University of Babylon



ACUTE INFLAMMATORYINTESTINAL DISORDERSAny part of the lower GI tract is susceptible to acute inflammationcaused by bacterial, viral, or fungal infection.Two such conditions are appendicitis and diverticulitis,both of which may lead to peritonitis, an inflammation of the lining of the abdominal cavity.AppendicitisThe appendix is a small, fingerlike appendage about 10 cm(4 in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (ie, appendicitis)., is the most common reason for emergency abdominal surgery. Although it can occur at any age, it more commonly occurs between the ages of 10 and 30 years (NIH, 2007).PathophysiologyThe appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body. The inflammatory process increases intraluminal pressure, initiating a progressively severe, generalized, or per umbilical pain that becomes localized to the right lower quadrant of the abdomenwithin a few hours. Eventually, the inflamed appendix fills with pus.Clinical ManifestationsVague epigastric or periumbilical pain (ie, visceral pain that is dull and poorly localized) progresses to right lower quadrant pain (ie, parietal pain that is sharp, discrete, and well localized) and is usually accompanied by a low-grade fever and nausea and sometimes by vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tendernessis elicited at McBurney’s point when pressure is applied. Rebound tenderness (ie, production or intensification of pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existence of constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix. If the appendix curls Pain on defecation suggests that the tip of the appendix is resting against the rectum; pain on urination suggests that the tip is near the bladder or impinges on the ureter. Some rigidity of the lower portion of the right rectus muscle may occur. Rovsing’s sign may be elicited bypalpating the left lower quadrant; this paradoxically cause Spain to be felt in the right lower quadrant If the appendix has ruptured, the pain becomes more diffuse;abdominal distention develops as a result of paralytic ileus, and the patient’s condition worsens. Constipation can also occur with appendicitis. Laxatives administered in this instance may result in perforation of the inflamed appendix. In general, a laxative or catharticshould never be given when a person has fever, nausea, and abdominal pain.Assessment and Diagnostic FindingsDiagnosis is based on results of a complete physical examinationand on laboratory findings and imaging studies. The complete blood cell count demonstrates an elevated white blood cell count with an elevation of the neutrophils. Abdominalx-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel. A pregnancy test may be performed for womenof childbearing age to rule out ectopic pregnancy and before x-rays are obtained. A diagnostic laparoscopy may be used to rule out acute appendicitis in equivocal plicationsThe major complication of appendicitis is perforation of theappendix, which can lead to peritonitis, abscess formation(collection of purulent material), or portal pylephlebitis,which is septic thrombosis of the portal vein caused by vegetativeemboli that arise from septic intestines. Perforationgenerally occurs 24 hours after the onset of pain. Symptomsinclude a fever of 37.7_C (100_F) or greater, a toxic appearance,and continued abdominal pain or tenderness.Medical ManagementImmediate surgery is typically indicated if appendicitis is diagnosed.To correct or prevent fluid and electrolyte imbalance,dehydration, and sepsis, antibiotics and IV fluids are administered until surgery is performed. Appendectomy (ie surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. It may be performed using general or spinal anesthesia with a low abdominalincision (laparotomy) or by laparoscopy. Both laparotomy and laparoscopy are safe and effective in the treatment of appendicitis with perforation. However, recoveryafter laparoscopic surgery is generally quicker. Consequently, laparoscopic appendectomy is more common. When perforation of the appendix occurs, an abscess mayform. If this occurs, the patient may be initially treated with antibiotics, and the surgeon may place a drain in the abscess. After the abscess is drained and there is no further evidenceof infection, an appendectomy is then typically performed.Nursing ManagementGoals include relieving pain, preventing fluid volumedeficit, reducing anxiety, eliminating infection due to thepotential or actual disruption of the GI tract, maintainingskin integrity, and attaining optimal nutrition. The nurse prepares the patient for surgery, which includes an IV infusion to replace fluid loss and promote adequate renal function and antibiotic therapy to prevent infection. If there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted. An enema is not administered because it can lead to perforation. After surgery, the nurse places the patient in a semi sitting position.1Gastric and Duodenal UlcersA peptic ulcer is an excavation (hollowed-out area) that forms inthe mucosal wall of the stomach, in the pylorus (opening betweenstomach and duodenum), in the duodenum (first part ofsmall intestine), or in the esophagus. A peptic ulcer is frequentlyreferred to as a gastric, duodenal, or esophageal