Grace Mellaine Castillo

BSN 4-1

Identify at least 3 gastrointestinal disease or disorders that needed emergency care. Explain each
disorder/disease including the signs and symptoms, complications, medical/surgical and nursing
interventions.

1. Appendicitis
The appendix is a small, vermiform (i.e., wormlike) appendage about 8 to10 cm (3 to 4 inches) long that
is attached to the cecum just below the ileocecal valve. The appendix fills with byproducts of digestion
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 (i.e., appendicitis).
Appendicitis, the most frequent cause of acute abdomen in the United States, is the most common
reason for emergency abdominal surgery. Although it can occur at any age, it typically occurs between
the ages of 10 and 30 years. Its incidence is slightly higher among males and there is a familial
predisposition (Craig, 2015; NIDDK, 2014a).

Clinical Manifestations
Vague periumbilical pain (i.e., visceral pain that is dull and poorly localized) with anorexia progresses to
right lower quadrant pain (i.e., parietal pain that is sharp, discrete, and well localized) and nausea in
approximately 50% of patients with appendicitis (Craig, 2015). A low-grade fever may be present. Local
tenderness may be elicited at McBurney point when pressure is applied. Rebound tenderness (i.e.,
production or intensification of pain when pressure is released) may bepresent. Rovsing sign may be
elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower
quadrant. If the appendix has ruptured, the pain becomes consistent with peritonitis (see previous
discussion); abdominal distention develops as a result of paralytic ileus, and the patient’s condition
worsens (Craig, 2015; Saccomano & Ferrara, 2013). Constipation can also occur with appendicitis.
Laxatives given in this instance may result in perforation of the inflamed appendix. In general, a laxative
or cathartic should not be given when a person has fever, nausea, and abdominal pain.

Complications
The major complications of appendicitis are gangrene or perforation of the appendix, which can lead to
peritonitis, abscess formation, or portal pylephlebitis, which is septic thrombosis of the portal vein
caused by vegetative emboli that arise from septic intestines. Perforation generally occurs within 6 to 24
hours after the onset of pain and leads to peritonitis (Craig, 2015; Saccomano & Ferrara, 2013).

Medical Management
Immediate surgery is typically indicated if appendicitis is diagnosed (Craig, 2015; Saccomano & Ferrara,
2013). However, conservative nonsurgical medical management for uncomplicated appendicitis (i.e.,
absence of gangrene or perforation of the appendix, empyema or abscess formation, or peritonitis) has
been instituted in some instances with a reduced risk of complications and similar hospital length of stay
as appendectomy (Salminen, Paajanen, Rautio, et al., 2015). To correct or prevent fluid and electrolyte
imbalance, dehydration, and sepsis, antibiotics and IV fluids are given until surgery is performed.
Appendectomy (i.e., surgical removal of the appendix) is performed as soon as possible to decrease the
risk of perforation. It is typically performed using general anesthesia with either a low abdominal
incision (laparotomy) or by laparoscopy. Both laparotomy and laparoscopy are safe and effective in the
treatment of appendicitis with or without perforation. However, recovery after laparoscopic surgery is
generally quicker (Andersson, 2014; Bozkurt, Unsal, Kapan, 2015). For complicated appendicitis (e.g.,
with gangrene or perforation), the patient is typically treated with a 3- to 5-day course of antibiotics
postoperatively (van Rossem, Schreinemacher, Treskes, et al., 2014). Although it had been common
practice for the surgeon to place a surgical drain, recent research findings suggest there is no
improvement in outcomes but longer hospital lengths of stay when drains are used (Cheng, Zhou, Zhou,
et al., 2015). Some patients may have abscess formation that involves the cecum and/or terminal ileum.
In these selected cases, appendectomy may be deferred until the mass is drained. Most commonly,
these abscesses are drained percutaneously or surgically. The patient continues to receive treatment
with antibiotics. After the abscess is drained and there is no further evidence of infection, an
appendectomy is then performed (Ansari, 2014; Craig, 2015).

