L17

Question 1

Inflammatory bowel disease

Answer 1

autoimmune disease that leads to chronic inflammation and tissue destruction of GI tract

Question 2

Risk factor of inflammatory bowel disease

Answer 2

1. High dietary intake of total fats, poly-unsaturated fatty acid, omega-6 fatty acids, and meat
2. Smoking
3. Stress
4. Hygiene
5. Use of NSAID

Question 3

Toxic megacolon

Answer 3

1. Symptoms: fever, abdominal pain and distention
2. Medical management:
   - within 24-72 hours: NG suction and IV fluid with electrolytes, corticosteroids, and antibiotics
   - or else surgery is needed

Question 4

Diagnostic test for inflammatory bowel disease

Answer 4

1. Blood test for CBC, LRFT, CRP level
   - decreased hemoglobin shows blood loss
   - increased WBC and CRP show infection, toxic megacolon, and perforation
   - decreased albuminemia shows malnutrition
   - decreased potassium shows electrolyte imbalance by diarrhea and vomiting
2. Stool x occult blood and infection
3. Barium contrast
4. Sigmoidoscopy and colonoscopy with biopsy
5. USG

Question 5

Treatment for inflammatory bowel disease

Answer 5

1. Diet: high calorie, vitamin, and protein; low residue
2. Physical and emotional rest
3. Parental nutrition
4. Surgery
   - abdominal access
   - fistulas
   - intestinal obstruction
   - massive hemorrhage
   - perforation
5. Medications:
   - 5-aminosalicylates: decrease GI inflammation
   - Corticosteroids : decrease inflammation
   - immunomodulators: inhibit the cytokine tumor necrosis factor; decrease inflammatory response
   - antimicrobials: prevent or treat secondary infection
   - immunosuppressants: suppress immune response
   - antidiarrheals: decrease GI motility
   - hematinics and vitamins: correct iron deficiency anemia and promote wound healing

Question 6

Diverticular disease

Answer 6

Herniation in the bowel lining that extends through a defect in the muscle layer
- diverticulosis: without inflammation or symptoms
- diverticulitis: food and bacteria retained in a diverticula lead to infection and inflammation; impede drainage lead to perforation and abscess formation

Question 7

Risk factors for diverticular disease

Answer 7

Low fiber intake, high in refined carbohydrates
–> more water is absorbed from the stool, making it more difficult to pass through the lumen and raise intraluminal pressure

Question 8

Clinical manifestations of diverticulosis

Answer 8

1. Abdominal pain
2. Bloating
3. Flatulence
4. Change in bowel habits

Question 9

Clinical manifestations of diverticulitis

Answer 9

1. Acute pain in left lower quadrant (sigmoid colon)
2. A palpable abdominal mass
3. s/s of infection

Question 10

Diagnostic test for diverticular disease

Answer 10

1. Stool for fecal occult blood
2. CT scan with oral contrast
3. Abdominal x-ray
4. Chest x-ray
5. Blood test for CBC
6. Blood culture
7. Barium edema
8. Sigmoidoscopy
9. Colonoscopy

Question 11

Conservative therapy for diverticular disease

Answer 11

1. High fiber diet and dietary fiber supplement
2. Stool softener, mineral oil, bulk laxatives
3. Weight reduction if overweight (avoid increased intraabdominal pressure)

Question 12

Acute care for diverticulitis

Answer 12

1. Antibiotic therapy
2. NPO status
3. NG suction
4. IV fluids
5. Bed rest
6. Surgery
   - possible resection of involved colon for obstruction and hemorrhage
   - possible temporary colostomy if bowel perforation

Question 13

Type of intestinal obstruction

Answer 13

1. Mechanical obstruction
   e.g. Hernia, tumor, inflammatory bowel disease, fecal impaction
2. Functional obstruction
   e.g. paralytic ileus (inflammatory response, electrolyte imbalance, spinal fracture)

Question 14

Clinical manifestations of small bowel obstruction

Answer 14

1. Initial symptoms: colicky abdominal pian腹絞痛
2. Sudden onset of pain followed by nausea and vomiting
   –> projectile (forceful expulsion) and contains bile
3. Vomiting from a more distal small bowel obstruction has a gradual onset and a fecal, foul-smelling
4. Bowel sound above the obstruction maybe high-pitched; absent in paralytic ileus
5. Signs of dehydration

