05

Intestinal and
Rectal
Disorders
 Abnormalities of Fecal Elimination
a. constipation – an abnormal infrequency, irregularity of
defecation. Abnormal hardening of stool.
• causes:

• Medications- diuretics, antidepressants, tranquilizers,

aluminum-based antacids, iron preparation
• Rectal/anal disorder
• Neurologic conditions
• Endocrine disorders ( hypothyroidism )
 10 D’s of constipation in the older adult
. Side effects of drugs . Defecatory dysfunction
. Degenerative disease . Decrease dietary intake
. Dementia . Decrease mobility
. Dependence on others . Decrease privacy
for assistance . Dehydration
. Depression
 Pathophysiology
Interference with one of the three major functions of the colon:
• Mucosal transport
• Myoelectric activity
• Processes of defecation
Three Classes of Constipation:
• Functional
• Slow-transit
• Defecatory disorders
 Symptoms
• Fewer that 3 defecation per week
• Straining at stool, abdominal distention, headache, fatigue
• Pain and bloating; a sensation of incomplete evacuation;
and the elimination of small-volume, lumpy, hard, dry stools.
 Management
• Education , Exercise, bowel habit training
• Increase fluid and fiber intake
• Use of laxatives: decusate (colace), bisacodyl ( dulcolax )
polyethelene glycol and electrolytes ( colate)
• Gastrocolic reflex
• Cholinergic agents ( bethanecol)

- increase propulsive motor activity of the large intestine

• Cholinesterase inhibitors (neostegmine)
 Diarrhea
- increase frequency of bowel movements, an increase in the
amount of stool and altered consistency of stool ( increase
liquidity)

causes:
• Infection
• Tube feeding formula
• Malabsorptive disorders
• AIDS ( acquired immuno-deficiency syndrome)
• Medications – stool softeners
• Metabolic and endocrine disorders
 Types of Diarrhea
a. secretory - high volume diarrhea, associated with bacterial
toxins, neoplasm. It is caused by increased
production and secretion of H2O and electrolyte
by the intestinal mucosa into the intestinal
lumen.
b. Osmotic – occurs when water is pulled into the intestine by
the osmotic pressure of unabsorbed particles
c. Malabsorptive – inhibit effective absorption of nutrients
d. Infectious – cause by infectious agents
e. Exudative – caused by changes in mucosal integrity by
radiation or chemotherapy
 Symptoms
• Increase in frequency and fluid content of the stool
• Borborygmus ( rumbling and noise caused by movement of
gas through the intestine )
• Tenesmus ( painful straining with strong urge to defecate )
• Painful spasmodic contraction of the anus
• Voluminous greasy stool – suggest intestinal malabsorption

• Gerontologic consideration:
- older patient become dehydrated quickly and develop
hypokalemia.
 Management
• Loperamide ( Imodium ) – medication of choice
• Lomotil
• IV fluid therapy
• Bed rest and intake of liquid food low in bulk
• To avoid – caffeine, carbonated beverages, very hot and very
cold (it will stimulate intestinal motility)
- restrict milk products, fat, fresh fruits and
vegetables
• Perianal care
 Fecal Incontinence
- involuntary passage of stool from the rectum
Causes:
-Trauma after surgery of the rectum
-Neurologic condition ( stroke, MS, dementia, diabetic
neuropathy )
-Inflammation, infection, radiation, chemotherapy, pelvic
floor relaxation, laxative abuse, advancing age
-Fecal impaction

Management:
- directed towards the cause
- bowel training program
 Celiac Disease
• is a disorder of malabsorption caused by an autoimmune
response to consumption of products that contain the
protein gluten.
• Celiac disease also has a familial risk component,
particularly among first-degree relatives.
 Celiac Disease
• Those who develop celiac disease exhibit an autoimmune
response to gluten products that is both humoral and cell
mediated.
• It is not known what trigger or triggers may incite this
autoimmune response, although it cannot occur if gluten is
not ingested.
• Inflammation of the small intestines
• Losing ability to absorb both micronutrient and
macronutrients.
 Celiac Disease
• Clinical manifestations- diarrhea, steatorrhea, abdominal
pain, abdominal distention, flatulence, and weight loss.
• Enamel of their adult teeth, as well as discoloration or
yellowing.
• Dermatitis herpetiformis is a rash that is frequently
associated with celiac disease in adults.
 Celiac Disease
• Management:

• No drugs that induce remission.

• Refrain from exposure to gluten in foods and other

products.

