FECAL INCONTINENCE

Fecal incontinence describes the involuntary passage of stool from the rectum. It is
estimated that over 40% of residents is extended-care facilities and more than 10% of
adults in the community have fecal incontinence. A substantial number of residents in
extended-care facilities have what is termed “double incontinence,” or difficulties with both
urine and stool continence (Shahin & Lohrmann, 2015). Factors that influence fecal
continence include the ability of the rectum to sense and accommodate stool, the amount
and consistency of stool, the integrity of the anal sphincters and musculature, and rectal
motility. It is an embarrassing and socially incapacitating problem that requires a many-
tiered approach to treatment and much adaptation on the patient’s part.

Nursing Alert
Management of double incontinence should include frequent toileting assistance,
identifying patients who may most benefit from targeted toileting programs, and
treating underlying fecal disorders including chronic constipation.

1902
Pathophysiology
Continence is maintained by tonic contraction of the muscles around the rectum. During
defecation, nerves relax the muscles, causing a straightening of the rectoanal angle.
Distension of the rectum causes relaxation of the sphincter. Fecal incontinence is a failure
of this process and can occur for a variety of reasons.

1903
Risk Factors
Fecal incontinence can result from trauma (e.g., after surgical procedures involving the
rectum), neurologic disorders (e.g., stroke, multiple sclerosis, diabetic neuropathy,
dementia), inflammation, infection, chemotherapy, radiation treatment, fecal impaction,
pelvic floor relaxation, laxative abuse, medications, or advancing age (i.e., weakness or loss
of anal or rectal muscle tone).

1904
Clinical Manifestations and Assessment
Patients may have minor soiling, occasional urgency and loss of control, or complete
incontinence. Patients also may experience poor control of flatus, diarrhea, or constipation.
The nurse obtains a thorough health history, including information about previous
surgical procedures, chronic illnesses, dietary patterns, bowel habits and problems, and
current medication regimen. A visual and digital examination of the rectal area is
completed, checking for abnormalities (fecal impaction, hemorrhoids, fissures, and fistulas)
that may be contributing to the incontinence.
Diagnostic studies are necessary because the treatment of fecal incontinence depends on
the cause. A rectal examination and other endoscopic examinations, such as a flexible
sigmoidoscopy, are performed to rule out tumors, inflammation, or fissures. X-ray studies,
such as barium enema, computed tomography (CT), anorectal manometry, and transit
studies, may be helpful in identifying alterations in intestinal mucosa and muscle tone or in
detecting other structural or functional problems.

1905
Medical and Nursing Management
Specific management techniques can help the patient achieve a better quality of life. If fecal
incontinence is related to diarrhea, the incontinence may disappear when diarrhea is treated
successfully. Frequently fecal incontinence is a symptom of a fecal impaction. After the
impaction is removed and the rectum is cleansed, normal functioning of the anorectal area
can resume. If the fecal incontinence is related to a more permanent condition, other
treatments are initiated. Biofeedback therapy can be of assistance if the problem is
decreased sensory awareness or sphincter control. Bowel training programs also can be
effective. Surgical procedures include surgical reconstruction, sphincter repair, or fecal
diversion.
The nurse initiates a bowel training program that involves setting a schedule to establish
bowel regularity. The goal is to help the patient achieve fecal continence. If this is not
possible, the goal should be to manage the problem so the person can have predictable,
planned elimination. Sometimes, it is necessary to use suppositories to stimulate the anal
reflex. After the patient has achieved a regular schedule, the suppository can be
discontinued.

1906
Complications
Fecal incontinence may cause problems with perineal skin integrity. Maintaining skin
integrity is a priority, especially in the debilitated or elderly patient. Incontinence briefs,
although helpful in containing the fecal material, allow for increased skin contact with the
feces and may cause excoriation of the skin. The nurse encourages and teaches meticulous
skin hygiene, and, in the hospital setting, interventions, such as turning the patient every 2
hours and applying barrier creams or sprays to protect the skin, may be warranted.
Continence sometimes cannot be achieved, and the nurse assists the patient and family
to accept and cope with this chronic situation. The patient can use fecal incontinence
devices, which include external collection devices and internal drainage systems. External
devices are special, drainable pouches. They are attached to a synthetic adhesive skin barrier
specially designed to conform to the buttocks. Internal drainage systems can be used to
eliminate fecal skin contact and are useful especially when there is extensive excoriation or
skin breakdown. A rectal catheter is inserted into the rectum and connected to a drainage
system, and stool is collected in order to preserve skin integrity. Rectal catheters are
contraindicated in patients who are postoperative from rectal or prostate surgery, recent
myocardial infarction, rectal mucosal disease, bleeding dyscrasia, and impaired immune
status. It is important to consider that at present, long-term consequences of indwelling
fecal collectors have not been studied yet, although some research suggests that some
commercially available catheters may be safe for upward of 30 days. A provider’s order is
required to place these devices.

1907
IRRITABLE BOWEL SYNDROME
IBS is one of the most common GI conditions. Approximately 11% of adults globally
report classic symptoms of IBS (Canavan, West, & Card, 2014). Roughly 30% of patients
with IBS will consult a health care provider for their symptoms, and patients with IBS have
a higher likelihood of other functional GI disorders than those in the general population
(Canavan et al., 2014). There is no current evidence that patients with IBS have an
increased mortality risk, yet this disorder disrupts daily life for millions of people
(Grundmann & Yoon, 2014).

1908
Pathophysiology
IBS results from a functional disorder of intestinal motility. The change in motility may be
related to neuroendocrine dysregulation, infection or irritation, or a vascular or metabolic
disturbance. The peristaltic waves are affected at specific segments of the intestine and in
the intensity with which they propel the fecal matter forward. There is no evidence of
inflammation or tissue changes in the intestinal mucosa.

1909
Risk Factors
Although no anatomic or biochemical abnormalities have been found that account for the
common symptoms, various factors are associated with the syndrome: heredity, a diet high
in fat and stimulating or irritating foods, alcohol consumption, smoking, and psychological
stress or conditions such as depression and anxiety. As many as 90% of people diagnosed
with IBS present with symptoms of major depression, and it is now suggested that
psychotherapy and some antidepressant medications may, in fact, help with symptoms of
IBS (Ford et al., 2014).
IBS occurs more commonly in women than in men (Grundmann & Yoon, 2014).

1910
Clinical Manifestations and Assessment
There is a wide variability in symptom presentation. Symptoms range in intensity and
duration from mild and infrequent to severe and continuous. The primary symptom is an
alteration in bowel patterns—constipation, diarrhea, or a combination of both. Pain and
abdominal distention often accompany changes in bowel pattern. Sometimes the
abdominal pain is precipitated by eating, and frequently it is relieved by defecation.
A definite diagnosis of IBS requires tests that confirm the absence of structural or other
disorders. Stool studies, contrast x-ray studies, and proctoscopy may be performed to rule
out other colon diseases. Barium enema and colonoscopy may reveal spasm, distention, or
mucus accumulation in the intestine (Fig. 24-1). Manometry and electromyography
(EMG) are used to study intraluminal pressure changes generated by spasticity.

1911
Medical and Nursing Management
The goals of treatment are relieving abdominal pain, controlling the diarrhea or
constipation, and reducing stress. 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, fried foods, alcohol, and spicy foods). A high-fiber diet is
prescribed to help control the diarrhea and constipation. Exercise can assist in reducing
anxiety and increasing intestinal motility. Patients often find it helpful to participate in a
stress reduction or behavior modification program. Hydrophilic colloids (i.e., bulk) and
antidiarrheal agents (e.g., loperamide [Imodium]) may be given to control the diarrhea and
fecal urgency. Antidepressants can assist in treating underlying anxiety and depression.
Anticholinergics (e.g., propantheline [Pro-Banthine]) may be taken to decrease smooth
muscle spasm, thus decreasing cramping and constipation.

FIGURE 24-1 In irritable bowel syndrome (IBS), the spastic contractions of the bowel can be seen on
x-ray contrast studies.

Research is ongoing to continue to identify pharmacologic and psychological therapies,

including hypnotherapy and cognitive behavioral therapy to lessen the impact of IBS in
patients. Current therapies, including antidepressants, hypnotherapy, and various forms of
psychotherapy, all are potential effective treatments for IBS (Ford et al., 2014). The role of
alternative and complementary therapies for the treatment of IBS is increasing, and research
into alternative therapies, such as acupuncture, is ongoing (Halland & Talley, 2013).
The nurse’s role is to provide patient and family education. The nurse emphasizes

1912
teaching and reinforces good dietary habits. Patients are encouraged to eat at regular times
and to chew food slowly and thoroughly. 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 cigarettes should be avoided.

Nursing Alert
The key to treating IBS in patients is to treat each patient as an individual. Nursing
care plans should include interventions that are based on that patient’s unique and
individual symptoms blending both pharmacologic and psychological-based
interventions specific to that particular patient.

1913
MALABSORPTION
Malabsorption is the inability of the digestive system to absorb one or more of the major
vitamins (especially A and B12), minerals (i.e., iron and calcium), and nutrients (i.e.,
carbohydrates, fats, and proteins). Interruptions in the complex digestive process may occur
anywhere in the digestive system and cause decreased absorption.

1914
Pathophysiology
The conditions that cause malabsorption can be grouped into the following categories:
Mucosal (transport) disorders causing generalized malabsorption (e.g., celiac sprue,
regional enteritis, radiation enteritis)
Infectious diseases causing generalized malabsorption (e.g., small bowel bacterial
overgrowth, tropical sprue)
Luminal disorders causing malabsorption (e.g., bile acid deficiency, Zollinger–Ellison
syndrome, pancreatic insufficiency)
Postoperative malabsorption (e.g., after gastric or intestinal resection)
Disorders that cause malabsorption of specific nutrients (e.g., disaccharidase deficiency
leading to lactose intolerance)
Table 24-2 lists the clinical and pathologic aspects of malabsorptive diseases.

1915
Risk Factors
Risk factors predisposing people to malabsorption include any process that interferes with
the body’s ability to absorb nutrients. These can include pathologic factors, including
abdominal diseases or deformities, surgery, radiation therapy, and certain medications that
inhibit bacterial growth within the intestine (antibiotics). Bodily fluid losses, from such
things as polyuria, emesis, wound drainage, or diarrhea, can decrease absorption. Finally,
use of medications, such as mineral oil or laxatives, can decrease absorption by increasing
peristalsis.

