Disorders of the Digestive System

1
Disorders of the Digestive System

• Cathy Gibbs BSN, RN

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Disorders of the Digestive System

• Sources of digestive problems
• Mechanical
• Nervous
• Chemical
• Hormonal

3
Eating Disorders

• Anorexia
• Chronic loss of
• appetite
• Possible emotional,
• social factors
• Anorexia Nervosa
• Psychological disorder
• Bulimia
• Binge-purge syndrome

4
Causes of Anorexia

• Anxiety, depression
• Improper fit of dentures
• Illness, physical discomfort
• Constipation
• Intestinal obstruction

5
Anorexia, Nursing Implementation

• Become familiar with patients eating habits
• Permit patient to choose own food
• Dont force patient to eat
• Provide pleasant environment
• Serve small portions

6
Dental Plaque and Caries

• Erosive process that dissolves tooth enamel
• Medical management
• Removal of affected area and
• replace with dental material
• Dental check ups
• Fluoridated water
• Nursing interventions
• Teach patient oral care
• Diet changes

7
Gingivititis

• Inflammation of the gums
• Symptoms
• Bleeding, swollen, tender gums
• Difficulty chewing
• Causes
• Accumulation of food between teeth
• Vitamin deficiency
• Anemia
• Leukemia
• Prevention
• Brushing teeth gums
• Daily flossing
• Adequate diet

8
Periodontitis

• Untreated Periodontitis
• Teeth loosen
• Spreads to mandible
• Prevention
• Impeccable tooth gum
• Regular flossing
• Adequate diet
• Treatment
• Drainage of abscess
• Antibiotics
• Extraction

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Recurrent Aphthous Stomatitis

• Multi system disorder
• Painful ulcers
• Mouth
• Genitals
• Uveal tract of the eye
• Causes
• Viruses, bacteria, fungus
• Chemotherapy
• Vitamin deficiency
• Four Forms
• Minor Type
• Canker sores
• Lesions are 2- 4 mm in diameter
• Usually fewer than 5 in number

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Recurrent Aphthous Stomatitis

• Major Aphthous Stomatitis
• Referred to as Suttons disease
• 10 mm or greater in diameter
• They frequently occur in the
• posterior portion of the mouth
• Take four to six weeks to heal
• These lesions may result in scarring
• Herpetiform
• Confused with herpes
• Numerous, 1-2 mm ulcers, cropped
• together
• When the neutrophil count returns
• to normal the lesions resolve

11
Recurrent Aphthous Stomatitis

• Fourth form is known as Behçet's disease
• Complex multi-system disorder including
• Synovitis
• Uveitis
• Vasculitis
• Meningoencephalitis
• Oral and/or genital mucosa are the first
  manifestation
• It is a rare, non-infectious disease
• Very uncommon in North America and Europe
• Half of the patients have evidence of immune
  dysfunction

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Recurrent Aphthous Stomatitis

• Immune Dysfunction seen with Behçet's disease
• 5-20 of Crohn's patients develop disease
• Ulcerative colitis
• Malabsorption syndromes
• Gluten-sensitive enteropathy
• HIV infection
• The lesions appear to be more severe, more
  painful and deeper
• Cyclic neutropenia

13
Behcets
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Herpes Simplex Virus

• Acute viral infection
• Two strains of herpes simplex virus
• HSV-1 Common cold sore
• Forms clusters of fluid filled blisters
• HSV-2
• Sexually transmitted
• Can develop in and around the mouth or genitals
• Shingles
• Form along nerve path

15
Candidiasis

• Etiology/Pathophysiology
• Fungus normally present in the mouth, intestine,
  vagina, and on the skin
• Also referred to as thrush and moniliasis
• Clinical manifestations/assessment
• Small pearly-white patches on the mucous membrane
  of the mouth
• Thick white discharge from the vagina

16
Candidiasis

• Causes
• Cancer
• Diabetes
• Alcoholism
• Treatment
• Nystatin
• Gentician Violet
• OTC medications
• Nursing care
• Good hand washing
• Bland or soft food for patient
• Oral care
• Education on medication administration