• Provide patient and family education regarding

adherence to a gluten-free diet
 Peritonitis
• localized or generalized inflammation of the peritoneum.
• in response to acute inflammation, large amount of fluids
shift into the abdominal cavity, blood is shunted to the
involved area, and peristalsis slows or stops. Intestine
become distended with gas and fluid.
 Peritonitis
• Primary peritonitis- spontaneous bacterial peritonitis (SBP)
• Secondary peritonitis- occurs secondary to perforation of
abdominal organs with spillage that infects the serous
peritoneum.
• Tertiary peritonitis- occurs as a result of a suprainfection in
a patient who is immunocompromised.
 Peritonitis
• Causes:

• Ruptured appendix, perforation associated with peptic

ulcer

• Malignancy

• Extension of infection through the wall of hollow organs

like: gallbladder, uterus, urinary bladder
 Peritonitis
• Secondary peritonitis is caused by leakage of contents from
abdominal organs into the abdominal cavity, usually as a
result of inflammation, infection, ischemia, trauma, or tumor
perforation.
 Symptoms
• Local or diffuse abdominal pain, guarding, rigidity
• Distention and absence of bowel sound
• Fever, elevated WBC
• Signs of early shock – tachycardia, tachypnea, restlessness,
weakness, pallor, diaphoresis
 Management
• Fluid and electrolyte replacement, oxygen therapy
• Antibiotic
• Intestinal intubation to relieve distention
• Surgery to correct underlying problem

(common complication post op – evisceration and abscess

formation )
 Appendicitis
• - inflammation of the vermiform appendix
• Symptoms:

• Periumbilical pain, nausea and vomiting

• Rebound tenderness at the McBurney’s point

• Psoas sign – pain that occur upon slow extension of the R

thigh with patient lying on the left side
 Appendicitis
• Appendix becomes inflamed and edematous.
• Inflammatory process increases intraluminal pressure.
• Resulting to edema and obstruction of the orifice.
• Obstruction causes ischemia, bacterial overgrowth and
eventually gangrene/perforation of the appendix.
 Appendicitis
• Obturator sign – pain that occurs with passive internal
rotation of the flexed right thigh with patient in supine
• Fever, leukocytosis
• Rovsing’s sign- elicited by palpating the LLQ

Management:
• appendectomy
 Categories of Bowel Obstruction
a. mechanical
-Adhessions, hernias, tumors
-Fecal impaction
-Strictures of the intestine from IBD
b. nonmechanical
-Paralytic ileus/adynamic ileus ( c0mmon after
abdominal surgery
-MS (multiple sclerosis )
-Hirschsprung’s disease
 Symptoms
• Abdominal pain: crampy, poorly localized
• Frequent high-pitched bowel sounds early; decrease or
absent late in obstruction
• abdominal distention, vomiting, constipation
• Signs of dehydration and fluid shifts
• Hypokalemia and hyponatremia
 Management
• Correct fluid and electrolyte imbalance
• Decompression by means of NGT to relieve distention
• Prevent infection by use of antibiotics to combat bacterial
overgrowth in the bowel
• Elevate the head of the bed to relieve pressure on
abdomen; side lying often comfortable
• NPO with small amount of ice chips for thirst
• Oral and nasal care
 Intestinal Obstruction
• Volvulus
• twisting of the bowel that commonly occurs about a
stationary focus
• Cancer
• Adhession
• Intussusception
• - invagination or telescoping
• common site – ileocecal valve
 Intestinal Obstruction
• Symptoms:
• Currant jelly like stools with mucous and blood

• Palpable sausage-like mass in the upper right quadrant

of the stomach
 Intussusception
• Increasing absence of bowel sound
• Vomiting that is bile stained with a foul odor
• History of a piercing cry, severe abdominal pain and
pulling of legs up to the trunk