1916
Clinical Manifestations and Assessment
The hallmarks of malabsorption syndrome are diarrhea or frequent, loose, bulky, foul-
smelling stools that have increased fat content and often are grayish in color. Patients often
have associated abdominal distention, pain, increased flatus, weakness, weight loss, and a
decreased sense of well-being. The chief result of malabsorption is malnutrition, manifested
by weight loss and other signs of vitamin and mineral deficiency (e.g., easy bruising
[vitamin K deficiency], osteoporosis [calcium deficiency], anemia [iron, vitamin B12
deficiency]).
Patients with a malabsorption syndrome, if untreated, become weak and emaciated
because of starvation and dehydration. Failure to absorb the fat-soluble vitamins A, D, and
K causes a corresponding avitaminosis (chronic or long-term vitamin deficiency).
Several diagnostic tests may be prescribed, including stool studies for quantitative and
qualitative fat analysis, lactose tolerance tests, D-xylose absorption tests (absorption of
sugar), and Schilling tests (B12 deficiency). The hydrogen breath test that is used to evaluate
carbohydrate absorption is performed if carbohydrate malabsorption is suspected. This test
requires the patient to be fasting before he or she ingests 25 g of carbohydrate dissolved in
water. Exhaled breath is assayed for hydrogen content at baseline and at specific intervals
for several hours. Since hydrogen is not a normal product of human metabolism, any
increase in breath hydrogen concentration suggests bacterial fermentation and indicates
that unabsorbed carbohydrate has reached an area with high concentrations of intraluminal
bacteria, typically the colon (Schiller & Sellin, 2016).
Endoscopy with biopsy of the mucosa is the best diagnostic tool. Biopsy of the small
intestine is performed to assay enzyme activity or to identify infection or destruction of
mucosa. Ultrasound studies, CT scans, and x-ray findings can reveal pancreatic or intestinal
tumors that may be the cause. A CBC is used to detect anemia. Pancreatic function tests
can assist in the diagnosis of specific disorders.

1917
Medical and Nursing Management
Intervention is aimed at avoiding dietary substances that aggravate malabsorption and at
supplementing nutrients that have been lost. Common supplements are water-soluble
vitamins (e.g., B12, folic acid), fat-soluble vitamins (e.g., A, D, and K), and minerals (e.g.,
calcium, iron). Primary disease states may be managed surgically or medically. Dietary
therapy is aimed at reducing gluten intake in patients with celiac sprue. Folic acid
supplements are prescribed for patients with tropical sprue (see Table 24-2). Sometimes
antibiotics (e.g., tetracycline [Tetracap, Tetracyn], ampicillin [Polycillin]) are needed in the
treatment of tropical sprue and bacterial overgrowth syndromes. Antidiarrheal agents may
be used to decrease intestinal spasms. Parenteral fluids may be necessary to treat
dehydration.
The nurse provides patient and family education regarding diet and the use of
nutritional supplements. It is important to monitor patients with diarrhea for fluid and
electrolyte imbalances. The nurse conducts ongoing assessments to determine whether the
clinical manifestations related to the nutritional deficits have abated. Patient education
includes information about the risk of osteoporosis related to malabsorption of calcium
(refer to Chapter 41 for information on osteoporosis).

Pathophysiology Alert
Patients who are severely malnourished are at a higher risk of developing refeeding
syndrome if fed too rapidly. Excessively high dextrose administration (e.g., PPN,
TPN) stimulates insulin release, which rapidly lowers phosphorus, magnesium, and
potassium in the blood (due to intracellular shift and use in carbohydrate metabolic pathways).
The hyperinsulinemia also tends to cause sodium and fluid retention. Thiamine also is consumed
with high carbohydrate loads. The combination of fluid and sodium retention, decrease in blood
electrolyte levels (which can cause arrhythmias), and hypermetabolism due to increased calories
can result in heart failure. Thus, the complications of refeeding syndrome can include a variety of
fluid and electrolyte disturbances, which can include hypoglycemia, cardiac arrhythmias, and
death. Risk factors for refeeding syndrome include pre-existing malnutrition, electrolyte depletion,
or alcoholism, and after prolonged periods of intravenous hydration therapy (e.g., 5% dextrose)
without nutrition support (Chiappetta & Stein, 2016).

TABLE 24-2 Characteristics of Diseases of Malabsorption

1918
TABLE 24-3 Malabsorption of Nutrients, Water, and Electrolytes

1919
1920
Complications
Complications are related to the underlying disease causing the malabsorption. Depending
on the etiology, medical management may include the administration of corticosteroids
(for regional enteritis), which may cause a host of adverse effects, such as hypertension,
hypokalemia, insomnia, and euphoria. Antibiotics may reduce vitamin K–producing
intestinal flora, resulting in a prolonged prothrombin time (PT) and international
normalized ratio (INR) if the patient is concurrently taking warfarin (Coumadin). Refer to
Table 24-3 for clinical manifestations of malabsorption.

ACUTE INFLAMMATORY CONDITIONS

1921
Appendicitis
The appendix is a small, finger-like appendage about 10 cm (4 in) long that is attached to
the cecum just below the ileocecal valve. The appendix fills with food 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 is the most common reason for emergency abdominal surgery, with an
incidence rate in the overall population of 7% to 14% in (Flum, 2015). The disease is most
common in patients between 10 and 30 years of age, with a higher incidence in men than
women (Flum, 2015).

1922
Pathophysiology
The appendix becomes inflamed and edematous as a result of becoming kinked or occluded
by a fecalith (i.e., hardened mass of stool), tumor, or foreign body. The inflammatory
process increases intraluminal pressure, initiating a progressively severe, generalized or
periumbilical pain that becomes localized to the right lower quadrant of the abdomen
within a few hours. Eventually, the inflamed appendix fills with pus.

1923
Risk Factors
Appendicitis is most prevalent in the young, but it can occur at any age. Most cases appear
in the winter months although no clear reason as to why has been established. Having a
family history of appendicitis may increase a child’s risk for the illness, especially in males,
and having cystic fibrosis also seems to put a child at higher risk (Lavelle et al., 2015).

1924
Clinical Manifestations and Assessment
Vague epigastric or periumbilical pain progresses to right lower quadrant pain and usually
is accompanied by a low-grade fever and nausea and, sometimes, vomiting. Loss of appetite
is common. In up to 50% of presenting cases, local tenderness is elicited at McBurney
point when pressure is applied (Fig. 24-2). Rebound tenderness (production or
intensification of pain when pressure is released) may be present. The extent of tenderness
and muscle spasm and the existence of constipation or diarrhea depend not so much on the
severity of the appendiceal infection as on the location of the appendix. If the appendix
curls around behind the cecum, pain and tenderness may be felt in the lumbar region. If its
tip is in the pelvis, these signs may be elicited only on rectal examination. Pain on
defecation suggests that the tip of the appendix is resting against the rectum; pain on
urination suggests that the tip is near the bladder or impinges on the ureter. Some rigidity
of the lower portion of the right rectus muscle may occur. Rovsing sign may be elicited by
palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower
quadrant (see Fig. 24-2). If the appendix has ruptured, the pain becomes more diffuse;
abdominal distention develops as a result of paralytic ileus, and the patient’s condition
worsens.

Nursing Alert
Constipation also can occur with an acute process, such as appendicitis. Laxatives
administered in this instance may result in perforation of the inflamed appendix. In
general, a laxative or cathartic should never be given when a person has fever,
nausea, or pain.

1925
 FIGURE 24-2 When the appendix is inflamed, tenderness can be noted in the right lower quadrant at
McBurney point, which is between the umbilicus and the anterior superior iliac spine. Rovsing sign is
pain felt in the right lower quadrant after the left lower quadrant has been palpated.

Diagnosis is based on results of a complete physical examination and on laboratory

findings and imaging studies. The CBC demonstrates an elevated white blood cell (WBC)
count with an elevation of the neutrophils. Abdominal x-ray films, ultrasound studies, and
CT scans may reveal a right lower quadrant density or localized distention of the bowel. A
diagnostic laparoscopy may be used to rule out acute appendicitis in equivocal cases.
Acute appendicitis is uncommon in the elderly population. When it does occur, classic
signs and symptoms are altered and may vary greatly. Pain may be absent or minimal.
Symptoms may be vague, suggesting bowel obstruction or another process. Fever and
leukocytosis may not be present. As a result, diagnosis and prompt treatment may be
delayed, causing complications and mortality. The patient may have no symptoms until the
appendix ruptures. The incidence of perforated appendix is higher in the elderly population
because many of these patients do not seek health care as quickly as younger patients.

1926
Medical and Nursing Management
Typically, immediate surgery is indicated if appendicitis is diagnosed. To correct or prevent
fluid and electrolyte imbalance, dehydration, and sepsis, antibiotics and IV fluids are
administered 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 may be
performed using general or spinal anesthesia with a low abdominal incision (laparotomy) or
by laparoscopy. Both laparotomy and laparoscopy are safe and effective in the treatment of
appendicitis with perforation. However, generally recovery after laparoscopic surgery is
quicker.
When perforation of the appendix occurs, an abscess may form. If this occurs, the
patient may be treated initially with antibiotics, and the surgeon may place a drain in the
abscess during the operative procedure to facilitate drainage. Subsequent surgical
procedures may be performed to ensure complete drainage of the abscess. The
postoperative care of the patient with a perforated appendix is more complex and
complicated due to the risk of developing sepsis and organ damage.
The nurse prepares the patient for surgery, which includes an IV infusion to replace
fluid loss and promote adequate kidney function, and antibiotic therapy to prevent
infection. If there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted.
An enema is not administered 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. An
opioid, usually morphine sulfate, is prescribed to relieve pain. When tolerated, oral fluids
are administered. Any patient who was dehydrated before surgery receives IV fluids. Food is
provided as desired and tolerated on the day of surgery, once normal bowel sounds are
present.
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
uncomplicated. Discharge teaching for the patient and family is imperative. The nurse
instructs the patient to make an appointment to have the surgeon remove the sutures
between the fifth and seventh days after surgery. Incision care and activity guidelines are
discussed; usually normal activity can be resumed within 2 to 4 weeks.
If there is a possibility of peritonitis, a drain is left in place at the area of the incision.
Patients at risk for this complication may be kept in the hospital for several days and are
monitored carefully for signs of intestinal obstruction or secondary hemorrhage. Secondary
abscesses may form in the pelvis, under the diaphragm, or in the liver, causing elevation of
the temperature, pulse rate, and WBC count.
When the patient is ready for discharge, the nurse teaches the patient and family 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.

1927
Complications
The major complication of appendicitis is perforation of the appendix, which can lead to
peritonitis, abscess formation (collection of purulent material), or portal pylephlebitis,
which is septic thrombosis of the portal vein caused by vegetative emboli that arise from
septic intestines. Perforation generally occurs 24 hours after the onset of pain if no
intervention has occurred. Symptoms include a fever of 37.7°C (100°F) or greater, a toxic
appearance, and continued abdominal pain or tenderness. Other complications of
appendectomy are listed in Table 24-4.

TABLE 24-4 Potential Complications and Nursing Interventions After

Appendectomy

1928
1929
DIVERTICULAR DISEASE
A diverticulum is a sac-like herniation of the lining of the bowel that extends through a
defect in the muscle layer. Diverticula may occur anywhere in the small intestine or colon
but occur most commonly in the distal sigmoid colon. The incidence of diverticular disease
of the colon is 35% to 50%, and increases with age. For example, the incidence is less than
10% under age 40, but rises to 80% when over 85 (Ferri, 2017). The health care cost of
diverticular disease is estimated at more than $2 billion (Perry et al., 2012).

