Week 5: GI Flashcards
1
Q
Risk Factors for GI Disorders
A
- Family Hx
- Lifestyle - stress, poor diet, alcohol, tobacco, smoking can all lead to these disorders - many of the disorders are associated with lifestyle behaviors
- Domino Effect
- Previous abdominal surgeries or trauma
- Neurologic disorders
2
Q
What can GERD lead to?
A
Barret’s esophagus –> predisposition for esophageal cancer
3
Q
What can chronic gastritis lead to?
A
Predisposition to gastric cancer
4
Q
What can previous abdominal surgeries lead to?
A
Can lead to adhesions (development of scar tissue) which can lead to intestinal obstructions
5
Q
Neurological disorders like MS/Parkinsons can impair what?
A
Patient’s ability to: 1. Move and have peristalsis which impairs movement of waste products2. Chew and swallow
6
Q
What is GERD?
A
Backward movement of gastric or duodenal contents resulting in heartburnEpisodes occur more than 2 times a week
7
Q
What is the major cause of GERD?
A
Relaxation or weakness of LES (lower esophageal sphincter)
Obesity can also cause GERD
8
Q
Things that Trigger LES Relaxation
A
- Fatty Food
- Caffeinated Beverages
- Carbonation
- Chocolate
- Milk
- Tobacco
- Alcohol
- Peppermint/Spearmint
- Progesterone during pregnancy
- Hormonal replacement in older women
- NG tube
- Medications: NSAIDS, Calcium Channel Blockers, Blood Pressure Meds, Nitroglycerine for chest pain
- Pyloric Stenosis
- Overeating or being overweight
- Eating right before bed or eating/sleeping in recumbent position
- Wearing tight clothing
- Mucosal irritants - tomato’s and citrus
9
Q
What should you do prior to laying down for the night when you have GERD?
A
Do not eat 3 hours prior to laying down Avoid laying supine if you do
10
Q
What is a classic symptom of GERD?
A
Waking up in the middle of the night feeling a pain in their throat or feeling heartburn
11
Q
Clinical Manifestations of GERD
A
- Pyrosis
- Dyspepsia
- Sour Taste
- Hypersalivation - patients will clear throats & swallow more frequently
- Dysphagia
- Ordynophagia
- Eructation
- Fullness (even when eating a v small amount of food)
- Early Satiety
- Nausea
12
Q
Pyrosis
A
Burning in the esophagus / heartburnMay radiate to neck and jaw
13
Q
Dyspepsia
A
Indigestion that leads to pain in the upper abdomen
14
Q
Dysphagia
A
difficulty swallowing
15
Q
Ordynophagia
A
Painful swallowing
16
Q
Eructation
A
Belching
17
Q
When do symptoms of GERD occur?
A
30 min - 2 hours after a meal
18
Q
When do symptoms worsen for GERD?
A
Worsen when lying down, bending over, or straining
19
Q
What should you assess when a patient comes in and complains of symptoms of GERD?
A
Need to determine if s/sx are caused from GERD or something else (ex: cardiac event)
20
Q
What are some non-surgical interventions for GERD?
A
- Dont let the sphincters relax
- Eat small meals
- Explore weight loss options
- Smoking cessation
- Keeping HOB up at night
- Avoid tight clothing
- Avoid lying down after meals - Promote gastric emptying and avoid gastric distention
- Watch those acidic foods
- Medications
21
Q
Which medications help with GERD?
A
- Antacids - decrease overproduction of gastric acids2. Pepcid3. Proton pump inhibitors (PPIs) - provide long lasting reduction in amount of acid created by the stomach (ex: Prevacid, Prilosec)4. Prokinetic drugs - for those that have issues with delayed gastric emptying; increase motility/movement (ex: Reglan)
22
Q
What is a surgical intervention for GERD?
A
Nissen Fundoplication
23
Q
What is the procedure forNissen Fundoplication?
A
Takethe fundus and wrap it around the LES to reinforce the closing function of the sphincter
24
Q
What are the risks of surgery for Nissen Fundoplication?
A
- Hemorrhage, bleeding, infection
- Obstruction (If too tight)
- Short bouts of temporary dysphagia
- Bloating and gas buildup
25
Does Nissen Fundoplication cure GERD?
No, patients still need to follow non-surgical recommendations
26
What is Barretts Esophagus?
