MS2

• Irritable Bowel Syndrome


  The presence of abdominal pain with altered bowel habits. It has no known exact etiology.
• It's 1.5-2x more prevalent in women than in men.
• Women are more likely to report abdominal pain & constipation whereas men are more likely to report diarrhea.
• Rome IV Diagnostic Criteria

  Recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following: 1. related to defecation 2. associated with a change in frequency of stool 3. associated with change in form (appearance) of stool. Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
• Irritable Bowel Syndrome occurs at ANY AGE
• Risk factors for Irritable Bowel Syndrome

  • heredity
  • psychological stress
  • conditions such as depression and anxiety
  • diet high in fat & irritating food
  • alcohol consumption
  • smoking
• Clinical Manifestations of Irritable Bowel Syndrome

  • alteration in bowel patterns-constipation, diarrhea, or both
  • pain
  • bloating
  • abdominal distention often accompany this change in bowel pattern
  • abdominal pain is sometimes precipitated by eating & may be relieved by defecation
• Medical Management of Irritable Bowel Syndrome

  • NPO then gradual reintroduction of foods
  • Identify food that may act as irritants (eg, beans, caffeinated products, fried foods, alcohol, spicy foods)
  • High-fiber diet (to help regulate Sx of diarrhea & constipation)
  • Exercise, stress reduction or behavior modification (to help reduce anxiety & increase intestinal motility)
  • Hydrophilic colloids (ie, bulk-forming laxatives) & antidiarrheal agents (eg, loperamide) (to control the diarrhea & fecal urgency)
  • Antidepressants
  • Anticholinergics & Ca-channel blockers (decrease smooth muscle spasm, decreasing cramping and constipation)
• Nursing Management of Irritable Bowel Syndrome

  • A healthy, high-fiber diet (to help control the diarrhea and constipation)
  • Exercise can assist in reducing anxiety & increasing intestinal motility
  • Stress reduction or behavior-modification program
  • Identification of food that causes irritation (eg, beans, caffeinated products, fried foods, alcohol, spicy foods)
  • Hydrophilic colloids (ie, bulk)
  • Antidiarrheal agents (eg, loperamide)
  • Antidepressants (can assist in treating underlying anxiety & depression)
• Examples of Anticholinergics

  • propantheline (Pro-Banthine)
  • atropine (Atropen)
  • hyoscyamine (Buscopan; Levsin)
• Inflammatory Bowel Diseases (IBD) is characterized by repetitive episodes of inflammation of the gastrointestinal tract caused by an abnormal immune response to gut microflora.
• IBD is more prevalent in North America & Europe than in Asia or Africa. They have no specific cause.
• Types of Inflammatory Bowel Diseases

  • Ulcerative colitis: involves diffuse inflammation of the colonic mucosa. It affects the rectum (proctitis), sigmoid (proctosigmoiditis), or the entire colon into the cecum (pancolitis).
  • Crohn disease: results in transmural (entire wall - 4 walls) ulceration of any portion of the GIT most often affecting the terminal ileum & colon.
• Crohn's Disease


  • non-caseating granulomas form involving all layers of the intestinal wall. It develops into the classic cobblestone mucosal appearances & skip lesions along the length of the intestine sparing areas with normal mucosa.
  • affect both the large & the small intestine
  • ulcerations & skipping lesions
• Epidemiology of Crohn's Disease

  • strong link with tobacco use
  • adults: 20-40 years of age
  • Northern Europe & Jewish population (Ashkenazi Jewish)
• Crohn's Disease has cobblestone mucosal appearances
• Ulcerative Colitis


  It is an idiopathic inflammatory condition of the colon which results in diffuse friability (fissuring or splitting) & superficial erosions on the colonic wall associated with bleeding. It involves inflammation restricted to the mucosa & submucosa of the colon. Typically, the disease starts in the rectum & extends proximally in a continuous manner.
• Ulcerative colitis is worse than Crohn's and affects the ENTIRE LENGTH of the colon. It has an absence of Haustra (LEAD PIPE APPEARANCE)
• Epidemiology of Ulcerative Colitis

  • Ulcerative colitis has a greater prevalence in adults than Crohn's Dse
  • Ulcerative colitis is less prevalent in pediatric population than Crohn's disease
  • The main onset of UC peaks between 15 & 30 years
  • A second but smaller peak occurs between 50 and 70 years
• Pathophysiology of Ulcerative Colitis

  The pathophysiology involves defects in the epithelial barrier, immune response, leukocyte recruitment, and microflora of the colon. The epithelial barrier has a defect in colonic mucin, and possibly tight junctions, leading to increased uptake of luminal antigens.
• Severe Ulcerative colitis can have pseudopolyps
• Endoscopic view of milder ulcerative colitis
• Diagnostic Evaluation of Ulcerative Colitis

  • Flexible Proctosigmoidoscopy/Colonoscopy - Clear picture
  • Ba enema "lead-pipe appearance"
  • Hgb and Hct
• Medical Management of Ulcerative Colitis

  • Mild to Moderate Form: 1. Low roughage diet (remove vegetables) with no milk products 2. Drug therapy (Antimicrobials, corticosteroids, anticholinergics, antidiarrheals, immunosuppressants, hematinic agents)
  • Severe form: 1. Client kept NPO with F & E replacement, NGT with suction 2. surgery
• Differences between Crohn's Disease and Ulcerative Colitis