1930
Pathophysiology
Diverticula form when the mucosa and submucosal layers of the colon herniate through the
muscular wall because of high intraluminal pressure, low volume in the colon (i.e., fiber-
deficient contents), and decreased muscle strength in the colon wall (e.g., muscular
hypertrophy from hardened fecal masses). Bowel contents can accumulate in the
diverticulum and decompose, causing inflammation and infection. The diverticulum also
can become obstructed and then inflamed if the obstruction continues. Inflammation and
subsequent infection of the diverticulum (i.e., diverticulitis) can cause the development of
abscesses, which may eventually perforate, leading to peritonitis and erosion of the arterial
blood vessels, resulting in bleeding. Diverticulitis may occur as an acute attack or may
persist as a continuing, smoldering infection. The symptoms manifested generally result
from complications: abscess, fistula formation, obstruction, perforation, peritonitis, and
hemorrhage.
Diverticulosis (see Fig. 24-3) exists when multiple diverticula are present without
inflammation or symptoms. A low intake of dietary fiber is considered a predisposing
factor, but the exact cause has not been identified. Most patients with diverticular disease
are asymptomatic, so its exact prevalence is unknown.

1931
Risk Factors
It is estimated that 10% to 25% of people with diverticulosis have diverticulitis at some
point in their lives (Shahedi et al., 2013). A congenital predisposition is suspected when the
disorder occurs in those younger than 40 years of age.

1932
Clinical Manifestations and Assessment
Chronic constipation often precedes the development of diverticulosis, sometimes by many
years. Frequently, no problematic symptoms occur with diverticulosis. Signs and symptoms
of diverticulosis are relatively mild and include bowel irregularity with intervals of diarrhea,
nausea, anorexia, and abdominal distention. Abdominal pain may radiate to the back,
flank, or suprapubic region. With repeated local inflammation of the diverticula, the large
bowel may narrow with fibrotic strictures, leading to cramps, narrow stools, and increased
constipation or, at times, intestinal obstruction. Weakness, fatigue, and anorexia are
common symptoms. With diverticulitis, the patient reports an acute onset of mild to severe
pain in the lower left quadrant, accompanied by nausea, vomiting, fever, chills, and
leukocytosis (elevated WBC). Rebound tenderness is suggestive of perforation. The
condition, if untreated, can lead to septicemia (see Chapter 54).

FIGURE 24-3 (Top) Location of diverticula in the sigmoid colon; (Bottom left) Diverticulosis;
(Bottom right) Diverticulitis. (Reprinted with permission from Diepenbrock, N. (2011). Quick
reference to critical care (4th ed.). Philadelphia, PA: Wolters Kluwer.)

Typically diverticulosis is diagnosed by colonoscopy, which permits visualization of the

extent of diverticular disease and allows the clinician to biopsy tissue to rule out other
diseases as needed. Until recently, barium enema had been the preferred diagnostic test, but
now it is used less frequently than colonoscopy. However, if acute diverticulosis is suspected
or there are symptoms of peritoneal irritation, a colonoscopy or barium enema is
contraindicated because of potential for perforation. CT scan is the diagnostic test of choice
if the suspected diagnosis is diverticulitis; it also can reveal one or more abscesses.
Abdominal x-rays may demonstrate free air under the diaphragm if a perforation has

1933
occurred from the diverticulitis, which causes peritonitis. Laboratory tests that assist in
diagnosis include a CBC, revealing an elevated WBC count, and elevated erythrocyte
sedimentation rate (ESR).

1934
Gerontologic Considerations
The incidence of diverticular disease increases with age because of degeneration and
structural changes in the circular muscle layers of the colon and because of cellular
hypertrophy. The symptoms are less pronounced in the elderly than in other adults. The
elderly may not have abdominal pain until infection occurs. They may delay reporting
symptoms because they fear surgery or are afraid that they may have cancer. Frequently
blood in the stool is overlooked, especially in the elderly because of a failure to examine the
stool or the inability to see changes if vision is impaired.

1935
Medical and Nursing Management
Usually diverticulitis can be treated on an outpatient basis with diet and medication. When
symptoms occur, rest, analgesics, and antispasmodics are recommended. Initially, the diet is
clear liquid until the inflammation subsides; then a high-fiber, low-fat diet is
recommended. This type of diet helps increase stool volume, decrease colonic transit time,
and reduce intraluminal pressure. Antibiotics are prescribed for 7 to 10 days. A bulk-
forming laxative also is prescribed.

Nursing Alert
High-fiber foods include items such as potatoes, rice, artichoke, and split peas. In
addition, patient teaching can include adding foods such as raspberries and pears as
snacks to help increase fiber intake. In the past, it was recommended that people with
diverticular disease (diverticulosis or diverticulitis) avoid nuts, corn, popcorn, and seeds for fear
that these foods would become lodged in the diverticula and lead to inflammation. However,
there is no convincing evidence to support any particular foods that should be favored or avoided
(Wilkins, Embry, & George, 2013).

In acute cases of diverticulitis hospitalization may be required for patients who cannot
tolerate PO fluids and food. Measures taken to rest the bowel include withholding oral
intake, administering IV fluids and antibiotics, and instituting nasogastric suctioning if
vomiting or abdominal distention are present. An opioid is prescribed for pain relief.
Historically, morphine was considered to be contraindicated because of a claim that it
could increase intraluminal pressure in the colon, thus exacerbating symptoms; however, no
research evidence is available to support this claim. Uncomplicated acute diverticulitis can
be managed with oral antibiotics for 7 to 10 days in the outpatient setting. Nonsteroidal
anti-inflammatory drugs (NSAIDs) are associated with increased risk of perforation and
should be avoided.
More often than not, acute diverticulitis will subside with medical management.
Immediate surgical intervention is necessary if complications (e.g., perforation, peritonitis,
hemorrhage, obstruction) occur. In cases of abscess formation without peritonitis,
hemorrhage, or obstruction, CT-guided percutaneous drainage may be performed to drain
the abscess, and IV antibiotics are administered. Stabilization of the patient by drainage of
the abscess and resolution of the inflammation is complete after approximately 6 weeks;
surgery may be recommended to prevent repeated episodes. Typically two types of surgery
are considered either to treat acute complications or to prevent further episodes of
inflammation:
One-stage resection, in which the inflamed area is removed and a primary end-to-end
anastomosis is completed
Multiple-stage procedures for complications such as obstruction or perforation (Fig. 24-
4)
The type of surgery performed depends on the extent of complications found during
surgery. When possible, the area of diverticulitis is taken out and the remaining bowel is

1936
joined end-to-end (i.e., primary resection and end-to-end anastomosis). This is performed
through traditional surgical or laparoscopically assisted colectomy. A two-stage resection
may be performed in which the diseased colon is removed (as in a one-stage procedure) but
no anastomosis is performed; both ends of the bowel are brought out onto the abdomen as
stomas. Then this “double-barrel” temporary colostomy is reanastomosed in a later
procedure. Fecal diversion procedures are discussed later in this chapter.

FIGURE 24-4 The Hartmann procedure for diverticulitis: primary resection for diverticulitis of the
colon. The affected segment (clamp attached) has been divided at its distal end. In a primary
anastomosis, the proximal margin (dotted line) is transected and the bowel attached end-to-end. In a
two-stage procedure, a colostomy is constructed at the proximal margin with the distal stump oversewn
(Hartmann procedure, as shown) or brought to the outer surface as a mucous fistula. The second stage
consists of colostomy takedown and anastomosis.

1937
Complications
Complications of diverticulitis include peritonitis (see below), abscess formation, and
bleeding. If an abscess develops, the associated findings are tenderness, a palpable mass,
fever, and leukocytosis. An inflamed diverticulum that perforates results in abdominal pain
localized over the involved segment, usually the sigmoid; local abscess or peritonitis follows.
Abdominal pain, a rigid board-like abdomen, loss of bowel sounds, and signs and
symptoms of shock occur with peritonitis. Noninflamed or slightly inflamed diverticula
may erode areas adjacent to arterial branches, causing massive rectal bleeding.

1938
PERITONITIS
Peritonitis is inflammation of the peritoneum, the serous membrane lining the abdominal
cavity and covering the viscera. Peritonitis is typically a life-threatening emergency that
requires prompt surgical intervention and typically involves postoperative critical care
monitoring due to the risk of sepsis, organ failure, and subsequent infections.

Nursing Alert
The development of peritonitis can include a variety of signs and symptoms in
patients, including a firm and distended abdomen, rebound tenderness, and
guarding by the patient of the abdomen during the examination. These signs and
symptoms should cue nurses into suspecting peritonitis in their patients.

1939
Pathophysiology
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. Bacterial proliferation occurs. Edema of the tissues ensues, and exudation of
fluid develops in a short time. Fluid in the peritoneal cavity becomes turbid with increasing
amounts of protein, WBCs, cellular debris, and blood. The immediate response of the
intestinal tract is hypermotility, soon followed by paralytic ileus with an accumulation of air
and fluid in the bowel.

1940
Risk Factors
Usually, peritonitis is a result of bacterial infection; the organisms come from diseases of the
GI tract or, in women, from the internal reproductive organs. Peritonitis also can result
from external sources, such as injury or trauma (e.g., gunshot wound, stab wound) or an
inflammation that extends from an organ outside the peritoneal area, such as the kidney.
The most common bacteria implicated are gram-negative organisms (Escherichia coli,
Klebsiella, Proteus), gram-positive bacteria (enterococci, streptococci, staphylococci),
anaerobic bacteria (Bacteroides, Clostridium), and fungi (Ferri, 2016). Inflammation and
paralytic ileus are the direct effects of the infection. Other common causes of peritonitis are
appendicitis, perforated ulcer, diverticulitis, and bowel perforation (Fig. 24-5). Peritonitis
also may be associated with abdominal surgical procedures and peritoneal dialysis.

1941
Clinical Manifestations and Assessment
Symptoms depend on the location and extent of the inflammation. The early clinical
manifestations of peritonitis frequently are the symptoms of the disorder causing the
condition, aptly nicknamed an “acute abdomen.” At first, a diffuse type of pain is felt. The
pain tends to become constant, localized, and more intense near the site of the
inflammation. Movement usually aggravates it. The affected area of the abdomen becomes
extremely tender and distended, and the muscles become rigid. Rebound tenderness and
paralytic ileus may be present. Diminished perception of pain in peritonitis can occur in
people receiving corticosteroids or analgesics. Patients with diabetes who have symptoms of
advanced neuropathy and patients with cirrhosis who have signs of ascites may not
experience pain during an acute bacterial episode. Usually, nausea and vomiting occur, and
peristalsis is diminished (decreased bowel sounds). A temperature of 100° to 101°F (37.8°
to 38.3°C) can be expected, along with an increased pulse rate, tachypnea, dyspnea, and
hypotension.

FIGURE 24-5 Common gastrointestinal causes of peritonitis.

The WBC count is almost always elevated. The hemoglobin and hematocrit levels may

1942
be low if blood loss has occurred. Serum electrolyte studies may reveal altered levels of
potassium, sodium, and chloride.
An abdominal x-ray study may show air and fluid levels as well as distended bowel
loops. A CT scan of the abdomen may show abscess formation, acute inflammation or
infection of one of the major abdominal organs, or a perforation of the small or large
bowel. Peritoneal aspiration and culture and sensitivity studies of the aspirated fluid may
reveal infection and identify the causative organisms.