Occurs w/ prolonged GERD
Acid erodes lining of the esophagus and turns cells of esophagus to look like the lining of the intestines
Alterations can lead to esophageal cancer
27
How is Barrett's Esophagus diagnosed?
Via an endoscopy and biopsy
28
What is a Hiatal Hernia?
When the opening through the diaphragm where the esophagus passes becomes enlarged and part of upper stomach moves into lower portion of the thorax
29
Risk Factors for Hiatal Hernias
1. Age
2. Obesity
3. Women more at risk
30
Concerns of Hiatal Hernias
Obstructions and Strangulations
31
What are the two types of Hiatal Hernias?
1. Sliding
2. Rolling
32
Sliding Hiatal Hernia
Occur when the upper stomach, lower esophageal sphincter, and the gastroesophageal junction are displaced upward and they slide in and out of the thorax
Gastroesophageal junction is compromised
33
Rolling Hiatal Hernia
Gastroesophageal junction remains in position
The stomach is pushed through the diaphragm and sits next to esophagus
The fundus rolls through the hiatus and into the thorax
34
How does a Sliding Hiatal Hernia present?
Can be asymptomatic
GERD symptoms
35
How does a Rolling Hiatal Hernia present?
Can be asymptomatic
GERD symptoms
Breathlessness after eating
Chest pain that mimics angina
Feeling of suffocation
Worse lying down (SOB)
*Patients will complain of more respiratory symptoms
36
Which type of hiatal hernia has a higher risk for strangulation?
Rolling Hiatal Hernia
Piece of stomach can be strangulated - leading to higher risk for strangulation
37
What are the s/s of strangulation with a hiatal hernia?
1. Sudden pain in affective area
2. Fever
3. N/V
4. SOB
This is a MEDICAL EMERGENCY!
38
Interventions for Hiatal Hernias
Similar to Non-Surgical Interventions for GERD
1. Limit or eliminate foods that relax LES
2. Promote gastric emptying or avoid gastric distention (this also helps prevent movement of the hernia)
3. Limit or eliminated foods that add fuel to the acid fire d/t acidic content (tomato and citrus)
4. Medications
5. Sleep in low fowlers position
39
What is gastritis?
When the lining of the stomach becomes inflamed or swollen - disrupted stomach lining
Over time the mucosa can erode due to this
40
Gastritis can be ___ or ___
acute or chronic
41
How long is acute gastritis compared to chronic gastritis?
Acute = few hours to days
Chronic = repeated exposure/recurrent episodes
42
What is the cause of non-erosive acute gastritis?
H. pylori
43
What is the cause of erosive Gastritis?
NSAIDS, Motrin, ASA, Alcohol use
44
Why can H Pylori lead to pernicious anemia?
Chronic Gastritis can destroy the parietal cells of the stomach leading --> lack of intrinsic factor production which is needed for VitB12 absorption
Vit B12 is needed for RBC production, therefore anemia results
Patients may need lifelong supplementation
45
What makes gastritis worse?
1. Stress
2. Caffeinated beverages
3. Tobacco
4. Spicy/highly seasoned foods
5. NSAIDs
6. Alcohol
46
What are some s/s of acute gastritis?
1. Anorexia
2. Epigastric pain
3. Hemtaemesis
4. Hiccups
5. Melena or hematochezia
6. NV
47
What are some s/s of chronic gastritis?
1. Belching
2. Early satiety
3. Intolerance to fatty or spicy foods
4. NV
5. Pyrosis
6. Sour taste in mouth
7. Vague epigastric discomfort relieved by eating
48
How is gastritis diagnosed?
Via an upper endoscopy
Other orders may include fecal occult blood & CBC to monitor H&H
49
How is gastritis treated?
Treatment will typically be supportive, which may include:
1. NG tube - so the stomach can rest and heal. It will be placed for decompression
2. Medications - antacid, Pepcid, PPIs (Prilosec, Prevacid)
3. If the patient is NPO, they are given parenteral nutrition (TPN)
4. IV fluids
5. Foods will be slowly introduced
50
What are the goals for patients hospitalized for gastritis?
1. Relieving pain (abdominal)
2. Promote fluid balance
3. Reduce anxiety
4. Promote optimal nutrition
5. Educate about the disorder
51
Why is nutrition balance and fluid balance impaired with gastritis?