Nursing Management
Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, preventing or treating
surgical site infection, preventing atelectasis, maintaining skin 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, antibiotic therapy to prevent infection, and administration of
analgesic agents for pain (Saccomano & Ferrera, 2013). An enema is not given because it can lead to
perforation. After surgery, the nurse places the patient in a high Fowler position. This position reduces
the tension on the incision and abdominal organs, helping to reduce pain. It also promotes thoracic
expansion, diminishing the work of breathing, and decreasing the likelihood of atelectasis. The patient is
educated on the use of an incentive spirometer and encouraged to use it at least every 2 hours while
awake. A parenteral opioid (e.g.,morphine) is typically prescribed to relieve pain; this is switched to an
oral agent when the patient is able to tolerate oral fluids and foods. Any patient who was dehydrated
before surgery receives IV fluids. When tolerated, oral fluids are given. Food is provided as desired and
tolerated on the day of surgery when bowel sounds are present. The nurse auscultates for the return of
bowel sounds and queries the patient for passing of flatus. Urine output is monitored to ensure that the
patient is not hampered by postoperative urinary retention and to ensure that hydration status is
adequate. The patient is encouraged to ambulate the day of surgery to reduce risks of atelectasis and
venous thromboemboli (VTE) formation. The patient may be discharged on the day of surgery if the
temperature is within normal limits, there is no undue discomfort in the operative area, and the
appendectomy was performed laparoscopically. Discharge instruction for the patient and family is
imperative. The nurse instructs the patient to make an appointment to have the surgeon remove any
sutures and inspect the wound between 1 and 2 weeks after surgery (Evans & Curtin, 2014). Incision
care and activity guidelines are discussed; heavy lifting is to be avoided postoperatively, although
normal activity can usually be resumed within 2 to 4 weeks. Patients with a gangrenous or perforated
appendix are at greater risk for infection and peritonitis; therefore, they may be kept in the hospital for
several days. Secondary abscesses may form in the pelvis, under the diaphragm, or in the liver, causing
elevation of the temperature, pulse rate, and white blood cell count. When the patient is ready for
discharge, the patient and family are educated about how to care for the incision and perform dressing
changes and irrigations as prescribed. A home care nurse may be needed to assist with this care and to
monitor the patient for complications and wound healing.

2. Celiac Disease
Celiac disease is a disorder of malabsorption caused by an autoimmune response to consumption of
products that contain the protein gluten. Gluten is most commonly found in wheat, barley, rye, and
other grains, malt, dextrin, and brewer’s yeast. Celiac disease has become more common in the past
decade, with an estimated prevalence of 1% in the United States. Women are afflicted twice as often as
men. This disease is more common among Caucasians, although the rates of celiac disease are on the
rise among non-Caucasians. Celiac disease also has a familial risk component, particularly among first-
degree relatives. Others at heightened risk include those with type 1 diabetes, Down syndrome, and
Turner syndrome. Celiac disease may manifest at any age in a person who is genetically predisposed
(Ferrara & Saccamano, 2015; Heavey & Stoltman 2016; NIDDK, 2016a; Robinson, Davis, Vess, et al.,
2015; Roos, Hellstrom, Hallert, et al., 2013).

Clinical Manifestations
The most common GI clinical manifestations of celiac disease include diarrhea, steatorrhea, abdominal
pain, abdominal distention, flatulence, and weight loss. However, these manifestations are more
common among children than adults. Adults can present with non-GI signs and symptoms of celiac
disease, which are highly variable and can include fatigue, general malaise, depression, hypothyroidism,
migraine headaches, osteopenia, anemia, seizures, paresthesias in the hands and feet, and a red, shiny
tongue. Some adults and children may evidence ridges in the 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; it manifests as clusters of erythematous macules that develop into itchy papules and
vesicles on the forearms, elbows, knees, face, or buttocks (Heavy & Stoltman, 2016; NIDDK, 2016a).

Medical Management
Celiac disease is a chronic, noncurable, lifelong disease. There are nodrugs that induce remission; the
treatment is to refrain from exposure to gluten in foods and other products (see later discussion). A
consult with a dietician may be advisable. The patient should be advised that it will likely take time
before bothersome signs and symptoms resolve; indeed, it will take a full year before the integrity of the
intestinal villi can be restored. Other manifestations of celiac disease may require specific, targeted
treatment. For instance, patients who present with anemia may require folate, cobalamin, or iron
supplements (see Chapter 33). Patients with osteopenia may require treatment for osteoporosis (see
Chapter 41) (Ferrera & Saccomano, 2015; Heavey & Stoltman, 2016; Robinson et al.,2015).

Nursing Management
The nurse provides patient and family education regarding adherence to a gluten-free diet (see Chart
47-5), and how to avoid other gluten products. For instance, oats are not contraindicated in gluten-free
diets; however, many oat products are produced in facilities that are cross-contaminated with wheat or
other contraindicated grains. Likewise, gluten-free foods prepared in restaurants or dining areas that
share preparatory space can become gluten-contaminated. For instance, gluten-free toast prepared in a
toaster that is also used for wheat-based toast can become glutencontaminated. Patients must become
vigilant in asking restaurant and dining hall staff about how gluten-free foods are prepared. Products
that are not foods can also contain gluten. Many generic and over-the-counter drugs can be prepared
with gluten gels. Toothpastes, communion wafers, and some cosmetics (e.g., lipsticks) and art supplies
(e.g., modeling clay) can also contain gluten. Patients must understand how to carefully read labels on
both foods and nonfood products to determine if they contain gluten. Since 2013, the U.S. Food and
Drug Administration (FDA) has regulated and monitored the appropriate application of gluten-free labels
(Heavey & Stoltman, 2016; Robinson et al., 2015).