1943
Medical and Nursing Management
Fluid, colloid, and electrolyte replacement is the major focus of medical management. The
administration of several liters of an isotonic solution is emergently prescribed.
Hypovolemia occurs because massive amounts of fluid and electrolytes move from the
intestinal lumen into the peritoneal cavity and deplete the fluid in the vascular space.
Analgesics are prescribed for pain. Antiemetics are administered as prescribed for nausea
and vomiting. Placement of a nasogastric tube is warranted, and suction is maintained to
assist in relieving abdominal distention. Fluid in the abdominal cavity can cause pressure
that restricts expansion of the lungs and causes respiratory distress. Oxygen therapy by nasal
cannula or mask generally promotes adequate oxygenation, but airway intubation and
ventilatory assistance occasionally are required due to the patient’s inability to compensate
for the metabolic acidosis that typically occurs with peritonitis.
Antibiotic therapy is initiated early in the treatment of peritonitis. Large doses of a
broad-spectrum antibiotic and antifungicide are administered IV until the specific organism
causing the infection is identified and appropriate antibiotic therapy can be initiated.
Surgical objectives include removing the infected material and correcting the cause.
Surgical treatment is directed toward excision (i.e., appendix), resection with or without
anastomosis (i.e., intestine), repair (i.e., perforation), and/or drainage (i.e., abscess). With
sepsis accompanying the peritonitis, a fecal diversion may need to be created.
The two most common postoperative complications are wound evisceration and abscess
formation. Any suggestion from the patient that an area of the abdomen is tender or
painful or “feels as if something just gave way” must be reported. The sudden occurrence of
serosanguineous wound drainage strongly suggests wound dehiscence and is a surgical
emergency that must be reported promptly to the on-call provider.
Often intensive care is needed. The blood pressure is monitored by arterial line if shock
is present. Accurate recording of all intake and output and central venous pressures and/or
pulmonary artery pressures assists in calculating fluid replacement. The nurse administers
and closely monitors IV fluids response.
In addition, ongoing assessment of pain, GI function, and fluid and electrolyte balance
is important. Bladder pressure also is measured routinely to identify abdominal
compartment syndrome (refer to Chapter 53, Fig. 53-4). The nurse reports the nature of
the pain, its location in the abdomen, and any changes in location. Administering analgesic
medication and positioning the patient for comfort are helpful in decreasing pain. The
patient is placed on the side with knees flexed; this position decreases tension on the
abdominal organs.
Signs that indicate that peritonitis is subsiding include a decrease in temperature and
pulse rate, softening of the abdomen, return of peristaltic sounds, and passing of flatus and
bowel movements. The nurse increases fluid and food intake gradually and reduces
parenteral fluids as prescribed. A worsening clinical condition may indicate a complication,
and the nurse must prepare the patient for emergency surgery.
Frequently drains are inserted during the surgical procedure, and the nurse must observe
and record the character of the drainage postoperatively. Care must be taken when moving
and turning the patient to prevent the drains from being dislodged. It is prudent to safety-
pin the drains to the patient’s gown to limit the chance of accidental dislodgement. Also it

1944
is important for the nurse to prepare the patient and family for discharge by teaching the
patient to care for the incision and drains if the patient will be sent home with the drains
still in place. Referral for home care or rehabilitation may be indicated for further
monitoring and patient and family teaching.

1945
Complications
Frequently, the inflammation is not localized, and the entire abdominal cavity shows
evidence of widespread infection. Sepsis is the major cause of death from peritonitis. Shock
may result from septicemia or hypovolemia. The inflammatory process may cause intestinal
obstruction, primarily from the development of bowel adhesions, and care must be made to
monitor the patient’s nasogastric tube drainage and input and output closely. The patient is
also at high risk of developing pulmonary emboli, and compression stockings, sequential-
compression boots, and subcutaneous anticoagulation may be prescribed.

1946
INFLAMMATORY BOWEL DISEASE
IBD refers to two chronic inflammatory GI disorders: regional enteritis (i.e., Crohn disease)
and ulcerative colitis (UC). Both disorders have striking similarities but also several
differences (Table 24-5); medical and nursing management for both types is similar and
discussed jointly.
The incidence of IBD in the United States has increased to well over 1 million cases
(Kaplan, 2015). Typically IBD presents during childhood or later in life and is attributed
to a high morbidity and a decreased quality of life (Kaplan & Jess, 2016). Women and men
tend to be affected equally, and family history appears to predispose people to develop IBD,
particularly if a first-degree relative has the disease.
Despite extensive research, the cause of IBD is still unknown. Researchers theorize that
it is triggered by environmental agents, such as pesticides, food additives, tobacco, and
radiation (Kaplan & Jess, 2016). NSAIDs have been found to exacerbate IBD. Allergies
and immune disorders also have been suggested as causes. Abnormal response to dietary or
bacterial antigens has been studied extensively, and genetic factors also are being examined.

REGIONAL ENTERITIS (CROHN DISEASE)

Usually regional enteritis (Crohn disease) is diagnosed first in adolescents or young adults
but can appear at any time in a person’s life. The incidence of regional enteritis has risen
both nationally and internationally, suggesting that Crohn disease is emerging as a disease
of global significance (Conley & Redeker, 2016). The most popular theory is that the
body’s immune system reacts abnormally in people with Crohn disease, mistaking bacteria,
foods, and other substances for dangerous foreign substances (National Institutes of Health
[NIH], U.S. Department of Health and Human Services, 2009; Targownik, Coneys, &
Dhillon, 2016). Recent research also has suggested that lower levels of vitamin D may play
a role in the increasing incidence of regional enteritis and warrants further study (Holmes,
Xiang, & Lucas, 2015).

TABLE 24-5 Comparison of Regional Enteritis and Ulcerative Colitis

1947
1948
Pathophysiology
Regional enteritis is a subacute and chronic inflammation of the GI tract wall that extends
through all layers (i.e., transmural lesion). Although it can occur anywhere in the GI tract,
it most commonly occurs in the distal ileum but can be seen in the ascending colon. It is
characterized by periods of remission and exacerbation. The disease process begins with
edema and thickening of the mucosa. Ulcers begin to appear on the inflamed mucosa. The
ulcerations in regional enteritis differ from UC in that they are not continuous or in
contact with each other and are separated by normal tissue. Hence, these clusters of ulcers
tend to take on a classic “cobblestone” appearance on colonoscopy. Fistulas, fissures, and
abscesses form as the inflammation extends down into the peritoneum. Granulomas
(localized nodular inflammation) occur in 50% of patients. As the disease advances, the
bowel wall thickens and becomes fibrotic, and the intestinal lumen narrows. Diseased
bowel loops sometimes stick to other loops surrounding those developing adhesions.

1949
Clinical Manifestations and Assessment
Usually the onset of symptoms is insidious in regional enteritis, with prominent lower right
quadrant abdominal pain unrelieved by defecation, fatigue, diarrhea, and weight loss. Scar
tissue and the formation of granulomas interfere with the ability of the intestine to
transport products of the upper intestinal digestion through the constricted lumen,
resulting in crampy abdominal pains. There is abdominal tenderness and spasm. Because
eating stimulates intestinal peristalsis, the crampy pain typically occurs after meals. The
patient will tend to limit food intake in order to reduce the crampy pain and, in fact, can
reduce the amount and type of food to such a degree that normal nutritional requirements
often are not met. As a result, weight loss, malnutrition, and secondary anemia occur.
Ulcers in the membranous lining of the intestine and other inflammatory changes result
in a weeping, edematous intestine that continually empties a colonic- and skin-irritating
discharge. Disrupted absorption causes chronic diarrhea and associated fluid and electrolyte
imbalances (hypokalemia, hypomagnesemia, hypocalcemia, and low albumin) as well as
nutritional deficits. In some patients, the inflamed intestine may perforate, leading to intra-
abdominal and anal abscesses. Fever and leukocytosis may occur. Chronic symptoms of
regional enteritis may include steatorrhea (i.e., excessive fat in the feces).
Abscesses, fistulas, and fissures are common. Manifestations may extend beyond the GI
tract and commonly include joint disorders (e.g., arthritis), skin lesions (e.g., erythema
nodosum), ocular disorders (e.g., conjunctivitis), and oral ulcers. The clinical course and
symptoms can vary; in some patients, periods of remission and exacerbation occur, but in
others, the disease follows a fulminating course.
Usually a proctosigmoidoscopy is performed initially to determine whether the
rectosigmoid area is inflamed. A stool examination also is performed; the result may be
positive for occult blood and steatorrhea. Endoscopy, colonoscopy, and intestinal biopsies
may be used to confirm the diagnosis. A CT scan may show bowel-wall thickening and
fistula formation.
A CBC is performed to assess hematocrit and hemoglobin levels (usually decreased) as
well as the WBC count (may be elevated). Usually the ESR is elevated in relation to the
inflammation. Albumin (the long-term marker of nutrition) and protein levels may be
decreased, indicating malnutrition.

1950
Complications
Complications of regional enteritis include intestinal obstruction or stricture formation,
perianal disease, fluid and electrolyte imbalances, malnutrition from malabsorption, and
formation of fistulas and abscesses. The most common type of small bowel fistula caused by
regional enteritis is the enterocutaneous fistula (i.e., an abnormal opening between the
small bowel and the skin). Abscesses can be the result of an internal fistula that results in
fluid accumulation and infection. Patients with regional enteritis are also at increased risk
of colon cancer.

ULCERATIVE COLITIS

UC is a recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers
of the colon and rectum. The prevalence of UC is highest in Caucasians and people of
Jewish heritage (Centers for Disease Control [CDC], 2016). It affects men and women
equally. It is a serious disease, accompanied by systemic complications and a high mortality
rate. Approximately 3% of patients with UC develop colon cancer (Desai et al., 2015;
NIH, U.S. Department of Health and Human Services, 2009). Worldwide incidence of
UC is more common than incidence of Crohn disease (Ferri, 2016).

1951
Pathophysiology
UC affects the superficial mucosa of the colon and is characterized by multiple ulcerations,
diffuse inflammations, and desquamation or shedding of the colonic epithelium. Bleeding
occurs as a result of the ulcerations. The mucosa becomes edematous and inflamed. The
lesions are contiguous, occurring one after the other. Abscesses form, and infiltrate is seen
in the mucosa and submucosa, with clumps of neutrophils found in the lumens of the
crypts (i.e., crypt abscesses) that line the intestinal mucosa (Porth, 2015). The disease
process usually begins in the rectum and spreads proximally to involve the entire colon.
Eventually, the bowel narrows, shortens, and thickens because of muscular hypertrophy
and fat deposits.