They become essentially NPO and are not consuming enough calories so they aren't getting the food they need or are drinking and risk dehydration
52
Interventions to Treat Chronic Gastritis
1. If caused by H Pylori --> combo of antibiotics
2. NSAIDS/Alcohol --> collaborate with health care team, educate patient, refer
3. Smoking cessation
4. Stress management
5. Avoid trigger foods
* focus on the mind-gut connection*
53
What is Peptic Ulcer Disease (PUD)?
Sores in the lining of the GI system and these sores can erode the mucosa
54
How do gastritis and PUD differ?
Gastritis only affects the stomach lining while peptic ulcers are localized sores that can erode past the mucosal layer at least half a centimeter (deeper than gastritis)
55
A patient with H Pylori induced chronic gastritis is at high risk for developing ____?
PUD
56
What are the 4 locations peptic ulcers can be found?
1. Duodenum
2. Stomach
3. Pylorus
4. Esophagus
57
___ is the most common location for a peptic ulcer, and ___ is the second most common
Duodenum; Stomach
58
Risk Factors for PUD
1. Age (> 65 y/o)
2. Genetics
3. Stress
4. NSAID use
5. Diet
59
Main Underlying Cause of PUD
H Pylori and Excessive secretion of hydrochloric acid by parietal cells
60
What is the major symptom of PUD?
Dull, gnawing, burning pain in the mid epigastric area that can radiate into the back
*due to radiation to the back rule out other potential causes*
61
What are other symptoms of PUD?
1. Pyrosis (heartburn)
2. Vomiting
3. Constipation
4. Diarrhea
5. Bloody stools, or emesis
* If the bleeding is considerable, the patient may demonstrate s/s of anemia - monitor CBC, H&H
62
How is PUD diagnosed?
Upper endoscopy to visualize the inflammation, ulcer, and lesions
63
Nursing Management and Interventions for PUD
Dietary Modification
Smoking cessation
Pharmacologic therapy
surgical management
64
What is the drug regimen like for H Pylori infection
triple or quadruple therapy (with quadruple adding bismuth salts)
65
What is the timing of pain like for PUD depending on if it is duodenal or gastric?
Duodenal (farther down so takes longer): 2-3 hours after a meal, occurs at night, relieved by food
Gastric: Immediately after a meal or 30-60 min after a meal, rarely at night, worse with food
66
What is the stomach acid secretion like for PUD depending on if it is duodenal or gastric?
Duodenal - Hypersecretion
Gastric - Hypo or normal
67
What is weight change like with PUD depending on if it is duodenal or gastric and why?
Duodenal - Weight Gain - since food relieves the pain
Gastric - Weight Loss - since it becomes worse with food
68
4 Types of Surgical Interventions for PUD
1. Vagotomy
2. Pyloroplasty
3. Biliroth I
4. Biliroth II
69
When is surgical intervention for PUD done?
if the obstruction or perforation or ulcer wont heal over 12-16 weeks
70
Vagotomy
Surgical Intervention for PUD
Involves severing the vagus nerve to decrease gastric acid making them less responsive to gastrin which can help prevent PUD
71
Pyloroplasty
Surgical Intervention for PUD
widens the opening of the lower part of the stomach so contents pass easier into the duodenum
72
Biliroth I (Gastroduodenostomy)
PUD Surgery
Lower portion of stomach (gastrin release area) and a small part of the duodenum and pylorus are removed and then what remains is resewn to the duodenum
Removes the pylorus so risk for dumping syndrome
73
Biliroth II (Gastrojejunostomy)
PUD Surgery
Removes lower portion of stomach and connects it to the jejunum
Can have dumping syndrome here
74
Nursing Dx for PUD
Pina
Fluid and Nutrition Balance
Anxiety
Home and Community Based Care
75
What are some common complications of PUD
Hemorrhage
Perforation and Penetration
Gastric Outlet Obstruction
76
___% of PUD pts hemorrhage and present with bloody stool or emesis
15%
77
What does perforation and penetration with PUD cause
erode the serousa --> gastric contents leak into peritoneum (peritonitis) --> EMERGENCY
78
When does gastric outlet obstruction from PUD occur
Area near pyloric sphincter is scarred and stenosed from healing ulcers over time meaning the sphincter cannot function right leading to scar tissue and obstruction
79
T/F: Most pepetic ulcers result from infection with the gram negative bacteria H pylori which may be acquired through ingestion of food and water
True
80