17
Mumps

• Contagious viral infection of parotid salivary
  glands
• Possible complications
• Inflammation of testicles
• Sterility in males
• MMR vaccine

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Achalasia

• Etiology/Pathophysiology
• LES cannot relax (cardiospam)
• Causes decreased motility of the lower portion of
  the esophagus
• Absence of peristalsis and dilation of the lower
  portion of the esophagus
• Decreased amount or no food can enter the stomach
• The esophagus can hold as much as a liter
• Possible causes
• Nerve degeneration, esophageal dilation, and
  hypertrophy
• Disruption of the normal neuromuscular activity
  of the esophagus

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Achalasia

• Clinical manifestations/Assessment
• Dysphagia-PRIMARY SYMPTOM
• Regurgitation of food
• Substernal chest pain
• Loss of weight
• Weakness
• Poor skin turgor

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Achalasia

• Diagnostic tests
• Radiologic studies- Esophagoscopy
• Medical management
• Medications anticholinergics, nitrates, and
  calcium channel blockers
• Dilation of cardiac sphincter
• Surgery-Cardiomyectomy

21
Gastroesophageal Reflux Disease (GERD)

• Etiology/Pathophysiology
• Backward flow of gastric acid into the esophagus
• Reduced LES pressure
• Clinical manifestations
• Pain may mimic angina
• Heartburn (pyrosis) 20 min 2 hrs after eating
• Regurgitation
• Dysphagia or odynophagia (painful swallowing)
• Eructation (belching)
• Cough
• Wheezing
• Hoarseness

22
Gastroesophageal Reflux Disease (GERD)

• Risk factors
• Alcohol, tobacco, smoking
• Delayed gastric motility
• Diagnostic tests to differentiate GERD from
  angina
• Esophageal motility
• Bernstein tests evaluate LES function
• pH monitoring for 24 hours to record reflux
  episodes
• Barium swallow endoscopy to evaluate for
• hiatal hernia

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Gastroesophageal Reflux Disease (GERD)

• Medical management Nursing interventions
• Antacids or acid-blocking medications
• Diet
• 4-6 small meals/day
• Low fat, adequate protein
• Remain upright for 1-2 hours after eating
• Lifestyle
• Eliminate smoking
• Avoid constrictive clothing
• HOB up at least 6-8 inches for sleep

24
Barretts Esophagus

• Etiology/Pathophysiology
• Cells in esophagus change to cells normally found
  in the intestine (metaplasia)
• Patients feel less discomfort as metaplastic
  cells are less sensitive
• Cant cure, treat GERD
• Medications
• Antacids
• GI stimulants
• Histamine H2 antagonists
• Proton pump inhibitors
• Surgery
• Fundoplication

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Acute Gastritis

• Etiology/Pathophysiology
• Inflammation of the lining of the stomach
• Associated with
• Alcoholism smoking
• Bacteria viruses
• Chemical toxins
• Stressful physical problems
• Clinical manifestations
• Fever
• Headache
• Epigastric pain
• Nausea and vomiting
• Coating of the tongue
• Anorexia

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Acute Gastritis

• Long term
• Changes in the mucosal lining that interferes
  with acid and pepsin secretion
• Gastritis usually resolves once the offending
  agent is removed
• Diagnostic tests
• Stool for occult blood
• WBC
• Electrolytes

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Acute Gastritis

• Medical management
• Antiemetics
• Antacids
• Antibiotics
• IV fluids
• NG tube
• Nutritional Supplementation
• Administration of blood
• NPO until signs and symptoms subside

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Nausea

• Etiology/Pathophysiology
• Feeling the urge to vomit
• May occur independently or precede vomiting
• Specific neural pathways not identified
• Probably controlled by parts of brain that
  control involuntary bodily functions
• Signs and symptoms
• Increased salivation
• Diminished functional activities of the stomach
• Altered small intestine motilility

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Vomiting

• Etiology/Pathophysiology
• Forceful expulsion of gastric contents
• Increased intrathoracic pressure
• Increased intracranial pressure
• Controlled by
• Vomiting center (medulla)
• Initiates vomiting when stimulated
• Chemo-receptor trigger zone
• Must be stimulated by a drug or toxin

