SPRUE

A chronic, degenerative disorder resulting from malabsorption of

nutrients from the small intestine characterized by diarrhea, weakness,
weight loss, poor appetite, pallor, muscle cramps, bone pain, ulceration of
the mucous membrane lining the digestive tract, and a smooth, shiny
tongue.

CELIAC SPRUE/DISEASE
- Also known as gluten-sensitive enteropathy, gluten-induced
enteropathy is a genetic, chronic malabsorption disorder that results from
a sensitivity or abnormal immunologic response to protein, particularly
gluten, a protein commonly found in barley, rye, oats, and wheat
(BROW). Upon ingestion of foods containing gluten, changes occur in the
intestinal mucosa or villi that prevent the absorption of foods.

Causes:
• Immunological responses to an environmental factor (gluten)
• Genetic factors (children of North European background; Down’s
syndrome)

Clinical Manifestations: (noticeable bet. 6 – 18 mos. old)

• Steatorrhea
• Deficiency of vitamins A, D, E, and K
• Malnutrition
• Distended abdomen
• Rickets and hypoprothrombinemia may occur
• IDA and hypoalbuminemia
• Anorexia, irritability, poor weight and height gain
• Skinny, with spindly extremities and wasted
buttocks but face may be plump and well-
appearing

Diagnosis:
• serum analysis of antibodies against gluten (IgA antigliadin
antibodies)
 • biopsy of intestinal mucosa (via endoscopy)
• Oral glucose tolerance test = >200 mg/dl
• stool – tested for increased fat content
• observing response to a gluten-free diet: begins to gain weight,
steatorrhea improves, irritability fades

Management:
• Gluten-free diet for life
• Avoid BROW!
o Wheat flour, gravy, soups, sauces
o Packaged and frozen foods
usually contain gluten as fillers
o Favorite school-age foods:
spaghetti, pizza, hotdogs, cake,
cookies
o Birthday cake, turkey stuffing
• Nutritional counseling for parents:
o Be careful shoppers and read food labels
o Small servings
o Create incentives to eat
• Administration of water-soluble forms of vitamins A and D
• Iron and folate supplementation

Evaluation:
The disappearance of steatorrhea is a good indicator that the child’s
ability to absorb nutrient is improving
INFLAMMATORY BOWEL CONDITIONS
Inflammatory Bowel Disease (IBD)
a. Crohn’s disease
b. Ulcerative Colitis

Inflammatory Bowel Disease (IBD)

• A group of chronic disorders resulting in inflammation or ulceration of the bowel
lining
• Cause: unknown
• Triggered by environmental agents (pesticides, food additives, tobacco,
radiation), NSAIDS, allergies, immune disorders
• Predisposing factors:
o 15 -30 y.o. ; 50-70 y.o.
o Genetic

Crohn’s Disease (Regional Enteritis)

• Chronic inflammation of the GIT wall that extends through all layers
• Prevalence: Adolescents or young adults; smokers

Ulcerative Colitis
• A recurrent ulcerative and inflammatory disease of the mucosal and submucosal
layers of colon and rectum
• Prevalence: Caucasians, Jews

Crohn’s Disease Ulcerative Colitis

Part affected Ileum, ascending colon Rectum, colon (mucosal &

(transmural inflammation) submucosal inflammation)

Characteristic of discontinuous continuous

lesion
Predominant Crampy RLQ abdominal Diarrhea, passage of mucus
symptoms pain, diarrhea, steatorrhea, and pus, LLQ pain,
anorexia, weight loss, intermittent tenesmus, rectal
malnutrition, anemia bleeding, anorexia, weight
loss, anemia, fever, vomiting
Complications Intestinal obstruction, perianal Anemia, abscesses, toxic
dse, F&E imbalances, fistulas, megacolon, perforation,
fissures, abscesses bleeding

Risk of increased increased

developing colon
cancer

Other Accompanied by systemic

characteristics manifestations
High mortality rate

Crohn’s Disease (Regional Enteritis)

• Assessment and Diagnostic findings:
 o Proctosigmoidoscopy (rectosigmoid area inflammation)
o Stool examination
▪ (+) occult blood
▪ (+) steatorrhea
o Barium swallow (most conclusive): classic “string sign” on x-ray
o Endoscopy, colonoscopy, intestinal biopsies
o Barium enema: ulcerations, fissures & fistulas
o CT scan: bowel wall thickening and fistula formation
o Decreased Hct and Hgb
o Increased WBC and ESR
o Decreased albumin and protein levels

