GIT - Lower - Conditions

Question 1

Irritable Bowel Syndrome (IBS)

Answer 1

• characterised by a variable combination of chronic and recurrent intestinal symptoms not explained by structural or biochemical abnormalities
• S&S - abdominal pain, altered bowel function, flatulence, bloating, nausea & anorexia, constipation or diarrhoea, anxiety or depression
• abdominal pain usually relieved by defaecation, pain usually intermittent, cramping, in the lower abdomen, does not occur at night or interfere with sleep
• increased motility and contractions thought to be connected to psychological and physiological stress
• women affected more than men
• diagnostic - symptoms lasting at least 12 weeks in the last 12 months, relief with defaecation, onset associated with a change in bowel frequency and faecal appearance, history of lactose intolerance
• treatment - stress management, increase fibre, avoid precipitating dietary intake, antispasmodics, anticholinergics

Question 2

Inflammatory Bowel Disease

Answer 2

• autoimmune disease characterised by chronic inflammation of the GIT
• Crohn’s Disease & Ulcerative Colitis - share many of the same features, periods of unpredictable episodes of exacerbation & remission, unknown cause, no cure
• common features - diarrhoea, bloody stools, weight loss, abdominal pain, fever, arthritis

Question 3

Crohn’s Disease

Answer 3

• recurrent, granulomatous (mass of inflamed granulation tissue), inflammatory response
• mucosa has a cobblestone appearance caused by fissures & crevices that develop, submucosa affected by inflammation & fibrosis, affects entire thickness of bowel
• eventually bowel wall becomes thickened & inflexible
• skip lesions
• most commonly affects proximal portion of the colon or terminal ileum, can affect anywhere from mouth to anus
• usually strikes in 20s / 30s, women slightly more affected than men

Question 4

Crohn’s Disease - Signs & Symptoms

Answer 4

• insidious onset
• crampy abdominal pain (especially after meals)
• diarrhoea - rare - bleeding (never feel bowel has been totally emptied)
• fatigue
• weight loss
• malnutrition
• secondary anemia
• fever
• complications
  
  • fistula formation
  • abdominal abscess formation
  • intestinal obstruction

Question 5

Ulcerative Colitis

Answer 5

• non-specific inflammatory condition of the colon, confined to the rectum & colon, usually begins in the rectum & spreads along the colon
• affects mainly mucosa & submucosa
• affected area tends to be continuous rather than skipping areas as Crohn’s does
• mucosal layer often develops tongue like projections that resemble polyps & are called pseudopolyps, bowel wall thickens due to repeated episodes of colitis
• can occur at any age

Question 6

Ulcerative Colitis - Signs & Symptoms

Answer 6

• severe diarrhoea - can be up to 30-40 bowel movements a day, stools typically contain blood / mucus
• abdominal pain
• cramping abdominal pain
• rectal bleeding - common in UC
• urgent need to defecate
• tenesmus (intermittent)
• anorexia
• fatigue / weakenss
• fever
• vomiting
• anemia

Question 7

Inflammatory Bowel Disease - Management

Answer 7

• depends on disease type & severity
• aim is to reduce inflammation, maintain fluid & electrolyte balance, and relieve symptoms
• nutritional therapy - low fat & fibre, high calorie & protein, supplementary vitamins & iron, if acute, nil orally, IVT / TPN
• medications - steroids - don’t stop abruptly, random BSLs, have with food, suppress immunity & increase risk of infection
• medical management usually sufficient for ulcerative colitis, surgical treatment is used for persistent clinical manifestations
• 75% with crohn’s disease will require ileostomy or bowel resection
• 25-40% with ulcerative colitis will need surgery

Question 8

Diverticular Disease

Answer 8

• condition in which the mucosal layer of the colon herniates through the muscularis layer
• can be multiple diverticula, mainly in the sigmoid colon
• caused by dietary factors (not enough fibre), decrease in physical activity, poor bowel habits (avoiding urge to defecate), effects of aging
• may be asymptomatic, symptoms can include ill defined low abdominal discomfort, changed bowel habits, bloating, flatulence
• diagnosed by x-ray

Question 9

Diverticulitis

Answer 9

• complication of diverticular disease, inflammation and gross or microscopic perforation of the diverticulum, with development of small, localised abscess
• S&S - pain in the lower left quadrant, nausea & vomiting, tenderness in the lower left quandrant, slight fever, elevated white cell cound
• complications - perforation with peritonitis, haemorrhage, bowel obstruction, fistular formation (usually involving bladder)
• diagnosis - history, presenting manifestations, barium enema x-rays (avoided in acute diverticulitis), CT scans, ultrasound scans

Question 10

Diverticulitis - Management

Answer 10

• goal is to relieve symptoms and rest bowel
• uncomplicated
  
  • high residue diet
  • anticholinergic medications (to stop activity of bowel)
  • increased fluid intake
• acute
  
  • NBM
  • bed rest
  • parenteral fluids
  • antibiotics
  • analgesics
  • may need emergency colostomy

Question 11

Bowel Obstruction

Answer 11

• mechanical
  
  • surgical adhesions
  • hernias and tumors
  • can occur within days of surgery, weeks, or even years
  • large bowel obstructions usually due to cancer
• non mechanical
  
  • paralytic ileus - general anesthesia causes bowel paralysis, no peristatic movements
  • usually after bowel surgery
• impairs ability of gut contents to pass through, if not treated, strangulation and gangrene may occur
• more common in small bowel

Question 12

Bowel Obstruction - Clinical Manifestations

Answer 12

• nausea & vomiting
• abdominal pain
• abdominal distention (specific to obstruction)
• no flatus
• with paralytic ileus - no bowel sounds

Question 13

Bowel Obstruction - Diagnosis

Answer 13

• abdominal x-ray
• barium enema (if perforation suspected no barium that can leak & cause peritonitis or septic shock
• FBE
• U&E (GIT conditions = N&V, diarrhoea, electrolyte imbalance need bloods)
• on xray - stepladder pattern, lines caused by fluid, domes by gas - looks like a stepladder

Question 14

Bowel Obstruction - Management

Answer 14

• NBM
• IV fluid replacement
• NG tube, rest GI tract & decompress
• FBC
• assess vomitus
• auscultate bowel (hyperactive, hypoactive, absent)
• mouth care

Question 15

Bowel Obstruction - Prevention

Answer 15

• early management - hernias
• decrease risk of fecal impaction
• post surgery - listen for bowel sounds before fluids / food given
• in surgery - less handling of bowel

Question 16

Bowel Obstruction - Pathophysiology

Answer 16

• small bowel obstruction
• fluid, gas and chyme accumulate
• decreased absorption of fluids
• increased intestinal secretions
• increased intraluminal pressure
• movements of fluid and electrolytes out of the bowel
• ischemic cells & necrotic cells = death of bowel

Question 17

Appendicitis

Answer 17

• appendix becomes inflamed, swollen & gangrenous, eventually perforates
• frequent in 5-30 age group, but an occur at any age

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