LOWER GIInflammatory disorders• Can be in any portion of the bowel• Clostridium difficile (C-diff)– From large doses of antibiotics– On antibiotics for longer than 7 days• Gastroenteritis- inflammation of stomach and small bowel– Pain and Diarrhea– N&V, fever, anorexia, – Tenesmus• persistent spasms of rectum with desire to empty the bowel– Caused by food-borne bacteriaAppendicitis• Causes– Stone that occludes the lumen of the appendix– Bowel swelling, adhesions, kink– Bacterial infection• Symptoms– Acute abdominal pain, comes in waves– Feeling of pressure to pass gas– Pain starts in epigastrium and localizes to R lower quadrant• Rebound tenderness– Guarding of abdomen by drawing up legs– Treatment is appendectomy, before rupture• Never give enema or laxative• Never apply abdominal heat• Assess for rebound tenderness:– Pain is elicited by the sudden release of the fingertips pressing on the abdomen• Assess for pain that abruptly changes and abdomen becomes rigid or board-like– Do not medicate for abdominal pain of unknown origin as it may mask the presence of appendicitisPeritonitis• Peritoneum – Double-layered membrane lining the walls and organs of the abdominal cavity– Filled with 1500 ml of fluid– Lots of nerve endings in peritoneum• Inflammation of peritoneum from perforated colon, fistula, contamination during bowel surgery, ruptured bile duct• Common agents– E-coli– Klebsiella– Pseudomonas• Symptoms– Diffuse or localized pain– Rebound tenderness– Severe rigidity– Board-like abdomen- classic symptom– Distention– Anorexia, N&V–  or absent bowel sounds (ileus)– Fever– Can cause severe systemic problems• Diagnosis– Abdominal flat plate – air in peritoneum, dilated bowel loops–  WBC– Fever– Rebound tenderness and severe pain– Shallow respirations to try not to move which increases pain– N&V• Treatment– Laparotomy to correct perforation or other source of the infection– If abscess forms- surgical draining• Penrose, Jackson-Pratt drain• Systemic Antibiotics not helpful– Incision may be left open to heal by tertiary intention• Drains, packingsInflammatory Bowel Disease Types◦ Crohn’s Disease◦ Ulcerative Colitis Chronic and recurrent◦ Each bout leaves colon more scarred and less able to absorb nutrients  Usually young adults, 15-30 yrs No known cure◦ Treatment is symptomaticCrohn’s• Can involve any part of GI tract, usually terminal ileum or large intestine• Involves all layers of GI mucosa– Less success with surgical treatment– Can resolve in one area and exacerbate in another area of the bowel• Lesions in several segments at same time• Granular lesion on mucosa• Fissures can penetrate the bowel wall• Fistulas connect bowel to other structures, and abcesses• Nutrition probems– Less intestinal absorptive surface– Malabsorption of protein, carbohydrates, fat, and vitamins– Metabolic needs increase due to infection and inflammation- body working harder– Immune system affected, because of poor nutrition so  resistance to infection,  wound healingUlcerative Colitis (UC)• Inflammation –– crypt abscess– secrete purulent discharge- may become necrotic• Involves mucosa and submucosa only• Characterized by profuse watery diarrhea with a combination of blood, mucous, and pus• Often starts in rectum and moves up• Infections cause further inflammation– Perforation of the ulcers can lead to peritonitis• Can lead to cancer of the colon• Usually involves contiguous portions of the bowel- connected• Has remissions and exacerbations• Symptoms– Predominant symptom is rectal bleeding– Inflammation more localized– Better response to surgical treatment– 20 or more stools per day– Colicky pain in lower left quadrant– Can have severe dehydration with  K– Symptoms worse with stress, poor diet, laxatives or antibioticsDrugs and treatment for crohns and UC• Surgical removal of – damaged colon– fistulas – obstruction due to inflammation• For UC – total removal of large intestine with permanent ileostomy• Antibiotics and steroids short term to treat infection and inflammation• Nutritional support- TPN• Exacerbations with remissions are common• Asulfidine: – sulfa, antirheumatic, anti-inflammatory • Glucocorticoids • Immunomodulators– methotrexate– ImuranTeaching points for patient with stoma Enteric coated pills – look in stool Assess skin with each pouch change- up to 6 days May not be able to tolerate some foods◦ If diarrhea or pain eliminate the foods Need to chew food more completely High fiber can cause constipation/obstruction Urolithiasis- more concentrated urine since water is lost in