1952
Clinical Manifestations and Assessment
The clinical course is usually one of intermittent exacerbations and remissions. The
predominant symptoms of UC include bloody diarrhea, passage of mucus, urgency, lower
left quadrant abdominal pain, intermittent tenesmus, and fever. Symptoms will differ
according to the extent of disease. The bleeding may be mild or severe, and pallor, anemia,
and fatigue are the result. The patient may have anorexia, weight loss, vomiting, and
dehydration, as well as cramping, the feeling of an urgent need to defecate, and the passage
of 10 to 20 liquid stools each day. The disease is classified as mild, severe, or fulminant,
depending on the severity of the symptoms. Hypocalcemia and anemia frequently develop.
Rebound tenderness may occur in the right lower quadrant. Extraintestinal manifestations
include skin lesions (e.g., erythema nodosum), eye lesions (e.g., uveitis), joint abnormalities
(e.g., arthritis), and liver disease.
The patient should be assessed for tachycardia, hypotension, tachypnea, fever, and pallor
(hypovolemic shock) from rectal bleeding. UC bleeding is painless and stops spontaneously
in approximately 60% of patients (Ferri, 2016). Treatment is aimed at blood replacement
and correction of volume and any clotting abnormalities. Other assessments address level of
hydration and nutritional status. The abdomen is examined for bowel sounds, distention,
and tenderness. Peripheral edema can occur secondary to hypoalbuminemia. These findings
assist in determining the severity of the disease.
The stool can be positive for blood, and laboratory test results reveal low hematocrit and
hemoglobin levels in addition to an elevated WBC count, low albumin levels, and an
electrolyte imbalance. Iron-deficiency anemia may be present because of chronic blood loss.
Hypokalemia, metabolic alkalosis, and elevated serum levels of blood urea nitrogen and
creatinine may be present in severe flares of UC, reflecting volume depletion (Osterman &
Lichtenstein, 2016). Abdominal x-ray studies are useful for determining the cause of
symptoms. Free air in the peritoneum and bowel dilation or obstruction should be
excluded as a source of the presenting symptoms, as peritonitis also can occur.
Colonoscopy should be avoided during acute diverticulitis due to the risk of perforation.
In general, it can be performed after 6 weeks to rule out the presence of cancer and IBD
(Ferri, 2016). Colonoscopy may reveal friable, inflamed mucosa with exudate and
ulcerations. This procedure assists in defining the extent and severity of the disease. With
the advent of endoscopy, barium studies have been used less often but remain important
for certain specific scenarios, such as evaluation of colonic strictures; barium enema
provides information on their location, length, and diameter and allows visualization of the
entire colon when the presence of strictures precludes advancement of the colonoscope
(Osterman & Lichtenstein, 2016). CT scanning can identify acute diverticulitis and
diverticulosis, abscesses, and perirectal involvement. Arteriography may be performed with
significant rectal bleeding, in which case vasopressin may be infused directly into the
arteries supplying the bleeding, as well as selective arterial embolization (Ferri, 2016).

1953
 FIGURE 24-6 Ulcerative colitis. A schematic representation of the major features of ulcerative colitis in
the colon. (Reprinted with permission from Strayer, D. S., & Rubin, E. (2014). Rubin’s pathology (7th
ed.). Philadelphia, PA: Wolters Kluwer.)

Careful examination of the patient’s stool for parasites and other microbes is performed
to rule out dysentery caused by common intestinal organisms, especially Entamoeba
histolytica and Clostridium difficile.

1954
Complications
Complications of UC include toxic megacolon, perforation and bleeding as a result of
ulceration, vascular engorgement, and highly vascular granulation tissue (Fig. 24-6). In
toxic megacolon, the inflammatory process extends into the muscularis, inhibiting its
ability to contract and resulting in colonic distention. Symptoms include fever, abdominal
pain and distention, vomiting, and fatigue. If the patient with toxic megacolon does not
respond within 24 to 72 hours to medical management with nasogastric suction, IV fluids
with electrolytes, corticosteroids, and antibiotics, then surgery is required. Then total
colectomy is indicated. For many patients, surgery becomes necessary to relieve the effects
of the disease and to treat these serious complications; an ileostomy usually is performed.
The surgical procedures involved and the care of patients with this type of fecal diversion
are discussed later in this chapter. In addition, hypercoagulability is a well-recognized
complication of UC, resulting in deep vein thrombosis and pulmonary emboli. The
mechanism of increased thrombotic risk is unclear. Standard anticoagulants would be
administered. Episcleritis (painless hyperemia of the sclera and conjunctiva without loss of
vision) and uveitis (acute or subacute pain in the eye with visual blurring often
accompanied by photophobia and headache) occurs in 5% to 8% of patients with UC.
Episcleritis parallels the level of bowel disease and generally responds to anti-inflammatory
therapy. In contrast, the occurrence of uveitis increases with the dose and duration of
glucocorticoid use. Patients with uveitis should receive prompt ophthalmologic
examination and treatment with glucocorticoid ocular drops to prevent progression to
blindness. Steroid therapy also can lead to cataracts. Thus, patients receiving glucocorticoid
therapy should undergo annual ophthalmologic examination (Osterman & Lichtenstein,
2016).
Patients with IBD also have a significantly increased risk of osteoporotic fractures due to
decreased bone mineral density. Corticosteroid therapy also may contribute to the
diminished bone density.

MEDICAL AND NURSING MANAGEMENT OF INFLAMMATORY

BOWEL DISEASE

Medical treatment for regional enteritis and UC is aimed at reducing inflammation,

suppressing inappropriate immune responses, providing rest for a diseased bowel so that
healing may take place, improving quality of life (Box 24-1), and preventing or minimizing
complications. Most patients have long periods of well-being interspersed with short
intervals of illness, and management depends on the disease location, severity, and
complications.
Oral fluids and a diet that is low residue, high protein, and high calorie with
supplemental vitamin therapy and iron replacement are prescribed to meet nutritional
needs, reduce inflammation, and control pain and diarrhea. Fluid and electrolyte
imbalances from dehydration caused by diarrhea are corrected by IV therapy as necessary if
the patient is hospitalized or by oral fluids if the patient is managed at home. Any foods
that exacerbate diarrhea are avoided. Milk may contribute to diarrhea in those with lactose

1955
intolerance. Smoking is avoided because of increased intestinal motility. Consultation with
a dietitian is highly recommended regarding oral diet or enteral feeding; parenteral
nutrition has not yielded clinical benefit in this patient population (see Chapter 22).
Aminosalicylate formulations, such as sulfasalazine (Azulfidine), often are effective for
mild or moderate inflammation and are used to prevent or reduce recurrences in long-term
maintenance regimens. Sulfa-free aminosalicylates (e.g., mesalamine [Asacol, Pentasa]) are
effective in preventing and treating recurrence of inflammation. Antibiotics (e.g.,
metronidazole [Flagyl]) are used for secondary infections, particularly for purulent
complications, such as abscesses, perforation, and peritonitis.

BOX 24-1 Nursing Research

Bridging the Gap to Evidence-Based Practice

The Effect of Abdominal Massage on Constipation and Quality of Life
Does Abdominal Massage have an effect on GI function, quality of life (QOL), and the
use of laxatives in patients who have not had a bowel movement in the first 3 days after
surgery?

Turan, N., & Atabek Asti, T. (2016). The effect of abdominal massage on constipation
and quality of life. Gastroenterology Nursing, 39(1), 48–59.
Purpose
Constipation is a common problem that has a profound effect on people’s health and
well-being. There are few existing studies related to nursing interventions regarding
abdominal massage. Therefore, the purpose of this study was to identify the effects of
abdominal massage in patients with constipation related to their GI function, QOL,
and the use of laxatives.
Design
A randomized controlled study was conducted. Sample criteria included patients 18
years of age or older, who had surgery and were hospitalized for treatment, and who had
not had a bowel movement for the first 3 days after surgery. A total of 60 patients (30
in the control group and 30 in the experimental group) fit criteria and agreed to be in
the study. Abdominal massage was defined for this study as applied daily for 15 minutes
in a clockwise fashion using four basic strokes: stroking, effleurage, kneading, and
vibration.
Several data collection instruments were used to measure gastrointestinal symptom
ratings, constipation severity scores, and the general health of the patient. Analysis of
the data showed that patients who had abdominal massage completed defecation more
often, had decreased symptoms of constipation, and stated there was improvement in
their QOL. The study also showed that abdominal massage decreased the symptoms of
constipation more than the use of laxatives, suppositories, or enemas.
Nursing Implications

1956
 This study has shown that abdominal massage is an effective tool in decreasing the
symptoms of constipation and increasing the QOL for patients who are constipated.
The nurse plays an important role in the treatment of constipation in postoperative
patients. Implementing abdominal massage, in conjunction with dietary changes and
increasing exercise, provide nonpharmacologic treatments for patients that can be
implemented by the nurse in the early postoperative period. Future studies should
analyze other patient groups to determine the ability of abdominal massage to treat
patients with constipation in other clinical settings.

Corticosteroids are used to treat severe and fulminant disease and can be administered
orally (e.g., prednisone [Deltasone]) in outpatient treatment or parenterally (e.g.,
hydrocortisone [Solu-Cortef]) in hospitalized patients. Topical (i.e., rectal administration)
corticosteroids (e.g., hydrocortisone enema, budesonide [Entocort]) also are used widely in
the treatment of distal colon disease. When the dosage of corticosteroids is reduced or
stopped, the symptoms of disease may return. If corticosteroids are continued, adverse
sequelae, such as hypertension, fluid retention, cataracts, hirsutism (i.e., abnormal hair
growth), adrenal suppression, steroid-induced diabetes mellitus (secondary to the
hyperglycemia associated with glucocorticoid therapy), poor wound healing, and loss of
bone density, may occur.
Immunomodulators (e.g., azathioprine [AZA], 6-mercapt-opurine [6-MP],
methotrexate, and cyclosporine) and antitumor necrosis factor agents have been used to
alter the immune response. The exact mechanism of action of these medications in treating
IBD is unknown. These medications are useful in maintenance regimens to prevent
relapses. Biologic therapies using monoclonal antibodies, such as natalizumab (Tysabri),
continue to be used to treat Crohn disease (Scott & Osterman, 2015) and infliximab
(Remicade) for treating UC (Bressler et al., 2015). Initial reports from clinical trials appear
promising for both these medications (Arias et al., 2015; Scott & Osterman, 2015),
although the use of natalizumab is limited currently to patients who have not tolerated or
failed treatment with other biologic agents (Scott & Osterman, 2015).
When nonsurgical measures fail to relieve the severe symptoms of IBD, surgery may be
necessary. Approximately 75% of all patients with regional enteritis who have had the
disease for 20 years required some type of surgery. Fortunately, this number has been
decreasing steadily with the increased use of infliximab therapy (Bressler et al., 2015). The
most common indications for surgery are medically intractable disease, poor quality of life,
or complications from the disease or its treatment. Recurrence of inflammation and disease
after surgery in regional enteritis is inevitable.
A common procedure performed for strictures of the small intestines is laparoscope-
guided strictureplasty, in which the blocked or narrowed sections of the intestines are
widened, leaving the intestines intact. In some cases, a small bowel resection is performed:
diseased segments of the small intestines are resected, and the remaining portions of the
intestines are anastomosed. Surgical removal of up to 50% of the small bowel usually can
be tolerated. In cases of severe regional enteritis of the colon, a total colectomy and
ileostomy may be the procedure of choice.
A newer surgical procedure developed for patients with severe regional enteritis is
intestinal transplant. Now this technique is available to children and to young and middle-

1957
aged adults who have lost intestinal function from disease. Although this procedure is not a
cure, eventually it may provide improvement in quality of life for some patients. The
associated technical and immunologic problems remain formidable, and the costs and
mortality rates remain high.
Long-term colectomy rates for patients with UC for 3 years ranges from 50% to 62%
(Seah & De Cruz, 2016). When the colon is surgically removed, the patient is considered
“cured” in that extraintestinal manifestations subside and the disease process is otherwise
limited to the colon. Indications for surgery include lack of improvement and continued
deterioration, profuse bleeding, perforation, continued stricture formation, and cancer.
Surgical excision usually improves quality of life. Proctocolectomy with ileostomy (i.e.,
complete excision of colon, rectum, and anus) is recommended when the rectum is severely
diseased. If the rectum can be preserved, the procedure of choice is restorative
proctocolectomy with ileal pouch anal anastomosis (IPAA).