Currently the most commonly used therapy for peptic ulcers is a combination of ___, proton pump inhibitors, and bismuth salts that suppresses or eradicates H Pylori
Antibiotics
81
Chronic Constipation
Fewer than 3 BMs weekly or hard, dry, small, and difficult to pass based on normal BM schedule
82
Clinical manifestations of chronic constipation
straining
pain or pressure
sensation of incomplete evacuation
lumpy hard stools
fewer stools
83
Causes of Chronic Constipation
diet - low fiber
holding in poop
inadequate fluid intake (<8 glasses)
being a couch potato / lack of exercise
too active leading to being too busy and forgetting or not having time to BM
medications: pain meds, chronic laxative use
Hypothyroidism and Spinal Cord Injuries
84
Nursing Management for Chronic Constipation should focus on what
education and controlling any pain
85
Ways to prevent constipation
high residue high fiber diet
making sure pt is consuming enough fluids unless contraindicated
exercising
diet
86
Diarrhea
increased frequency of BM (more than 3 / day) and alternative consistency of the stool
87
When is diarrhea considered chronic
when changed consistency and 3/day stools persist 2-3 weeks or more
88
Clinical Manifestations of Diarrhea
Urgency
Perianal discomfort from frequency of BM and skin irritation around anus
abdominal cramping and distention
rumbling in the stomach or intestinal region
89
Causes of Diarrhea
stool softeners
antibiotics
tube feedings
C Diff
diabetic neuropathy or pancreatic insufficiency
inflammation
90
Complications of Diarrhea
dehydration!!
cardiac dysrhythmias
low potassium
skin irritation around anus
91
What is nursing management of diarrhea focused on
Dehydration!!!
But also:
Lyte Balance
Skin Integrity
Accurate Health Hx
Exploring Diet and IV Hydration / Lyte Replacement
92
Small bowel disorder leads to what stool characteristics
watery
93
Large bowel disorders leads to what stool characteristics
loose, semi solid
94
Malabsorption syndrome leads to what stool characteristics
voluminous, greasy
95
Inflammatory disorders leads to what stool characteristics
blood, mucus, pus
96
Pancreatic Insufficiency leads to what stool characteristics
oil droplets
97
Diabetic neuropathy leads to what stool characteristics
nocturnal frequency
98
C Diff leads to what stool characteristics
diarrhea, unexplained, and they are on antibiotics which can alter things
99
Diarrhea is defined as the increased frequency of more than 3 bowel movements per day
true
100
Inflammatory Bowel Disease (IBD)
A group of chronic disorders: Ulcerative colitis and Crohns disease
101
Ulcerative colitis
IBD
recurrent ulcerations that affect the mucosa and submucosa layers of the colon and rectum (particularly the transcending and descending colon
ulcers are often continuous/contiguous and are connected to one another
102
Crohn's disease
IBD - AKA: Regional enteritis
Subacute and chronic inflammation of the GI tract that spreads deep into the tissue layers (deeper than UC) of the affected bowel tissue
Can happen anywhere mouth to anus but is typically found in the ileum and ascending colon
Has a cobblestone appearance because it does go deeper into the bowel layers
103
IBD is most common in what age group
15-30 year olds
Young people!: HS Students, College Students, Young Adults
Some links to smoking and active smoking for UC but needs more research
104
Location of UC v CD
UC - Colon
CD - Mouth to anus
105
What are the lesions like in UC v CD
UC - Contiguous
CD - Cobblestone / Not contiguous
106
What are the exacerbations like in UC v CD
UC - Exacerbations and remissions
CD - Prolonged bouts
107
What is the diarrhea like in UC v CD
UC: More severe (10-20 bouts QD)
CD: Less severe (5-6 bouts of QD)
108
Symptomology of UC v CD
UC: LLQ pain (where descending colon is), passage of mucus and pus, tenesmus (ineffective painful straining), rectal bleeding, anorexia
CD: RLQ crampy pain (ileum here), eating stimulates cramps, anorexia, steatorrhea, fever
109
Bleeding of UC v CD
UC: Common and severe
CD : not common and mild
110
Fistulas in UC v CD
UC: Rare
CD: Common
111
Other Complications in UC v CD
UC - Perforation, Toxic Megacolon --> Bowel perforation
CD: Bowel obstruction, abscesses, colon cancer
112
Surgery in UC v CD
UC: Curative (since removal can cure)
CD: Non curative (since it can be anywhere it cannot be cured)
113
What sort of pharmacologic treatments are done for IBD
corticosteroids and antibiotics
114
Big concern with IBD is ....