Ulcerative Colitis
• Assessment and Diagnostic findings:
o Systemic manifestations: tachycardia, hypotension, tachypnea, fever and
pallor
o Stool: (+) for blood
o CBC: low Hct & Hgb, increased WBC
o Low albumin
o Sigmoidoscopy, colonoscopy : inflamed mucosa with exudate and
ulceration
o Barium enema: shortening of bowel
o CT scan, MRI, ultrasound: abscesses and perirectal involvement

Management Goals for IBD

• Reduce inflammation
• Suppress inappropriate immune responses
• Provide rest to the bowel
• Improve quality of life
• Prevent or minimize complications

Management for IBD

• Nutritional Therapy
o Oral fluids
o Low residue, high-protein, high-calorie diet
o Vitamin supplementation
o Iron replacement
o Avoid foods/activities that exacerbate diarrhea
o Parenteral nutrition

• Pharmacologic Therapy
o Sedatives and antidiarrheal agents - peristalsis (rest the bowel)
o Aminosalicylates: sulfasalazine: to decrease inflammation
o Prednisone; hydocortisone; budesonide (Entocortec): if severe and
fulminant
o Immunomodulators: natalizumab (Crohn’s); infliximab (ulcerative colitis)
 • Surgical (Crohn’s disease)
o Laparoscope-guided strictureplasty – the
blocked or narrowed sections of the intestines
are widened, leaving the intestine intact
o Small bowel resection
o Total colectomy with
ileostomy
o Intestinal transplant

• Surgical (Ulcerative colitis)

o Total colectomy with ileostomy
o Proctocolectomy with ileostomy
o Restorative proctocolectomy with
ileal pouch anal anastomosis (IPAA)

NURSING INTERVENTIONS
a. Maintain normal elimination patterns
• Ready access to bathroom, commode, or bedpan
• CFAC of stools
• Bed rest
• Administer anticholinergic agents 30 mins before a meal
b. Relieve pain
• Pain assessment
• Interventions for pain
c. Maintain fluid intake
• Accurate I&O
• Monitor daily weight
• Assess for s/s of FVD
d. Maintain optimal nutrition
• Small frequent feeding
• Parenteral nutrition
• Glucose monitoring
e. Promote rest
• Activity restrictions
• Active or passive ROM exercises
f. Reduce anxiety
g. Enhance coping measures
• Stress reduction techniques
• Counseling
h. Prevent skin breakdown
• Perianal care
• Relieve pressure on bony prominences
i. Monitor and manage potential complications
j. Patient teaching
IRRITABLE BOWEL SYNDROME
• Functional disorder characterized by an abnormally increased motility of the
intestines affecting the frequency of defecation and consistency of stool
• Cause: unknown; no anatomic or biochemical abnormalities
• Factors associated with IBS:
o Heredity
o Psychological stress
o Diet high in fat, stimulating, or irritating foods
o Alcohol consumption
o Smoking

Criteria for Diagnosis

• Recurrent abdominal pain or discomfort for at least 3 days in a month in the past
3 months, including 2 or more of the following:
o Improvement with defecation
o Onset associated with change in frequency of stool
o Onset associated with change in appearance (form) of stool
• No evidence of inflammation or tissue changes in the intestinal mucosa
• Clinical manifestations:
o Alteration in bowel pattern: diarrhea, constipation or both
o Abdominal pain
o Abdominal distention and bloating

Medical Management Goal:

1. Relieve abdominal pain
2. Control diarrhea or constipation
3. Reduce stress

Treatment:
• Hydrophilic colloids and antidiarrheal agents
• Antidepressants
• Anticholinergics or antispasmodics [propantheline (Pro-Banthine)] – to decrease
smooth muscle spasm
• Probiotics (Lactobacillus, Bifidobacterium) – to help decrease abdominal
bloating and gas

Nursing Management
• Teaching good dietary habits: high fiber diet, avoid irritating foods/drinks
(beans, caffeinated products, corn, wheat, dairy lactose, fried foods, alcohol,
spicy foods)
• Symptom and food diary
• Eat at regular times
• Chew food slowly and thoroughly
• Fluids should not be taken with meals to avoid abdominal distention
• Discourage alcohol and cigarette smoking
• Stress management
• Exercise
HEMORRHOIDS
• Dilated portions of veins in the anal canal
• Most common cause of bright-red bleeding
with defecation
What causes hemorrhoids?
• Chronic constipation or diarrhea
• Straining during bowel movements
• Prolonged sitting/standing
• Lack of fiber in the diet
• Weakening of the connective tissue in the
rectum and anus that occurs with age.
• Pregnancy
• Wearing constricting clothing
• Liver cirrhosis, RSHF

Hemorrhoids
• Types:
o Internal hemorrhoids – not painful
o External hemorrhoids – severe pain
o Mixed hemorrhoids
• Itchy, painful
• Prolapsed hemorrhoid can become inflamed and thrombosed

