Gastrointestinal Disorders and Management

Medical management for IBD includes corticosteroids to reduce inflammation during acute flares, though they are not used for long-term maintenance. Immunosuppressants and aminosalicylates are often used for long-term control. If complications such as hemorrhage, perforation, or fistulas arise, surgical intervention like a colectomy (removal of the colon) may be necessary.

Mechanical and Functional Disturbances

Bowel Obstruction and Hernias

A bowel obstruction is a blockage that prevents the movement of digestive contents through the intestine. This can be caused by tumors, post-operative adhesions, strictures, or even a paralytic ileus, which is the absence of normal peristalsis (bowel sounds) without a physical blockage. Patients with proximal small-intestine obstructions often present with acute symptoms like projectile vomiting and prominent abdominal distention.

Hernias are another common cause of obstruction. They occur when tissue (such as the small intestine or omentum) protrudes through a defect in the abdominal muscle.

• Reducible Hernias: These can be returned to the abdominal cavity with gentle pressure.
• Incarcerated (Irreducible) Hernias: These cannot be returned to the abdomen and may become strangulated, meaning blood flow to the tissue is impaired. This is a surgical emergency because it can lead to intestinal gangrene and perforation.

Constipation, Diarrhea, and Functional Disorders

Disruptions in bowel regularity can lead to severe systemic issues, including dehydration, electrolyte imbalances, and metabolic acidosis.

• Constipation: While normal frequency varies, severe constipation can lead to fecal impaction (retained stool), hemorrhoids, and megacolon. In megacolon, the large intestine loses effective contraction ability, often requiring urgent surgery.
• Diarrhea: Severe diarrhea can lead to malnutrition and anemia. A critical clinical note is that liquid stool trickling around a hard mass may be mistaken for true diarrhea, but it is actually a sign of fecal impaction.
• Ogilvie’s Syndrome: This is a functional disorder where the bowel resembles an obstruction due to inadequate peristalsis, even though no physical blockage is present.

Malignancy and Ostomy Care

Colorectal Cancer

Colorectal cancer can develop anywhere in the large intestine, but most tumors occur in the rectum or lower sigmoid colon. Clinical presentation often depends on the tumor's location:

• Right-sided tumors: Often present with vague cramping and unexplained anemia due to occult blood loss.
• Left-sided tumors: Often present with changes in bowel habits (diarrhea/constipation), blood in the stool, and "pencil-thin" stools.

The primary treatment is surgical resection. Depending on the extent of the disease, a surgeon may perform a standard colon resection or an abdominoperineal resection, which involves incisions in both the abdomen and the perineum.

Ostomy Management

Surgery for cancer or severe IBD may result in the creation of a stoma. This can be temporary (to allow a diseased segment to heal) or permanent.

• Ileostomy: The small intestine is diverted to the surface; this produces more liquid stool.
• Colostomy: The large intestine is diverted; this produces more formed stool.

Nursing care for ostomy patients is multifaceted, focusing on:

1. Physical Assessment: Monitoring stoma color and assessing skin integrity around the stoma.
2. Psychosocial Support: Addressing anxiety, grief, and body image changes.
3. Patient Education: Teaching the patient how to change appliances, manage diet, and maintain skin care.

Exam Tip: Ostomy Assessment When assessing a new stoma, the color is a critical indicator of viability. A healthy stoma should be pink or red and moist. A pale, dusky, or black stoma may indicate impaired blood flow and requires immediate notification of the surgeon.