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Causes of Nausea Vomiting

• Stress, fear, and depression
• Pain
• Acute febrile illness
• Medications
• Food poisoning
• Anesthesia
• Diseases of the stomach
• Intestinal obstruction
• Pregnancy
• Head injury

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Nursing Implementation for Nausea Vomiting

• Administer antiemetics
• Monitor fluid electrolyte replacement
• Protect patient from unpleasant sight or smells
• Attempt to keep stomach empty
• Ventilate room
• Observe record the character and quantity of
  emesis

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Peptic Ulcers (PUD)

• Gastric ulcers and duodenal ulcers
• Ulcerations of the mucous membrane or deeper
  structures of the GI tract
• Most commonly occur in the stomach and duodenum
• Result of acid and pepsin imbalances
• Chronic NSAID use
• H. pylori
• 70 of patients with gastric ulcers
• 95 of patients with duodenal ulcers

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Peptic Ulcers (PUD)

• Gastric ulcer
• In the distal half of the stomach
• Bleed more, harder to control
• Duodenal ulcers
• May or may not be caused by hypersecretion of
  gastrin
• Ulceration occurs when the acid secretion exceeds
  the buffering factors
• More likely to have chronic bleeding and
  perforate

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Peptic Ulcers (PUD)
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Peptic Ulcers (PUD)

• Clinical manifestations
• Pain Dull, burning, boring, or gnawing,
  epigastric
• Dyspepsia
• Hematemesis
• Melena
• Diagnostic tests
• Esophagogastroduodenoscopy (EGD)
• Breath test for H. pylori

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Peptic Ulcers (PUD)

• Complications of peptic ulcers
• Bleeding
• Hematemesis
• Melena
• Gastric outlet obstruction

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Peptic Ulcers (PUD)

• Diagnosis
• Esophagogastroduodenoscopy (EGD)
• Visualize tissue and Biopsy if necessary
• Wireless capsule endoscope
• Complications
• Stool impaction
• Small bowel stricture

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Peptic Ulcers (PUD)

• Medical management/Nursing interventions
• NG tube until bleeding subsides
• Antacids
• Histamine H2 receptor blockers
• Proton pump inhibitor
• Mucosal healing agents
• Antibiotics
• Anticolingerics
• Reclining for 1 hour post meal
• IV fluid
• Diet
• High in fat and carbohydrates
• Low in protein and milk products
• Small frequent meals
• Limit coffee, tobacco, alcohol, and NSAID use

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Peptic Ulcers (PUD)

• Medical management/Nursing interventions
• Surgery
• Antrectomy-
• Gastrodudodenostomy (Billroth I)
• Gastrojejunostomy (Billroth II)
• Total gastrectomy
• Vagotomy
• Pyloroplasty

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Types of gastric resections with anastomoses. A,
Billroth I. B, Billroth II.
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Peptic Ulcers

• Complications after gastric surgery
• Dumping syndrome
• Eat 6 small meals a day
• high in protein and
• carbohydrates
• Eat slowly and avoid fluid
• with meals
• Pernicious anemia
• Iron deficiency anemia

42
Diarrhea

• Rapid movement through intestines of loose,
  watery stools resulting from increased
  peristalsis
• Causes
• Fecal impaction
• Ulcerative colitis
• Intestinal infections
• Drugs

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Diarrhea

• Nursing implications
• Meticulous skin care
• Observe stool for color, odor, consistency,
  mucous, blood, or pus
• Administer anticholinergics
• Reduce bowel spasticity
• Administer anti-diarrheal agents
• Mild diarrhea
• Moderate diarrhea
• Severe diarrhea (infectious agent)

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Constipation

• Etiology/Pathophysiology
• Fecal mass in rectum
• Water is absorbed and feces hardens
• Painful to pass
• Causes
• Neurological conditions
• Disease
• Medications
• Diet
• Decreased activity
• Ignoring the urge to defecate
• Chronic laxative use