3. Irritable Bowel Syndrome (IBS)

Irritable bowel syndrome (IBS) is a chronic functional disorder characterized by recurrent abdominal
pain associated with disordered bowel movements, which may include diarrhea, constipation, or both
(Lacy et al., 2016; Skrastins & Fletcher, 2016). Global prevalence of IBS is 11.2% (Lacy et al., 2016) and
prevalence among American adults is 15% (NIDDK, 2015). Women are affected more often than men,
with twice as many women diagnosed with IBS in the United States than men. IBS is typically diagnosed
in adults younger than 45 years of age (NIDDK, 2015). A complex interplay of genetic, environmental,
and psychosocial factors are thought to be associated with the onset of IBS. It is believed that some
triggers can either herald the initial onset of IBS or exacerbate symptoms in those with diagnosed IBS;
these may include chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods
(e.g., milk, yeast products, eggs, wheat products, red meat) (Lacy et al., 2016; Zigich & Heuberger, 2013).
The diagnosis of IBS is made after tests confirm the absence of structural or other disorders (Lacy et al.,
2016).

Clinical Manifestations
Symptoms can vary widely, ranging in intensity and duration from mild and infrequent to severe and
continuous. The main symptom is an alteration in bowel patterns: constipation (classified as IBS-C),
diarrhea (classified as IBS-D), or a combination of both (classified as IBS-M for “mixed”). The few patients
with IBS who do not fit any of these three categories of IBS-C, IBS-D, or IBS-M, are classified as IBS-U for
“unknown.” Pain, bloating, and abdominal distention often accompany changes in bowel pattern. The
abdominal pain is sometimes precipitated by eating and is frequently relieved by defecation. IBS
frequently occurs concomitant with other GI disorders, including gastroesophageal reflux disease (GERD)
and with a variety of non-GI functional disorders, including chronic fatigue syndrome, chronic pelvic
pain, fibromyalgia, interstitial cystitis, migraine headaches, anxiety, and depression (Lacy et al., 2016;
NIDDK, 2015).

Medical Management
The goals of treatment are to relieve abdominal pain and control diarrhea or constipation. Lifestyle
modification, including stress reduction, ensuring adequate sleep, and instituting an exercise regimen,
can result in symptom improvement. The introduction of soluble fiber (e.g., psyllium) to the diet
is important to IBS management (Lacy et al., 2016). Restriction and then gradual reintroduction of foods
that are possibly irritating may help determine what types of food are acting as irritants (e.g., beans,
caffeinated products, corn, wheat, dairy lactose, fried foods, alcohol, spicy foods,
aspartame) (Zigich & Heuberger, 2013). For patients with IBS-D, antidiarrheal agents (e.g., loperamide)
may be given to control the diarrhea and fecal urgency. Women with severe IBS-D
that persists for more than 6 months that does not respond to other therapies may be prescribed
alosetron (Lotronex), a highly selective 5-HT3 antagonist that slows colonic motility (Lacy et al. 2016).
Other newer drugs that can mitigate IBS-D symptoms include rifaximin (Xifaxan), a nonabsorbable oral
antibiotic, and eluxadoline (Viberzi, Allergan), a mureceptor agonist/delta-receptor antagonist that
neuromodulates colonic motility (Lembo, Lacy, Zuckerman, et al., 2016). Lubiprostone (Amitiza),
a chloride channel regulator in the gut, can be prescribed for patients with IBS-C (Lacy et al., 2016).
Patients with all types of IBS complain of abdominal pain. This symptom may be mitigated by prescribing
smooth muscle antispasmodic agents (e.g., dicyclomine [Bentyl]). Antidepressants can assist in treating
underlying anxiety and depression but also have secondary benefits. Antidepressants may affect
serotonin levels, thus modulating intestinal transit time and improving abdominal comfort. Peppermint
oil, a complementary medication, has proven effective in diminishing abdominal discomfort (Lacy et al.,
2016). Other alternatives for IBS management include probiotics. Probiotics are bacteria that include
Lactobacillus and Bifidobacterium that can be given to help decrease abdominal bloating and gas (Lacy
et al., 2016).

Nursing Management
The nurse’s role is to provide patient and family education and encourage self-care activities
(Ghiyasvandian, Ghorbani, Zakerimoghadam, et al.,2016) (see Chart 47-3). The nurse may provide
education on the appropriate use of a bowel habit diary, such as the Bristol Stool Form Scale (see Fig.
47-2A). The nurse emphasizes and reinforces good sleep habits and good dietary habits (e.g., avoidance
of food triggers). A good way to identify problem foods is to keep a 1- to 2-week food diary.
Patients are encouraged to eat at regular times and to avoid food triggers. They should understand that
although adequate fluid intake is necessary, fluid should not be taken with meals because this results in
abdominal distention. Alcohol use and cigarette smoking are discouraged. Stress management via
relaxation techniques, cognitive-behavioral therapy, yoga, and exercise can be recommended
(Ghiyasvandian et al., 2016; Skrastins & Fleccher, 2016).