  • Weight loss
  • Treatment (Crohn's: Steroids, Hyperalimentation, partial/complete colostomy & ileostomy or anastomosis; UC: Steroids, partial/complete colostomy, proctocolectomy & ileostomy)
  • History (Crohn's: Deteriorating; UC: Acute Pancreatitis)
  • Areas of Inflammation (Crohn's: Mixed, all 4 layers; UC: Only mucosa & submucosa)
  • Complications (Crohn's: Scarring, obstruction, susceptible to cancer; UC: Continuous inflammation of the colon, only affects inner lining, scarring, susceptible to cancer)
• Acute Pancreatitis


  "Escape" of activated proteolytic (trypsin) & lipolytic enzymes from the pancreas → tissue damage & autodigestion of the pancreas
• Risk Factors for Acute Pancreatitis

  • Biliary tract disease (80% of patients e.g. cholecystitis; cholelithiasis; choledocholithiasis- stone in gallbladder canal or duct)
  • Heavy alcohol intake
  • Infxn: viral or bacterial
• Clinical Manifestations of Acute Pancreatitis


  • left upper quadrant or epigastric abdominal & back pain (occurring 24-48 H after a very heavy meal or alcohol ingestion & difficult to localize)
  • vomiting, shallow respirations, mild jaundice, tachycardia, decrease or absent bowel sounds, hypotension
  • Grey-Turner's spot (flank) & Cullen's sign (Bleeding in periumbilical area)
• Diagnostic Evaluation of Acute Pancreatitis

  • Serum amylase & serum lipase (elevated 3x the normal)
  • Amylase returns to normal within 48-72 H
  • Lipases remains elevated for 7-14 days
  • Leukocytosis (> 16,000 mm3)
  • Hypocalcemia
  • Transient hyperglycemia (>200 mg/dL (>11.1 mmol/L))
  • Serum LDH (>350 IU/L (>350 U/L)) *Elevated
  • AST (>250 U/mL (120 U/L))
  • Stool Exam (bulky,pale, & foul-smelling) - cause no bilirubin pigment
• Medical Management of Acute Pancreatitis

  • NPO
  • Nasogastric suction (to relieve NV, painful abdominal distention, paralytic ileus, and to remove HCI)
  • H2 receptor blockers (ranitidine, nizatidine, famotidine)
  • Proton pump inhibitors (esomeprazole, lansoprazole, omeprazole)
  • AVOID: morphine (could use NUBAIN) & its derivatives. They cause spasm of the sphincter of Oddi
  • Demerol (analgesic of choice)
  • Antiemetic agents (metoclopramide)
• Nursing Diagnoses for Acute Pancreatitis

  • Acute pain related to inflammation, edema, distention of the pancreas, and peritoneal irritation
  • Ineffective breathing pattern related to severe pain, pulmonary infiltrates, pleural effusion, atelectasis, and elevated diaphragm
  • Imbalanced nutrition, less than body requirements, related to reduced food intake & increased metabolic demands
• Nursing Management of Acute Pancreatitis

  • Initially place on NPO (food stimulates activity of pancreas & gall bladder)
  • Insertion of NGT (suctioning)
  • Diet modifications: low fat & low protein. AVOID: caffeine & alcohol
  • CBR (to decrease the metabolic rate & reduce the secretion of pancreatic & gastric enzymes)
  • May place on semi-Fowler's position
  • Monitor serum glucose q4-6H
• Chronic Pancreatitis


  An inflammatory disorder characterized by progressive anatomic and functional destruction of the pancreas. As cells are replaced by fibrous tissue with repeated attacks of pancreatitis, pressure within the pancreas increases. The result is mechanical obstruction of the pancreatic and common bile ducts & the duodenum.
• Etiology of Chronic Pancreatitis

  • Alcoholism (major cause of chronic form; 50x greater than non-alcoholics)
  • Biliary Obstructive Dse (cholelithiasis; choledocholithiasis)
  • Hyperparathyroidism/Cystic Fibrosis
  • Trauma
• Clinical Manifestations of Chronic Pancreatitis

  • Severe upper abdominal & back pain
  • N/V
  • Weight loss (decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack)
  • Abdominal distention with increasing fullness
  • Malabsorption
  • Steatorrhea (fatty stools which are frothy & foul-smelling)
  • Irritability & confusion
• Diagnostic Evaluation of Chronic Pancreatitis

  • Elevated amylase & lipase
  • Leukocytosis
  • Hyperglycemia & glycosuria
  • Hypocalcemia (Leads to TETANY, Chvostek's sign, Trousseau's sign)
  • ERCP (endoscopic retrograde cholangiopancreatography)
• Medical Management of Chronic Pancreatitis

  • Drug Therapy: Meperidine (Demerol), Ca++gluconate - For hypocalcemia, Antibiotics, Antacids
  • Endoscopy (to remove pancreatic duct stones & stent strictures may be effective in selected patients to manage pain & relieve obstruction)
• Surgical Management of Chronic Pancreatitis

  • Pancreaticojejunostomy (also referred to as Roux-en-Y) with a side-to-side anastomosis or joining of the pancreatic duct to the jejunum allows drainage of the pancreatic secretions into the jejunum.
  • Whipple resection (pancreaticoduodenectomy) has been carried out to relieve the pain of chronic pancreatitis.
• Nursing Management of Chronic Pancreatitis

  • During exacerbation to NPO then may progress to clear liquid to regular low-fat diet. Note: TPN while on NPO
  • Eliminate odor & sight of food to decrease pancreatic stimulation
  • Institute nonpharmacologic measures to decrease pain
  • Diet Modification: low fat but high CHO & CHON
  • Position of comfort: fetal position or the knee chest
  • AVOID: alcohol & caffeine
• Cholecystitis


  Inflammation of the gall bladder usually caused by a gallstone in the cystic duct (cholelithiasis). Acute cholecystitis may also result from poor or absent blood flow to the gall bladder (not enough WBC are reaching the area causing infiltration of bacteria).