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Constipation

• Clinical manifestations/Assessment
• Abdominal distention
• Indigestion
• Rectal pressure
• Hard, dry stools
• Decrease appetite
• Rectal pressure
• Intestinal rumbling

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Constipation

• Complications
• Fecal impaction
• Cardiac complications from straining
• Dilation of colon (Megacolon)
• Colonic mucosal atrophy
• Fecal incontinence

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Constipation

• Treatment
• High fiber diet
• 2-3 liters of fluid a day
• Strengthening of abdominal muscles
• Behavior changing
• Diet
• Whole grains
• Fresh fruits
• Vegetables

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Constipation

• Medications
• Bulk forming agents
• Absorb fluid and swell in the intestine and
  increase peristaltic action
• Laxatives
• Bulk forming, stool softeners, stimulant, and
  saline
• Stool softeners
• Detergent like drugs that permit easier
  penetration and mixing of fats and fluids with
  the fecal mass
• Stimulant
• Increase the motility of GI tract by chemical
  irritation of the intestinal mucosa
• Golytely
• Causes a large volume of water to be retained in
  the colon
• Results in diarrhea within 30-60 minutes

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Constipation

• Enemas
• Instilled directly into the lower colon
• Retained in bowel
• Cleansing
• Types of enemas
• Tap water
• Saline
• Soap
• Oil
• Medicated

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Infection

• Etiology/Pathophysiology
• Invasion by pathogenic microorganisms
• Person-to-person contact
• Fecal-oral transmission
• Long-term antibiotic therapy
• Clinical manifestations
• Rectal urgency
• Tenesmus
• Nausea, vomiting diarrhea
• Abdominal cramping
• Fever

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Infection

• E-coli 0157H7
• Not part of normal human intestinal flora
• Found in 1 of food cattle
• Contaminated or under cooked meat or contaminated
  water
• Signs and symptoms
• Bloody diarrhea, abdominal cramping and
  tenderness
• Avoid-anti-diarrheals and anti-mobility
• C-Difficle
• Complication of antibiotic because it inhibits
  the growth of normal intestinal flora and allows
  for the overgrowth of C-Difficile
• A toxin is produced that causes tissue damage in
  the intestine
• Stop the offending antibiotic
• Diagnosis-stool culture
• Treatment-Flagyl or Vancomycin

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Infection

• Risk Factors
• Recent travel to endemic area
• Food borne Illness
• Waterborne Illness
• Day care exposure
• High-risk sexual behavior
• Antibiotic use within 6 months (C-Difficile)

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Infection

• Diagnostic tests
• Stool culture
• Blood chemistry
• Medical management/nursing interventions
• Antibiotics
• Fluid and electrolyte replacement
• Kaopectate
• Pepto-Bismol

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Irritable Bowel Syndrome (IBS)

• Etiology/Pathophysiology
• Episodes of alteration in bowel function
• Spastic and uncoordinated muscle contractions of
  the colon
• Related to eating coarse or highly seasoned food
• Clinical manifestations
• Abdominal pain and distention relieved by BM
• Frequent bowel movements
• Sense of incomplete evacuation
• Flatulence, constipation, and/or diarrhea

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Irritable Bowel Syndrome (IBS)

• Red Flags Suggestive of other diagnosis
• Nighttime Diarrhea
• Nocturnal stool incontinence
• Nocturnal awakening due to abdominal discomfort
• Abdominal pain that interferes with normal sleep
• Visible or occult blood in stool
• Weight loss
• Recurrent Fever
• Family History of Colon Cancer
• Family History of Inflammatory Bowel Disease
• Laboratory abnormality
• Leukocytosis
• Anemia
• Increased Erythrocyte Sedimentation Rate (ESR)

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Irritable Bowel Syndrome (IBS)

• Increase in functional diarrhea with stress
• Associated with psychiatric issues
• Panic attacks
• Chronic pelvic pain
• Childhood sexual abuse
• Diagnostic tests
• History and physical examination
• Often by exclusion

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Irritable Bowel Syndrome (IBS)

• Medical management Nursing interventions
• Diet and bulking agents
• Education
• Medications
• Anticholinergics
• Milk of Magnesia, fiber, or mineral oil
• Opioids
• Anti-anxiety drugs