nutritional imbalance
the anorexia - IBD often underweight, malnutrition, malnourished - so its common (esp in CD) to see Parenteral nutrition - GI will need rest and anorexia
115
Biggest complication concerns of IBD
electrolyte imbalance
cardiac dysrhythmias related to electrolyte imbalances
GI bleeding with fluid volume loss
perforation of the bowel
116
Nursing Goals of IBD
bowel elimination
pain management
fluid volume
nutrition
fatigue
anxiety (v bad they are young)
coping
skin (frequent BM)
knowledge (deficit about IBD)
self health management
complications
117
Nursing Interventions for IBD
Diet, activity and stressors - nutritional therapy
ready access to restroom
pain management
fluid volume and low residue diet --> low gas diet easy to digest
rest
anxiety and coping
skin
understanding and self care
118
Irritable Bowel Syndrome (IBS)
chronic functional disorder associated with pain and disordered BMs
diagnosed s/s
119
What differentiates IBD and IBS
IBD - the doctor can do an endoscopy and visually see the ulcers
IBS - functional disorders means there is no diagnostic finding on colonoscopy (scope shows nothing) - diagnosed based on s/s
120
Clinical Manifestations of IBS
Disorder of frequency and consistency of stool - diarrhea to constipation back and abdominal pain/pain assoc with change in stool and stool appearance and frequency
121
Interventions for IBS
Education
Dietary Habits
Chew and Dont Drink with Meals - Fluid cause distention
Stress Management
122
T/F: The patient with IBS should select foods low in fiber in order to minimize intestinal irritation
False - want them to have high fiber foods
123
In Crohn's disease, the clusters of ulcerations on the intestinal mucosae have a ___ appearance
Cobblestone
124
What are the 3 subclasses of Intestinal Obstructions be
Mechanical v functional
small bowel v large bowel
partial v complete
125
Mechanical Intestinal Obstruction
Caused from pressure on the intestinal wall and the pressure leads to adhesions, intussusception, inguinal hernia, hernia, or tumor
126
Functional Intestinal Obstruction
"Paralytic Obstruction"
When intestinal musculature cannot propel food, cannot do peristalsis, cannot propel weight
127
Common causes for Intestinal Obstructions
Endocrine Disorders and Neurological Disorders
128
What is the difference between partial and complete intestinal obstructions
Parial means only part of the movement is occluded; complete means nothing can move
129
A patient with intestinal obstruction is at significant risk for what
fluid imbalance - critically imbalanced
We want to maintain the fluid and lyte balance, insert and NG tube as orders, and be NPO
130
S/S of Intestinal Obstruction
Pain
May or may not have BM reported
potential mucus of blood in stool
abdomen distended!!!! (large and firm)
emesis
weakness
potential weight loss
131
Nursing Interventions for Bowel Obstructions
IV fluids
NG tube decompression
fluid and lyte replacement
surgery - if tissue is strangulated
fix root cause - ex: hernia
anti nausea meads- not PO, IV or suppository's
132
T/F: Decompression of the bowel through a nasogastric tube is necessary for all patients with a small bowel obstruction
True - if the pt is obstructed they are getting an NG tube
133
General Nursing Considerations Post GI Surgery
1. Resuming enteral intake (PO) - get them back up and moving
2. Dysphagia
3. Gastric Retention
4. Bile Reflux (when pylorus removed/broken)
5. Dumping Syndrome (when pylorus removed/broken)
6. Vit and Min Deficiencies
134
Intestinal Diversion
Allows stool to leave the body when there is disease or injury
It is a pouch with a stoma that is from the wall of the colon or ileum v- brought to surface and fused with it
135
Ostomy location depends on...