Diagnosis:
• Barium enema

Management:
• Manual reduction of the telescoping bowel
• Resection of the affected bowel if the bowel is strangulated
or gangrenous
 Inflammatory Bowel Disease
- consists of immunologically related to disorders of Crohn’s
disease and ulcerative colitis.
 Crohn’s Disease ( Regional Enteritis )
• a chronic nonspecific inflammation of the GI tract wall that
extends through all layer – transmural lesion
• the common site is the terminal ileum characterized by
periods of remission and exacerbation
• inflammation affect all layers of the bowel wall, deep
ulcerations develop “SKIP LESION”
 Pathophysiology
• Begins with crypt inflammation and abscesses, which
develop into small, focal ulcers.
• Cluster of ulcers tend to take on a classic “cobblestone”
appearance.
• Skip lesions- diseased bowel segments are sharply
demarcated by adjoining areas of normal bowel tissue.
• Bowel wall thickens, stricture develops, lumen of the bowel
narrows.
 Symptoms
• Diarrhea, malabsorption of nutrients from the damage
bowel.
• Crampy abdominal pain.
• Abdominal tenderness and spasm.
• Weight loss, malnutrition, and secondary anemia
• Fever, leukocytosis- perforation of intestine → anal
abscesses.
 Crohn’s Disease ( Regional Enteritis )
Dx:
• Barium swallow, endoscopy
• “String sign”
• CT Scan and MRI (preferred/accurate)
Management:
• Nutritional therapy
• TPN when necessary
• Low residue, low-roughage, low fat, high caloric, high protein
 Crohn’s Disease ( Regional Enteritis )
Drug therapy:
• Sulfazalazines, cortecosteroids
• Immunosuppressive
• metronidazole
 Ulcerative Colitis
- characterized by inflammation and ulceration of the colon
and the rectum.
- inflammation starts in the rectum and moves in a
continuous pattern toward the cecum
- multiple ulcerations, inflammations and shedding of the
epithelium
- cause bleeding and diarrhea
- mucosal musculature becomes thickened, shortening of
the colon
 Pathophysiology
• Affects the superficial mucosa of the colon
• Multiple ulcerations, diffuse inflammations, and
desquamation or shedding of the colonic epithelium.
• Ulcerations→ BLEEDING.
• Mucosa→ edematous and inflamed
• Contiguous lesions
• Shortening, narrowing, thickening of colon
 Symptoms
• Predominant symptoms: DIARRHEA, with mucus, pus, or
blood.
• LLQ abdominal pain
• Intermittent tenesmus
• Bleeding (mild or severe) → anemia and fatigue
• Anorexia, weight loss, fever, vomiting, and dehydration.
• Rectal bleeding
 Assessment and Diagnostic Findings
• Abdominal x-ray studies
• Colonoscopy (definitive screening test)
• Biopsy
• CT Scan, MRI, Ultrasound studies
 Management
• Replacement of fluid and electrolyte
• Diet high caloric,high protein, low residue with vitamins and
mineral supplements
• Sulfasalazines the drug of choice
• Metronidazole (flagyl)
• Corticosteroid ( prednisone )
• Total proctocolectomy with Ileostomy
 Surgical Management
• ULCERATIVE COLITIS- proctocolectomy → cures the disease.
• CROHN’S DISEASE- surgical cure not possible.
• Laparoscope-guided strictureplasty- which blocked or
narrowed sections of the intestines are widened.
• Bowel resection
• Intestinal transplant- for CROHN’S DISEASE
• Proctocolectomy with ileostomy- severe Ulcerative Colitis
 Total Colectomy with Ileostomy
• An ileostomy is commonly performed after a total colectomy
and is either temporary or, less commonly, permanent.
• It allows for drainage of fecal matter from the ileum to the
outside of the body.
• The drainage is liquid to unformed and occurs at frequent
intervals.
 Restorative Proctocolectomy With Ileal
Pouch Anal Anastomosis
• is the surgical procedure of choice in cases where the
rectum can be preserved because it eliminates the need for
a permanent ileostomy.
• A temporary diverting loop ileostomy that promotes healing
of the surgical anastomoses is constructed at the time of
surgery and closed about 3 months later
 Ileostomy Care
• Ostomy care
• Prevent infection
• Reduce odor