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Ulcerative Colitis

• Etiology/Pathophysiology
• Ulceration of the mucosa and submucosa of the
  colon
• Tiny abscesses form
• Produce purulent drainage, slough the mucosa, and
  ulcerations occur
• Starts on the left and progresses to the right
  side of colon
• The capillaries become friable and bleed
• bloody diarrhea
• Pseudopolyps may turn cancerous
• Scar tissue may form
• Loss of elasticity and absorption abilities

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Ulcerative Colitis

• Clinical manifestations/Assessment
• Diarrhea-pus and blood
• 15-20 stools per day
• Fluid/electrolyte imbalance
• Abdominal cramping
• Involuntary leakage of stool
• The urge to defecate lessons as scar tissue
  replaces functional tissue
• Weight loss and deficient nutrition
• Megacolon

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Ulcerative Colitis

• Diagnostic tests
• Barium studies
• Colonoscopy biopsy
• Stool for occult blood
• X-rays
• Labs such as chemistries, CBC
• Medical management/Nursing interventions
• Diet
• No milk products or spicy foods
• High protein, high calorie
• Total parenteral nutrition (TPN)
• Stress control
• Assist patient to find coping mechanisms

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Ulcerative Colitis

• Medical management/Nursing interventions
• Medications
• Azulfidine
• Dipentum Rowasa
• Corticosteroids
• Imodium
• Anticholinergic drugs are avoided
• Surgical interventions
• Colon resection
• Ileostomy
• Ileoanal anastomosis
• Proctocolectomy
• Kock pouch

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Crohns Disease

• Etiology/Pathophysiology
• Inflammation, fibrosis, scarring, and thickening
  of bowel wall
• Inflammation of segments of the GI tract from
  mouth to anus
• Possible association between Crohns and altered
  immune mechanisms
• Typically occurs in the small intestine (jejunum
  and terminal ileum)
• Clinical manifestations/Assessment
• Weakness, loss of appetite, dehydration
• Diarrhea, 3-4 daily, contain mucus and pus
  (steatorrhea)
• Right lower abdominal pain
• Anal fissures and/or fistulas
• Anemia

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Crohns Disease

• Complications
• Malabsorption
• Pernicious anemia
• Acid/base disturbance related to diarrhea
• Fistulas may occur
• Medical management/Nursing interventions
• Diet
• High protein
• High in nutrients
• Avoid lactose-containing foods, vegetables,
  caffeine, beer, MSG, highly seasoned foods,
  carbonated beverages, fatty foods

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Crohns Disease

• Medical management/Nursing interventions
• Medications
• Corticosteroids
• Antibiotics
• Anti-diarrheals
• Antispasmodics
• Enteric-coated fish oil capsules
• B12 replacement
• Surgery
• Segmental resection of diseased bowel
• Diagnostic tools
• Small bowel barium
• Colonoscopy with biopsy

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Crohns Disease
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Colon surgery and colostomy procedure
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Colostomy and Bowel Resections

• Sigmoid Resection Right
• with colostomy Hemicoloctomy

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Bowel Resections

• Left Hemicolotomy Anterior Recto
  Sigmoidectomy

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Appendicitis

• Etiology/Pathophysiology
• Inflammation of the vermiform appendix
• Lumen of the appendix becomes obstructed
• Clinical manifestations/Assessment
• Rebound tenderness over McBurneys point
• Vomiting
• Low-grade fever
• Diagnostic tests
• WBC
• CT scan
• Ultrasound

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Appendicitis

• Medical management/Nursing interventions
• Laparoscopy
• Appendectomy
• Post-op complications
• Peritonitis
• Intra-abdominal abscess
• Mechanical bowel obstruction

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Diverticular Disease

• Etiology/Pathophysiology
• Diverticuli become inflamed
• Fecal matter becomes stuck in the pouches
• Perforation is a risk
• Diverticulosis
• Pouch-like herniations through the muscular layer
  of the colon
• Diverticulitis
• Inflammation of one or more diverticuli