ILEOSTOMY

Procedures
An ileostomy, the surgical creation of an opening into the ileum or small intestine (usually
by means of an ileal stoma on the abdominal wall), is commonly performed after a total
colectomy (i.e., excision of the entire colon). It allows for drainage of fecal matter (i.e.,
effluent) from the ileum to the outside of the body. The drainage is typically loose to
semiformed and may occur at frequent intervals.
Another procedure involves the creation of a continent ileal reservoir (i.e., Kock pouch)
by diverting a portion of the distal ileum to the abdominal wall and creating a stoma (Fig.
24-7). This procedure eliminates the need for an external fecal collection bag.
Approximately 30 cm of the distal ileum is reconstructed to form a reservoir with a nipple
valve that is created by pulling a portion of the terminal ileal loop back into the ileum. GI
effluent can accumulate in the pouch for several hours and then be removed by means of a
catheter inserted through the nipple valve. In many patients, a total colectomy also is
performed with the Kock pouch. Possible indications for a total colectomy with Kock
pouch placement (rather than a restorative proctocolectomy with IPAA) include a badly
diseased rectum, lack of rectal sphincter tone, or inability to achieve fecal continence post-
IPAA.
The major problem with the Kock pouch is malfunction of the nipple valve. The
ileocecal nipple valve is used commonly to create a continent, catheterizable channel.
Another surgical option is the appendicovesicostomy, which repurposes the appendix to
create a tunneled channel (Levy & Elliott, 2016).
A restorative proctocolectomy with IPAA is the surgical procedure of choice in cases in
which the rectum can be preserved in that it eliminates the need for a permanent ileostomy.
It establishes an ileal reservoir, and anal sphincter control of elimination is retained. The
procedure involves connecting a portion of the ileum to the anus (i.e., ileoanal anastomosis)
in conjunction with removal of the colon and the rectal mucosa (i.e., total abdominal
colectomy and mucosal proctectomy) (Fig. 24-8). A temporary diverting loop ileostomy is
constructed at the time of surgery and closed about 3 months later.

1958
 FIGURE 24-7 Anatomy of a Kock pouch. A Kock pouch is formed by surgically looping part of the
distal ileum, stapling the loops together, and opening the inner canals to form a reservoir for the soft,
watery stool to be held until catheterized for removal. The nipple valve is formed as shown, by pulling
part of the pouch tissue back over the terminal end of the ileum and stapling it closed to reduce the size
of the opening and form a canal for the catheter. The length and smaller diameter of the nipple valve
prevents waste products from escaping, although some mucus drainage may be expected. (Reprinted
with permission from Lippincott’s Nursing Advisor. (2009), Wolters Kluwer.)

With ileoanal anastomosis, the diseased colon and rectum are removed, voluntary
defecation is maintained, and anal continence is preserved. The ileal reservoir decreases the
number of bowel movements by 50%, from approximately 14 to 20 per day to seven to 10
per day. Nighttime elimination is reduced gradually to one bowel movement.
Complications of ileoanal anastomosis include irritation of the perianal skin from leakage
of fecal contents, stricture formation at the anastomosis site, and small bowel obstruction.
Nursing management of patients with IBD may be medical, surgical, or both. Patients
in the community setting or those recently diagnosed may require education about diet and
medications as well as referral to support groups. Hospitalized patients with longstanding
or severe disease also require careful monitoring, parenteral nutrition, fluid replacement,
and possibly emergent surgery. The surgical procedures may involve a fecal diversion with
attendant needs for physical care, emotional support, and extensive teaching about
management of the ostomy.

1959
Nursing Management for Ileostomy
Some patients with IBD eventually require a permanent fecal diversion with creation of an
ileostomy to manage symptoms and to treat or prevent complications. Ileostomy education
can be started while the patient is still in the hospital, and with a small amount of planning
and care, the patient lives a very normal life. A plan of nursing care for a patient
undergoing ostomy surgery is available online at [Link]

FIGURE 24-8 (A) Proctocolectomy. (B) Ileal J-pouch, stapled anastomosis, and temporary ileostomy.
(C) Closure of the temporary ileostomy. The entire surgical procedure is based on four steps: removal
of the colon; pelvic dissection and rectum removal sparing the pelvic nerves and the anal sphincter;
construction of the ileal pouch, usually with the last 30 to 40 cm of the terminal ileum; and
anastomosis of the pouch to the canal anal. (Reprinted with permission from Holzman, R. S.,
Mancuso, T. J., & Polaner, D. M. (2015). A practical approach to pediatric anesthesia (2nd ed.).
Philadelphia, PA: Wolters Kluwer.)

Providing Preoperative Care

A period of preparation with intensive replacement of fluid, blood, and protein is necessary
before surgery is performed. Antibiotics may be prescribed. If the patient has been taking
corticosteroids, they will be continued during the surgical phase to prevent steroid-induced
adrenal insufficiency. Usually, the patient is provided with frequent, small feedings. All
other preoperative measures are similar to those for general abdominal surgery. The
abdomen is marked for the proper placement of the stoma by the surgeon or the
enterostomal therapist. Care is taken to ensure that the stoma is placed in a convenient
location—usually in the right lower quadrant about 2 in below the waist, in an area away
from previous scars, bony prominences, skin folds, or fistulas.
The patient must have a thorough understanding of the surgery to be performed and
what to expect after surgery. Information about an ileostomy is presented to the patient by
means of written materials, models, and discussion. Preoperative teaching includes
management of drainage from the stoma, the nature of drainage, and the need for
nasogastric intubation, parenteral fluids, and, possibly, perineal packing.

1960
Providing Postoperative Care

Nursing Alert
A healthy stoma appears pink or red and moist; the nurse alerts the surgeon if the
stoma is dusky, white, or dark since circulation may be compromised.

General abdominal surgery wound care is required. The nurse observes the stoma for color
and size. It should be pink to bright red and shiny. Typically, a temporary plastic bag with
an adhesive facing is placed over the ileostomy in the operating room and firmly pressed
onto the surrounding skin. The nurse monitors the ileostomy for fecal drainage, which
should begin about 72 hours after surgery. The drainage is a continuous liquid from the
small intestine because the stoma does not have a controlling sphincter. The contents drain
into the plastic bag and thus are kept from coming into contact with the skin. They are
collected and measured when the bag becomes full. If a continent ileal reservoir was
created, as described for the Kock pouch, continuous drainage is provided by an indwelling
reservoir catheter for 2 to 3 weeks after surgery. This allows the suture lines to heal.
As with other patients undergoing abdominal surgery, the nurse encourages those with
an ileostomy to engage in early ambulation. It is important to administer prescribed pain
medications as required.
Because these patients lose much fluid in the early postoperative period, an accurate
record of fluid intake, urinary output, and fecal discharge is necessary to help gauge the
fluid needs of the patient. There may be up to 1 L of fluid lost each day, in addition to
expected fluid loss through urine, perspiration, respiration, and other sources. With this
loss, sodium and potassium are depleted. The nurse monitors laboratory values and
administers electrolyte replacements as prescribed. Fluids are administered IV for 4 to 5
days to replace lost fluids.
Nasogastric suction is also a part of immediate postoperative care, with the tube
requiring frequent irrigation as prescribed. The purpose of nasogastric suction is to prevent
a buildup of gastric contents. After the tube is removed, the nurse offers sips of clear liquids
and gradually progresses the diet. It is important to report nausea and abdominal distention
immediately because they may indicate intestinal obstruction.
By the end of the first week, rectal packing is removed. Because this procedure may be
uncomfortable, the nurse may administer an analgesic an hour before its removal. After the
packing is removed, the perineum is irrigated two or three times daily until full healing
takes place.
The patient with a traditional ileostomy cannot establish regular bowel habits because
the contents of the ileum are fluid and are discharged continuously. The patient must wear
a pouch at all times. Stomal size and pouch size vary initially; the stoma should be
rechecked 3 weeks after surgery, when the edema has subsided. The final size and type of
appliance is selected in 3 months, after the patient’s weight has stabilized and the stoma
shrinks to a stable shape.
The location and length of the stoma are significant in the management of the ileostomy
by the patient. The surgeon positions the stoma as close to the midline as possible and at a
location where even an obese patient with a protruding abdomen can care for it easily.
Usually, the ileostomy stoma is about 2.5 cm (1 in) long, which makes it convenient for the
attachment of an appliance.

1961
 Skin excoriation around the stoma can be a persistent problem. Peristomal skin integrity
may be compromised by several factors, such as an allergic reaction to the ostomy
appliance, skin barrier, or paste; chemical irritation from the effluent; mechanical injury
from the removal of the appliance; and infection. If irritation and yeast growth occur,
nystatin powder (Mycostatin) is dusted lightly on the peristomal skin.

Changing an Appliance

A regular schedule for changing the pouch before leakage occurs must be established for
those with a traditional ileostomy. The amount of time a person can keep the appliance
sealed to the body surface depends on the location of the stoma and on body structure. The
usual wearing time is 5 to 7 days. The appliance is emptied every 4 to 6 hours or at the
same time the patient empties the bladder. An emptying spout at the bottom of the
appliance is closed with a special clip made for this purpose.
Most pouches are disposable and odor-proof. Foods such as spinach and parsley act as
deodorizers in the intestinal tract; foods that cause odors include cabbage, onions, and fish.
Bismuth subcarbonate tablets, which may be prescribed and taken orally three or four times
each day, are effective in reducing odor. Oral diphenoxylate (Lomotil) also can be
prescribed to diminish intestinal motility, thereby thickening the stool and assisting in odor
control.
Changing an ileostomy appliance also allows for examination of the skin around the
stoma, and assists in controlling odor if this becomes a problem. The appliance should be
changed at any time that the patient complains of burning or itching under the disk or pain
in the area of the stoma; routine changes should be performed early in the morning before
breakfast or 2 to 4 hours after a meal, when the bowel is least active. See Box 24-2 for
guidelines on changing an ostomy appliance.

1962
Managing Dietary and Fluid Needs
A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are
given. These foods are important sources of vitamins A and C. Foods are reintroduced one
at a time. The nurse assesses the patient’s tolerance for these foods and reminds him or her
to chew food thoroughly.
Fluids may be a problem during the summer when fluid lost through perspiration adds
to the fluid loss through the ileostomy. Fluids such as Gatorade are helpful in maintaining
electrolyte balance.

