating a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours. The inflamed appendix fills with pus. Clinical Manifestation: Vague epigastric or periumbilical pain progress to right lower quadrant pain and usually accompanied by a low-grade fever and nausea and sometimes by vomiting Loss of appetite Local tenderness is elicited at McBurneys point when pressure is applied Rebound tenderness Muscle spasm Constipation or diarrhea Rovsings sign

Diagnostic Test and Findings: Complete blood cell count: elevated white blood cell count, leukocyte count may exceed 10,000 cells/mm3, neutrophil count may exceed 75% Abdominal x-ray, ultrasounds and CT scan: reveal a right lower quadrant density or localized distention of the bowel. Complication: Perforation of the appendix which can lead to peritonitis or an abscess Medical Management: Surgery is indicated if appendicitis is diagnosed Correct or prevent fluid and electrolyte imbalance and dehydration Antibiotics and intravenous fluids are administered until surgery is performed. Analgesics Appendectomy: performed as soon as possible to decrease the risk of perforation.

Nursing Management: Relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection from the potential or actual disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition Prepares the patient for surgery - Intravenous infusion to replace fluid loss and promote adequate renal function - Antibiotic therapy: to prevent infection - NGT is inserted: if there is evidence of paralytic ileus After surgery - Place the patient in a semi-fowler position: reduce tension on the incision and abdominal organs, helping reduce pain - Opioid usually morphine sulfate is prescribe: to relieve pain Instruct the patient to make an appointment to have the surgeon remove the sutures between the fifth and seventh days after surgery. Teach the patient and the family to care for the incision and perform dressing changes and irrigations as prescribe. -GAMES-

PERITONITIS
Definition: Is the inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera. Cause: Bacterial infection Appendicitis Perforated ulcer Diverticulitis Bowel perforation

Pathophysiology: Leakage of contents from the abdominal organs into the abdominal cavity, usually as a result of inflammation, infection, ischemia, trauma, or tumor perforation. Bacterial proliferation occurs Edema of the tissues results and exudation of fluid develops in a short time. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris, and blood. Hypermotility Paralytic ileus with an accumulation of air and fluid in the bowel. Clinical Manifestation: Diffuse type of pain Area of the abdomen becomes extremely tender and distended, and the muscles become rigid Rebound tenderness Paralytic ileus Nausea and vomiting Temperature and pulse rate increase Diagnostic Findings: Leukocyte count is elevated Hemoglobin and hematocrit levels may be low if blood loss has occurred Serum electrolyte studies: reveal altered levels of potassium, sodium and chloride

 Abdominal x-ray is obtained: may show air and fluid levels as well as distended bowel loops. CT Scan of the abdomen: may show abscess formation Peritoneal aspiration and culture and sensitivity studies of the aspirated fluid: reveal infection and identity the causative organisms. Complication: Sepsis Shock may result from septicemia or hypovolemia Two most common postoperative complication - Wound evisceration - Abscess formation Medical Management: Fluid, colloid and electrolyte replacement Administration of several liters of an isotonic solution Analgesics: for pain Antiemetics: for nausea and vomiting Intestinal intubation and suction: assist in relieving abdominal distention and in promoting intestinal function. Oxygen therapy: promote adequate oxygenation Massive antibiotic therapy: Nursing Management: Assessment of pain, vital signs, GI function, and fluid and electrolyte balance Administering analgesic medication Positioning the patient for comfort: decreasing pain Patient is placed on the side with knees flexed: decrease tension on the abdominal organs. Increase fluid and food intake gradually: reduce parenteral fluids

LABORATORY AND DIAGNOSTIC TEST

Liver Biopsy Is the removal of a small amount of liver tissue, usually through needle aspiration. It permits examination of liver cells. Most common indication is to evaluate diffuse disorders of the parenchyma and to diagnose space-occupying lesions. Can be performed percutaneously under ultrasound guidance or transvenously through the right internal jugular vein to right hepatic vein under fluoroscopic control. Preparation: - Secure written consent - NPO 2-4 hrs. - Vit. K injection - Monitor ProTime ; initial VS - Position client to the left side - Instruct client to exhale deeply; hold breath for 5-10 sec. during needle insertion Fat Metabolism Serum total cholesterol and cholesterol esters - Decrease in hepatocellular damage - Increase obstruction Normal range: 140-220 mg/dl Serum Phospholipids Decrease in hepatocellular damage Increase biliary obstruction Normal range: 150-250mg/dl Protein Metabolism Total serum protein - Decrease in hepatocellular damage Immunoglobulins - IgA, IgG- increase liver cirrhosis - IgG- increase in chronic active hepatitis biliary cirrhosis - IgM- increase in hepatitis A BUN - Decrease in severe hepatocellular disease-> obstruction of portal venous flow

 Pro Time: PTT, APTT - Increase in hepatocellular damage Blood ammonia levels - Increase in severe hepatocellular damage - Normal value: 75 ug/dl Bilirubin metabolism Total serum bilirubin - Increase in hepatocellular damage - Nomal value: 0.1- 1 mg/dl Conjugated/ direct bilirubin - Increase biliary obstruction Unconjugated/ Indirect bilirubin - Increase in hemolysis of rbc and hepatocellular damage Urine bilirubin - Increase conjugate bilirubin in urine Urine urobilinogen - Decrease in obstructive biliary disease - Increase in hepatocellular damage - Normal value:0.2-1.2 units Fecal urobilinogen - Increase in hemolysis of rbc - Absence of fecal urobilinogen Serum Enzymes AST/SGOT ALT/SGPT LDH GGT(Gamma Glutamyl Trnspeptidase) - Increase liver cirrhosis is alcohol- induced Alkaline Phosphatase - Slight to moderate elevation - Severe elevation Ultrasound of the liver Preparation - NPO 8-12 hrs.

Laxative the night before the procedure Adequate hydration

Paracentesis Preparation - Secure written consent - initial VS - ask client to empty bladder to prevent puncture - check serum protein studies - place client sitting/ upright position Endoscopic Retrograde Cholangiopancreatgraphy (ERCP) direct visualization with radiographic examination of the liver, gallbladder, and the pancreas. Preparation: - Secure written consent - NPO 10-12 hrs. - Check for allergy to iodine/ seafoods - Take initial VS - At SO4; valium as ordered - Local anesthetic spray into the throat - Place in the left side Other Diagnostic Test Ultrasonography, Computed tomography (CT), Magnetic resonance imaging (MRI): to identify normal structures and abnormalities of the liver and biliary tree. Radioisotope liver scan: assess liver size and hepatic blood flow and obstruction. Laparoscopy (insertion of a fiber-optic endoscope through a small abdominal incision): to examine the liver and other pelvic structures. Used to perform guided liver biopsy, to determine the etiology of ascites, and to diagnose and stage tumors of the liver and other abdominal organs. -GAMES-