Interventions:
• Good personal hygiene
• Avoid excessive straining upon defecation
• To promote passage of soft, bulky stools:
o Take high-residue diet
o Increase fluid intake
o Hydrophilic bulk-forming agents: psyllium (Metamucil)
• To reduce engorgement:
o Apply cold packs followed by warm sitz bath -to relieve soreness and pain
by relaxing sphincter spasm
o Analgesic ointments
o Suppositories
o Astringents (calamine, witch hazel and zinc oxide) - cause coagulation
(clumping) of proteins in the cells of the perianal skin or the lining of the
anal canal
o Bed rest
o Prone position at intervals
• Patient teaching:
o Set aside a time for bowel movement
o Heed urge to defecate ASAP
o Prevent constipation
o Moderate exercise

Nonsurgical treatment:
• Infrared photocoagulation – use of heat to shrink hemorrhoid
• Bipolar diathermy – use of heat
• Laser therapy –use of heat
• Injection of sclerosing agents
Surgical treatment:
• Rubber-band ligation
• Cryosurgical hemorrhoidectomy – freezing to cause necrosis
• Stapled hemorrhoidopexy – use of surgical staples for prolapsing hemorrhoids
• Hemorrhoidectomy

Rubber-band ligation

Stapled hemorrhoidopexy

• Preop care of client undergoing hemorrhoidectomy

o Low residue diet – to reduce bulk of feces
o Stool softeners
• Postop care for hemorrhoidectomy
o Promote comfort – analgesics as prescribed
o Side-lying or prone position
o Apply ice packs over dressing for first 12 hrs
o Warm sitz bath 12 to 24 hrs postop (best time: after BM)
o Stool softeners, increase fluids, high fiber foods
DIVERTICULAR DISEASE
Types of Diverticular Diseases:
• Diverticulum: saclike herniation of the lining of esophagus/bowel that extends
through a defect in the muscle layer
o Meckel's diverticulum - a pouch on the wall of the
lower part of the intestine that is present at birth
(congenital).
• Diverticulosis: presence of multiple diverticula
• Diverticulitis: results when food and bacteria retained
in a diverticulum produce infection and inflammation

• Cause: unknown
• Predisposing factor: low fiber intake, developed countries, increasing age
• Pathophysiology: high intraluminal pressure, low fiber, decreased muscle
strength
• Manifestations:
o Preceded by chronic constipation
o Mild s/s:
▪ diarrhea
▪ Anorexia, nausea
▪ Bloating
▪ weakness
o Diverticulitis: LLQ pain, fever, leukocytosis

Complications:
Diverticulosis

Accumulation & decomposition

of bowel contents obstruction

Inflammation & infection

Abscess formation

Perforation

Peritonitis bleeding

septicemia

Assessment and Diagnostic findings:

• Colonoscopy
• Barium enema - contraindicated for diverticulitis because of the potential for
perforation
• CT with contrast – test of choice for diverticulitis
• Abdominal x-ray
• CBC: increased WBC
• Elevated ESR
Management:
• Rest
• Diet
o NPO ⇢ Clear liquid ⇢ high fiber, low fat
• Pharmacologic:
o Antibiotics
o Antispasmodics
o Bulk-forming laxatives
o Opioid analgesic
o Stool softeners
o suppository
INTESTINAL OBSTRUCTION
Most common site: small intestine
Most common cause: adhesions, hernias, neoplasms
Most common site for large bowel obstruction: sigmoid colon
Most common causes of large bowel obstruction: carcinoma, diverticulitis, IBD, tumors

A. Small Bowel Obstruction

Clinical Manifestations:
• Crampy, wavelike and colicky abdominal pain
• Passage of blood & mucus; no fecal matter, no flatus
• Vomiting
• S/S of dehydration
• Abdominal distention
• Hypovolemic shock

Medical Management
• Decompression of the bowel
• IVF
• Surgical – depends on cause
o Herniorraphy
o Adhesiotomy
o Bowel resection

Nursing Management
• Monitoring NG drainage
• Assess for F&E imbalances
• Monitor nutritional status
• Assess for improvement

S/S of improvement: return of normal bowel sounds, decreased abdominal

distention, decreased pain, passage of flatus or stool

B. Large Bowel Obstruction

• Can lead to severe distention and perforation
• Undramatic unless blood supply is cut off
• Dehydration occurs more slowly
• Symptoms progress slowly – constipation only
• blood loss results to Iron Deficiency Anemia
 • Fecal vomiting, s/s of shock
• Barium studies are contraindicated

Medical Management
• NG aspiration and decompression
• Colonoscopy – to untwist bowel
• Cecostomy – for relief from obstruction
• Rectal tube for decompression
• Surgical resection
• Colostomy

Nursing Management
– same with small bowel obstruction