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Diverticular Disease

• Clinical manifestations/Assessment
• Patient can become septic
• Diverticulosis
• May have few, if any, symptoms
• Constipation, diarrhea, and/or flatulence
• Pain in the left lower quadrant
• Diverticulitis
• Mild to severe pain in the left lower quadrant
• Elevated WBC
• Low-grade fever
• Abdominal distention
• Vomiting
• Blood in stool

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Diverticular Disease

• Medical management/Nursing interventions
• A temporary colostomy may be indicated with
  closure in 6 weeks to 3 months
• Diverticulosis with muscular atrophy
• Low-residue diet stool softeners
• Bedrest
• Diverticulosis with increased intracolonic
  pressure and muscle thickening
• High-fiber diet
• Sulfa drugs
• Antibiotics if indicated
• Analgesics

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Diverticular Disease

• Medical management/Nursing interventions
• Surgery
• Hartmanns pouch
• Double-barrel transverse colostomy

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Diverticulosis
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Progression of Diverticular Disease
77
Diverticulitis
78
Umbilical Stoma Stoma Infected with Candida
Albicans
79
Prolapsed Loop Colostomy
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Colostomy Pouch
81
Colostomy Irrigation
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Pancreatitis

• Pancreatic enzymes back up into pancreas
• Can be fatal
• Inflammation of the peritoneum following
  infection
• Localized
• Generalized

83
Peritonitis

• Etiology/Pathophysiology
• Inflammation of the abdominal peritoneum
• Bacterial contamination of the peritoneal cavity
  from fecal matter or chemical irritation
• Medical emergency
• The prognosis for untreated peritonitis is very
  poor

84
Peritonitis

• Causes
• Internal perforation of the gastrointestinal
  tract
• Intestinal foreign body
• Colonic diverticulum
• A ruptured appendix

85
Peritonitis

• Clinical manifestations/Assessment
• Severe abdominal pain
• May present in the fetal position with knees
  drawn up
• Pain with movement
• Nausea and vomiting
• Abdomen is rigid
• Tympanic or absent bowel sounds
• Chills
• Weakness
• Weak rapid pulse
• Fever
• Hypotension

86
Peritonitis

• Diagnostic tests
• Flat plate of the abdomen
• CT scan
• Medical management
• Semi-Fowlers position
• Surgery
• Fecal contamination
• Removal irritants
• Parenteral antibiotics
• NG tube
• IV fluids

87
Meconium peritonitis
88
External Hernias

• Etiology/Pathophysiology
• Congenital or acquired weakness of the abdominal
  wall or postoperative defect
• Hernia is a protrusion of viscus through an
  abnormal opening or weakened wall of the cavity
  in which it was normally contained
• Abdominal or Ventral
• Femoral or inguinal
• Umbilical

89
External Hernias

• Clinical manifestations
• Protrusion at umbilicus, groin or incision
• Pain may or may not be present
• Complications
• Incarceration
• Strangulation
• Diagnostic tests
• Radiographs
• Palpation

90
External Hernias

• Medical management/Nursing interventions
• If no discomfort, hernia is left unrepaired,
  unless it becomes strangulated or obstruction
  occurs
• Truss
• Surgery
• Synthetic mesh is applied to weakened area of the
  abdominal wall

91
Umbilical Hernia
92
Hiatal Hernia

• Etiology/Pathophysiology
• Protrusion of the stomach and other abdominal
  viscera through an opening in the membrane or
  tissue of the diaphragm
• Contributing factors obesity, trauma, aging
• Clinical manifestations/Assessment
• Most people display few, if any, symptoms
• Gastroesophageal reflux

93
Hiatal Hernia

• Medical management/Nursing intervention
• Head of bed should be slightly elevated when
  lying down
• Small frequent meals
• OTC medications for GERD
• Surgery
• Posterior gastropexy
• Transabdominal
• fundoplication (Nissen)

94
Hiatal Hernia

• Intestinal obstruction
• Etiology/pathophysiology
• Intestinal contents cannot pass
• Partial or complete
• Mechanical
• Non-mechanical
• Clinical manifestations/assessment
• Vomiting dehydration
• Abdominal tenderness and distention
• Constipation