1963
Preventing Complications
Monitoring for complications is an ongoing activity for the patient with an ileostomy.
Peristomal skin irritation, which results from leakage of effluent, is the most common
complication of an ileostomy. A drainable pouching system that does not fit well is often
the cause. Components of the drainable pouching system include the pouch, a solid skin
barrier, and adhesive. The enterostomal therapist typically recommends the appropriate
drainable pouching system. The solid skin barrier is the component of this system that is
most important in ensuring healthy peristomal skin. Solid skin barriers typically are shaped
as rectangular or elliptical wafers and are composed of polymers and hydrocolloids. They
protect the skin around the stoma from effluent from the stoma and provide a stable
interface between the stoma and the pouch.
Other common complications include fluid volume deficit, stomal stenosis, urinary
calculi, and cholelithiasis. Even in the presence of a properly fitted drainable pouching
system, loose watery effluent can be problematic, often filling the pouch (every hour or
sooner), which can quickly lead to dehydration and electrolyte losses. Supplemental water,
sodium, and potassium are administered to prevent hypovolemia and hypokalemia.
Antidiarrheal agents or bile salt sequestrants may be administered to decrease the watery
effluent.
Stenosis is caused by circular scar tissue that forms at the stoma site. The scar tissue must
be released surgically. Urinary calculi may occur in patients with ileostomies and are
attributed, at least partly, to dehydration from decreased fluid intake. Intense lower
abdominal pain that radiates to the legs, hematuria, and signs of dehydration indicate that
the urine should be strained. Fluid intake is encouraged. Sometimes, small stones are passed
during urination; otherwise, treatment is necessary to crush or remove the calculi (see
Chapter 28).

BOX 24-2 GUIDELINES FOR NURSING CARE

Changing an Ileostomy Appliance

Equipment Needed
Mild soap
Clean cloths or towels
Skin barrier (stoma adhesive, Convatec)
Cutting guide
Appliance pouch
Optional Equipment
Barrier powder
Antifungal spray or powder
Barrier washer

Implementation

1964
1965
 Cholelithiasis (i.e., gallstones) occurs more commonly in patients with an ileostomy
than in the general population because of changes in the absorption of bile acids that occur
postoperatively. Spasm of the gallbladder causes severe upper right abdominal pain that can
radiate to the back and right shoulder (see Chapter 25).

MASSES IN THE COLON AND RECTUM

A polyp is a mass of tissue that protrudes into the lumen of the bowel. Polyps can occur
anywhere in the intestinal tract and rectum. They can be classified as neoplastic (i.e.,
adenomas and carcinomas) or nonneoplastic (i.e., mucosal and hyperplastic).

1966
NONNEOPLASTIC POLYPS
Although most polyps do not develop into invasive neoplasms, they must be identified and
followed closely.

1967
Risk Factors
Nonneoplastic polyps, which are benign epithelial growths, are common in the Western
world. They occur more commonly in the large intestine than in the small intestine.
Adenomatous (benign) polyps are more common in men. The proportion of these polyps
arising in the proximal part of the colon increases with age (after 50 years of age).
Prevalence rates vary from 25% to 60%, depending on age. Nonneoplastic polyps occur in
80% of the population, and their frequency increases with age.

1968
Clinical Manifestations and Assessment
Clinical manifestations depend on the size of the polyp and the amount of pressure it exerts
on intestinal tissue. The most common symptom is rectal bleeding. Lower abdominal pain
also may occur. If the polyp is large enough, symptoms of obstruction occur. The diagnosis
is based on history and digital rectal examination, barium enema studies, sigmoidoscopy, or
colonoscopy.

1969
Medical and Nursing Management
After a polyp is identified, it should be removed. There are several methods: colonoscopy
with the use of special equipment (i.e., biopsy forceps and snares), laparoscopy, or
colonoscopic excision with laparoscopic visualization. The latter technique enables
immediate detection of potential problems and allows laparoscopic resection and repair of
the major complications of perforation and bleeding that may occur with polypectomy.
Microscopic examination of the polyp then identifies the type of polyp and indicates what
further surgery is required, if any.

1970
COLORECTAL CANCER
Tumors of the colon and rectum are relatively common; the colorectal area (the colon and
rectum combined) is now the third most common site of new cancer cases and deaths in
the United States. Colorectal cancer is the second most common cause of cancer death
among men who are 40 to 79 years of age (Siegel, Miller, & Jemal, 2016). Improved
screening strategies have helped reduce the number of deaths from colon cancer in recent
years. Of the approximately 150,000 people diagnosed each year, fewer than half that
number dies annually (American Cancer Society [ACS], 2015).
Early diagnosis and prompt treatment could save almost three of every four people. If
the disease is detected and treated at an early stage, the 5-year survival rate is 90%; however,
in the more distal stages of disease, the 5-year survival rate is only approximately 13%
(ACS, 2015). Most people are asymptomatic for long periods and seek health care only
when they notice a change in bowel habits or rectal bleeding. Prevention and early
screening are the keys to detection and reduction of mortality rates.

1971
Pathophysiology
Cancer of the colon and rectum is predominantly (95%) adenocarcinoma (i.e., arising from
the epithelial lining of the intestine) (ACS, 2015). It may start as a benign polyp but may
become malignant, invade and destroy normal tissues, and extend into surrounding
structures. Cancer cells may migrate away from the primary tumor and spread to other
parts of the body (most often to the liver).

1972
Risk Factors
Colorectal cancer is a disease of Western cultures. The incidence increases with age (the
incidence is highest in people over 85 years of age) and is higher in people with a family
history of colon cancer and those with IBD or polyps. In men, only the incidence of
prostate cancer and lung cancer exceeds that of colorectal cancer. In women, only the
incidence of breast and lung cancer exceeds that of colorectal cancer.
Colon cancer in the elderly has been closely associated with dietary carcinogens. High-
fiber intake, particularly from fruits and cereals, reduces the risk of colorectal cancer
(Kunzmann et al., 2015). Excess dietary fat, high alcohol consumption, and smoking all
increase the incidence of colorectal tumors. Physical activity and dietary folate have
protective effects (Siegel et al., 2016).

1973
Clinical Manifestations and Assessment
Symptoms are often insidious. Patients with colorectal cancer usually report fatigue, which
is caused primarily by iron-deficiency anemia. In early stages, minor changes in bowel
patterns and occasional bleeding may occur. The later symptoms reported most commonly
by the elderly are abdominal pain, obstruction, tenesmus, and rectal bleeding.
The symptoms are greatly determined by the location of the cancer, the stage of the
disease, and the function of the intestinal segment in which it is located. The most
common presenting symptom is a change in bowel habits. The passage of blood in the
stools is the second most common symptom. Symptoms also may include unexplained
anemia, anorexia, weight loss, and fatigue.
The symptoms most commonly associated with right-sided lesions are dull abdominal
pain and melena (black, tarry stools). The symptoms most commonly associated with left-
sided lesions are those associated with obstruction (abdominal pain and cramping,
narrowing stools, constipation, distention), as well as bright red blood in the stool.
Symptoms associated with rectal lesions are tenesmus (ineffective, painful straining at
stool), rectal pain, the feeling of incomplete evacuation after a bowel movement, alternating
constipation and diarrhea, and bloody stool.
Along with an abdominal and rectal examination, the most important diagnostic
procedures for cancer of the colon are fecal occult blood testing, barium enema,
proctosigmoidoscopy, and colonoscopy (see Chapter 21). The majority of colorectal cancer
cases can be identified by colonoscopy with biopsy or cytology smears.
Carcinoembryonic antigen (CEA) studies also may be performed. Although CEA may
not be a highly reliable indicator in diagnosing colon cancer because not all lesions secrete
CEA, studies show that CEA levels are reliable prognostic predictors. With complete
excision of the tumor, the elevated levels of CEA should return to normal within 48 hours.
Elevations of CEA at a later date suggest recurrence.

1974
Medical and Nursing Management
The patient with symptoms of intestinal obstruction is treated with IV fluids and
nasogastric suction. If there has been significant bleeding, blood component therapy may
be required.
Treatment for colorectal cancer depends on the stage of the disease and consists of
surgery to remove the tumor, supportive therapy, and adjuvant therapy. Patients who
receive some form of adjuvant therapy, which may include chemotherapy, radiation
therapy, immunotherapy, or multimodality therapy, typically demonstrate delays in tumor
recurrence and increases in survival time.
Radiation therapy is used before, during, and after surgery to shrink the tumor, to
achieve better results from surgery, and to reduce the risk of recurrence. For inoperative or
unresectable tumors, radiation is used to provide significant relief from symptoms.
Intracavitary and implantable devices are used to deliver radiation to the site. The response
to adjuvant therapy varies.
Surgery is the primary treatment for most colon and rectal cancers. It may be curative or
palliative. Advances in surgical techniques can enable the patient with cancer to have
sphincter-saving devices that restore continuity of the GI tract. The type of surgery
recommended depends on the location and size of the tumor. Cancers limited to one site
can be removed through the colonoscope. Laparoscopic colotomy with polypectomy
minimizes the extent of surgery needed in some cases. A laparoscope is used as a guide in
making an incision into the colon; then the tumor mass is excised. Use of the
neodymium/yttrium-aluminum-garnet (Nd:YAG) laser has proved effective with some
lesions as well.
Surgical procedures include the following:
Segmental resection with anastomosis (i.e., removal of the tumor and portions of the
bowel on either side of the growth, as well as the blood vessels and lymphatic nodes)
(Fig. 24-9)
Abdominoperineal resection with permanent sigmoid colostomy (i.e., removal of the
tumor and a portion of the sigmoid and all of the rectum and anal sphincter) (Fig. 24-
10)
Temporary colostomy followed by segmental resection and anastomosis and subsequent
reanastomosis of the colostomy, allowing initial bowel decompression and bowel
preparation before resection
Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions
Construction of a coloanal reservoir called a colonic J pouch, which is performed in two
steps. A temporary loop ileostomy is constructed to divert intestinal flow, and the newly
constructed J pouch (made from 6 to 10 cm of colon) is reattached to the anal stump.
About 3 months after the initial stage, the ileostomy is reversed and intestinal continuity
is restored. The anal sphincter and, therefore, continence are preserved.
A colostomy is the surgical creation of an opening (i.e., stoma) into the colon. It can be
created as a temporary or permanent fecal diversion. It allows the drainage or evacuation of

1975
colon contents to the outside of the body. The consistency of the drainage is related to the
placement of the colostomy, which is dictated by the location of the tumor and the extent
of invasion into surrounding tissues (Fig. 24-11). With improved surgical techniques,
colostomies are performed in less than one third of patients with colorectal cancer.

1976
1977
FIGURE 24-9 Examples of areas where cancer can occur, the area that is removed, and how the
anastomosis is performed (small diagrams).