Dietary Modification:
• Low residue diet that is high in protein, carbohydrates
• Supplemental vitamins A,D,E,K,B12
• Not to eat large meal close to bedtime
• Chew food well
• Limit foods – popcorn, peanuts, vegetable with skin tough
fibrous meats
 Hirschsprung’s Disease
• an obstructive disorder of the colon caused by the absence
of autonomic parasympathetic ganglion cells resulting in
inadequate motility.
• Results in a lack of enervation needed for peristaltic or
propulsive movements
 Hirschsprung’s Disease
Symptoms:
• Failure to pass meconium
• Reluctance to take feedings
• Abdominal distention; stool watery, ribbon or pellet-like
• Bile stained and fecal vomiting
 Hirschsprung’s Disease
Diagnostic Test:
• Barium enema
• Rectal biopsy to check for presence or absence of ganglion
cells
Management:
• for mild defect – administration of stool softeners, isotonic
irrigations to prevent fecal impaction
• colostomy
 Anorectal Disorders
Proctitis
• refers to inflammation of the mucosa of the rectum, which
may be secondary to infection, IBD, or radiation.
• Symptoms include mucopurulent discharge or bleeding,
rectal pain, and diarrhea.
• Sigmoidoscopy is performed to identify portions of the
anorectum involved.
• Antibiotics, Antiamebic therapy
 Anorectal Disorders
Anorectal Abscess
• is caused by obstruction of an anal gland with dried debris,
resulting in retrograde infection.
• Abscess may occur in a variety of spaces in and around the
rectum.
• Complain of dull perianal discomfort and itching, and
increased pain with defecation.
• Incision and Drainage
 Anorectal Disorders
Anal Fistula
• is a tiny, tubular, fibrous tract that extends into the anal
canal from an opening located beside the anus in the
perianal skin.
• Purulent drainage or stool may leak constantly from the
cutaneous opening.
• Surgery- fisculectomy
 Anorectal Disorders
Anal Fissure
• is a longitudinal tear or ulceration in the lining of the anal
canal usually just distal to the dentate line.
• Painful defecation, burning, and bleeding.
• Bright red blood may be seen.
• Treated with conservative measures
 Anorectal Disorders
Hemorrhoids
• are dilated portions of veins in the anal canal.
• Internal hemorrhoids- are also classified by degree of
prolapse. First, Second, Third, Fourth Degree.
• External hemorrhoids- are associated with severe pain from
the inflammation and edema caused by thrombosis
 Anorectal Disorders
• Relieved by good hygiene and by avoiding excessive
straining during defecation.
• High residue diet.
• Non-surgical management- Infrared photocoagulation,
bipolar diathermy, and laser therapy. Sclerotherapy.
• Conservative Surgical Treatment- rubber band ligation,
stapled hemorrhoidopexy
• HEMORRHOIDECTOMY
 Special Diets
CLEAR LIQUID DIET
• limited to water, tea, coffee, clear broths,
• ginger ale, strained and clear juices and plain gelatin
• this diet provides the client with fluid and carbohydrate in
the form of sugar but does not supplement adequate
protein, fats, vitamins, minerals or calories.
• it is short term diet 24 to 36 hours
• *the major objective of this diet is to relieve thirst, prevent
dehydration, minimize stimulation of the GIT
 Special Diets
FULL LIQUID DIET
- diet contains only liquids or foods that turn to liquid at body
temperature, like:

• Ice cream

• Vegetable juices
• Refined or strained cereals
• Yogurt
• milk and milk drinks
 Special Diets
DIET AS TOLERATED
• is ordered when the client’s appetite, ability to eat and
tolerance for certain foods may change.
• Normal intestinal motility has returned with active bowel
sound and client reports passing gas
 Special Diets
ENTERAL NUTRITION
• NGT feeding
• Gastrostomy feeding
• * done to clients at risk for aspiration

• Decrease level of consciousness

• Poor cough, gag reflex

• Inability to participate in feeding , restlessness/agitation

 Total Parenteral Nutrition
• method of supplying nutrients to the body by intravenous
route
Types of Solution:
a. amino acid-dextrose formulas (intralipid – 500 ml of 10% fat
emulsions) fine bacterial filter used

b. total nutrient admixture – amino acid-dextrose-lipid no

bacterial filter used
 Total Parenteral Nutrition
Methods of Administration:
a. peripheral – should not administer dextrose concentrations
above 10% due to irritation of vessel walls, usually used for less
than 2 weeks

b. central – catheter is inserted into subclavian vein

 Total Parenteral Nutrition
Interventions:
• Initial rate of infusion 50ml/hour gradually increased to 100-
125ml.hr as patient’s fluid and electrolyte permits
• Infuse solution by pump at constant rate to prevent abrupt
change in infusion rate.
 Total Parenteral Nutrition
Monitor for signs of complications
- sepsis
- pneumothorax because of placement lines
- hyerosmolar coma – monitor for glucose level and
serum osmolality
 Total Parenteral Nutrition
• Change IV tubing and filter every 24 hours
• Keep solutions refrigerated until needed; allow to warm to
room temperature before use
• If new solution unavailable, use dextrose 10% and water
solution until available
• Monitor daily weights, glucose, temperature, I and O 3times
a week
 Total Parenteral Nutrition
• Discontinuation

• gradually tapered to allow patient to adjust to

decreased levels of glucose

➢ After discontinuation, isotonic glucose solution

administered to prevent rebound hypoglycemia ;
weakness, faintness, diaphoresis, shakiness, confusion,
tachycardia.
 Thank you!
God Bless ☺