Question 15

Clinical manifestations of large bowel obstruction

Answer 15

1. Abdominal distention, change in bowel movement, lack of flatus
2. Persistent cramping abdominal pain; Strangulation causes severe, constant, rapid-onset pain
3. Bowel sound is present and progressively becomes hypoactive
4. Signs of dehydration
5. Rarely vomit

Question 16

Diagnostic test for bowel obstruction

Answer 16

1. Abdominal x-ray, CT scan
2. Sigmoidoscopy or colonoscopy
3. Blood test for CBC and blood chemistries
   - increased WBC shows perforation or strangulation
   - increased Hct shows hemoconcentration (RBC)
   - decreased Hct and hemoglobin shows bleeding from cancer or strangulation with necrosis
   - serum electrolytes and creatinine shows degree of dehydration
   - metabolic alkalosis can develop from vomiting

Question 17

Management for intestinal obstruction

Answer 17

1. Conservative treatment:
   Keep NPO, NG tube for decompression, IV fluid +- potassium after RFT, administer analgesic for pain control
2. For bowel strangulation, perform emergency surgery
3. Monitor for deterioration (hypotension, increase pain); dehydration and electrolyte imbalance.
4. Administer IV fluid as prescribed; Monitor s/s of fluid overload
5. Check NG tube Q4H
6. Oral care after vomiting

Question 18

Causes of hernia

Answer 18

1. Weakness of abdominal muscles
2. Congenital malformation
3. Inadequate healing of surgical incisions
4. Increased intra-abdominal pressure

Question 19

Types of hernia

Answer 19

1. Reducible: can be returned manually to the abdominal cavity
2. Irreducible
3. Strangulated: twisting or edema –> compromised blood supply –> necrosis and obstruction

Question 20

Clinical manifestation of hernia

Answer 20

1. Lump, swelling or bulge in the groin
2. Pain may radiate to the scrotum
3. Strangulated hernia:
   - severe abdominal pain
   - abdominal distention
   - nausea and vomiting
   - tachycardia and fever

Question 21

Diagnostic test for hernia

Answer 21

1. Physical examination:
   - in supine, standing or sitting
   - a bulge may be seen or felt when cough or bear down
2. No laboratory test needed unless suspect strangulation or obstruction
   - X-ray e.g. abdomen
   - Blood test for WBC (increased shows bowel obsturction)

Question 22

Treatment for hernia

Answer 22

1. Educate the patient to reduce hernia by lying down and gently push against the mass
2. Use binder or truss (supportive garment)
3. Hernioplasty to surgical repair the hernia
   - restrict 3 weeks for heavy lifting

Question 23

Appendicitis

Answer 23

Obstruction of lumen –> mucosa secrete fluid –> increase internal pressure and strict blood flow –> pain and inflammation

Question 24

Diagnostic test for appendicitis

Answer 24

1. Pelvic examination: should be done on all women with abdominal pain
2. Blood test for CBC (increased WBC)
3. Abdominal x-ray: harden fecal material in appendix, localized ileus
4. USG or CT scan: differentiation from other causes

Question 25

Treatment of appendictis

Answer 25

Appendectomy (reduced risk of perforation)

Question 26

Pre-op care for appendictis

Answer 26

1. Monitor vital signs every 2-4 hours 2. NG tube insertion 3. Administer IV fluid (replace fluid loss to promote adequate renal function) 4. Administer antibiotics therapy to prevent infection 5. Administer analgesic only after diagnosis is made

Question 27

Things to avoid for appendictis

Answer 27

1. Do not apply heat over the area of pain (cause appendix rupture) 2. Do not administer analgesic before diagnosis is made (subside pain cause inaccurate diagnosis) 3. Do not administer laxatives (induced peristalsis may cause perforation)

Question 28

Post-op care

Answer 28

1. Monitor vital signs 2. Administer IVF 3. Administer opioid to relieve pain 4. Provide fluid and food as desired after bowel sound present 5. Discharge within 2-3 days if no complications; educate on wound care (deep suture --> absorbable materials)