1978
Complications
Tumor growth may cause partial or complete bowel obstruction. Extension of the tumor
and ulceration into the surrounding blood vessels result in hemorrhage. Perforation, abscess
formation, peritonitis, sepsis, and shock may occur.
The elderly are at increased risk of complications after surgery and may have difficulty
managing colostomy care. Some elderly patients may have decreased vision, impaired
hearing, and difficulty with fine motor coordination. It may be helpful for patients to
handle ostomy equipment and simulate cleaning the peristomal skin and irrigating the
stoma before surgery. Skin care is a major concern in older patients with a colostomy
because of the skin changes that occur with aging—the epithelial and subcutaneous fatty
layers become thin, and the skin is irritated easily. To prevent skin breakdown, special
attention is paid to skin cleansing and the proper fit of an appliance. Arteriosclerosis causes
decreased blood flow to the wound and stoma site. As a result, transport of nutrients is
delayed, and healing time may be prolonged. Some patients have delayed elimination after
irrigation because of decreased peristalsis and mucus production. Most patients require 6
months before they feel comfortable with their ostomy care.

1979
 FIGURE 24-10 Abdominoperineal resection for carcinoma of the rectum. A. Prior to surgery. Note
tumor in rectum. B. During surgery, the sigmoid is removed and the colostomy is established. The
distal bowel is dissected free to a point below the pelvic peritoneum, which is sutured over the closed
end of the distal sigmoid and rectum. C. Perineal resection includes removal of the rectum and free
portion of the sigmoid from below. A perineal drain is inserted. D. The final result after healing. Note
the healed perineal wound and the permanent colostomy.

INTESTINAL OBSTRUCTION

Intestinal obstruction exists when blockage prevents the normal flow of intestinal contents
through the intestinal tract. In mechanical obstruction, intraluminal or mural obstructions
secondary to pressure on the intestinal wall occur. Examples are intussusception
(telescoping of a portion of the intestine within another immediately adjacent portion of
intestine), polypoid tumors and neoplasms, stenosis, strictures, adhesions, hernias, and
abscesses. Figure 24-12 depicts additional causes of obstruction. In functional obstruction,

1980
intestinal musculature cannot propel the contents along the bowel thereby causing a
blockage within the intestine. Examples are amyloidosis, muscular dystrophy, endocrine
disorders such as diabetes mellitus, or neurologic disorders such as Parkinson disease. The
blockage also can be temporary and the result of the manipulation of the bowel during
surgery.
The obstruction can be partial or complete. Its severity depends on the region of bowel
affected, the degree to which the lumen is occluded, and especially the degree to which the
vascular supply to the bowel wall is disturbed.
Most bowel obstructions occur in the small intestine. Adhesions are the most common
cause of small bowel obstruction, followed by hernias and neoplasms. Other causes include
intussusception, volvulus (i.e., twisting of the bowel), and paralytic ileus. Most
obstructions in the large bowel occur in the sigmoid colon. The most common causes are
carcinoma, diverticulitis, inflammatory bowel disorders, and benign tumors. Table 24-6
and Figure 24-12 list mechanical causes of obstruction and describe how they occur.

1981
FIGURE 24-11 Placement of permanent colostomies. The nature of the discharge varies with the site.
Shaded areas show sections of bowel removed. With a sigmoid colostomy (A), the feces are solid. With
a descending colostomy (B), the feces are semiformed. With a transverse colostomy (C), the feces are
unformed. With an ascending colostomy (D), the feces are fluid.

1982
FIGURE 24-12 Three causes of intestinal obstruction. A. Intussusception invagination or shortening
of the colon caused by the movement of one segment of bowel into another. B. Volvulus of the sigmoid
colon; the twist is counterclockwise in most cases. Note the edematous bowel. C. Hernia (inguinal).
The sac of the hernia is a continuation of the peritoneum of the abdomen. The hernial contents are
intestine, omentum, or other abdominal contents that pass through the hernial opening into the hernial
sac.

1983
SMALL BOWEL OBSTRUCTION
Pathophysiology
Intestinal contents, fluid, and gas accumulate above the intestinal obstruction. The
abdominal distention and retention of fluid reduce the absorption of fluids and stimulate
more gastric secretion. Increases in intestinal lumen pressure causes occlusion of capillary
blood flow and compromise of venous return and arterial flow. This causes edema,
congestion, necrosis, and eventual rupture or perforation of the intestinal wall, with
resultant peritonitis.

TABLE 24-6 Mechanical Causes of Intestinal Obstruction

Reflux vomiting may be caused by abdominal distention. Vomiting results in loss of

hydrochloric acid (HCl) and potassium from the stomach, leading to reduction of chlorides
and potassium in the blood and to metabolic alkalosis. Dehydration develops from loss of
water and sodium. With acute fluid losses, hypovolemic shock may occur.

1984
Clinical Manifestations and Assessment
The initial symptom is usually crampy pain that is wavelike and colicky. The patient may
pass blood and mucus but no fecal matter and no flatus. Vomiting occurs. If the
obstruction is complete, the peristaltic waves initially become extremely vigorous and
eventually assume a reverse direction, with the intestinal contents propelled toward the
mouth instead of toward the rectum. If the obstruction is in the ileum, fecal vomiting takes
place. First, the patient vomits the stomach contents, then the bile-stained contents of the
duodenum and the jejunum, and finally, with each paroxysm of pain, the darker, fecal-like
contents of the ileum. The signs of dehydration become evident: intense thirst, drowsiness,
generalized malaise, aching, and a parched tongue and mucous membranes. The abdomen
becomes distended. The lower the obstruction is in the GI tract, the more marked the
abdominal distention. If the obstruction continues uncorrected, hypovolemic shock occurs
from dehydration and loss of plasma volume.
Diagnosis is based on the symptoms described previously and on imaging studies.
Abdominal x-ray and CT findings include abnormal quantities of gas, fluid, or both in the
intestines. Laboratory studies (i.e., electrolyte studies and a CBC) reveal a picture of
dehydration, loss of plasma volume, and possible infection.

1985
Medical and Nursing Management
Decompression of the bowel through a nasogastric tube (see Chapter 22) is successful in
most cases. When the bowel is obstructed completely, the possibility of strangulation
warrants surgical intervention. Before surgery, IV therapy is necessary to replace the
depleted water, sodium, chloride, and potassium.
The surgical treatment of intestinal obstruction depends largely on the cause of the
obstruction. In the most common causes of obstruction, such as hernia and adhesions, the
surgical procedure involves repairing the hernia or dividing the adhesion to which the
intestine is attached. In some instances, the portion of affected bowel may be removed and
an anastomosis performed. The complexity of the surgical procedure for intestinal
obstruction depends on the duration of the obstruction and the condition of the intestine.
Nursing management of the nonsurgical patient with a small bowel obstruction includes
maintaining the function of the nasogastric tube, assessing and measuring the nasogastric
output, assessing for fluid and electrolyte imbalance, monitoring nutritional status, and
assessing improvement (e.g., return of normal bowel sounds, decreased abdominal
distention, subjective improvement in abdominal pain and tenderness, passage of flatus or
stool). The nurse reports discrepancies in intake and output, worsening of pain or
abdominal distention, and increased nasogastric output. If the patient’s condition does not
improve, the nurse prepares him or her for surgery. The exact nature of the surgery depends
on the cause of the obstruction. Nursing care of the patient after surgical repair of a small
bowel obstruction is similar to that for other abdominal surgeries (see Chapter 23).

Unfolding Patient Stories: Stan Checketts • Part 2

Recall from Chapter 7 Stan Checketts, who arrived in the emergency department with
severe abdominal pain. He is diagnosed with a small bowel obstruction. He is NPO and
has a nasogastric (NG) tube placed to low intermittent suction. Describe the steps of a
focused GI assessment performed by the nurse. How would the nurse explain the
rationale for an NG tube and NPO status? What are specific assessments and nursing
care responsibilities for an NG tube?
Care for Stan and other patients in a realistic virtual environment:
([Link]/vSimMedicalSurgical). Practice documenting these patients’ care in
DocuCare ([Link]/DocuCareEHR).

1986
LARGE BOWEL OBSTRUCTION
Pathophysiology
As in small bowel obstruction, large bowel obstruction results in an accumulation of
intestinal contents, fluid, and gas proximal to the obstruction. Obstruction in the large
bowel can lead to severe distention and perforation unless some gas and fluid can flow back
through the ileal valve. Large bowel obstruction, even if complete, may be without
catastrophic issue if the blood supply to the colon is not disturbed. However, if the blood
supply is cut off, intestinal strangulation and necrosis (i.e., tissue death) occur; this
condition is life threatening. In the large intestine, dehydration occurs more slowly than in
the small intestine because the colon can absorb its fluid contents and can distend to a size
considerably beyond its normal full capacity.
Adenocarcinoid tumors account for the majority of large bowel obstructions. Most
tumors occur beyond the splenic flexure, making them accessible with a flexible
sigmoidoscope.

1987
Clinical Manifestations and Assessment
Large bowel obstruction differs clinically from small bowel obstruction in that the
symptoms develop and progress relatively slowly. In patients with obstruction in the
sigmoid colon or the rectum, constipation may be the only symptom for months. The
shape of the stool is altered as it passes the obstruction that is gradually increasing in size.
Blood in the stool may result in iron-deficiency anemia. The patient may experience
weakness, weight loss, and anorexia. Eventually, the abdomen becomes markedly distended,
loops of large bowel become visibly outlined through the abdominal wall, and the patient
has crampy lower abdominal pain. Finally, fecal vomiting develops. Symptoms of shock
may occur.
Diagnosis is based on symptoms and on imaging studies. Abdominal x-ray and
abdominal CT or MRI findings reveal a distended colon and pinpoint the site of the
obstruction. Barium studies are contraindicated because of risk of perforation.

1988
Medical and Nursing Management
Restoration of intravascular volume, correction of electrolyte abnormalities, and nasogastric
aspiration and decompression are instituted immediately. A colonoscopy may be performed
to untwist and decompress the bowel. A cecostomy, in which a surgical opening is made
into the cecum, may be performed in patients who are poor surgical risks and urgently need
relief from the obstruction. The procedure provides an outlet for releasing gas and a small
amount of drainage. A rectal tube may be used to decompress an area that is lower in the
bowel. However, the usual treatment is surgical resection to remove the obstructing lesion.
A temporary or permanent colostomy may be necessary. An ileoanal anastomosis may be
performed if it is necessary to remove the entire large bowel.
The nurse’s role is to monitor the patient for symptoms that indicate that the intestinal
obstruction is worsening and to provide emotional support and comfort. The nurse
administers IV fluids and electrolytes as prescribed. If the patient’s condition does not
respond to nonsurgical treatment, the nurse prepares the patient for surgery. This
preparation includes preoperative teaching as the patient’s condition indicates. After
surgery, general abdominal wound care and routine postoperative nursing care are
provided.

FIGURE 24-13 Various types of anal lesions. A. Fistula. B. Fissure. C. External and internal
hemorrhoids.

DISEASES OF THE ANORECTUM

Diseases of the anorectum include anal fistulas and fissures, hemorrhoids, sexually
transmitted anorectal diseases, and pilonidal cysts. Nursing management of these
conditions is discussed in Box 24-3.

1989