95
Hiatal Hernia
Sliding hernia
Rolling hernia
96
Intestinal Obstruction

• Etiology/Pathophysiology
• Mechanical
• An occlusion of the lumen of the intestinal tract
• Adhesions, incarcerated hernias, impacted feces,
  tumor, intussusception, volvulus, strictures of
  inflammatory bowel disease
• Non-mechanical
• Neuromuscular or vascular disorder
• Paralytic ileus, trauma to the spine, mesenteric
  thrombosis that reduces blood flow to the bowel

97
Intestinal Obstruction
Intestinal obstructions. A, Adhesions. B,
Volvulus.
98
Intestinal Obstruction

• Clinical manifestations/Assessment
• Loud high pitched bowel sounds above the
  obstruction and absent bowel sounds below
• Inability to pass stool or gas
• Vomiting, abdominal cramps, abdominal distention
• Diagnostic tests
• Radiographic examinations
• BUN, sodium, potassium,
• hemoglobin and hematocrit

99
Intestinal Obstruction

• Medical management/Nursing interventions
• Evacuation of intestine
• NG tube to decompress the bowel
• Intestinal tube to evacuate the contents
• Surgery
• Required for mechanical obstructions
• Bowel resection

100
Hemorrhoids

• Etiology/Pathophysiology
• Varicosities (dilated anorectal vessels/veins)
• External or internal
• Contributing factors
• Straining with defecation, diarrhea,
  constipation, pregnancy, obesity, CHF, portal
  hypertension, family history, prolonged sitting
  and standing
• Anatomic abnormalities
• Intrinsic weakness of anal blood vessels

101
Hemorrhoids

• Clinical manifestations/Assessment
• Varicosities in rectal area
• Bright red bleeding with defecation
• Pruritus
• Rectal Pain
• Prolapsed hemorrhoid
• Fullness or mass sensation

102
Hemorrhoids

• Diagnostic tests
• Visual inspection
• Digital Rectal Exam
• Anoscopy
• Differential Diagnosis
• Fissure
• Perirectal Abscess
• Rectal Fistula
• Condyloma
• Rectal carcinoma

103
Hemorrhoids

• Medical management/Nursing interventions
• Bulk stool softeners
• Hydrocortisone cream
• Analgesic ointment
• Sitz baths
• Ligation
• Sclerotherapy
• Cryotherapy
• Infrared photocoagulation
• Hemorrhoidectomy

104
Anal Fissure

• Etiology/Pathophysiology
• Linear ulceration or laceration of the skin of
  the anus
• Usually caused by trauma
• Lesions usually heal spontaneously
• May be excised surgically
• Usually follows trauma or diarrheal illness
• Increased anodermal blood flow causes fissures
• Affects young and middle-aged adults

105
Anal Fissure

• Clinical manifestations/Assessment
• Onset after forced hard bowel movement
• Bright red rectal bleeding
• Pain during bowel movement
• Cut with sharp glass sensation
• Pain persists for an hour after stooling
• Avoid anoscopy if possible
• Painful and usually not needed
• Use local anesthesia if performed

106
Anal Fissure

• Clinical manifestations/Assessment (continued)
• Crack or crevice in anoderm at anal verge
• Usually in canal midline (anterior or posterior)
• Lateral suggests other diagnosis
• Best seen with lateral traction on opposite
  buttock
• Sentinel pile (distal skin tag)
• Tag-like swelling of fissure end
• Results from infection and edema

107
Anal Fistula

• Etiology/Pathophysiology
• Abnormal opening on the surface near the anus
• Usually from a local abscess
• Common in Crohns disease
• Treated by a fistulectomy or fistulotomy
• Perirectal abscess sequelae of rupture or surgery
  
• Anal Fissure
• Anorectal cancer
• Tuberculosis
• Local radiation therapy
• Lymphogranuloma venereum

108
Anal Fistula

• Clinical manifestations/Assessment
• Chronic seropurulent or mucus drainage from
  fistula
• Communicating tract between perianal skin and
  anus
• One or several external openings tracking toward
  anus
• Associated conditions
• Perirectal Abscess