ulcer, dependingon its location, or as peptic ulcer disease. Erosion of a circumscribedarea of mucous membrane is the cause (Fig. 37-2). Table 37-2 page 1015 differences between duodenal and gastric ulcerStress ulcer is the term given to the acute mucosal ulceration ofthe duodenal or gastric area that occurs after physiologically stressfulevents, such as burns, shock, severe sepsis, and multiple organtraumas.Clinical ManifestationsSymptoms of an ulcer may last for a few days, weeks, or monthsand may disappear only to reappear, often without an identifiablecause. Many people have symptomless ulcers, and in 20% to 30%perforation or hemorrhage may occur without any precedingmanifestations.As a rule, the patient with an ulcer complains of dull, gnawingpain or a burning sensation in the mid epigastrium or in theback. It is believed that the pain occurs when the increased acidcontent of the stomach and duodenum erodes the lesion andstimulates the exposed nerve endings. Another theory suggeststhat contact of the lesion with acid stimulates a local reflex mechanismthat initiates contraction of the adjacent smooth muscle.Pain is usually relieved by eating, because food neutralizes.Sharply localized tenderness can be elicited by applying gentle pressure to theepigastrium at or slightly to the right of the midline.Other symptoms include pyrosis (heartburn), vomiting, constipationor diarrhea, and bleeding. Pyrosis is a burning sensationin the esophagus and stomach that moves up to the mouth.it may be a symptom of a peptic ulcer complication. It resultsfrom obstruction of the pyloric orifice, the passage of tarry stools.Medical ManagementMethods used include medications, lifestyle changes, and surgicalintervention.Currently, the most commonly used therapy in the treatment ofulcers is a combination of antibiotics, proton pump inhibitors,and bismuth salts that suppresses or eradicates H. pylori; histamine2 (H2) receptor antagonists and proton pump inhibitors areused to treat NSAID-induced and other ulcers not associatedwith H. pylori ulcers.STRESS REDUCTION AND RESTReducing environmental stress requires physical and psychologicalmodifications on the patient’s part as well as the aid and cooperationof family members and significant others,SMOKING CESSATIONStudies have shown that smoking decreases the secretion of bicarbonatefrom the pancreas into the duodenum, resulting in increasedacidity of the duodenum.DIETARY MODIFICATIONThe intent of dietary modification for patients with peptic ulcersis to avoid oversecretion of acid and hypermotility in the GI tract.These can be minimized by avoiding extremes of temperatureand overstimulation from consumption of meat extracts, alcohol,coffee (including decaffeinated coffee, which also stimulates acidsecretion) and other caffeinated beverages, and diets rich in milkand cream (which stimulate acid secretion). In addition, an effortis made to neutralize acid by eating three regular meals a day.Small, frequent feedings are not necessary as long as an antacid ora histamine blocker is taken. Diet compatibility becomes an individualmatter: the patient eats foods that can be tolerated andavoids those that produce pain..SURGICAL MANAGEMENTThe introduction of antibiotics to eradicate H. pylori and of H2receptor antagonists as treatment for ulcers has greatly reduced theneed for surgical interventions. However, surgery is usually recommendedfor patients with intractable ulcers (those that fail to healafter 12 to 16 weeks of medical treatmentinclude vagotomy, with or without pyloroplasty, and the Billroth INURSING DIAGNOSESBased on the assessment data, the patient’s nursing diagnoses mayinclude the following:? Acute pain related to the effect of gastric acid secretion ondamaged tissue? Anxiety related to coping with an acute disease? Imbalanced nutrition related to changes in diet? Deficient knowledge about prevention of symptoms andmanagement of the conditionNursing InterventionsRELIEVING PAINPain relief can be achieved with prescribed medications. The patientshould avoid aspirin, foods and beverages that contain caffeine, anddecaffeinated coffee, and meals should be eaten at regularly pacedintervals in a relaxed setting. Some patients benefit from learningrelaxation techniques to help manage stress and pain and to enhancesmoking cessation efforts.REDUCING ANXIETYThe nurse assesses the patient’s level of anxiety. Patients with pepticulcers are usually anxious, but their anxiety is not always obvious.Appropriate information is provided at the patient’s level ofunderstandingMAINTAINING OPTIMAL NUTRITIONAL STATUSThe nurse assesses the patient for malnutrition and weight loss.After recovery from an acute phase of peptic ulcer disease, the patientis advised about the importance of complying with the medicationregimen and dietary restrictionsMONITORING AND MANAGINGPOTENTIAL COMPLICATIONSHemorrhagePerforation and PenetrationPerforation is the erosion of the ulcer through the gastric serosainto the peritoneal cavity without warningPyloric ObstructionPyloric obstruction, also called gastric outlet obstruction (GOO),occurs when the area distal to the pyloric sphincter becomesscarred and stenosed from spasm or edema or from scar tissue ................
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