disease and condition location - depends on where in the GI system is affected
136
What changes based on ostomy location
stool consistency
137
Colostomies
Sigmoidostomy
Descending Colon Ostomy
Transverse Colon Ostomy
Ascending Colon Ostomy
138
Ileostomy Stool
ostomy that bypasses the entire large intestine, so stools are liquid, frequently contain digestive enzymes, and must be pouched at all times
has lots of digestive enzymes so can be irritating to skin
139
How do the colostomy stools compare
Sigmoid - stool may be more solid - water absorbed
Descending - semisolid, less solid than sigmoid
Transverse - more mushy than descending
Ascending - liquid stool
140
Ileostomy byupasses what
colon, rectum, and anus
141
Which ostomy has fewest complications
Ileostomy
142
Colostomy
diverts colon to a stoma
143
Ileoanal Reservoir
essentially a "new rectum"
large intestine removed but anus remains intact and disease free
colon like pouch from last several inches of ileum
stool collects and exits during bowel movement
144
Continent Ileostomy (K Pouch)
For pts, with rectal or anal damage who do NOT want ostomy pouch
large intestine removed and a Kock pouch is made from the end of the ileum
effluent is then drained by inserting a catheter into a valve
145
Ostomy Care education should include
basic assessments
size
strict I&O
effluent monitoring
skin care and pouch care
diet and medications
monitor and report increase or decrease of effluent, stomal swelling, abdominal cramping and distention
146
When does effluent post ostomy surgery appear
not until 24-48 hours after surgery
147
Nursing Dx for Ostomy Care
Disturbed body image
Risk for impaired skin integrity r/t to irritation of the peristomal skin by the effluent
Imbalanced nutrition: less than body requirements r/t avoidance of foods
Anxiety r/t to the loss of bowel control
Risk for deficient fluid volume
Sexual dysfxn
Deficient Knowledgeo
148
Ostomy Irrigation
to stimulate emptying at scheduled times
note always in routine care but can help stop unplanned bowel movements or fecal drainage in social situations
gives pts control
149
T/F: The pt with an ileostomy with a Kock Pouch will not need to use an external collection bag
True
150
What is the main risk factor for esophageal cancer
barrets esophagus
151
what gender is more likely to get esophageal cancer
men
152
what race is more likely to get esophageal cancer
African American
153
Risk factors for esophageal cancer
smoking
ETOH use
gender
age
comorbidities
154
One of the number one complaints about esophageal cancer is what
dysphagia - trouble swallowing
sensation in throat or something is getting stuck
*also weight loss and weakness
155
by the time esophageal cancer symptoms appear
the cancer has advanced
156
Diagnostics for Esophageal Cancer
biopsy and endoscopy
157
Treatments for Esophageal cancer
chemo
radiation
re-sectioning esophagus with part of small intestine
158
What gender and races are more likely to get gastric cancer
men > women
native america, hispanic, african american > caucasian
159
Risk Factors for Gastric Cancer
poor diet
smoking
alcohol use
gastritis
160
How does gastric cancer present
clinical manifestations present like PUD
undiagnosed until CT scan
161
Diagnostic for Gastric Cancer
CT Scan
162
Treatments for Gastric Cancer
chemo and radiation - may be palliative not curative
total gastrectomy if it hasnt spread and is caught early
163
Duodenal Tumors
Usually benign and diagnosed incidentally
present asymptomatic
if severe, intermittent pain and occult bleeding occurs
can be removed with surgery
164
3rd most common cause of cancer death is via ____ cancer
colorectal
165
chief sign for colorectal cancer
change in bowel habits!!!'
*second most common manifestation is blood in stool
166
____ is the most prevalent cancer diagnosis in colorectal cancers
adenocarcinomas
167
How is colorectal cancer diagnosed
via colonoscopy and biopsy
168
Tenesmus
recurrent inclination to evacuate bowels - can be painful or spasming sensation
169
Risk Factors for colorectal cancer
increasing age - >50 yo
family hx of colon cancer or polyps
high consumption of ETOH
cig smoking
obesity
hx of gastrectomy
hx of inflammatory bowel disease
high fat, high protein (with high intake of beef), low fiber
genital cancer (endometrial CA< ovarian CA) or breast CA (in women)
170
S/S of Colorectal Cancer
Right Sided Lesions - Dull abdominal pain and melena
Left Sided Lesions - abdominal pain, cramping, narrowed stools, constipation, distention, bright red blood
Rectal lesion - tenesmus, rectal pain, feeling of incomplete evacuation after a BM. alternating constipation and diarrhea, bloody stool
171
The etiology of cancer of the colon and rectum is predominantly (90%) ____, a malignancy arising from the epithelial lining of the intestine
adenocarcinoma
