Gastro Intestinal Disorders

GASTRO INTESTINAL DISORDERS

Hernia

Cholecystitis

Appendicitis

1.  Hernia

A hernia is a protrusion of an organ, tissue or structure through the wall of the cavity in which it is normally contained.

Causes

·           Congenital weakness of the abdominal wall.

·           Acquired causes (traumatic injury, aging).

·            Increased intra-abdominal pressure due to heavy lifting, obesity, pregnancy, straining and chronic coughing.

Types of hernia

·           Reducible: The protruding mass can be placed back into the abdominal cavity.

·           Irreducible: the protruding mass cannot be moved back into the abdomen.

·           Incarcerated: An irreducible hernia in which the intestinal flow is completely obstructed.

·           Strangulated: An irreducible hernia in which the blood and intestinal flow are completely obstructed. Develops when the loop of intestine in the sac becomes twisted or swollen and a constriction is produced at the neck of the sac.

Classification of hernia by site

1.  Inguinal hernia

Hernia into the inguinal canal (more common in males.)

Indirect inguinal hernia: Due to weakness of the abdominal wall at the point through

which the spermatic cord emerges in the male and the round ligament of uterus in the female. Through this opening the hernia extends down, the inguinal canal and often into the scrotum or the labia.

•            Direct inguinal hernia: Passes through the posterior inguinal wall.

2.  Femoral hernia

Hernia into two femoral canals appearing below the inguinal ligament that is below the groin.

3. Umbilical hernia

Protrusion of part of the intestine at the umbilicus due to failure of umbilical orifice will close. Occurs most often in obese women, in children and in patients with increased intra abdominal pressure from cirrhosis and ascites.

4. Ventral (or) incisional hernia

Hernia through the weak abdominal wall may occur after impaired healing of incision due to infection.

5. Diaphragmatic (or) hiatus hernia (or) oesophageal hernia

It is the protrusion of a part of the stomach that slides or follows the normal path of the esophagus and enters into the thoracic cavity through an enlarged hiatal opening.

Signs and Symptoms

·           Bulging over herniated area when patient stands or strains, and disappears when supine.

·           Hernia tends to increase in size and recurs with intra abdominal pressure.

·           Strangulated hernia presents with pain, vomiting, swelling of hernia sac, peritoneal irritation and fever.

·           In hiatus hernia the patient complaints of heart burn after large meals and during the night, food may be regurgitated.

Diagnosis

·           Based on signs and symptoms.

·           Abdominal X-rays: Reveals abnormally high level of gas.

·           Laboratory studies: Complete blood count and electrolytes may show haeconcentration (increased hematocrit), dehydration (increased or decreased sodium) and leucocytosis.

Management

Mechanical

A truss is an appliance with a pad and belt that is holding snugly over a hernia to prevent abdominal contents entering the hernial sac.

Surgical management

·           Recommended to correct hernia before strangulation.

·           Strangulation of hernia is an emergency condition that necessitates emergency laparotomy.

Herniorrhaphy

•            Removal of hernial sac, contents replaced into the abdomen, layers of muscle and fascia sutured.

•            Laparoscopic herniorrhaphy is a possibility is often performed on outpatient basis.

Hernioplasty

Involves reinforcement of surturing (often with mesh) for extensive hernia repair.

Strangulated

Strangulated hernia requires resection of ischemic bowel in addition to repair of hernia.

Nursing management

1.  Achieving comfort of the patient:

•            Fit patient with truss or belt when hernia is reduced, if ordered

•            Trendelenburg’s position may reduce pressure on hernia, when appropriate

•            Emphasize patient to wear truss under clothing and to apply before getting out of the bed when hernia is reduced

2.  Post operative care

•            Encourage the patient to splint the incision site with hand or pillow when coughing to lessen pain and protect the site from increased intra-abdominal pressure and wound dehiscence

•            Administer analgesics as ordered

•            Encourage ambulation as soon as permitted

•            Advise patient that difficulty in urinating is common after surgery; promote elimination to avoid discomfort, and catheterise if necessary

3.  Prevention of infection

·            Monitor the vital signs

·            Check dressings for drainage and incision for redness and swelling

·            Monitor for other signs and symptoms of infections; fever, chills, malaise, diaphoresis

·            Administer prescribed antibiotics

4.  Patient education on discharge

·            Advise that pain and scrotal swelling may be present for 24 to 48 hours after repair of an inguinal hernia

·            Apply ice intermittently

·            Elevate scrotum by using scrotal support

·            Take prescribed medication to relieve discomfort

·            Inform that heavy lifting should be avoided for 4-6 weeks

·            Athletics and extremes of extension are to be avoided for 8 to 12 weeks postoperatively

Complications

·            Bowel obstruction

·            Gangrene formation

·            Wound dehiscence

2.   Cholecystitis

Inflammation of the gall bladder

Causes

·            Exact cxauses is not known

·            Gall stones and kinking or twisting of bile duct

Risk factor

·            Sedentary life style

·            Obesity

Signs & Symptoms

·            Pain on right upper quadrant/epigastric or both

·            Nausea

·            Vomiting

·            Increased temperature

·            Mild jaundice

Investigations

·           Ultrasonography

·           Abdominal X-ray

·           Blood cell count Test (TC, DC)

Management

Medical Management

·           Hospitalization

·           Administration of antibiotics

·           Administration of parenteral analgesic

·           Insertion of nasogastric tube if patient has vomiting

·           Maintain of fluid and electrolyte balance with IV fluids

Surgical Management

·           Cholecystecotmy (Removal of Gall bladder by surgery)

Nursing management

·           History collection

·           Client symptoms should be carefully monitored

·           Check vital signs

·           Administer pain medication

·           Administer IV fluids

·            Monitor intake output chart

·            Watch for signs for dehydration

3. Appendicitis

Appendicitis is an inflammation of the vermiform appendix caused by obstruction of the intestinal lumen from infection, stricture, fecal mass, foreign body or tumour.

Causes

·           Obstruction of the appendix causes accumulation of mucus and swelling leading to appendicitis.

·            Obstruction occurs due to the accumulation of faecal matter, enlargement of lymphoid follicles, intestinal worms, and tumours.

Pathophysiology

Obstruction of the intestinal lumen is followed by edema, infection and ischemia of the appendix. As intraluminal tension develops, necrosis and perforation usually occur.

Signs and Symptoms

The typical symptoms of acute appendicitis are

·           Severe pain in the right side of the lower abdomen.

·           Rebound tenderness at McBurney’s point.

·           Anoxia.

·           Low-grade fever.

·           Nausea and vomiting.

·           Constipation or diarrhoea occurs.

Diagnosis

·           Physical examination. Rebound tenderness at Mc Burney’s point.

·           Laboratory test: complete blood count will show

·            Leucocytosis

·            Urinalysis

·           Abdominal X-ray to visualize shadow consistent with fecalith in appendix.

·            U.S.G. Abdomen

Management

Surgery: The standard Management for appendicitis is surgery that involeves removal of the appendix. The procedure is called appendectomy that can be done in two methods:

·            Laparotomy – a single incision is made to remove the appendix

·            Laparoscopic appendectomy – several small incisions are made using special surgical tools to remove the appendix. The advantage of this surgery is fast recovery

Complication

·            Peritonitis

·            Perforation

·            Abscess formation