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Adult Medical Surgical Nursing. Gastro-intestinal Module: Conditions of Malabsorption Inflammatory Bowel Disorder: Crohn’s Disease; Ulcerative Colitis. Conditions of Malabsorption. Malabsorption is the inability of the intestinal mucosa to absorb one or more of the major nutrients.

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adult medical surgical nursing

Adult Medical Surgical Nursing

Gastro-intestinal Module:

Conditions of Malabsorption

Inflammatory Bowel Disorder: Crohn’s Disease; Ulcerative Colitis

conditions of malabsorption
Conditions of Malabsorption
  • Malabsorption is the inability of the intestinal mucosa to absorb one or more of the major nutrients
conditions of malabsorption1
Conditions of Malabsorption
  • Infection: gastro-enteritis, amoeba, giardia
  • Post-intestinal surgery (resection)
  • Specific nutrient disorders: lactose intolerance, cystic fibrosis, coeliac
  • Maldigestion of fats (also fat-soluble vitamins ADEK): related to obstruction of bile flow into the intestine
  • Inflammatory bowel disorder: Crohn’s Disease and Ulcerative Colitis
conditions of malabsorption clinical manifestations
Conditions of Malabsorption: Clinical Manifestations
  • Diarrhoea, watery or with blood, mucus and/ or pus
  • Frequent loose bulky offensive stools
  • Pale, grey fatty stools
  • Abdominal distension/ flatulence
  • Weakness, muscle-wasting, weight loss
  • Malnutrition and loss of well-being, dehydration
  • Vitamin deficiency, anaemia, bruising tendency, osteoporosis, osteomalacia
conditions of malabsorption diagnostic tests
Conditions of Malabsorption: Diagnostic Tests
  • History and physical examination
  • Blood: CBC, ESR, CRP, Urea, Electrolytes, LFTs, Plasma proteins
  • Stool: analysis, culture, parasites, 24-hour fat content, Guaic occult blood
  • Endoscopy
  • Colonoscopy
  • Barium or Gastrografin studies
inflammatory bowel disorder
Inflammatory Bowel Disorder
  • A chronic inflammatory condition which may relate to auto-immune disorder
  • There are two major conditions:
  • Crohn’s Disease (regional enteritis)
  • Ulcerative Colitis
  • Both conditions hold a risk for development of colon cancer
crohn s disease pathophysiology
Crohn’s Disease: Pathophysiology
  • Sub-acute/ chronic inflammation of the distal ileum and ascending colon mainly
  • Mucosal ulceration in patches, separated by normal tissue
  • Ulceration may extend through all layers
  • Can cause perforation to the peritoneum
  • Inflammatory process leads to fibrosis, thickening the bowel wall and narrowing the lumen
crohn s disease clinical manifestations
Crohn’s Disease:Clinical Manifestations
  • Abdominal mild colicky pain (cramps from semi-obstruction)
  • Chronic diarrhoea (containing blood, mucus, pus): oedematous inflamed intestine with weeping irritating discharge
  • Weight loss, malnutrition, anaemia (chronic malabsorption), emaciation, dehydration
  • Fever and pain if abscesses
  • Acute severe pain/ shock if perforation
  • Remission and exacerbation
crohn s disease diagnosis
Crohn’s Disease: Diagnosis
  • Blood:
  • ↑ WCC, ESR, CRP (inflammation)
  • ↓ Hb, ↓ plasma proteins (albumen)
  • Electrolyte imbalance
  • Stool: blood, mucus, pus
  • Endoscopy/ colonoscopy: typical ulcerated patches seen
  • Barium or gastrografin studies: “string” sign, stricture/narrowing of intestinal lumen
ulcerative colitis pathophysiology
Ulcerative Colitis: Pathophysiology
  • Chronic inflammatory disease of the mucosa of the colon and rectum (10-15% will develop colon cancer)
  • Ulceration, desquamation and shedding of mucosa, bleeding, pus (severe protein loss)
  • Begins in rectum. May affect whole colon
  • Recurrent lesions, one after the other
  • Strictures and muscular hypertrophy
ulcerative colitis clinical manifestations
Ulcerative Colitis:Clinical Manifestations
  • Abdominal cramp-like pain (rebound tenderness right lower quadrant)
  • Diarrhoea (10-20 liquid stools daily with blood, mucus and pus in stool)
  • Rectal bleeding and urge to defaecate
  • Anorexia, severe weight loss, emaciation, muscle wasting, malnutrition, dehydration, anaemia, hypocalcaemia
  • Erythema, uveitis, arthritis (auto-immune)
ulcerative colitis diagnosis
Ulcerative Colitis: Diagnosis
  • Blood:
  • ↑ WCC, ESR, CRP (inflammation)
  • ↓ Hb, ↓ plasma proteins (serum albumen)
  • Electrolyte imbalance
  • Stool: frequent diarrhoea with pus, blood, mucus
  • Sigmoidoscopy: severe mucosal ulceration and shedding
  • Barium/ Gastrografin: shows shortening and dilatation of bowel (may perforate)
slide15
Inflammatory Bowel Disorder:

(Crohn’s Disease and Ulcerative Colitis)

Management

inflammatory bowel disorder medical treatment
Inflammatory Bowel Disorder: Medical Treatment
  • Rest for the patient and for the bowel (to reduce inflammation and inappropriate immune response)
  • Nutrition and fluid replacement:
  • Encourage oral fluids
  • Intravenous infusion if electrolyte imbalance
  • Low-residue, high protein, high calorie diet as tolerated, with vitamin, minerals
  • Total Parenteral Nutrition (TPN)
inflammatory bowel disorder medications
Inflammatory Bowel Disorder: Medications
  • Medications:
  • Sedatives and antispasmodics to control bowel motility and pain: Diazepam, Codeine Phosphate, Imodium, Buscopan
  • Antibiotics (Sulphonamides) to control secondary infection/ abscesses
  • Corticosteroids (oral and by enema): anti-inflammatory; immunomodulators if severe- lower immune response (Imuran)
inflammatory bowel disorder surgery
Inflammatory Bowel Disorder: Surgery
  • Where conservative treatment fails or complications occur
  • Resection of the affected part of the intestine and ileostomy is performed above as a faecal diversion
  • May be temporary or permanent stoma*
  • May involve pouch of ileum (Kock pouch)
  • Contents of ileostomy drainage are fluid, contain proteolytic enzymes and are irritant to the skin (extreme care needed)
post surgery complications
Post-Surgery Complications
  • Diarrhoea leading to dehydration and electrolyte imbalance: excessive fluid loss through stoma
  • Stomal stenosis/ retraction
  • Peri-stomal irritation/ excoriation (poorly-fitting pouch; proteolytic enzymes in fluid)
  • Psychological/ social implications
  • Renal calculi (dehydration)
  • Gall-stones (change in absorption of bile acids)
inflammatory bowel disorder nursing considerations
Inflammatory Bowel Disorder:Nursing Considerations
  • Emotional support (patient is often depressed)
  • Teaching about fluids, diet, medications, rest
  • Monitoring progress, stool frequency, fluid balance, electrolytes, weight, skin turgor
  • Post-surgery stoma care: check that stoma is pink and moist, no stenosis
  • Skin care: anti-fungal powder or barrier cream
  • Accurate fitting (and avoid frequent changing) of stomahesive patches (proteolytic enzymes)
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