Peritonitis
: inflammation of the lining of the abdominal cavity, usually as a result of a bacterial infection of an area in the GI tract with leakage of contents into the abdominal cavity
Peritoneum: serous membrane lining the abdominal cavity
Causes of peritonitis
bacterial infection (organisms from GIT, in women also from internal reproductive organs)
injury/trauma (gunshot/stab wound)
inflammation extending from retroperitoneal organs (ie: kidney)
most common bacteria implicateded: Escherichia coli, Klebsiella, Proteus, Pseudomonas
appendicitis, perforated ulcer, diverticulitis, bowel perforation
may also be ass’d with abdominal surgical procedures and peritoneal dialysis
S/S of peritonitis
-symptoms depend on the location and extent of the inflammation
-early clinical manifestations of peritonitis frequently are the symptoms of the disorder causing the condition
pain begins diffus, becomes constant, localized, more intense near the site of the inflammation
-movement usually aggravates the pain
-affected area of abdomen becomes extremely tender and distended, 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
nausea and vomiting occur, persitalsis is diminished
temperature of 37.8 to 38.3 can be expected, along with an increased pulse rate
S/S of paralytic ileus
- abdominal distension
- nausea
- Vomiting
- vague discomfort
- auscultation reveals a silent abdomen or hypoactive bowel sounds
Treatment of paralytic ileus
- continuous NG suction
- NPO status
- IV fluids and electrolytes
- minimal sedatives and avoidance of opioids and anticholinergic drugs
- Maintaining normal serum K levels ( >4 mEq/L)
- If ileus lasts more than a week probably has an obstructive cause and surgery may be required
Ischemic colitis
Ischemic colitis is the most common form of GI ischemia. It is characterised by reduced blood flow to the colon due to narrowed or blocked arteries, or hypoperfusion to the colon. It can range from being transient self-limited ischemia involving the mucosa and sub-mucosa to acute ischemia that may progress to necrosis. It can affect any part of the colon, but due to its vascular structure, it more commonly affects the left colon (Green & Tendler, 2005).
Causes of ischemic colitis
embolism, thrombosis, atherosclerosis, hypovolemia, strenuous physical exercise, shock, complications of cardiac surgery, or medications
S/S of ischemic colitis
- Acute-onset abdominal cramping and pain (this is often associated with the urge to defecate)
- Hematochezia (passage of fresh blood through the anus)
- Diarrhea
- Abdominal distention
- Nausea/Vomiting
- Mild to moderate tenderness over the affected area of the colon
Dx of ischemic colitis
- Colonoscopy is the diagnostic tool of choice
- CBC
- PTT/INR
- lactate, LDH, CPK, amylase levels, leucocytes, alkaline phosphatase, inorganic phosphate, intestinal fatty acid binding protein and alfa-glutathione S-transferase have been used as laboratory makers; however, they only serve to diagnose severe ischemia
- CT of the abdomen (to rule out other conditions)
- Stool sample (to rule out infection as cause of ischemia)
- Abdonimal angiography
Complications of ischemic colitis
- Gangrene
- Abscess formation
- Perforation
- Obstruction
- Sepsis
What do the following GI bleeding colours mean? Bright red Dark red/tarry Coffee ground Maroon/purple
- Bright red – recent acute bleeding, could be arterial
- Dark red/tarry – old blood that has been retained or venous blood from varices.
- Coffee ground – suggestive of partially digested blood, slow bleed.
- Maroon/purple - Intestinal bleeding
Palpation findings with GI bleeds
- Hard, distended, tender are warning signs. Indicate large bleed that could have been occurring over a long period of time.
How do the following amounts of blood loss affect you physiologically?
500mL
1000-2000mL
2000-3000mL
- 500 ml, body can compensate. Generally do not see many signs if at all
- 1000-2000 ml, tachycardia, tachypnea, decrease in Hgb, skin cool to touch, weak pulse, decreased urine output, diaphoretic, decrease in systolic blood pressure.
- 2000-3000 ml, same as above but more extreme, peripheral cyanosis, cool to touch, low SpO2, decrease in LOC.
Causes of GI bleeds
- Please see handouts on varices and peptic ulcer disease
- Trauma
- Vomiting
- Medications (NSAIDs)
- Coagulation disorders
- Cancer
- Gastritis
- Diverticular disease
- IBD
- Polyps
- Fissures
- Tears
- Perforations
- Liver disease
- Some infectious diseases
Irritable Bowel Syndrome
Intermittent abdominal pain or discomfort relieved by defecation
Changes in bowel frequency: More than 3 times a day OR less than 3 times a week
Abnormal stool form: Lumpy/hard OR watery/loose, mucus in stool
Abnormal stool passing: Straining, urgency, feeling of incomplete emptying
Flatulence, bloating, nausea, constipation, diarrhea
Anxiety or depression
INFLAMMATORY BOWEL DISEASE
Both Crohns and U.C. produce an inflammation of the bowel, pattern of familial occurrence and can be accompanied by systemic manifestation.
•Ulcerative Colitis
is a recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum.
- Unaffected by diet
- Most often starts in rectum
- Continuous inflammation in affected areas, unlike the patchiness of Crohn’s. - a serious disease that often has systemic complications, a high mortality rate and “approximately 5% of patients [will] develop colon cancer”
- it is an exacerbation and remission conditionS/S of UC
- diarrhea, LLQ abdominal pain, intermittent tenesmus (inclination to evacuate the bowels), and rectal bleeding
- bleeding may result in pallor, anemia, and fatigue
- “may cause anorexia, weight loss, fever, 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”
- extra-intestinal manifestations include: skin lesions, eye lesions, joint abnormalities, and liver disease
Crohn’s Disease
May be periods of remission and exacerbation
· Prominent lower right quadrant abdominal pain and diarrhea that is relieved by defecation.
· After meals cramp pains occur
· Abdominal tenderness and spasms.
· Chronic S&S: diarrhea, abdominal pain, steatorrhea (excessive fat in the feces), anorexia, weight loss, and nutritional deficits.
S/S of Hepititis
- may occur with or without flulike symptoms
- headache, malaise, fatigue, anorexia, fever, dark urine, jaundice, tender liver
How are the following transmitted? Hep A Hep B Hep C Hep D Hep E
A (ass) = fecal oral B (blood) = parenteral C (mix) = both D = parenteral E = fecal oral
Pharmacologic therapy for GI bleeds
1) somatostatin (Stilamin) and octreotide (Sandostatin) are the treatment of choice for upper GI bleeds
cause selective splanchnic vasoconstriction
2) propranolol (Inderal) and nadolol (Corgard)
beta-blocking agents that decrease portal pressure
prevent recurrent bleeding from esophageal varices in some patients and should be started once they are hemodynamically stable
3) nitrates such as isosorbide (Isordil) lower portal pressure by venodilation and decreased cardiac output
Cholecystitis
- Inflammation of the gallbladder
- Severe pain in your upper right abdomen
- Pain that radiates from to your right shoulder or back
- Tenderness over your abdomen when it’s touched
- Nausea
- Vomiting
- Fever
Appendicitis
- Appendix inflames and has edema after occluding by hardened fecal material, foreign body, or tumor.
- Increasing intraluminal pressure causes pain in the umbilicus/RLQ within a few hours.
- Fills with pus.
